In his latest blog, Elliott Campbell MD, Dermatology Resident at Mayo Clinic, Pastest question writer and high-scoring candidate, presents his approach to dominating the curriculum of USMLE Step 1, including where to find it, how to study it, and high yield concepts within major categories.

On first glance, the enormous scope of the Step 1 curriculum is daunting. There is a massive number of resources that try to outline this content in a digestible way. Students are stuck trying to navigate these resources, hoping to come across the “high yield content”. This article will highlight an approach to navigating these resources, how to best utilize them, and a few high yield concepts within many of the categories.

What to include in your study plan

First Aid is an extremely popular resource that outlines the majority of the curriculum in a palatable way with helpful learning devices. This is an excellent place to record one’s thoughts and memorize fine details. I would never recommend someone start their Step 1 studying by reading First Aid (more on this later). In order to highlight the highest yield content within this resource and apply one’s knowledge, at least one credible Step 1 question bank is imperative (such as Pastest!).

Outside of these resources, there is a huge difference in opinion. It is important not to use too many resources, as this will deter mastering any of them. I personally believe Sketchy is a phenomenal learning device and Pathoma should be used during courses (and for some during Step studying). If you master a question bank and First Aid, that is all that is necessary to kill Step (note: First Aid references can be found within some question banks, as they are in Pastest, which makes things real easy).

Resource integration for long-term retention

Principles for success:

1. Dominating fewer resources is superior to partially knowing many.

2. Question banks should be used to determine the truly high yield content in book resources.

3. Repetition is key.

4. Content should be reviewed by category (do not use random mode on your question banks unless using a practice test).

5. Once you determine your study plan, stick with it. Don’t get freaked out by the other resources your colleagues are using.

One approach to following these principles is the “annotation strategy”. This is what I used for my Step 1 and has been used by many of my colleagues and mentees with great success. Use this approach ONLY if you plan two passes through your question bank (recommended). In this approach, questions are completed in tutor mode, untimed, and within categories (Cardiology, Pulmonary, etc.). After each question, relevant content is located and reviewed in First Aid. If content is missing in First Aid that was included in the question’s explanation, it should be quickly annotated into the book.

I would recommend also having the online version handy to search for page numbers. Any memory devices should also be noted (“How do I remember this?”, or “Why does this make sense?”). On the second pass, all of the annotations should be complete, but content with annotations should be reviewed again with each question. This results in a very organized framework. You will start to remember where content is located and which annotations were present.

If you plan a single pass through your question bank, skip the annotation approach. I would simply reference First Aid while completing your questions. I would advise using the annotation approach in your Biochemistry section regardless of number of passes.

High yield concepts in USMLE Step 1

Of course, there is absolutely no way to fit all of the content that is considered high yield in a document (that’s called First Aid). The following section highlights important themes within each category with some well-known favorites. If you haven’t reviewed the below concepts, it is advisable to do so prior to test day.

Biochemistry: Unless you are at the point where you have all of the clinical knowledge down, don’t waste time memorizing steps in pathways that do not have associated pathology. Pathway questions exist but are in most cases geared towards known clinical entities. Use the question bank to teach you which steps have associated pathology. I would not read this section (outside of referencing while completing each question) until you have completed a full pass through your bank. This will triage important concepts/steps in each pathway. Of course, muscular dystrophies, amino acid-related conditions (PKU, maple syrup urine disease, alkaptonuria, etc.), glycogen storage diseases, lysosomal storage diseases, and familial dyslipidemias are eminently testable. Find out more>>>

Genetics: This is a tough section. First, focus on learning the general principles (modes of inheritance and how that looks in a family tree). This is low hanging fruit and more likely to be tested. To excel in this section, learning specific mutations and features of the entities is necessary (imprinting conditions, trinucleotide repeat disorders, trisomies).  

Microbiology: This is an extremely detailed section. All details are fair game. I highly recommend Sketchy for this (and I have no financial relationship with them). If you use Sketchy, make sure to still memorize and practice using the gram-positive and gram-negative algorithms. This is a key tool when taking Step.

