This is the first article in the series “The Rebel Route”, written by Dr. Karen Tien based on her own experience with USMLE Step 1 Exam.

You can find the whole series here –

  1. First article
  2. Second article
  3. Third article

Part 3

Study Tips and FAQ



Image - Dr. Karen Tien
Dr. Karen Tien

we often get ourselves stressed out over NBME scores and our goals. All of that is actually beyond our control and so is the actual exam score. Just focus on things you can control – the time we put into studying and the quality of the study. For example, ask yourself how much ACTIVE QUALITY STUDYING  TIME are you actually spending each day on studying? Or are you just pseudo-studying (i.e. wasting time by reading but nothing is actually going into your head). It’s sometimes very difficult to critique the methods we have adopted to for many years but take a look at your study habits, are you studying smart or are you just studying hard? You do however have to…



  1.    PUT IN THE TIME and WORK

There are no shortcuts or quick ways to master concepts. The people who score high did not get there by mistake or had a “lucky” day when all the questions that came happened to be what they knew. The simple truth is that they have more knowledge and they have mastered core concepts better than everyone else.  It takes time, sacrifices, and patience. You have to build a strong foundation of concepts and a good foundation of pattern recognition. You exam depends on your ability to recognize the pattern of disease presentation and decipher information given to you in succinct and logical manner while not being sidetracked by the distractors they put in. Patients in real life don’t read textbooks so you should not expect the  USMLE examiners to give you the classical textbook cases. You score really comes down to how well you have mastered the concepts for you to get through the 2-3 step thinking they throw at you.



If you want to be a loner and do It yourself good for you! But for the rest of us, we need SP support when families and friends don’t understand your struggles and when you just need someone to tell you that you are not an idiot despite getting the same question wrong 3 times on UW. LOL. For real. It happens. Seriously though, thanks to my study partner, we were able to read in between the lines of FA and help each other iron out poor concepts or misunderstandings. It took us, on most days, 6 hours to get through 20 pages but we did them perfectly. Two brains are better than one, you will be surprised at how you miss things in FA that your SP picked up and vice versa.




we all avoid this – I  knew I was weak at genetics and pharmacology calculation but I chose to ignore it because I just thought the concepts are so boring. Face your procrastinations head on! If you know you are bad a renal and pharma calculations, the problem is not just going to disappear one day; go and do more questions and find more resources for it!  You will thank yourself in the final FA revision the week before your exam. For me, Genetics was my weakness so I did as many questions as I could find for genetics from UW, Rx, Kaplan (about 400 questions for each weakness areas). If your next NBME still shows weakness, what should you do? The answer is still, do more questions.


Image of a lighthouse



Ethics is just as important as cardio or neuro in terms of exam weighting – it’s easy to overlook ethics because often we think “ETHICS is simple, I’ll just use my gut instinct in the questions”. WRONG. The real exam puts your ethical judgment to the test by giving you options that you think are right but not necessarily the BEST choice. PRACTICE ETHICS! It’s completely UNETHICAL actually to get difficult cardiology questions right and then lose that point to ethics! it’s just UNETHICAL to the hard work you put in cardio! LOL.. you know what I am talking about, you probably spend ten times more effort in cardio compared to ethics. Good ethics sources besides UW and FA: Conrad Fischer 100 cases, Kaplan, and USMLE-Rx also have very tough ethics and behavioral science if you need more practice.


  1.    When you reach the plateau – PERSIST!

If you are one of those geniuses who don’t plateau, great; but for most of us you will reach a plateau – for me, it was NBME-15 (score 213) and NBME-16 (score 209) one month after one another. Don’t give up, just keep on studying. I bought a new question bank for a new perspective and the next NBME was a relief at 228. I don’t know whether it’s the new question bank or going through FA with a partner or doing UW again or going back to basics again. Believe in yourself and PERSIST. The reason why most people plateau is also because they are forgetting more of the past core knowledge as they are learning new things. ANKI. Make it your friend peeps. If you don’t know what I am talking about, do a little research on something called the “forgetting curve” and understand why spaced timed repetition is essential to your success. You can thank me later.



Be kind to yourself and forgive. You will question yourself very often – why did I forget that again? Why did I get the same question wrong again on UW? How Is everyone doing this in much shorter time than me? am I dumb or are people just not telling me their secret formula? These are all questions I know we all go through. When you are faced with these self-doubts, remember to be kind. To yourself.  Don’t take things so personally and always do your best. What can you ask more from yourself than the best?



I know it’s a very serious exam and sometimes we fail to see the bigger picture because we are stuck in the moment of wanting more and depressed because we fail expectations. Please find the humor in all of this and realize that we are, after all, just human, we make mistakes.



Being grateful is actually very powerful. It is such a blessing that we have been given the gift of education and self-improvement. I am grateful for this opportunity to challenge the USMLE, it has taught me humbleness, persistence, patience over and above knowledge. What have you learned about yourself on this journey so far?


Image of a lake




The place you choose to study plays a vital part in your ability to concentrate with minimal disturbance. If you have the option, don’t study in the same place you sleep or watch movies. Choose a place that is quiet, have a good source of light for those who study late nights, and Feng Sui tips- your seat should NOT have your back facing the door (it creates a sense of uneasiness).


