Step 1 Post-Mortem - The Very Short Version

Hi all,

Several people have asked me to comment on the outcome of my Step 1 adventure. I want to give it a more full treatment when I get time, but right now, I'll give the short and sweet version.


First, my score.
I am hesitant to blast my Step 1 score on the interwebz for all to see. I think you can appreciate. But I also know that that result is important for judging whether my Anki strategy is worthwhile. I will give a qualitative result:  I was extremely pleased with my outcome, and I couldn't have asked for more. Take that as you will.

Short story:
1. Anki works really really.  Many questions, both in qbanks and on the real test would jump out at me as an Anki card, and that would enable me to answer them quickly and correctly.
2. UWorld is amazing. Many real q's looked very similar. Putting qbanks above content review was a good strategy for me. Because Anki started me off with a very solid base, I could take full advantage of UWorld and USMLERx from day 1.
3. 7 weeks was too long.  I should have done 5 or 6 weeks. I had to work very hard to get marginal gains in my performance compared to my initial NBME test. Diminishing returns. The silver-lining of that story, however, is that that means I was already poised to do well on Step 1 from day 1 b/c of Anki. So its conceivable that someone might use Anki and do qbanks during their normal class schedule, and then not even have to use dedicated time for Step 1. So that means a 1+ month vacation for someone with the courage to try that.
4. If I had done Anki for subjects like biochem, behavioral science, etc. early on, I probably would have done no content review at all. Maybe like 2-3 days at max. So for the future, students who use Anki from day 1 of med school may not need to do much content review at all.


I promise I'll come give more detail at another time. But the take-away now is that the Anki-Step 1 strategy I've described on this blog works. If you use good cards and are dedicated and disciplined in using them, you be set for success (however you define that). And, best of all, your learning efforts are not for naught. The knowledge will not be fleeting. The stuff I studied in the preclinical years is now burned in my head, and I hope that some of it will be useful to me in the future.

Good luck to you all on your Step 1 journeys. And thanks for following my own path here on this blog. I hope I've helped some of you.

Now it's time to start doing (and writing about) other exciting things.

The Day After

Hey all,

I'm going to make this quick. Honestly, for the next few days at least, I want to have nothing to do with medicine. I've dedicated enough time, and I think I need to get back the world that doesn't revolve around crushing qbanks all day. I don't want to think about Step 1 either until I find out how I did. Doing otherwise is a sure-fire way to induce some needless anxiety.

So here's my impression: I feel fairly good about the test. What I've studied and what I know, I got those questions right. Most were very straightforward, bread and butter stuff. There were a couple of "what the heck" questions with terms or facts I had never seen before. I didn't expect that. Not many, but maybe 4-5 q's. I reasoned them out and think I got them right, but it was still surprising.

- Many questions looked just like UWorld. It's unreal actually how good UWorld is at identifying topics that Step likes to ask about.

- Questions stems are a bit longer than my practice qbank questions

I'm going to refrain from being too specific until after I find out how I did.

I was physically and mentally drained by the exam, I have to admit. I'm not used to sitting for 8 hours. I use a standing desk at home, so I can move around. Sitting for that many hours was definitely painful. Made my neck tight too.

When I walked out of the test center, I felt strange. I had just finished a marathon that had loomed for so long, and now it's all over. I had expended quite a bit of energy on it, and now it was done. Time to figure out what to do with my time now :)

And so, that is what I will begin to do today. I'm not starting lab rotations until the first week of November. I'm taking this week and the next for some R&R. I have a lot of projects and books I want to read, and I'll do that in the next week. Then will take a road trip to a wedding the following week.

Over the next few months, I'm going to transition this blog to talk more about science and grad school than med school.

For the next few days, here's a list of stuff I'm going to do:

(1) sleep
(2) clean the house
(3) spend time with my wife, whom I've neglected for too long because of my studies
(4) learn some computer science and programming
(5) work on AgoraMed, the med education startup I'm doing with my buddy Peter
(6) start reading books for grad school - I'm going to take a general study of scientific method, experimental design, practical programming for bio-ish stuff, biostats, etc. Stuff that I could use no matter what I'm doing in the lab.
(7) Develop my productivity workflow. I've been tinkering with some programs like Omnifocus, Papers, Devonthink, Anki and Scrivener, and I want to develop a clean workflow that helps me integrate these tools and make them work for me. I'm going to write more about this as I do it.
(8) Do some fall stuff - pick pumpkins, apples, etc. I'm really liking fall these days and want to enjoy it while it's here

That's it for now. Thanks for following me in my Step 1 journey. Hopefully my reflections have been useful to you all. That is my main reason for keeping this blog in fact. I enjoy getting stuff off my chest, but I like even more when my words help others.

