The Comprehensive USMLE Guide For Pakistani Medical Students (PART 2: Step 1 Guideline)

You’ll need the following resources:

1. First Aid
2. UWorld
3. Review Book for each subject.

FIRST-AID for STEP 1 (FA):

This is the single most important resource in your USMLE prep. If you master FA you’ve mastered Step 1. All AMGs and IMGs prepping to give STEP1 use this book. Your success in STEP1 depends on how well you use FA. Its called “the bible of USMLE” for a reason. You need to know FA inside out, anything that’s on FA any graph, diagram, figure, subscript anything at all; it’s extremely high yield. You need to know, understand, memorize and master it! Because it will be tested one way or another on the exam. Be prepared!

Many people follow the dogma that “all you have to do is learn First Aid,” but few actually stop and consider how it’s made.  Although I can’t give a first-hand account, I can tell you a story i read from a well-reputed site. If true (and I have no evidence to the contrary), his explanation helps elucidate both the beautiful simplicity with which the book is made, as well as how we should use it. It was told by an attending in Yale(where the book was originally made) that they approach students who have taken the test, and simply ask them what questions were on it.  Obviously, other organizations do the same thing (Doctors in Training comes to mind), but what First Aid does with that information is key: they simply write the answers to those questions, or at least the information you would have needed in order to answer the question.

In other words, the information in First Aid is a compilation of all of the raw information you would need to answer the questions remembered by people who have taken the exam.

This explains several vexing problems experienced by most people who study for Step 1, including:

• Why there doesn’t seem to be a particular order/flow between topics (now we know this is logical, since the goal is simply to give us an idea of what is being tested, and what kinds of facts we might need to know)
• Why even within each topic it seems to be a jumble of mixed facts (it is written that way)
• Why students struggle to apply what they’ve learned from First Aid to QBank/Step 1 questions (the First Aid approach emphasizes facts > understanding), and finally
• Why First Aid is so hard to learn from (again, the goal isn’t to teach, but rather to give you an insight into the kinds of questions asked/information required)

I know you’re probably thinking, “That’s great, but how does this help me study for Step 1?"

Since the USMLE Step 1 is going to emphasize the application and integration of knowledge, your goal should be to understand the mechanisms of disease, and move beyond the simple memorization of “facts,” no matter how “high yield” they are. You need to try to learn “why?” and “how?” rather than, “what?”  If you get nothing else from this, remember that while First Aid is a collection of facts tested on Step 1, you will be expected to apply and integrate those facts.

Don’t just memorize that glucagon can be used for a β-blocker overdose; instead, consider that glucagon works through Gs proteins, just as β-receptors do, and so that it can lead to the opposite downstream signalling.  It’s not enough to memorize that calcium channel blockers extend the PR interval; instead, understand that Ca++ is the dominant ion used in conduction because you lack IK1 channels in nodal tissue, so that Na+ channel inactivation can’t be removed.

UWORLD (UW):

It is the highest yield question bank. Most students use it during their prep. You’ll need to combine FA (first aid) with UW (UWorld) to actually master Step1. I.e. read one topic from FA and then assess yourself by doing questions on that topic from UW. It will assess your mastery of the topic (whether you’ll be able to apply the info you’ve gained from FA to actually answer the question that’ll appear in Step 1) in addition to pinpointing your strength and weakness.

It can be found at usmleworld.com. You can buy it for 100$ for one month. Subscriptions greater than a month have substantial discounts. You can get their books but they’re all pirated and illegal material.

I would highly recommend buying this for a single month at least. Typically this should be used to maximum effect about 1-2 months before your actual exam. If you can afford it, then definitely get a 6 month subscription and supplement your FA study with it. The explanations given in this resource are the best amongst all others and some Americans actually solely rely upon the explanations for their revision. Questions typically use 2-3 step thinking processes and require good integration of concepts, so it’s a tough question resource. My advice is to solve all questions and read their explanation regardless of whether you get any question correct or incorrect.

