Part Deux – Dedicated Period

The period after year 2 of medical school where you are free from all academic responsibilities

… but is dedicated to Step 1 studying. We were given 6 weeks, but I took 4.5 weeks so I could go on a decent vacation before starting year 3.

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About to climb up Mt Bukhan

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On top of Mt Bukhan

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The best part of the hike!

Basic schedule:

6-7am*

Wake up, breakfast

7-9am

Flashcards, read

9-12pm

Questions

12-1pm

Lunch, break

1-4pm

Questions

4-6pm

Gym/yoga, dinner

6-9pm

Questions

9-11pm

Read

11pm-6/7am

ZZZ

*One reason I woke up this early during dedicated was to train my body to be awake and well rested on test day.

When I wished it be more like..

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Flashcards:

I always started each morning with flashcards I made on Anki, a flashcard app (more about Anki in a later post). Every day, I had about 200-300 flashcards to go through which took at least 1-2 hours. Flashcards were the bane of my existence and I felt so liberated after Step 1. That being said, they really work so I eventually picked them up again during year 3. Some people swear by Brosencephalon’s deck, which is comprehensive and great. I tried it out and learned early on that I wasted a lot of time trying to understand what the question was asking. By making my own flashcards, I presented the questions and answers in a way that I could best process the information. This meant intentionally more time making cards as a form of processing and learning, but less time per card on recall.

During year 2, I also made SketchyMicro into flashcards. This took a while but reviewing the images all year really helped with recall on test day! I also think it’s fine to review as is, not as flashcards, if you don’t want to go through the trouble of turning them into flashcards.

Reading:

Before Pathoma and Uworld, I felt like most people were recommending this book: Goljan’s Rapid Pathology. I spent about 3 weeks reading through it. I would only recommend this to you if you are as neurotic as I am and feel like you need to pick up every little detail to attain the highest score possible. I mostly did it to feel confident about the breadth of information. Would I do it again? Probably not during dedicated. I did, however, probably got an extra 5 points because this book covered pathophysiology really well. Disclaimer: I made up the number of points.

In terms of Pathoma, I mainly watched the videos rather than reading this bible of pathology. My first run through was during the summer after first year when I had made flashcards. I circulated through these many times during year 2 so I technically reviewed Pathoma several times. I also went through Pathoma videos again during year 2 as reference to the related course material.

In the last 1.5 weeks, I read First Aid cover to cover. I hated doing this but it was a great way to do a final review on the highest yield points for Step 1. I wrote my notes on a digital copy of First Aid that I managed on OneNote. I highly recommend going through First Aid at least once for a final review!

 

 

Just to take a break from all my writing and show my practice test progress.

Last day of the academic year: April 25, 2016.

Test day: June 4, 2016

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Clearly an uptrend is a good sign. If your practice test score ever drops, use it as motivation to study harder for your next one! Not a good sign that my last practice test score dropped. It definitely kept me from becoming complacent in the last few days. Remember, n=1 for this.

Questions:

UWorld reset. At the start of dedicated time, I reset UWorld after going through it once during the year with my classes. My second time reviewing UWorld only took 3 weeks, which is about 10x as fast as the first run through! (Of course I went through more questions every day, and had less to write down.) I went through about 3 sets of 40 questions every day, taking about 2-3 hours each set. My strategy was to go through 20 questions at a time because I didn’t have the patience, and timing was never really an issue for me. I was averaging about 90-100% on the question sets, which definitely boosted my confidence. Still, I made sure to understand how UW differentiated the right from the wrong answers. Going through these questions is a good way to review and target content you need to review.

I also purchased Kaplan Qbank and rushed through it in about 1.5 weeks. It kind of hurt going through this after getting 90-100% on UW, since I averaged ~68% on Kaplan. I had to tough it out and keep reminding myself that more questions = more success. Kaplan Qbank was great for biochemistry and physiology review. People complain a lot about the minutiae being tested on Kaplan, but sometimes understanding minutiae ensures that you know the big picture! I definitely felt like a few of the Kaplan questions were on the real deal. Again, don’t get discouraged by your score because you should be learning from questions when you go through it for the first time.