Tomorrow is the day

So the time has come to finally take Step 1. It's been nearly 7 weeks of on-off but dedicated prep, and just about 2 years of learning med school stuff. I think enough of my energies have been expended on this test, and tomorrow will be the end.

I'm feeling pretty good right now. I did a quick cram this morning of stuff I care to forget - embryology,  some behavioral science stuff, helminths, etc. By midday I called it quits and did other stuff. Mowed the lawn, spent time with my wife. In about 30 mins, the computers and devices are going off and I'm going to chill out for the night. Dinner, some meditation and some Bible reading with the Mrs. Get to bed, then hopefully fall fast asleep so I can get to tomorrow morning sooner.

Taking this test marks the end of one of phase of my training and the beginning of another. I'm looking forward to devoting my time and energy to new pursuits, and without the burden of studying for Step, I'll be free to do all those things. More on that after tomorrow.

To those who have been following this series, I thank you. After I get my results, I'll do a post-mortem and see how my somewhat unconventional methodology fared.

Until next time...

Step 1 Preparation Series: Days... does it even matter?

Hey all,

Just an update. Nothing crazy going on over here. On Friday I finished the last of my content review days. My plan from here on out is to just do qbank questions all day, every day. As I come across things that I don't know, I make an Anki card. That's pretty much it. Qbank, Anki, review, repeat.

I'll try to make some more resources or videocasts in the next few days.

Until then,
Happy Studying

Step 1 Prep: Days 7-14: Lagging

Hey everyone,

Just an update. Last week was kind of a wash for me. I had a lot of family and school obligations, and thus, my study schedule fell by the wayside. I got some anatomy and embryology done at least. I might need to do a little more anatomy studying, but otherwise, I feel comfortable with those topics. With anatomy, biochemistry, behavioral science and embryology behind me, there is no more "new" learning to be done. I can really enter into study mode now and just do a lot of questions from UWorld and USMLERx.

The plan for the next few days is do some reading in selected topics:

Cardiac physiology - Boron and Boulpaep
Respiratory Physiology - Boron and Boulpaep
Pharmacology - autonomic, antiarrhythmics, pharmacodynamics/kinetics - Principles of Pharmacology by Golan

I'll be doing questions as I go along. I'm doing the above reading not so much because I feel deficient for the purposes of Step 1, but because these are topics that I want to really know well for the future and I see now as a fine time to delve in and fill holes. B&B is an awesome and detailed physiology book and I want to zoom in to that level so I can really know the heart and lungs well. I'll update my Anki decks with any nuggets I pull out.

I'll try to make some resources as I go along.

Day 0: Step 1 Preparation

Welcome to my Step 1 Preparation Series. Over the next few weeks, I plan to blog about my preparation for Step 1. My purpose is to record and reflect on my experiences in the hope that they will help others in their own Step 1 journey. I also plan to share insights about what goes well and what doesn't. And, I plan to create and share resources for Step 1 studying, such as videocasts on high-yield topics, my Anki cards, and whatever notes I put together. I truly hope that visitors to this blog find it useful and informative, and that everything I write is read with a critical eye.

So now that the clinical year here at Duke is over, there's one big hurdle I have to jump over before I go to grad school - Step 1. As most medical students well know, this exam, for good or bad, has a huge impact on what our residency prospects are, and so it has to be taken seriously.

Because of the gravity of this exam, like many med students, I've directed my efforts at preparing for Step since early in first year. To be sure, I've focused on learning medicine, period. But at the same time, I've made it a point to cover the things that are tested on Step.

Over the last two years, I've been conducting a personal experiment in learning. As I've written about so many times before, I've been using a digital flashcard program called Anki that is based on a learning principle called spaced repetition. Nothing else I've ever done has had such an impact on how I learn. Now, rather than briefly learning things just to binge, purge and forget on tests, I can now reliably retain the heaps of information I'm exposed to in medical school. 