  1.    PROTECT your neck

I had many bouts of neck pain because I had poor posture when studying. Please do a little reading to understand the ergonomics of your table and how well it suits your neck and back.


  1.    FIND your own sense of study style

Are you visual? Audio or teacher type? Do what works best for you. Everyone studies differently.



Please don’t ever assign your brain the task of “reading FA for 10 hours for the day”. That’s one recipe to brain graveyard. No brain (no heart for that matter) wants to leap out of bed in the morning thinking Yippee I’m going to read FA for 10 hours today! MIX IT UP! For example – 1 hour FA (usually can cover 3-5 pages as a beginner and 10 at pro level) then do 5 sketchy mico. Break 20 min… 1-hour FA. 2 hour of UW tutor mode. Long break. Then flash cards from last weeks UW for 1 hour and then so on. I got the idea from Pomodoro. Use the app if you like but please just make your schedule interesting and exercise even if it just to walk out for 20 min. You need the VIT D anyways because I know you have been living like a hermit. hehe.



ANKI is great, use whatever app you have to. Spaced time repetition is the key to long-term memory. why do you need long-term memory – if you haven’t already searched the “forgetting curve”. It’s a well-studied science and you should definitely try using it to your advantage.

When making flash cards, ask the questions that you think YOU might get wrong or most likely to forget and not just make flash cards about facts.


Image showing effect of spaced repitition



I mean this sincerely. Burnout Zombie is not a good look on anyone.


  1.    Use the FB Search Button on the Step-1 Forum

If you have a question, search it on the Facebook forum.  It’s most likely been asked before. Whether it’s a link to NBME offline or other resources or its some random fact you are querying that you came about on FA, it’s most likely been asked by someone else.


  1.    Do Difficult Topics in the Morning

Morning study sessions are usually more productive than evenings so prioritize the most difficult stuff for the mornings.



Questions I wished people gave me advice on when I was Preparing

How long does it take to study for Step-1 for an IMG?

average 6-12 months

It depends on several factors

  1. Years from graduation – the longer you have graduated from med school the more time you will need to rebuild your foundation. If you graduated more than 2 years ago. You most likely will need to start from scratch. I was 4 years out of med school and so going back to biochem, genetics, cell biology, biostats, microbiology, and immunology was a big struggle for me.
  2. Full time or dedicated. I worked for 6 months during my first 6 months of study, it was very difficult, I thought I could write after 6 months I was wrong. It was only after doing dedicated 3 months did my marks improve gradually from 209- 242.
  3. Family obligations
  4. How smart you study
  5. What is your goal ? to get above the mean of 228? Or 245? Which is one Standard deviation or is it 260, Which is two standard deviation? What does it mean? It means to get above 260, although not impossible, you need to surpass the other 97.5% of people who wrote with you. They are all just as ambitious as you are. Remember the scores depend on the bell curve and also the specialty you are aiming for.



What Sacrifices shall I have to make to prepare for USMLE as an IMG?

  1. TIME – 6-8 hours/day the average IMG takes about 2 years to write step 1 to 3 with the first test (whether you take step 2 or step 1 first) taking the longest which is 6-12 months.
  2. MONEY – Step 1 has already cost me more than 3000 USD.
ECFMG application for step 11100
UW 1 year450
Boards and beyond 1 year160
Rx online question bank 3 months100
Kaplan question bank 1 year220
Online nbme 12-1960×7 = 420
Extension fee60
Cancellation fee for prometric280
  1. FAMILY and friends – like a 2 year old, your favorite work will become NO, no to dinners, no to holidays, no to social events. This exam consumes you… don’t be stupid like me. Strike a balance.


Image showing a monk meditate



NBME – how to interpret your results?

I’m referring here to the online ones. NBME extended feedback (60 dollars versus no feedback which is 50 dollars) tell you about your performance in each area and shows you your incorrect attempts (without telling you the corrects answer) is a good way to determine your weaknesses. Besides looking to see where your subject weakness you have, you should also critically analyze your MCQ taking skills. Of the questions you got wrong, go through them and see

  1. How many silly mistakes did you make i.e. didn’t read the question properly or you made a presumptive diagnosis?
  2. How many were incorrect concepts? (crucial that you iron these out so you don’t make same concept errors again)
  3. How many were because of poor FA recall – ie you studied this before you just don’t remember this well.
  4. WTF questions where you just had no clue what they are asking (there is really not much you can do about these, except perhaps doing more question ie new question bank.

If it’s silly mistakes – you need to focus more, these are what we fear on actual exam day. If is the poor recall of FA – you need to do another round of FA.


How to improve NBME results/if you have reached a plateau?

In my humble experience, I feel There are three key factors why people don’t improve

  1.    Poor basics /poor foundation – (i.e. the beginning of FA – biochem, micro-immunology, patho, and pharma) for those of us who graduated more than 3 years ago, you can be guaranteed your basics are poor. Without a solid foundation – whether you used Kaplan, DIT, boards and beyond (best thing I ever bought for myself), you just cannot progress and you might even plateau and struggle for months with little improvement. NBME results will show you often have average or below average on “general principles”. Without a solid foundation, you will struggle to build good concepts. For example, if you don’t know what the difference between MHC 1 and 2 you will struggle to differentiate which disease are MHC 1/2 related.