Practice tests – I started taking the NBME tests before dedicated – roughly once per week until test day. Having finished a few practice tests before dedicated did motivate me to study harder for the test and provided a benchmark to work off of. I had to stay realistic about my scores and remind myself that most of the progress is during dedicated. I took both UW practice exams on one day to simulate the length of the exam. I also took the Free 150 at the testing center, which I highly recommend. Being familiar with the testing center relieves you of one less anxiety factor on test day. After each practice exam, I’d go through it and read up on a topic if I felt the need to. Of course it goes without saying that I made flashcards of my incorrect answers. Another thing I did was keep a separate note to reflect on how I took the practice test. Here’s a sample:

Summary

  • Started losing focus and got lazy about going through each answer and why it’s wrong
  • Looking for pertinent negatives to rule out is very helpful
  • KAPLAN had a fact that most other resources didn’t
    • Men Testosterone can → estraDIOL in testes
  • Kept it simple and got a couple questions right. Stopped myself from double jumping.
  • ~50/50 w/ changing answers second time. Got 1 right, but maybe 2 wrong from it. Just think hard the first time and act like it’s my last time (worked better this time)

I did end up using a score predictor (http://clinicalreview.com/ClinicalReview/resources/usmle-score-calculator.html) which put me in the right ballpark. I ranged the UW correct % from 70-90 depending on how much confidence I needed. Fair warning: I checked this neurotically.

Flexibility:

I outlined my general schedule but always let myself be flexible in terms of moving things around. The only thing I was rigid about was finishing flashcards and the minimum number of daily questions I needed to finish Qbank by my targeted dates.

My amazing fiance came every couple weeks to pack my fridge with more hearty food (picture). I even stayed home to study for her birthday, rather than taking a short 2 hour bus ride to spend one special day with her. I owe a lot of my success to her, my strong rock in the Step1 hurricane. I constantly relied on her emotional support, encouragement, and faith as a shining beacon a hope. It should be no surprise that I’m going to marry this amazing woman!

To show appreciation, I’m dedicating another paragraph about how great my fiance is. She drove from NY to pick me up after my test, packed MY stuff for our vacation that SHE planned, and then drove us to NY! And to that, I say:

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Ah, enjoying a private hot spring in Hakone, Japan

Day of:

I woke up at 6am and ate breakfast. By now my body was accustomed to waking up at this time and getting 7-7.5 hours of sleep every night. I took a melatonin the night before to ensure that I got enough sleep! I finished my flashcards and went to the gym for a 30 minute cardio to wake up my mind and body. During the hour I had left, I went through 20 questions of First Aid Rx and 20 questions of UWorld to boost confidence. I chose not to prepare a cheat sheet to write on my board. Instead, I’ve been making sure to learn things as I went along (biostats!) with spaced repetition. I actually reviewed my test taking summaries as I mentioned earlier. Finally, I put all the things I prepared for test day into a bag and then headed out.

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I’m ready!

Make sure you bring:

  • Government ID
  • Exam permit!
  • Snacks/Drinks/Lunch
  • Caffeine
  • Foam earplugs
  • Sweater
  • Comfortable clothes
  • All the preparation you did for the past 2 years!

