Basic Science Years and Step 1 Studying: What I Learned about How I Learn.

UPDATE: Many new resources are available out there since I was in medical school and one I wanted to highlight was Achievable which uses an evidence-based approach to help guide you through preparing for STEP 1. They have great support for the learner and does come at a cost comp to a lot of other study resources. although not personally used, I did have the ability to review it lately, and there appears to be a wealth of knowledge with images to help the learner prepare for their step exam.

STEP 1 is the first of the series of licensing exams one must pass to become a doctor and is usually taken after M2 (second year of medical school). STEP 2 Clinical Skills (CS) and STEP 2 Clinical Knowledge (CK) are the next two exams in the series usually taken at the end of M3 and they test the practical application of practicing medicine and the fundamental knowledge base needed to practice. STEP 3 is a two day exam taken at the end of your fourth year of school or during the first year of your residency and it also tests fundamental knowledge combined with advanced skills needed for diagnosing and managing healthcare. I will write at another time about the other STEP exams, but today's focus is how I prepared for STEP 1 and what I would do differently if I could do things differently.

During the Basic Sciences/Before Dedicated Prep Time

Firstly, studying starts day one of entering medical school. The first two years of learning is targeted towards growing this base of knowledge needed in disciplines like biochemistry, microbiology, pharmacology, etc. to be able to treat patients. Two resources that I thought were key to learning during the basic sciences were First Aid and Osmosis (open disclosure, I do currently volunteer with Osmosis in their Peer Education Program and have received free Prime access when helping with recruiting new students).

First Aid is the gold standard when it comes to review material for STEP 1. The book is divided by subjects and organ systems, and contains what is considered "high yield" knowledge for the exam. I pulled that book out day one of medical school and annotated details from my lectures along the way. In retrospect, I wish I would have been more consistent as I would forget to annotate occasionally and found myself looking things up during my dedicated study period. So purchase this book and it isn't as important to have the most up-to-date version when it is time to study for the exam. For example, I had the 2015 version with me on island and that is what I annotated. By the time I reached my dedicated STEP period, the 2017 version had been released and the only difference I noticed when quickly browsing through were the major changes in the Psychiatry section to reflect the change from DSMIV to DSMV and some changes to the statistics section to include linkage analysis. Otherwise, there were not many noticeable differences. Moral of the story: buy the latest edition when you are entering school and do not feel pressed to buy the newer one two years later if you are financially unable.

Osmosis is like a resource to manage your resources in a way. This is another resource you start using day one and it has many awesome features. Firstly, you can upload your lecture packets from each hour of lecture into the Osmosis platform and the program is able to search the document for key words and link the document to helpful resources to elaborate on said topics. You can annotate and highlight directly on these slides you upload, and since it is electronic through Osmosis you aren't worried about having printed paper everywhere and your notes from the first two years are easily located in one place. You also don't have to worry about memory or storage since everything is through the server at Osmosis. There is a way to print out the notes your create for those of you who are paranoid about a server crash or losing your notes eventually, but I personally didn't experience an issue with that and my notes from December 2015 are still there even as of now.

Also, you are able to create flashcards specific to the lectures that you can review everyday. The program is geared toward long-term memory retention and based on how you rank the flashcards, the cards are set to reappear at a length of time calibrated to help with long-term potentiation (making the long-term memories stronger associations in your brain for easy retrieval). Another awesome feature are the Osmosis videos that quickly summarize various topics in a way that is easy to digest. Here's an example on a video I thought was very succinct:

This is a patient experience video regarding Lesh-Nyhan syndrome that helps you put a face with a diagnosis:

These memory anchors are clutch and seriously help with long term retention. Osmosis is great for making the process of learning interesting and enjoyable while also efficient. The platform is affordable and more information can be found at osmosis.org.

There are many other resources for the basic science years that are golden and you will discover what works for you through trial and error. I could not have lived without: Sketchy Medical Series, Pathoma, UWorld Step 1 Qbank, KISS Pharm Videos, or the Becker Online GuideMD. There are many other resources out there, and there are some that I tried and did not care for but many of my peers liked them. Everyone's journey is different and there is no "right way" to prepare through medical school. Figure out your resources early and stick to them.