Kaplan series

Kaplan review books and videos are some really good study resources. Most IMGs (international medical graduates) use the Kaplan series.  However US medical students only rarely, if ever, turn to Kaplan for their study. Kaplan definitely is a good series but thinking that it lays out the syllabus content of Step1 for you is nonsense. Step1 does not have a very well defined syllabus. The closest you can get is finding the syllabus release on usmle.org for Step1. Instead of spending time cramming all of it, it’s more useful to concentrate on selected areas more. 


You can totally skip out its Physiology book and replace it with BRS Physiology. You can do the same to Pathology book and replace with Goljan. You’d need to supplement biostatistics with high yield biostatistics. A lot of information written in Kaplan is vague, especially the Genetics part of Biochemistry, and very rarely, if at all, tested. Some topics need more elaboration than what’s published: Cancer chemotherapy, Lysosomal storage diseases. Microbiology typically requires substantial usage of Levinson to fully master the bugs. At a later stage, as stated already, I would lay out the books you need to study for an efficient preparation.

Why use review books in Addition to FA and UW?

Now as I stated earlier FA is an extremely condensed book, it’s more of a compilation of facts so you need review books for each subject to actually make sense of everything that’s going on in FA. If you’re very well versed in these subjects and can grasp FA without supplementation then you can definitely proceed with FA from day one but in case you’re an average med student you’ll need review books. For example:

1. you do Biochemistry from Kaplan first to understand the subject

2. then you do the biochemistry portion of FA to really know which topics you need to master for MLE because if it’s on FA then it was in one way or another tested in STEP 1.

3. After reading it from FA you do that portion from UW to really master the subject and to ensure that you can apply the info you’ve gained from FA to clinical vignettes.

Recommended Books:

Get all of Kaplan series. You may omit Physiology totally. You may if you like, also omit Pathology. Buy the DVD lectures as well (remember the copies found in our country are illegal; if possible, they should be bought at kaplanmedical.com). Here’s a little run through the individual subjects:


 Physiology: All American students rely a lot on BRS Physiology. It’s a fantastic book that focuses on the most high yield content you need to know with all the necessary graphs. The problem with Kaplan is that it includes discussion of quite a few topics that are not tested on Step1 e.g. Vascular Physiology. These are also discussed in heavy details that entail a lot of time commitment. BRS Physiology has everything you need to know in Physiology plus an additional chapter on Neurophysiology which is not discussed even in Kaplan’s neuroanatomy.

 Biochemistry:  Kaplan should suffice here. Infact Kaplan is a good book. Some topics need supplementation. You should consider studying lysosomal storage diseases from elsewhere; first aid has details of all lysosomal diseases. Listen to the lectures as well if you like. Dr. Lionel Raymon explains the concepts exceptionally well.

Molecular Biology:
Again Kaplan should suffice here.  Techniques should be referred from High Yield Molecular Biology as they are poorly explained in Kaplan.

Genetics:
The first three chapters are fine. Add another chapter from Genetics chapter of the Pathology book. The last three chapters are something of a lost sheep wandering aimlessly. I have never heard LOD scores being tested in Step 1. Techniques of genetic analysis are very commonly tested but they haven’t explained it in a satisfactory way. Studying these techniques from high yield molecular biology may be time consuming, but they are well explained and may help you get questions correct. Although technique methodology is not tested, knowing the techniques give you confidence in answering the question so study them in detail. Don’t underestimate this topic!


Anatomy:

Neuroanatomy is good enough. High yield neuroanatomy is also a good book; Remember it is extremely important that you know the clinical scenarios very well, CT-scans, MRI’s, and gross specimen. In this manner, High yield is a very good book because it has many such illustrations and snaps. You should have a very good orientation of the brain in all planes: sagittal, coronal and transverse! Using help from university department websites can be of immense help. Search “webpath” on Google and navigate into the Pathology department of Utah University.