It’s about a 25 minute brisk walk to the testing center. It was a gorgeous day out, and the sunrays were patting me good luck. Once the test started, I took breaks every other set for about 10-15 minutes. I snacked whenever I felt a twinge of hunger in my stomach. I didn’t finish my PBJ sandwich for lunch. I went outside for a quick breath of fresh air for one of my breaks. I ended up using pretty much all my time during the test. I’m the type of test taker that goes through the questions once, and then goes through a second time to double check. For questions I was uncertain about, I made quick educated guesses, marked it, then moved on. After a long 8 hours, I was free. I was the last student out of the testing center. I re-entered the world, embracing freedom. Still, it felt unreal, similar to the day after graduation. I was quickly plagued by doubt and many rounds of bargaining my future.. This is all normal, and it will pass. That’s why it’s great to have something to look forward to the whole time! Trust in your dedication and know that hundreds of thousands of people did this before you and they mostly turned out OK. I went into studying for Step by telling myself that as long as I try my hardest, there’s nothing I can regret. And I can tell you now that I don’t regret it at all!

Take care of yourself

  • I signed up for a month trial of hot yoga at a studio a few doors down. I attended a class roughly every other day and it did my mind and body a lot of good. I’ve continued going after the trial but I still don’t buy into the “see the universe and feel its energy” bit.
  • I attended church every week. I figured that the trying time of Step studying was a good time to connect with any spirit out there, apologize to God for neglecting church and promising to use my amazing Step 1 score to become an amazing doctor.
  • I felt so restless by the afternoon that I figured it was the optimal time to unwind and let out all of that anxiety. I hit the gym on the days I didn’t do yoga. A few days, there was enough anxiety and body pain that I went to both. At the gym, I mainly rode the bike for 30 minutes, and added some weight training in hopes that it would make a dent in my large study-period-fat-reservoir for my big vacation. The biggest reason I probably went to the gym so often was for my daily human interaction with the guy working front desk (Hi, Tom!).
  • GF (now fiance) came by to cook meals! This was the time I let myself try out all the Trader Joe’s frozen meals. You can’t go wrong with the frozen Indian meals and garlic naan! As you can tell, I didn’t spend a lot of time on food. I made lots of smoothies with Soylent (link to post). Breakfast was simple and would usually be oatmeal with peanut butter, flaxseed, frozen blueberries, and sometimes syrup. This sadness of what I called “meals” I made up for during my vacation!
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    One of the meal preps that Grace did for me

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    A typical trip to Trader Joe’s during Dedicated study

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    Feasting in Korea!

  • Sleep: make sure you get how much you need! I was used to 7 hours for the past few years so I stuck with it. Going to the gym / doing something active helps you unwind and get a better night’s rest. I did use melatonin 1mg extended release if it was taking longer than 5 minutes to fall asleep. Trust me, my graduate school thesis was on sleep, so I don’t mess around with it!
  • Spaced repetition is key! Making Step-related flashcards from as early as summer before year 2 made a big difference. It made me recall details with much more confidence. The questions that took the most time on Step 1 were the ones where I had never directly learned the material. That’s hard to swallow but you have to realize that you will NEVER learn EVERYTHING. I hated this feeling so I relied on flashcards to retain as much as I could because I’d hate myself for not remembering something I had learned before. Takeaway: learn things in a way so you don’t forget it!

Conclusion

There are many ways to go about with your dedicated time. Figure out what works best for you, don’t keep comparing with your peers, and if you inevitably go on SDN or Reddit, use it to only motivate you more! The two tenants of my studying is Spaced Repetition Learning and lots of Questions! I had over 10,000 flashcards and went through more than 10,000 questions. In terms of how many weeks to take: many people who took 6 weeks said they were pretty burned out by weeks 4-5. If you study slow, take the full 6. If you can go full intensity with small breaks, shorten it! YOU decide how much hell you want to endure for you to lock in your future!

How I set myself up to score 250+ on Step 1 before even starting my dedicated study period

As you already know from my previous post, my MCAT score was very average (with an EIGHT in one of the sections – old MCAT had 3 sections worth 15 points each). But once I got into med school, I saw how close I was to the finish, saw the community I wanted to join, and made the conscious effort to excel.

