USMLE Step 1 – 269 – Dr. Rick
Hi everyone, I’m an IMG from Bolivia, graduated in June 2016. I wanted to write this experience
cause reading about other people’s experiences in this forum helped me a lot in this process so I
wanted to give back. The duration of my preparation was super long, I took some breaks, made
many mistakes but at the end it was worth it, I want to share this so people don’t make the same
mistakes as I did.
I started my preparation on September 2016, took the test on October. So it was like a year and
one month of prep.
First aid and Uworld were my main resources for everything. But I also did:
Kaplan Live online with the books for all subjects and the Kaplan Qbank.
Anatomy: shelf anatomy and Netter Flashcards (not the entire flashcard book, only some parts to
reinforce uworld and first aid concepts). Physiology: BRS physiology. Pathology: Pathoma (did NOT
read goljan nor Robbins, they are too long). Micro: Sketchy micro. High yield cell and molecular
biology. Biostat and ethics: uworld biostat subject review, usmle rx questions on the subject, BRS
behavioral science (only like 4 chapters), 100 cases by Conrad Fisher.
Kaplan Qbank 85%, UW first pass 87%, UW second pass 98%, UW third pass (only 1000 questions)
NBMEs online: NBME 15 238, NBME 16 253.
NBMES offline: nbme 6 got 14 wrong, nbme 7 got 15 wrong, nbme 11 got 11 wrong, in nbme 12
and 13 don’t remember how many wrong questions I had, in nbme 19 got 9 wrong, nbme 17 got 6
UWSA1: 277/ UWSA2:269.
Phase 1: Building a base
I started with the Kaplan live online lectures on September of 2016, which I believe helped to build
a base of knowledge since I barely remembered some of the topics tested on this exam like
biochem. The class was almost the same as the videos you can download from the internet I
think, I signed up for this class cause I didn’t know how else to prepare. I discovered this forum a
lot later in my preparation so all I knew about the test was coming from Kaplan. We finished the
class in December and then I started doing the qbank and also did their simulated exams until
January. This took almost 5 months, which in my opinion was waaaay to long. The qbank didn’t
help in terms of knowledge but it was good to get used to doing questions. After finishing
everything with Kaplan I took my first nbme. I think it was nbme 15 and got 238.
Advice: do Kaplan as fast as you can, try to understand yes, but don’t get caught in their details
cause at the end what you must master is Uworld and First Aid. Try to annotate important points,
high yield points directly into first aid so you don’t go through Kaplan more than once. While doing
micro with Kaplan, I also supplemented with sketchy micro, and annotated extra information
directly into first aid.
After that I took a break, travelled, and wasted more time (stupid me). I planned to take the test
on May but I underestimated the time I was going to take to study first aid and do uworld.
Phase 2: First Aid and Uworld.
I started reading first aid and it was painfully slow. As I was reading first aid I listened to the
Pathoma lectures for each corresponding topic and I annotated in first aid extra points that Dr.
Sattar mentioned. In this first pass of FA it is vital that you UNDERSTAND the material, when you
understand something you don’t need to memorize it. When you understand the mechanism of a
disease, you can anticipate the consequences of it, the symptoms and complications. Learn the
material, don’t just passively pass the pages. Every time I read a topic I asked myself how the
exam could test me on this, I tried to quiz myself as much as I could. If you don’t understand
something from fist aid, don’t just read it passively and pass over it, google it, actively search for
answers and explanations so you don’t forget. Associate as much as you can, example: you are
reading pulmonary physiology and carbon monoxide is mentioned, then go back to biochem and
quiz yourself on the specific step CO blocks on the electron transport chain, and then quiz
yourself again in all the ETC inhibitors. Make connections.
I started doing uworld when I was half way through the first aid book, I was delaying starting
uworld mainly because self-doubt and the fear of a bad uworld percentage. This was a mistake,
do uworld as soon as you can, add subjects as you go through first aid, and take uworld as a
learning tool. Don’t delay it cause of fear, your uworld percentage doesn’t determine your exam
My advice when solving uworld questions is to analyze your thought process for every right and
wrong question. Think why did I get this question right, what associations allowed me to get it
right. Read every explanation to detail! Make emphasis on how to differentiate between diseases.
