Normal, Abnormal, Review: Building a USMLE Step 1 Foundation

  • /Reviewed by: Amy Rontal, MD
  • There’s one thing that I’ve seen far too often as a tutor: Very dedicated, hard working students failing to break into the 230s on Step 1 not because of a lack of effort or ability, but because of a poor foundation for each of the organ systems.

    Working with MST, I’ve come to realize that almost every student has a suboptimal foundation in at least one area. Maybe your hematology lecturer bored you to tears, or you spent all of renal staring at the pretty girl across from you in class, or maybe cardiology just wasn’t your thing… Either way, the key to your success will be finding a way to create that foundation as early in your study period as possible. 

    When I joined MST as a tutor, one of the first study strategies I was educated on was the idea of “normal, abnormal, and then review.” What does this mean? Well, the point of this saying is the belief that mastery of any organ system comes from first understanding normal physiology, building on that by learning the abnormal pathology and pathophysiology, and then finally tying that together with a review of the entire organ system. Now let’s take a look at how this might work in a sample (and abbreviated) study schedule:

    Monday Tuesday Wednesday
    BRS Physiology – Cardiology Pathoma – Cardio & Vascular First Aid – Cardiovascular
    UWorld – Timed, Unused – Cardiology (Physiology) UWorld – Timed, Unused – Cardiology (Pathology & Pathophysiology) UWorld – Timed, Unused – Cardiology (All)

    1. How does all of this work?

    Most students tend to tackle their Step 1 studying with the goal of completing one organ system each day. And while that is a reasonable strategy when a strong foundation is already in place—it becomes much more problematic if you are building that knowledge base from scratch. By starting at a much slower and comprehensive pace, students can use their first pass through the material to focus on building the strong foundation that will help them when tackling difficult concepts and trick questions as they move through UWorld and subsequent passes through the material.

    2. Speaking of subsequent passes, I only recommend this strategy for the FIRST PASS through each organ system.

    Subsequent reviews should be more focused and will primarily rely on the use of First Aid and UWorld with BRS Physiology or Pathoma used as needed when addressing ongoing difficulties.

    3. Should everyone use this strategy?

    As I’ve said time and time again, there is no one size fits all approach to preparing for the USMLE. This approach is very time consuming and should typically only be utilized by students with at least 8-10 weeks until their exam. Additionally, many students will find that they either lack the time for such a comprehensive first pass or the need to utilize this method for each organ system. In these cases, I advise students to reflect on their NBME breakdown and prior class performance to determine if this approach could be beneficial for one or two of the organ systems.

    4. Can this be modified for use while in classes?

    Absolutely! Second year students searching for an easy way to incorporate Step 1 material into their daily or weekly routine could begin each new block by reviewing the corresponding normal anatomy, physiology, and biochemistry. Not only is this a great way to begin reviewing for Step 1, but it will likely make learning your second year curriculum easier as you are more current on the previous year’s foundation.

    So as you start planning ahead and working to develop your Step 1 study schedule, remember that the first step to success is in building that strong foundation. Utilizing some extra time during your first pass through the material will benefit you in the long run by giving you the necessary stepping stones to reach your goal.