Step 1: Post-Exam Thoughts

Took Step 1 ~~yesterday~~ nearly a week ago. I meant to write this the day after, but I have developed a strong aversion to the Internet since walking out of the testing center. The immediate post-test hysteria has worn off and I haven’t yet forgotten the test, so I figured it’s a good time to share my thoughts on the actual exam.

But here’s one thing to keep in mind when reading reports of Step 1: Take every single on of these “just took step 1, here are my thoughts” posts with a grain of salt. Yes, this includes mine. I don’t think that any two people have the same exact test. Everyone has strengths and weaknesses. No one feels “good” after the exam.

When I get my scores back, I’ll give a full breakdown of my preparation. For context, most of my practice test scores throughout dedicated were 250+. I never really felt pressure or anxiety during dedicated. I was well-prepared. That said, after some blocks on the real deal, I felt like a failure. During the test, it’s easy to get flustered, but you have to remember that everyone is in the same boat. There are going to be a few questions that are not found in First Aid or UWorld or any prep resource. Don’t sweat it.

I ended up getting pretty sick the weekend before the test, which wasn’t ideal. Took my final practice test shaking, feverish, with a blanket wrapped around me. Didn’t do so hot on that one, which hurt my confidence going into the exam. Like most, I didn’t sleep well the night before the exam, but that’s to be expected.

On exam day, I woke up around 6 am and did some quick review (I couldn’t help myself). Had a big peanut butter banana smoothie for breakfast. I paced around for an hour. Before leaving, my mother reminded that this day would have been my grandmother’s birthday. This Step 1 nonsense makes us all a little crazy, but sometimes you need to step back and remember that many, many people are proud of you and you have come so far since those pre-med days. So, about the exam…

Some general stuff

During the first block, I had razor-sharp focus and submitted with 5-10 minutes left. By the final block, I didn’t even have time to review all of my marked questions.
I took 5 minute breaks after each section to use the restroom, listen to a song, and take a few bites of a protein bar.
The only time I did not take a five minute break after a block was the before my last block. I’m certain that it was my worst. I was reading questions three times over again. Fatigue is real.
After my fourth block, I stepped outside for 20 minutes, sat on the curb, munched on a protein bar and listened to some music. I listened to “Push the Sky Away” by Nick Cave & The Bad Seeds and “Since I Left You” by the Avalanches. Those songs gave me a very strange, calm, confidence. The block afterwards was easily my best.
I only ate one protein bar and drank one redbull. I wasn’t hungry at all, but in hindsight I probably should’ve forced myself to eat a little more.
Definitely do the Free 120 within a week of the exam. I had two identical pictures from the Free 120 on my real exam. I also had a couple repeats from NBME exams.
The test felt like a mix of UWSA2 and the last three NBME exams.

Questions

One thing I did not expect was how easy some questions would be. Seriously. There were quite a few questions that were so incredibly easy that I read them three/four times over to make sure I wasn’t missing something or falling for a trick. Stuff like… “What is E. Coli?”
- Bacteria
- Parasite
- Virus
Micro wasn’t super difficult, but it was weird and very situational. I didn’t have any algorithmic bacterial identification. No catalase, oxidase, urease positive/negative. Nothing more than gram(+)/(-) rod/cocci. A good portion of my micro was questions such like…
- “Patient is septic and had a catheter. What’s the pathogen?”
- or “patient has surgical wound infection – what’s the pathogen?”
These weren’t actual questions obviously, but I had many questions of this style. The best word I can use to describe the questions was situational. The last few pages of the FA Micro section is golden.
My test was extremely heavy on anatomy. I had more anatomy on my exam than biochem and neuro combined. Which was definitely not cool because those were two of my strongest subjects. The anatomy questions weren’t particularly difficult, but spending a solid two days dedicated to re-learning anatomy would’ve been a very good use of time.
Legit had a picture of a pathogen. No symptoms. Just a picture.
Biochem, neuro, and Endocrine were the three subjects I felt I had truly mastered (on a Step 1 level) by test day. As in I didn’t even need to open them in First Aid. Of course my test was very light on biochem, neuro, and endo. Classic.
Like many people have said before me, this test has a weird way of exposing your weaknesses and hitting them over and over again. This happened with me and respiratory. Tons of respiratory stuff. Best way to prepare for this: Don’t have weaknesses. Best of luck.
Had a couple MCAT/pre-med level questions. USMLE – you wild!

Comments on Resources

Got one question right solely because of a weird Goljan story. The vignette described a vague pathology presentation with one very peculiar symptom. I was like bro, I have no idea. I marked it and moved on, but when I came back to it, a light bulb went off in my head as I remembered a story from Goljan audio describing this one peculiar symptom. I smiled at my prometric cubicle. Thank u Goljan.
Got several questions right because of Boards and Beyond. I used Boards and Beyond as my primary study resource, so obviously 90% of questions I got right on the test were due to information learned in B&B. But there were specific questions on the test that I wouldn’t have gotten right without B&B.
Got one question right because one time a doctor told me that I had lymphoma (I didn’t) which prompted a manic week of research into various lymphomas. Something I had read during that week actually showed up on my exam (not in FA, Uworld, or anywhere else). Nice.
First three chapters of Pathoma are filled with easy points on exam day. Know them cold.
Sketchy was enough for 80% of my micro. Like I said – situational. I’d make it a point to read through First Aid’s micro section a few times during dedicated.
LOTS OF PICTURES.
I had a good amount of pharm, but none of the pharm questions were crazy or hard. Pretty straightforward stuff. Didn’t watch Sketchy pharm so I can’t comment on it.
I missed one question because as an angsty second year med student with boards on the mind, I decided that class material wasn’t relevant if it didn’t overlap with FA. Jokes on me because I specifically remember thinking, “why would I go through the trouble of learning this, it won’t be on Step 1“. It was on Step 1. Haha!
I missed one question because I was too lazy to try to remember a particular card in my Anki deck. Every time it popped up, I just said, “nah”. Smh.

Above all, if I had to describe Step 1 (at least my exam) in one word it would this: random. It didn’t feel like a selected group of questions meant to be representative of the studying I had done. It was just flat out random. 99% of what you study isn’t on the test. It’s 280 questions. Then it’s over. You could have ten questions on antifungals. You could have eight questions on brachial plexus lesions. I think I had maybe 5 total biochem questions. and at least 30 respiratory. It’s weird and random. Just have to do your best and laugh when appropriate.

As I previously said, I was confident during dedicated and was scoring > 250 on my practice tests. Still, after the exam I felt pretty terrible. It’s easy to focus on those wacky out-of-left-field questions after the test, but the reality is that 90% of the test was manageable and at times, easy.

When you’re done, forget about it. The gold standard treatment for post-step psychosis is a cold drink with some friends. Go out. Have a beer. Or a mojito. Treat yourself to a steak or sushi or whatever you happen to enjoy. Go for a bike ride. Attend a concert. Kiss someone. Make new friends. Laugh with old friends. Smile and remember that you are more than medicine or some stupid three digit score. Be kind to yourself. You are wildly intelligent, you have already made those who love you very proud, and you deserve to enjoy yourself now.

Next up, a very special message to anyone entering their second year of medical school…