Tips: do more questions on general principles using Rx, or Kaplan question bank, old NBME 1-11 are also good for pointing out our weaknesses.

  1.    poor MCQ taking skills – as I wrote above, after each NBME you should look at how many silly mistakes you make, this can be the key difference between a 230 and 250 (just 10 to 12 questions). What I mean by silly mistakes are ones where you misread the questions or you made a presumption.

Tips: read the last sentence of the question first and the answers FIRST then highlight key words in the question stem. Make sure you cross out all options before you make your final decision. If you stuck between one of two options, flag it, come back to it in the end. A second look at the question often triggers a new memory

  1.  you are forgetting more than you are learning. If you haven’t done your research on the forgetting curve. Do yourself the favor and save yourself from pain. if you understand why your brain forgets then you will understand why people say they do FA 4 to 5 times, spaced time repetition is the key to long-term memory.


What should I do in my last month?

This plan is what I would have done in retrospect with the proviso you have done FA 2 or 3 times thoroughly and UW twice and done all old NBME-1 to 11.

  1. Ontop of revising incorrects of UW and marked questions of UW, do one block of NEW questions every day. use another qbank – why? because 20-25% of the exam are new concepts. You have to be able to handle them to train your brain to tackle new questions right up to the day of the exam.
  2. Do NBME-18, 3 weeks before your final exam – why? because if it is low, you have time to work on weakness so you don’t panic before your exam, NBME-19 has a weird scoring method at the moment, I got more corrects than 18 but points dropped by ten. If I had a choice I would have done 19 and 17 offline. 18 and 16 are the closest to actual exam in terms of difficulty.
  3. Then after NBME you have three weeks – of which I recommend still doing 40-80 new questions a day and one full read of FA (focus on your weakness from nbme-18) you need to be able to do this fast i.e. 50 pages a day (this is doable if you have done FA at least twice before) @ rate of 10 pages/hour.
  4. Remember to take one day off a week to relax and exercise 30 min day. Don’t burn out.  you do not want to be sick on the day or have a sore neck.
  5. one week before exam – take nbme 19 and work on weakness for 2 days
  6. Last 5 days before exam – continue 40-80 new questions a day , revise UW notes,   nbme notes, do your Uw marked questions
  7. One day before exam – do your list of forgettables – for me this was 60 tagged pages  I had in FA it took me 6 hours one day prior to exam, stop studying by 4pm so you can exercise and get good night rest before exam. Need 8 hours of good sleep .
  8. On the morning of the exam, wake up to revise your formulas (if you didn’t do so the day before) do 10 to 20 practice questions to get the brain in focus. DO not bring your FA to the exam center.



Image of a girl drinking coffee


How to extend the exam?

I had to extend because I couldn’t reach my target after 6 months. Firstly, I had to call Prometric to cancel the exam, that cost me 300 dollars! (Because I didn’t read the fine print about cancellation fees 1 week prior to exam). I did a 1-time extension on ECFGM which is 60 dollars. 15 days later they gave me a new permit, it was then that I paid Prometric the fine (with the credit card over the phone). After I had paid I had to send ECFGM proof of payment after which they sent me a scheduling permit (Prometric and ECFMG work as separate entities). The bottom line is if you are going to cancel the exam – do it 1 month before the scheduled date so that you don’t pay a fine. If you are canceling after you have already done a 1-time extension then that is a different story. As far as I know, you cancel with Prometric ( not showing up to your exam goes on your ECFMG record and ERAS so please don’t do that), call ECFMG for further advice, they will tell you that you need to wait 1 month after the expiration date of your triad before you can reregister.


Thank you for this group for all the experiences you have shared and for the resources and wisdom. Thank you to my family and friends for their understanding and support. Thank you to my study partner who is always my go to girl and who always knew the right thing to say to me to keep me going. Thank you to my boyfriend who never doubted me, pulled me out of depression after each NBME (NBME fear is real lol), dragged me to exercise and supported the inner nerdy medic that I am.


Hope you found this helpful. What a wonderful gift that we have been given to learn and improve our minds. Enjoy every moment of your every experience on this journey.

A mind that is stretched by a new experience can never go back to its old dimensions – Oliver Wendell Holmes, Jr.





published with permission from the author.


Image Attribution

Dr Karen Tien – Image of author.

Effect of spaced repetition on forgetting curve – by Arnab Mukherjee, attribution, share alike. For more information email at


✨  Note

We continuously update our articles by consulting with the author and changes in recent guidelines of the exam. Please make sure you are subscribed to our newsletter (it’s completely FREE) to get notified on future updates of this article.

Image designing by Arnab Mukherjee.

📚  Write an article today

The Paradigm Shift Group is a community website, where everyone can publish materials related to study. The goal is to provide high quality FREE study materials created, edited and studied by academic people (students, researchers and professionals). You find more information on this page. Email the article to or

One Comment

Feel free to comment here,