I’m sharing my score to show that someone who slacked off in college can still do well on USMLE Step 1. I wasn’t born a genius (to my knowledge…). I don’t have all the time in the world. What I can control is how hard I work. Medical school was a fresh start to try out this new mantra of “hard work will pay off!”. They say that Step 1 is one of the most important factors of residency! In fact, in the 2016 survey to Program Directors, Step 1 is the most important factor for interview selection.

Snippet from 2016 NRMP Director Survey:

f1

 

By working hard from the beginning, I succeeded in obtaining a competitive score in the most important factor for interview selection. I significantly increased my chances to interview at my dream schools! Impressing them on interview day, however, is a whole other beast…

My efforts were successful and I scored a 255 on Step 1. Based on the latest released USMLE Step Score Interpretation Guide, the average Step 1 in 2015 was 229 (I took the exam in 2016).

Following tables from usmle.org

 

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Table 2 – USMLE Score and Percentile for first time test-takers in US/Canada medical schools from Jan 1, 2013 to Dec 31, 2015

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Again, I’m sharing my experience in order to encourage you to continue working HARD towards a career in medicine. It’s a CHALLENGING road to get there. I, for one, know how hard it can be. Like most students tasting freedom for the first time, I went a little overboard during college. Although it took a few extra years to get back on track, I gained important experiences that shaped me to who I am today (and met my fiance 🙂). In retrospect, I can appreciate that extra time, as it taught me that hard work does pay off.

So here is my Step 1 study plan for pre-clinical years that took me from the 50 percentile on MCAT to the 91 percentile on USMLE Step 1! My advice for you is to take the parts that work with your study habits, be realistic about your progress throughout and manage your time carefully.

Plan

This plan is based on the curriculum at my school, which involved several courses overlapping during the first two years of basic science. For example, I had microanatomy (histology) and gross anatomy all year, physiology most of the year, and about a month of neuroscience, and a few months of biochemistry. Some schools condense the basic sciences into 1.5 years. Other schools take one course at a time, eg all of biochemistry, then all of gross anatomy, etc.

Note: First Aid for the USMLE Step 1 (FA) = the tome of Step 1. All high yield ← a term you’ll be hearing a lot of in medical school.

YEAR 1

That’s right. It sounds ridiculously early but I encourage you to start studying during your first year of medical school. This is when you build a foundation for understanding pathology and pathophysiology. First, you gotta understand the basic structure and function of the human body in order to understand how it can go wrong. You gotta learn the vocabulary of the human body to understand the medical language! This foundation is important, but not directly tested on Step 1. It might feel so irrelevant and low yield for Step 1, but learning it well will prepare you to do well in your second year.

General resources and strategy:

  • General: I used First Aid as an outline to learn my class material. The tables and images on FA organized many complex ideas into an easily digestible (and memorizable) unit. Check your library for printed or digital textbooks. I didn’t purchase any textbooks!
  • Anatomy: use flashcards and repetition, memorize the clinical pearls such as what causes winged scapula or the significance of the middle meningeal artery. Or perhaps you learn best from the cold bodies laying in your anatomy lab. In terms of textbook, I think it’s best to try different ones to see what works best for you. Moore’s Anatomy has “clinical pearls” that really make anatomy more interesting, and testable.
    • Quick tip: Learn the spatial relationship between muscles, artery, nerves. There are many well known ones (NAVEL, Water under the bridge). Check Google! TheBodyOnline website.
  • Physiology: BRS Physiology. Everybody loves this book! It definitely helps distill the physiology concepts to the basics. It’s useful if you want to avoid getting bogged down by details. This is one of the courses where I heavily relied on a whiteboard. Drawing out the concepts really helped me survive! I also used Kaplan, and Boards and Beyond, videos for physiology.
    • Quick tip: Draw things out. When you think you know it, do some questions.
  • Biochemistry: This is a very dense, conceptual course. It’s a beast that polarizes the class into lovers and haters of biochem. I learned it best through Kaplan, and some Boards and Beyond, videos. I drew out the pathways many, many times. Although I took this course three years prior during my masters, it was still very challenging the second time!
    • Quick tip: Learn the most important piece of information (such as the rate limiting step). Hinge new details to this anchor. Draw things out!
  • Neuroscience: Our course had tutorials that really helped a lot, so this doesn’t help 99% of you! I abused my whiteboard by drawing and redrawing all the pathways!
    • Quick tip: Draw things out! Make tables, memorize them.
  • Histology/Microanatomy: Extremely tough if you aren’t a visual person. Everything looks pink and purple!! Spend extra time on Google to get many different pictures of histology. Having taken this course in my masters, I can safely say repetition really is key.
    • Quick tip: Look at LOTS of variations of the same thing a la Google. LUMEN website.