For every wrong question, think why you got it wrong, was it that you didn’t read the vignette
properly, you didn’t understand the question, lack of time, etc. I did uworld the first time under
timed mode to be able to get used to managing my time appropriately, I took some notes on first
aid but then I realized that my book was so full of annotations that it was gonna be impossible to
read, so I started taking separate notes ONLY for the things that were not mentioned on first aid
(this took forever, and I was super super slow). I tried to finish every block with at least 10 minutes
to spare to solve my marked questions. How do I analyze a question: first I read the question,
underlined the sex/age/occupation of the patient, then I read the entire vignette every word, then
try to predict an answer, then look for the answer. When a difficult question shows up, ask
yourself on what educational point is this question trying to test me, because even the hardest
questions come from simple basic principles (this helped me a lot). I don’t know why but almost
every time I see a question I try to imagine the patient, it made it more real. Only change an
answer IF you have a logical reason to do so! (You remembered a new piece of information, or you
have now found out that you didn’t understand the question correctly in the first place).Use logic
as much as you can even if you don’t know what the question is about, to rule out answers.
Practice on reading the vignette only once so you don’t’ waste time on the exam. I also printed
some uworld tables and put it next to the corresponding topic on first aid.
After my first pass of first aid and uworld I was I think fed up with this exam, I was so tired I
wanted just to stop and forget about this journey so I took another break cause every time I
looked at my first aid full of things all I wanted to do was to vomit, it was a horrible mix of fear/anxiety/tiredness. I don’t remember exactly how much time it took me to recover to get my
energy back again but I wasted again precious time. I was determined to not get this exam on my
nerves again so I started meditating with headspace, for me this was key to manage my test
taking anxiety. I also started exercising but inconsistently. Don’t let go of your own health, try to
relax, exercise, eat healthy.
Phase 3: Improving my score.
I read first aid for the second time, this time trying to memorize everything, I tried to cover up the
tables, again quizzing myself on everything. I would not go to the next page before firmly knowing
the information on the current page. I marked things that I had hard time memorizing, and made
small notes that I posted on my wall to see every day on the things that were hard to memorize
for me. I also supplemented the equation page on the back on the first aid, adding the equations
that weren’t there. I tried Anki for a while, but I got bored, I remember someone in the forum
posted that the key for memorizing was doing Anki and that all “high scorers do it” but it didn’t
work for me I guess. ALWAYS DO WHAT WORKS FOR YOU, DON’T BLINDLY FOLLOW ADVICE. I also
did uworld again.
When I finished my second pass of FA, I gave nbme 16 and I got 253, I was happy but I did not felt
ready, this was in August at the beginning of my 3 month period, the only available date for the
test on La Paz was September and October, so I told myself to try to improve until September and
take another nbme to decide whether to take it on September or October. NBME 16 marked
biostat and behavioral sciences as my main weaknesses, I was shocked to see I did bad on biostat
because I never had any problems with it before. To improve on this subjects I read: BRS
behavioral sciences (not the entire book, only the part of the doctor patient relationship, legal and
ethical issues, health care in the US, medical epidemiology and statistical analysis), Conrad Fisher
100 cases, USMLE Rx questions on biostat and ethics only, I did uworld biostat review, I did all the
biostat questions I could get my hands on. Despite all of this I didn’t feel confortable with taking
the test on September. So I took the advice of another member of the forum, Snurp Splicesome to
take it in October. This was gonna give me enough time to do First aid and uworld again and to do
most of the NBMES.
NBME’s: This was the key to improving my score, I did old nbmes offline, I wrote down all the
wrong questions and important points in my notes, and I analyzed my thinking process and promised myself to never make the same mistakes again. I actively looked for explanations of
questions I did not understand. I felt more and more comfortable with the prospect of taking the
test. I read First Aid one more time focusing and giving more emphasis on my weaknesses like
biostat, ethics, doctor patient relationship and anatomy. After my third pass of First Aid I decided
to take UWSA1 and got 277, I scheduled my test for October after this, I knew that UWSA1
overpredicted but I was feeling confident in everything except anatomy and physiology, I mean I
felt I was ok but not yet excellent in those subjects. So I decided to read BRS physiology and also I
improved anatomy with shelf anatomy and Netter flashcards (I did not read Netter flashcards
entirely, only I reinforced topics tested on uworld and first aid).
