USMLE Step 1 for Canadians

With the USMLE Step 1 still fresh in my mind (and before I find out how terribly I did and decide never to speak of it ever again), I figure I'll write a post on approaching the exam as a Canadian medical student or resident. If you're neither of these things, please don't bore yourself with what is to come :)


So why would a Canadian bother writing the USMLEs?
Canadian medical students occasionally write the USMLEs to be eligible to apply for US residencies. But my impression is that they're a minority. The much more common scenario is a Canadian resident scrambling to get through the USMLEs before he/she finishes residency. As far as I can tell there are two reasons for this self-imposed torture:

1. US fellowship eligibility -- Apparently certain fellowships prefer/require applicants to have written their USMLEs (though not to worry, there apparently are also fellowships that don't).
2. US visa eligibility -- Apparently passing the USMLEs allows you to apply for an H1B visa, which allows you to bill/moonlight in ways that the J1 visa does not.

(So there are a lot of "apparently"s here because there is a lot of variability amongst fellowships and states, and most of the information that is available in this regard derives from hearsay +/- speculation.)

What are the downsides to writing the USMLEs?

I went back and forth a lot this year on whether I should bother with the USMLEs, the cons in my mind being:

• It's a huge bother to have to relearn basic med school stuff (Step 1!) while in residency.
• It's expensive (probably around $3000 in total)!
• Step 2 CS and Step 3 can only be written in the USA -- so even more bother and expense.
• It's all or nothing. There's no point in just writing Step 1...you've got to get through all four of 'em.
• And the biggest downside of all: My efforts may end up being for nothing, if I so happen to land a fellowship/job in Canada after residency and never practice in the States after all.

So why am I writing them?

Partially peer pressure (a number of my friends* have written them and I feel obliged to follow suit) and partially out of fear that not having written my USMLEs will stand between me and getting a job or fellowship, if there are none available in Canada (which sadly isn't entirely unlikely). I think that for Canadian residents, writing the USMLEs is sort of like buying insurance -- which isn't a bad idea if there's any chance that you might end up in the US post residency.

*They're mostly in surgical subspecialties or anaesthesia -- specialities in which it's not uncommon for Canadian residents to seek out US fellowships. If you're in family practice and are planning on working in Canada, lucky you -- you were clever to choose a specialty with jobs aplenty and can remove the phrase "USMLE" from your consciousness entirely.

When is the best time to write Step 1?
The USMLE Step 1 covers basic sciences -- essentially everything taught during the first two years of medical school. It's heavy on all the things you tend to forget by the time you reach residency clerkship, like anatomy, histology, biochemistry, cell biology, genetics, etc. I guess if you're smart and have an idea early on that you may end up in the US for residency or fellowship, the ideal time to write Step 1 is right after your second year of medical school -- when you actually remember a thing or two about basic science.

That being said, many Canadians don't realize until residency -- after chatting with other residents in their specialty -- that it may be advantageous to write the USMLEs, so many end up writing Step 1 in residency (preferably in first or second year as opposed to in fourth or fifth with Royal College exams looming).


How much does Step 1 cost?
590 USD (which amounted to 755 CAD).


What is the format of Step 1?
From the USMLE website:
"Step 1 is a one-day examination. The testing day includes 308 multiple-choice items divided into 7 blocks of 44 items; 60 minutes are allotted for completion of each block of test items. On the test day, examinees have a minimum of 45 minutes of break time and a 15- minute optional tutorial."

From my experience:
It felt long.


How high do I need to score on Step 1?
Step 1 is marked out of 300 with a passing score presently being 192 (and unfortunately seemingly getting higher each year). Fortunately for us Canadian residents, a pass is all it takes. Phew.


How I Studied for Step 1:
I found Step 1 tricky because the questions were for the most part quite detailed and multi-stepped. For instance, I'd read the case in the question stem, be relieved that I knew the diagnosis and feel smart that I knew the treatment -- then the question would go on and ask not for the diagnosis or the treatment, but for which step in the monophosphate dichloride carboxylic pentahydride acetylase ribonucleotide ethanoate pathway the treatment modifies. And so I'd guess and hope for the best :S I think that writing Step 1 as a Canadian resident, it's not realistic to aim to get every question -- since your mark on the exam really holds no bearing, it's enough to aim for a pass. To achieve that, here's how I'd suggest studying:

1. First Aid for the USMLE Step 1 -- I read this ebook (which I found online, shh) cover to cover, making notes as I went. I think it's a nice general overview that's a good, not particularly overwhelming, place to start.
   
2. First Aid "rapid review" pages -- I printed out the "rapid review" chapter at the end of First Aid for the USMLE Step 1, which conveniently has high-yield questions and answers in two separate columns on each page. This format lent itself to folding each sheet in half (longitudinally or "hot-dog" style) to create flash cards, which were handy to carry around in my bag for spare minutes in my days.
   
3. Pathoma videos -- I actually torrented the Pathoma videos, but regret that I only ended up watching a handful of them (there are 35 hours in total) as I ran short on time leading up to Step 1. They're really excellent videos though and I'll have to get to watching them one of these weeks.
   
4. Canada (or other) online QBank -- My medical school had subscribed to Canada QBank, an online question bank that proved an engaging way to study...until the subscription ran out and I was too cheap to renew it, which led me to
   
5. Kaplan (or other) Qbook -- I was given this book by a friend, but I know my university library also has copies of a similar sort of Step 1 question book. The day before my exam I spent sitting in bed and just reading this book. I got tons of questions wrong -- but that's the point -- you learn from the answers and don't get them wrong the next time around.
   

I hope some of this is helpful for Canadian graduates who may be considering writing the USMLEs. I really don't know much about the true necessity of the USMLEs for Canadians applying for US fellowships/staff positions, so if anyone has had experience with this I'd really appreciate it if you could please comment :) If I learn more I'll be sure to update this page!