Figure out your learning/studying system. I discovered that I learn best with questions, and that when I simply read, I don’t retain (any) information. I found that flashcard apps hold my attention and offer flexibility to study anytime, anywhere. There are many different flashcards apps out there but I prefer Anki because of the customizability. (Post to come on what I put on my flashcards!) Figure out what works best FOR YOU. I used Anki primarily with simple (mechanism of action, function, what is this structure) and pathophysiology (WHY does something happen).

Goal of year 1: Figure out how you learn best and get amazing at it.

YEAR 2

Use Pathoma, Sketchy (or Picmonic), FA first before lectures. These might seem like garble of nonsensical words during year 1, but when you start looking into Step1 material, these words pop up everywhere. Pathoma is a must. You’ll thank Dr. Sattar when you graduate medical school. Sketchy or Picmonic are visual mnemonics that condense seemingly disparate material into fun images. You memorize the picture and suddenly you know everything you need to know about Staph Aureus. It’s amazing. Use any other board review resources to prime your brain. It gives you the basics you need to know, and a good outline to follow. Supplement this with your course.

  • Example: I watched the relevant Pathoma before a Pathology lecture. I made a separate flashcard deck for class details.

Finish all the board review material as soon as you can, preferably in the first half of the unit. I actually had a free trial of USMLE Rx videos at the time, which was helpful in teaching me the “basics” of my classes. (USMLE Rx is the question bank made by the makers of First Aid. They also sell flashcards and videos which I didn’t use). I used Boards & Beyond and Kaplan videos as well. I don’t recommend one particular board review video over another – try to find which works best for you..you might not have a preference! Then I would study by answering relevant questions for that unit. Remember that you’re using the questions to also learn, not only to review.

  • Example: I watched all the cardiology videos, then worked on the cardiology Rx questions. It was not in sync with the order of the school cardiology lectures, but I was able to establish a good foundation by using this method. Then after watching all the school cardiology lectures, I’d work on UWorld questions. This takes a lot of time but TRUST IN THE FORCE.

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If you’re daring, use UWorld and Kaplan QBank (I used Rx), during your courses. I find that these questions provide a good clinical framework of the basic sciences. This does require a lot of faith that it will pay off and it did for me. I performed above average in my classes, but even better on Step 1.

Year 2 goal: Use a system where you can integrate board review first, and supplement with class material.

Breaks

Winter:

Take a break! Not just with Kit-Kats. At minimum, use 1-2 hours a day to catch up on your questions and study lightly with flashcards.

Spring:

Take a break if you need it. You’re buckling down for the craziest ride of your life and you’re probably reeeeally starting to feel the pressure at this point. Catch up on UW, get ahead if you can. You’re going to reset the beast that is UW for the dedicated study period.

Finally, avoid discouraging people/place/things. Surround yourself with motivation and support! Keep your goal in mind. If shooting for a “high” step 1 score seems unattainable, pick a more tangible goal, like a number. Mine was to hit 250, although I’ll admit during dedicated I was happy with 240s, then 230s, then just passing.. It’s all worth it! Find what works best and stick with it.

More to come about my specific dedicated study plan!

Questions about resources or classes? Let me know below!

GOOD LUCK!