Phase 4: Weeks before the test
After I scheduled my exam I had like a month left and I tried to do uworld a third time but it was
more of the same, I got bored of it, I think I did 1000 questions on my third pass but I couldn’t
finish it. I gave first aid one last read, started from the back and read to the front cause I wanted
to keep biochem/micro/ immunology fresh in my mind for test day. In this final month I also took
nbme 17, 18 and 19 along with UWSA2. UWSA 2 was the most predictive for me, I did it online. The
rest of the nbmes I took offline because I was determined not to change the date of my test, I
already had my flight ticket from my city to La Paz, and I knew my weaknesses. I tried to do 2
nbmes on the same day, I also did uwsa 2 and fred on the same day cause I wanted to simulate
the real exam, see when I was gonna need a bathroom break, when I got tired, when I needed
food to wake up etc. Do this to see how are you gonna manage your time on the test, I used to
always do 2 blocks without leaving my seat to get used to it for the exam.
In the last week, I also read my uworld notes, and also devoted an entire day to looking for images
on google, webpath, uworld, etc. I entered radiology pages to see CTs, MRIs and Xrays. I listened
to heart sounds and looked for EKG images.
One day before the test: I went to La Paz, got to a hotel near the test center. I revised the First aid
rapid review, all the equations in the back as well, the notes I had on my wall, the notes I took
from taking the NBMEs, and I revised some pages that I had marked on first aid. After that I had
lunch and went to the test center to see how it was. Then I went for coffee and watched a movie
in the hotel. I was calm because I knew I had done everything that I could to prepare for this test. I
put my clothes in order, my scheduling permit and all the things I needed for the test. Before sleep, I meditated to relax a bit more and have more positive thoughts, I read the bible to give
myself some courage, I prayed and then I fell asleep.
Test day experience:
I woke up fresh, before I left the hotel I took one last look at the equations on the back of first aid,
took breakfast. I tried to listen to my favorite music before the test to give me confidence and to
get myself in a happy mood, then meditated one last time. I went to the test center as
comfortable as I could, I basically went with my pajama pants, a shirt and a sweater, as for shoes I
wore a sort of slippers. To save break time, I used my pajama pants without pockets because
every time you get in and out of the test they look for your pockets so that saves time. Food: I took
with me some powerade, also a red bull cause I always get tired after lunch, also took some tea
cause it relaxes me. Took candy and some salty chips. For lunch I took a chicken wrap, something
not too heavy but with enough protein. If you have eye strain problems like me, take your eye
drops and put them in your breaks, during test I tried to avoid eye strain by setting up the black
screen (my eyes get tired with the white screen). I also took some Acetaminophen to the test
center in case my head hurt. You leave all of your stuff in your locker by the way, and you have
access to them on your breaks.
My first block was the hardest, thank god cause I did it when I was still fresh and not fatigued.
After that killer first block I tried to calm myself down, prayed to god to give me calm and I did my
usual breathing exercises before moving on to the second block. I basically solved all blocks
except the first one in about 40 to 50 minutes, giving me 10 or sometimes even 20 minutes to go
over my marked questions which were like 10 in every block, sometimes more. My break strategy
was: 2 blocks (with deep breathing in between blocks staying put in my seat), break, 2 more
blocks, break for lunch, 1 block, break, block, break, final block. I finished my test exhausted and I
felt ok but not happy about the test. The waiting for the results part was horrible, because I did
not feel confident with my performance, I even had nightmares about the test. Please don’t be like
me, after that test there’s nothing you can do, so just give yourself a nice break and relax until
results come. At the end everything turned out well for me, when I got the test I was so happy I
couldn’t believe it, hard work does pay off so just do it and don’t be an insecure person like me,
trust yourself and your knowledge.
I wanted to thank most importantly god and my family for putting up with me while I studied,
specially my mother cause she really was the most important person during this stressful journey,
always telling me to trust my abilities and giving me confidence to destroy my self-doubt and
telling me not to quit. Thanks to the best study partner in the world, my dog Spot which listened
to me reading First Aid out loud countless days. And to my friends Ceci, Fer, Adri, Fong and Jacob
which were always there for me. Also thanks to Snurp Splicesome for the advice.
Good luck to everyone!!