Pathology: Pathoma is a good way to learn this during your courses (again, no financial relationship). During Step studying, First Aid and question banks should be prioritized. I will say, some people swear by Pathoma so this may be the best approach for some learners. Pay attention to the different types of necrosis and what normal tissue looks like for each organ system before learning abnormal histopathology.

Allergy and Immunology: This is one section where small details, whether they are related to a specific pathology or not, are highly testable. Newer biologics rely on these concepts and are easy ways to write questions. The immuno-deficiencies are classic test questions and almost guaranteed to be seen. Find out more>>>

Cardiovascular system: This is a huge chapter with lots of pathology. Understand the evolution of a myocardial infarction (including histopathology and complications), cardiovascular embryology (arguably highest yield embryo), cardiac output variables and how to effect function (afterload), starling curves and how specific pathologic or pharmacologic entities will alter these curves, pressure-volume loops, congenital heart defects (and associated heart sounds), and general physiology of the heart. You should be able to quickly determine the significance of a heart sound in a timely fashion. Don’t neglect this section as it is heavily tested.

Dermatology: Surprisingly often over-represented compared to content displayed in First Aid. These are challenging questions. Students who excel in this section learn to compare similar entities based on the morphology and distribution of the conditions. Simply trying to memorize entities is not enough.

Respiratory: Understand ventilation-perfusion mismatch. The specific types of cells based on the location in the respiratory track is important (and their functions). Understand the general categories of obstructive vs. restrictive lung disease and which disease entities fall within each (and how to differentiate between them). Pulmonary function tests and how they relate to different entities is commonly tested. Oxygen-hemoglobin dissociation curves are favorites.

Renal: This is a physiology heavy section. Physiology may be tested straight out without associated pathology (renal tubule physiology). A good way to learn this physiology is through the diuretics and drugs that work on the tubule (again, Sketchy is a resource for this). Nephritic vs. nephrotic pathology (including direct immunofluorescence) and disease entities within each category with associated clinical manifestations and triggers are highly testable.

Psychiatry: This is one section where diagnostic criteria are important. They will write questions in accordance with the DSM-5 criteria which makes these questions simple if you know the criteria. For instance, if there are not five criteria for major depression, think twice before selecting this answer. Most other sections do not rely on strict criteria since there is no single source that lists all of the criteria for each of the entities within those sections.

Neurology: Gross anatomy is important. Be able to stick a pin into a gross section (or cartoon section) and determine the neurologic deficits. Be able to predict neurologic deficits based on location (artery) of cerebral vascular accident. If there is a name for a stroke, it’s a good idea to learn it. Cranial nerves are tested but not in the detail you likely learned in medical school. I would argue that spinal cord pathology is higher yield but of course this varies. Find out more>>>

Musculoskeletal: For just about every major muscle, you should be able to list the innervation and deficits if injured. First Aid and question banks do a great job highlighting the favorites. Rotator cuff, gluts, deltoid, latissimus dorsi, muscles of the thigh, and muscles of the hands are low hanging fruit. You should know the brachial plexus like the back of your hand.

Endocrine: Understand the physiology before learning the pathology. A great understanding of how all of these endocrine systems relate separates high scorers from the rest.

Gastrointestinal: Don’t underestimate the importance of understanding the physiology of this section. You are expected to know the details regarding how each factor effects one another and digestion in general. Understand the histopathology type of each location and where/how the pharmacotherapies take action. The malabsorption syndromes are favorites.

Hematology and Oncology: Histopathology is important. Look up pictures of the cells as you go. Of course, you have to know the coagulation cascade and platelet thrombus formation (emphasis on how pharmacotherapies effect this pathway and pathologic entities).  Don’t neglect the porphyria pathway or the specific lymphomas and leukemias.

Reproductive: Embryology is a massive section with not a huge yield. Use your question banks to guide relevant embryology as this is far too vast to learn it all. It is certainly important to be able to know which structures derive from the three major embryologic derivatives (ectoderm, mesoderm, endoderm) as well as the brachial arches/pouches. The teratogens are favorites. Know the hormonal pathways of the reproductive systems as well. If you don’t have a kid, pay attention to the section on developmental milestones. Sex chromosome disorders (Turner’s) are eminently testable.

Hope you've enjoyed reading this blog and you now know how to tackle the curriculum!

Elliott

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