Histology is written in a way you’d forget as soon as you read. When you go through again, the same happens. Third time isn’t too lucky either. Here use High Yield Histology. At first glance this book seems to be a lot more detailed than needed. But that detail isn’t just histology. It’s the bridging knowledge and concepts that spans physiology, pharmacology, biochemistry and pathology! Try to find the original textbook as there are excellent illustrations and photographs at end of every chapter.

Gross Anatomy is fair enough. But you may need help from major texts such as Snell to study the Pelvic region which is disappointingly poorly explained in Kaplan.


Embryology is spread throughout Gross Anatomy. It’s useful enough. Basic embryology needs supplementation from other texts. You can give a quick read through Langman’s embryology to get a hang of the initial development of the embryo. Most American students state First Aid embryology is good enough. You can trust that opinion. You may also use High Yield embryology. But you can just stick to First Aid.

Immunology:

Kaplan should suffice here. Remember again that immunology techniques, similar to genetic and molecular biology techniques, are very important and should be clearly understood and learnt. For example KNOW the difference between ELISA and Western Blot very well! Diseases are very frequently tested. When you supplement your study with First Aid Q and A book (Buy it!), immunology diseases would become progressively clear. Stay loyal to Kaplan here; you don’t have to spend too much time on other books. You can use Levinson occasionally especially for diseases. It takes time but it’s a fantastic book written by a UCSF professor who is an authority in Microbiology and Immunology. At end of Kaplan, there is an appendix detailing CD markers. Learn it by heart.

 Pharmacology:

Use Katzung Board Review series here. Surprised? I’m not. That is the best book. Again it is written by a group of three UCSF professors who know what’s needed for Step1. Some topics such as Chemotherapy and Anticancer drugs are so important you have to study them in detail. Katzung is more than enough detail and you can totally rely on it. Because Dr. Anthony Trevor is also a co-author of Kaplan’s Pharmacology, there are some similarities between the two which means once you go through Katzung, you can review Kaplan easily. You may consider annotating Kaplan with Katzung’s points. They test each and every drug, even Sitagliptin and Orlistat. Be careful studying Toxicology because it is important. You will have to study it from katzung to know what’s it all about. ANS and CVS drugs are definitely high yield.

 It would help you writing some points on a notebook and repeatedly revising it. For example, write all adverse effects of all anticancer drugs and keep going through it. Eventually you’d start remembering that pulmonary fibrosis is a prominent side effect of bleomycin and busulfan, Nephrotoxicity is not an issue with Sirolimus and a combination of Didanosine and Zidovudine has a high incidence of neutropaenia.

Microbiology : It would seriously help you if you just go and buy Levinson and just go through it atleast once. Some Americans recommend “Made ridiculously simple” Microbiology and you may use it if you like to. Viruses need constant referencing with Levinson to simply learn what haemorrhagic fever exactly is and what exactly is hand-foot-mouth disease. Parasites are just sugarcoated in tables. Again, study from Levinson. You won’t get the slightest hang of it from Kaplan. Microbial genetics is written fair. Remember you have to learn the mechanisms of resistant to different drugs, for example the acetyltransferase against chloramphenicol. You have to also learn which are plasmid mediated and which are chromosomal mediated. Transposons, plasmids, lysogeny etc are all a fair game and must be understood.

The case scenarios given at the end of Kaplan are slightly confusing but they’re a fair game as well. You can actually replace them with similar scenarios and common causative agents written in Levinson.

Pathology:

Goljan appears to be the undisputed king here. You can also listen to Goljan lectures (remember their possession is illegal! I don’t know if they even officially release any lectures in first place). But you can quite comfortably rely on its 3rd edition that spans not only Pathology but also bridging concepts to Pharmacology, Biochemistry and Physiology which ensure active revision and repetition of these subjects.  This is a detailed book so make sure you allocate enough time. Make sure to buy the original version so that all the micrographs and gross specimens are clear.

You can also study from PATHOMA! Listen to the video lectures as well. Goljan or Pathoma? That’s completely upto you and your study . Be sure you also utilize Utah University Pathology Department’s Webpath website.

SOURCES:
1. Dr. Ayaz Mehmood
2. Yousmle