When I first adopted Anki for med school back in the beginning of first year, I had a couple of goals. First and foremost, I wanted to make permanent the learning I was going to do in the classroom. I thought it an absurd notion that we were supposed to put so much effort into learning fundamental knowledge and then promptly forget the majority of it. What a waste of time and effort! So my goal was to keep the basics in my head for my future career as physician. Another important goal was for Step 1 preparation. The traditional way to treat Step 1 is to go through the preclinical years, binge and purge. Try to remember what you can, but do so in recognition that most of what you learned is going to have to be relearned before taking Step 1. Annotate First Aid with class notes. Then, take 4-6 weeks to do a huge review of all the material, plowing through First Aid and other review books. Then do 2000+ USMLE World questions. No doubt that works well for many people, but I think it is suboptimal for a couple of reasons.

(1) Stress: Trying to review so much information in so little time is highly stress-provoking. As you see all the information you've forgotten and envision all the information you need to now relearn, you bear a huge psychic cost. Plus, there are just limits as to how much the human brain can absorb in a limited amount of time.

(2) Long-term knowledge: With such rapid review, it is unlikely that the fruits of that labor will be preserved for long. What I mean is, since cramming doesn't lead to much long term knowledge retention, all the stuff people learn for Step 1 is lost shortly after taking the test. For some, that's a necessary evil of the game. And they don't mind forgetting Step 1 stuff, since many believe it's not clinically relevant. I don't deny that - some of the stuff is low-yield for life. But a lot of it isn't, and is worth remembering. So why spend so much time trying to learn but then forget?

(3) Performance: This is the most important factor. It makes sense to me that if one has a really solid base of medical knowledge that has been worked into long-term memory through continuous study that he would perform much better on Step. There would be less stress, more confidence, and a better score.

My Approach

So, I've decided to take an experimental approach. Most Step 1 study strategies have two basic elements: content review and practice questions.

My approach has been to spread out the content review over the last two years through my daily Anki reviews.  With only a couple of lapses (my honeymoon being a necessary and welcome one!), I've stuck to a review schedule on Anki nearly every day since first year. I've been studying continually, seeing material from the classroom years every day.

By this point, I feel that I've developed a really solid foundation of Step 1 knowledge that is burned deep into my brain. I feel confident and comfortable with the material. My Step 1 prep in the next 7 weeks will consist of only very minimal content review.

The majority of my time will be doing practice questions from USMLE World and USMLERx. Most people agree that doing questions is an incredibly useful and effective way of preparing for Step 1 because it forces integration and application of all that knowledge. Step 1 questions require "two-step" thinking, and that can't be learned just from remembering facts from Anki.

So because I've done most of the content review already, I'm going to weight my preparation heavily on doing practice questions, with the goal of getting through both qbanks by the time I take my test on October 18.

The Next 7 Weeks

I've decided to treat my Step 1 prep not merely as a way to get ready for a test, but as a time in which to take a broad view of all the knowledge I've amassed in the last two years, fill in the blanks, and synthesize a complete picture of the basic science groundings of medicine. In this light, the next few weeks should be actually... enjoyable. I think attitude counts for a lot, and if I were to be dreading the work I need to do, it would be miserable and not very effective. So I'm keeping my head up and trying to take the long view - what I'm about to do isn't just about a test, but it's about solidifying the knowledge I'll make use of as a physician-scientist.

More importantly, this time is the culmination of a two year personal experiment with spaced repetition. Now is the time to see whether or not the efforts I've put in with Anki will bear fruit, to test my hypothesis that a spaced repetition system would give me durable and retrievable knowledge. Just from my experience this past year on the wards, and in some of my preliminary Step assessments, I think I can say that Anki indeed does work, and it works very well. I'm more excited about the method than the actual particulars of Step studying. The implications are huge... here now is a system that I (and anybody else) can use to remember critical information for the long term. No longer do we have to just spend time, money and effort to "learn" and then in short time, have very little left in our brains to reflect those efforts.


OK, so what am I actually going to do. Here is a synopsis and my calendar:

Aug 27 - Sept 11: Content Review/Selected qbank questions
Topics covered: Biochemistry, Gross Anatomy, Embryology, Selected topics in physiology, pharmacology and gross anatomy. Also, one very quick First Aid 2012 overpass to glean any facts that I don't already have in my decks. One very quick pass over Pathoma videos too.

I'm doing this because there were parts of my school's curriculum which were either very weak or nonexistent, and occurred before I knew about Anki and about bucking the curriculum in general and doing my own thing. So I'm going to have to go back and do some review. In the ideal scenario, I wouldn't do any, but this is the reality. Plus, like I said, I want to use this time to fill in holes, and some topics I really want to learn at a deeper level for my personal interests, in particular cardiac/respiratory physiology and some gross anatomy.

