Guide for students taking USMLEs

Most people who pass the USMLEs and guide other people talk about study resources, daily schedules, importance of xyz things in a CV and a host of other things. I took the USMLEs and was not a high-scorer. But I learnt more than a few thigs down this path that I think could be useful for potential USMLE candidates. Here are some of them.


You develop a daily routine and follow it as best as you humanly can. It is hard. You have good days and bad. You hope that the good days would outnumber the bad ones. It is, in the end, a numbers’ game. Every hour in the library (or your room) that you spend, adds to your preparation, unless you end up watching YouTube videos of cats or go on a Daily Show binge (or both). You learn how to spend most of your waking hours sitting in front of a computer. You get addicted to coffee, tea or whatever drug keeps you alert. You start losing hair, gaining weight, having headaches and backaches. USMLE is not just an exam of your knowledge, it is as much an exam of your patience, your stamina, your confidence. Your best friends in this ‘Brave New World’ are a book named First Aid and a software named U-World. No parties for you, no casual hangouts, family functions, holidays, weekends, nothing. You’ll have to befriend solitude. You start thinking about what you are missing out on, and what you’d like to do once it’s over. You’ll learn new words over the course of this journey, words like NBME, ECFMG, CMS, CCS, Prometric, NRMP etc. Try not to underestimate your enemy (the exam), you will have to be sharp to tackle the challenge.

I read somewhere that ‘re-education’ is tougher than ‘education’ itself and that is what you do in the course of preparation: unlearn what you’ve learnt before, add new information and then learn how to use that new info in real-life scenarios. You need a one-track mind, a state of commitment far superior to undergrad education, to go through all of this. The state of affairs drives even the most stable people, a bit crazy. No one can understand what you are going through, except the people who have crossed this river of fire. During the course of preparing for steps myself, I discovered a newfound respect for people who voluntarily go through this grueling process. It is not impossible and thousands of people across the world do it. Just beware that this endeavor is going to consume a lot of mental and physical energy. You do emerge as a better doctor (and hopefully, a better human) after this.

The whole process though, is hard to explain to your parents, your siblings, your spouse, your friends, your co-workers, what you are actually doing. There is an exam which you are preparing for, but what happens after that? Oh, there’s another one. And after that? There’s more. Right, so you’ll get a job after passing all of these? Not really. There is a ‘match process’ and it’s a 50/50 chance at best. The odds are not in your favor and after explaining this sequence for the 50^th time, you start doubting your own self. There would be naysayers, people who will try to scare you, telling you how this is an uphill battle, that you’d be competing with people from all over the world. But this is as much a battle with yourself as it is with the rest of the world. You have to wake up each day with the attitude that you’re going to win today. They’ll always give you examples of people who either left the quest midway or faced issues after they were done with steps. They’ll never tell you the success stories, stories of people who survived despite the odds, the courageous lot, the go-getters.

The toughest thing about USMLE I found was the fact that I had to choose the exam date myself. It means taking the exam when you have optimal preparation. But can you ever have optimal preparation? How can you tell when you are ready? To tackle this question, you have to choose the time of the exam wisely. Too soon and you’ll be underprepared, too late and you’ll get lax. You can always delay the exam (at a certain cost) which is another thing that tugs at your heartstrings. It gives you a false sense of security. This is the real battle for USMLE, not the exam itself. What most people do is to plan ahead and take the date when they feel they are at the peak of their preparation. It works for some people, it doesn’t work for others.

What should be the sequence of Steps? Step 1 first or 2? When to take CS? There is no fixed guideline for that. However, you should start mentally preparing yourself sometime before you start the actual preparation. In my personal view (and you can choose to ignore it), if you think you are good in basic sciences, try taking step 1 during final year (while preparing for it during 4^th year). It is probably the best time to take step 1. It doesn’t mean you can’t take it and ace it later. If you think you really liked medicine, surgery and Gynae, take step 2 CK soon after final year. This is an ideal situation and human beings are not ideal. If you can’t take it during these times, prepare later but it will require more effort, as late as you take them after Final year.

One should not forget the financial cost of the exam. Just the exam fee for Step 1, 2 CK and 2 CS is about 4 lac rupees. The cost of U-world for different steps also gets higher than 1.5 lacs. For CS you need to visit the US and the lowest ticket cost is about 80 thousand rupees. If you stay in the US, the cost of staying here every month ranges from 700-1000 Dollars.

The Exam itself is fascinating. After preparing for six months to a year, you finally enter the exam room and you take that damn test. I wish I had the words to describe the sweet feeling that descends upon you when you start attempting the test. Just being there, after all those hours you put in, all the revisions, all the good things in life that you missed out on, all the friendships that were affected, the grind of it all, you make it to the final stretch. The exam is grueling, no doubt about that. I have a theory that at least 50% of your final score depends on your test day performance (the rest on your prior preparation). You could have every single word written in First Aid and UW on your fingertips and you can still score less than expected. Just wish that you don’t have a bad day and that you perform according to your preparation. There would be times during the test that you’d be amazed at how easy some things are and within the next 5 minutes, you may be kicking yourself for taking it too lightly (because they’ll ask you something totally ridiculous). Overall, it is a well-structured exam with much higher standard than the UHS or FCPS, both of whom I’ve suffered over the years.  

To decrease the misery a bit, people rely on SPs or study partners. There are Facebook groups and WhatsApp groups and a gazillion other things like that which you’ll encounter during the process. It works for some people, it doesn’t work for some. Choose what suits you. You’ll find all sorts of people during this journey. Some you’ll forget, some you’ll form life-long friendships with, some you’ll want to get away from faster than the speed of light. There is no hard and fast rules when you are preparing. Anyone that you’ll talk to, for advice, will give you their personal experience, which would be unique in each case. So be careful when seeking advice. Try to ask people whom you trust. Don’t use too many resources (unless you are absolutely comfortable), they’ll overwhelm you at the end. There is one thing though, every step is tougher than the previous one (with an exception of Step 2 CS). Remember one thing at the end though (for Steps and otherwise): the world is not a fair place, don’t expect it to be one either. Do your best and leave the rest to fate. Fight for every Inch. But if you don’t get that inch, be gracious in defeat. Use it to your advantage. Best of Luck. You’ll need it.