Dedicated Prep Time

So, once you're done with the basic sciences, it's time to generate a study schedule. Osmosis has a way to schedule your review materials across a specified amount of time so you can make sure you go through everything you want to before your exam. Another resource that does this is Cramfighter, which I used on top of Osmosis so I could have two simultaneous study schedules... this was a bad idea looking back but I sure did work hard everyday! I also liked the way Cramfighter had an easy user interface, was amenable to resorting topics if you fall behind, had a mobile app you that functioned as a daily checklist, and a year subscription has proven useful to me as I create schedules for studying for my shelf exams during my core rotations and the year subscription was reasonably priced.

On study days, I would designate:

• 4 hours to videos: SketchyMedical, Becker GuideMD Lectures (audio only), and Pathoma

• 2 hours to books like First Aid

• 1 hour to practice questions and flashcards

Every Sunday was designated as a "Catch-up" day that I would use to spend with family, and I made sure to be done with studying between 5-6 PM the other days of the week because it is important for me to spend time with my family. I also only allowed myself from January 1, 2017, to February 21, 2017, to study for the exam. I chose to take my exam on the 23rd because I wanted to enjoy my son's birthday and have time off before starting my Internal Medicine Foundations elective in April. I am glad I did push through and not prolong the exam because that is what worked for me and my family, but that short of time to prepare definitely could have backfired. Was I to redo things, I would:

• Taken 60 to 90 days to study and build in a week of break time every four weeks to refresh because the burnout game was strong.

• Do more "active studying" via more hours daily of practice questions and less of videos or books. This was the way I learned the most and I did not realize it until too late.

• When doing practice questions, read the explanation for every answer choice. Understand why the wrong choices are wrong because changing a word or two in the question can make a difference in the most-correct answer. When answering STEP questions, the ones that were the trickiest to answer for me were the scenarios where two answer seemed correct and a small piece of knowledge kept me from being confident on the more-correct option.

• Reach out to peers that I could study with via FaceTime or Skype because group study helped me with seeing what I was missing from different topics, or solidified concepts by explaining to others. Once I left the island, I went from seeing people I knew everyday and having people I could study with to being alone with my family. I did eventually rope my wife into quizzing me aloud so I could focus and not feel as though I was going insane with all the studying. Basically, find someone with whom you can study.

• I wish I would have started Osmosis in first semester and have been consistent. The spaced-repetition really helps with long-term retention of topics. Instead of using it mostly during second year, I could have used the platform from the beginning to strengthen my foundation of knowledge.

• My last week of studying was geared toward reviewing First Aid, writing down concepts I was uncomfortable with, and reviewing those concepts every evening. I wish I would have started doing this at the beginning of my study period. Taken a week in the middle to go through First Aid again, front to back, and write down what I was uncomfortable with, and then again do this the last week. Someone once cracked that "if you memorize First Aid then you will be fine"... now I understand what they were getting at but I realized it too late in the process.

Lastly, every other Saturday was used for a practice exam on top of my study schedule. The practice NBME exams cost me $65 a piece and took about four hours to complete. These questions and UWorld questions most closely resemble the actual exam based on the questions I was exposed to from some other question banks. UWorld explanations are amazing so pay attention to them. Too many people brush off topics or details that appear "low-yield" but there is no such thing as low-yield. Everything is fair game for the exam. You will be surprised how that professor's mind-numbing explanation and metaphor about a cup of fluid covering a tennis court could be what helps you answer that question correctly regarding the lung pleura and forces of volume expansion in the lungs. Every detail does matter and it is impossible to retain everything. The key is to learn as much as possible, and develop deductive skills to be able to sift through the information and choose the most correct answer. And if you're wondering why that's the key, think about what it takes to develop a differential diagnosis and how you label a patient with the most correct diagnosis because no one walks into a clinic or emergency room asking you to diagnose them with what's listed on page 227 of First Aid based on their clearly stated symptoms. Using flashcards is helpful for you with having some basic associations engrained in your mind so that you develop a somewhat reflex when it comes to certain words or topics.