Sources: First Aid 2012, Pathoma, Lippincott's Biochemistry, Boron and Boulpaep's Medical Physiology, Big Picture: Gross Anatomy.

Qbanks: USMLERx.

Sept 11-Oct 16: USMLERx/USMLEWorld qbanks, everyday, all the time, straight crushing. 

This is the heavy lifting here. Qbank questions are extremely useful - necessary in fact. This is a way to bring together the disparate facts and apply them to the real task of Step 1.




What I've Done Already

So I want to be clear about what I've already done because I want to give an accurate representation of what my studying has consisted of up until this point. This is important, because if anyone is going to use my resources or follow my study method in the future, they need to know what I've actually done.

USMLEWorld: I've been through this qbank 1x already. I did it casually from December 2011-Feb 2012. I used the explanations to make Anki cards for things I didn't already have curated in my decks. I did questions selectively, but got through the whole bank. My average was about 70-75% overall. I haven't touched these questions since February, so I don't think I'll be able to recall answers just from straight memorization. That's why I did the qbank a few months in advance.

Clinical Year: This is a big one. My school has us do clinical year in our 2nd year. So I've been on the wards
for a little more than 12 months, and so I've been continually exposed to medical knowledge, some of which overlaps with Step 1 material no doubt. Also, during the year, I've done some reading on pre-clinical topics whenever I had a free moment. I know most readers of this blog will not have had clinical year before taking Step. That's fine. I think it's somewhat helpful to have seen diseases in real life... it makes diagnosis that much easier. But clearly it's not a necessity to have been on the wards to crush Step 1.

Anki: Oh Anki. How I love you so. And how much time have we spent together?

Here is the breakdown*
This is not including every deck I've done. I threw out some too. But these are the ones I've kept and do continually to this day.

Deck  (as of 8/25/12)

Pathology: 507.3 hours
Physiology: 76.9 hours
Pharmacology: 132.2 hours
Microbiology: 82.1 hours
Immunology: 22.5 hours
Gross anatomy: 35.5 hours
Neurology: 35.8 hours
Biochemistry: 10.2 hours

That's a lot of hours! That, of course, doesn't include the hours spent doing the primary learning. That probably numbers into the thousands. But who's counting.


Pathoma

This is a great resource. I started checking it out in August of last year and used it casually throughout the year. I watched the videos and made cards for the Female Reproductive and Heme-Onc chapters. I'm going to blast through the whole video series at 1.7x starting next week.

Assessments and Progress

The first thing I did last Thursday was to take NBME 11 and USMLE World Self Assessment 1 to see where I'm at before I start this whole process. My goals were to identify areas of weakness and strength, to give me a fairly realistic picture of how well I'm doing now and how hard I'll need to study to perform at a high level on the real deal.

I've compiled the results of those tests in a Google Doc that I'm going to use to chart my progress throughout my studies. I want to share that progress, but I'm hesitant because I'm not exactly anonymous and I don't know if it's a great idea to post scores on the web. Tell me if I'm wrong here. Perhaps when all this is over, I'll make it all public so people can really scrutinize my recommendations and see if my non-traditional strategy is worth a shot.

I don't mind remarking in a qualitative way on how I did, however.

NBME 11: rocked it. very surprised and happy with how I'm doing at this point.
Areas of weakness: biochemistry, biostats, embryology. Not a surprise since these are the things I haven't studied seriously yet. Overall, the test seemed really simple to me. Almost too much so. I've heard NBME forms 11-13 are the most realistic, with 13 being the most true-to-life. I'll save that one for the end.

UWSA 1: rocked it too. Even more so than NBME 11. But I've heard the curve is quite generous so I can't be too certain as to the accuracy of their prediction. nevertheless, it was a boost. I thought the questions were slightly harder and more nit-picky than NBME 11. Not a bad resource though. I've still got UWSA 2 left.

Going Forward

All right. I've written enough for this post. I'll begin my studies on Monday and I welcome everyone to follow my progress. As I said above, I plan to share little nuggets, high-yield videos, resources, insights, etc. Any feedback or commentary is greatly appreciated. I think with a lot of discussion, we can make this a really robust and useful resource for future generation of med students.

Happy Studying!