The Rebel (Non-Kaplan) Route Series Part 2 — Practice Sessions and The Actual Exam

This is the second 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 2

Practice Sessions and The Actual Exam

TOP 3 questions banks

  1. UW
  2. NBME 1 to 19
  3. USMLE-RX hard questions

(Kaplan is a close 4th and I didn’t do Beckers so can’t compare with that).

I did a total of more than 10,000 questions — 2500 questions from UW (I did them twice and went through even the incorrect attempts), 3000 questions from NBME-1 to 19, 1000 questions from USMLE-Rx (hard), 1000 from FA Q+A book, 2200 from Kaplan Qbank, 1160 from UWSA, and 120 ECFMG FRED questions.

Practice Exams

All ONLINE (in retrospect, I should have done NBME-17 and 19 offline to save the money, as they are easier than the actual exam and are not predictive).

NBME-15 (Score 213): I took it after doing 1 round of boards and beyond lectures, accompanied by one round of UW and 1 round of FA.

NBME-16 (Score 209): Took it after another 2 weeks of FA-weaknesses. It was at the point I canceled my exam and postponed. Paid $280 in Prometric fines and 60 dollars on ECFMG to extend 3 months. This was the low point in my life, I almost gave up!


NBME-12 (Score 228): After another round of FA (2nd time) — proper line-by-line reading of FA with a study partner. I also did NBME-1 to 7, which helped me to get over the NBME-fear.

NBME-13 (Score 236): After I did one thousand hard questions from the USMLE-Rx.

NBME-17 (Score 246) and UWSA form-1 (Score 256): Took it after the second round of UW and FA-weaknesses (4 weeks out).

NBME-18 (Score 242) and UWSA-1 (Score 256): After working on the weaknesses and revising FA (3 weeks out).

NBME-19 (Score 232): This was final round (3rd time) of FA (1 weeks out). I made fewer mistakes in NBME-19 compared to 18, but scored lower). So be aware as this can happen to you too.

Practice sessions

Two weeks prior to the exam: I took the 120 practice exam at the Prometric test center. I strongly advise all of you to do the same, as it helps to decrease pre-exam anxiety by knowing what the setting is like, how the system works, how to pace yourself and how to calculate breaks.

The Actual Exam

The examples I give here are not questions I had in the exam; as discussing the actual questions is illegal so please don’t ask me.

The difficulty level is like UWSA-1 and NBME-18 (Form-1 is much more difficult than NBME 18 but because it scores higher people think its easier — it is NOT!).

50% straight from FA facts — one step thinking and pattern recognition — mostly testing FACTS and simple deduction — you can answer them on autopilot. I was very grateful and relieved by these. These are the pattern of presentations that you have seen over and over again in UW, USMLE-Rx, or Kaplan. The bread and butter of your hard work are these. For example, you are asked to diagnose SLE or sarcoidosis based on clinical presentation; another example like recognizing the presentation of statin-induced myopathy and then choosing the drug that is causing the problem. Each one takes about 30 seconds to read and answer. Usually, they are 2 to 3 lines.

25%-35% two step thinking — TESTING CONCEPT — these question tested your ability on recognizing patterns of a patient scenario and getting a diagnosis and applying it. For example, they will give you a picture of worm/egg in the stool, then from that diagnosis, they will ask the mechanism of action of the drug you are going to treat it with. Another example: the scenario describes a chronic bloody diarrhea case and asks you to first make a diagnosis of Crohn’s and chose the best option for why they develop kidney stones. 1 minute to answer generally. Expect that they will throw in distractors like irrelevant lab values and irrelevant signs and symptoms.

10–15% difficult 2 to 3 step thinking — APPLIED CONCEPTS — questions are difficult but not impossible. For example, the first step you must correctly make the diagnosis of atypical pneumonia by mycoplasma and then on the second step decide the best choice of drug and finally in the third step answer what is the most common mechanism of resistance to that drug. I would say about altogether 20–25% is the concept you didn’t previously encounter on UW (5–10 % of these are WTF type!); it’s not that they are new but just something you might not have thought about but you can work it out. Example, reading and interpreting Km-Vmax like questions using two drugs like warfarin and aspirin or if they gave you a drug that has spare receptors. Strong concepts are what get you through these tough thinking questions.

5–10% WTF type questions — these are just simply what WTF means. They are bizarre questions that you would have no idea even if you studied for ten years for step 1. What are you going to do? take your best educated guess and move on. The chances are everyone else in the exam also had the same gaping look on their faces when then saw this question. For example, these are random experiments about some random gene that tests a bizarre disease with bizarre outcomes. Just move on and let it go.

Exam flow

I used the tutorial time of 5 min to write out the formulas; so my total break time was 55 min (you can do the 15-min tutorial on the ECFMG website that also has the FRED questions).

Took 2 blocks — break for 10min — then another 2 blocks and then took a break of 20 min for lunch. In the remaining blocks, I took 5 min breaks between each block without leaving the computer. I just sat and cleared my mind before next block. It’s important to let go when you have sudden flashbacks (lol — like PTSD) of mistakes you made in the block before. Just breathe out and move on. Focus on the current question.

There will be distractions on the day: people coughing and typing, people nervously clicking their mouse and examiners walking up and down the aisle. Bring an extra pair of soft ear plugs to use with the noise cancellation headphones they provide. Works like a charm.

You will also feel frustrated. I did not have enough time in each block to check my marked questions (in all NBME I had 15 minutes to check my answers for each block but somehow on that day it didn’t work) and I just stopped marking the last 4 blocks because of it. I couldn’t finish one block on time as I had 10 questions left and there were only 5 minutes, I think my ability to decipher and break down information weaned around block 4 before lunch.

You might be asking why didn’t I have enough time on that day? there were many factors: stress, new concepts that required me to take extra time to think especially two to three step thinking questions where you must make sure your initial diagnosis is correct.

Night Before The Exam

You must be asleep by 9:30 PM to wake up at 5 AM to be ready for the exam. You have to bring your A game and 50% of that depends on sleep the night before!!!!! For the last 5 days before the exam, I woke up at 5 AM every day so my body was in sync. (I usually only wake up by 8 coz I liked to study late so when I went for my practice session at 7:00 AM my brain was completely not focused for the first 2 blocks). I knew I would sleep poorly the night before because of nervousness so I practiced with 50mg diphenhydramine 3 days prior to exam to make sure it would be sufficient to give me a good night sleep.

Important, many people feel drowsy the next day after antihistamines so make sure you do a trial test! I tried melatonin too but it didn’t work well with me because of stress.

I Stopped studying by 4 PM the day before. Went for a run to get rid of my excess energy and had a light dinner; took my antihistamines, and went to sleep by 9:30.

Woke up at 5 AM feeling mostly “fresh”, took a light breakfast of oats, took 10 question on RX and coffee on the road and arrived at test station at 7 am.

Things to Bring in The Exam

  1. Scheduling permit (The one with the CIN number on it),
  2. Passport or ID WITH signature,
  3. ear plugs, (no watches allowed),
  4. saline eye drops (air-con dried my eyes when I did practice tests).

You will be given 2 markers and 2 boards. Exam center has headphones (non noise cancellation) to listen to murmurs and another set of noise-canceling ones.

Lesson Learned

Most predictive is NBME–18 (my score was 242)


Dr Karen Tien


Published with permission from the author.

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Originally published at on June 23, 2017.