For example, I cannot think of the drug Clozapine without thinking of agranulocytosis which was helpful to me during my psychiatry rotation. I had a patient with a history of psychosis telling me their past medical history included ITP disease. Keep in mind the patient is young, still in their teens. Upon further inquiry, this patient recounted that ITP was diagnosed by an internist when they appeared because they were getting sick easily and their blood analysis showed low platelets and low white blood cells. It then clicked for me that ITP was referring to Immune thrombocytopenic purpura or idiopathic thrombocytopenia, which led me to inquire about previous Clozapine use. An internist would not diagnose agranulocytosis if the patient did not accurately disclose the clozapine treatment, but knowledge of clozapine use would make agranulocytosis stick out like a giant red flag saying "hey doc, come look for this". The patient was able the then confirm having used clozapine previously, and helped guide their treatment because I knew we were dealing with a more resistant schizophrenia. Being treatment resistant to other antipsychotics is a requirement before using Clozapine because of the agranulocytosis. Long story short, you never know what little details will help you answer questions correctly or treat a patient; and, after Step one you will underestimate how much you actually know.

Balance

I cannot describe studying without talking about the balance necessary to maintain good mental health and functioning. Breaks are essential to helping with processing material. I would sit and focus for 20-30 minutes at a time during reviewing material, and then I would take a walk either to the kitchen for a drink or outside for some sunlight. Breaks helped me be able to obtain maximum focus while studying.

Night time was family time. From 8A to 5P, my wife worked and the kids were in daycare so I able focus completely on studying. Being a morning person also explained why these were my most productive hours. If you study best at night, then study at night. Whatever you do, keep a schedule and stick to it for the most out of your time management. Everyone has different needs, and it's important to find out what yours are. While I needed to study, I also needed to work out to get out pent up energy from sitting all day and I also needed family time because I enjoy bonding with my kids and they're just cute at this age. So, there were basically certain components that I had to divide my time between: studying, sleeping, eating, personal hygiene, working out, time with children, time with wife, and time to relax/unwind. With 8 hours for sleep, and 8 hours for study, that leaves 8 hours for everything else. It helps that I am a creature of habit and like to do the same things everyday, but if you don't acknowledge your needs and plan accordingly then you risk neglecting one area of your life and that could be detrimental to your functioning overall.

Most students with children that started with me on the island ended up passing their Step exam and plowing forward with the program. Part of me wonders if children are what motivates us to get through, or if child rearing really helps us learn balancing multiple things at the same time. There were times were my youngest was sick and could not go to school. I still had to study so guess who has been getting experience to pathology and other medical topics? My little guy would be on my lap with a fever and snotty nose while I continued my study schedule. With my wife working, guess who got to run errands or take needed diapers to the daycare whenever they ran out? A schedule is essential to being successful, but flexibility and being able to adapt to changing needs is also essential. As parents we learn this early on as we accept things that we cannot control readily and we get creative with solutions. We accept certain truths: our children will get sick, our laundry never ends, money always feels tight, and that diaper blow-out will always happen during your quick trip to the grocery store when you forgot the diaper bag at home.

Support from extended family was also essential to my success. My mother-in-law and her partner have been amazing supporters through this process, and are our family's biggest fans. They have cheered our successes, and have been there to help us during our low points. They babysat when we needed a date night, and they encouraged me when I needed some motivation. I have asked myself many times, "What have I gotten myself into?" and they always seem to have the right thing to say. Family support is essential to finding your balance and helping you tap into your full potential, and I am forever grateful for the support I have received. So, for those times you question whether you can keep going or if you're good enough then turn to family and friends quick and squash the doubt because there is no room for doubting yourself when taking the exam. I sincerely believe that if I can do this then anyone can do this if they work hard enough and have the heart to fight for learning medicine.

Anyway, that's probably a good start for the work/life balance and step 1 preparation. If anyone has questions about anything, do not hesitate to reach out to me! I will try to be less wordy in my responses, but no promises.

My wife and I love to do escape rooms. I think I enjoy them because it's almost like the game of medicine. You have to use clues and solve puzzles in order to reach your goal at the end. We were in Denver for our anniversary a week after I took the Step exam.

#Osmosis #STEP1 #MedSchool #Step1Prep