Taking a (Practice) Step 1 Exam

When I started my embarrassingly long trek toward medical school three years ago, I studied for and took the MCAT. That exam was hands down the worst testing experience I’ve ever had – a six-hour MonsterTest covering basic science. I wrote about the studying process while cloistered in isolation in my Charlottesville apartment, where I didn’t see the sun for three or four days at a time. It was often hard to stay focused, which I covered.

Periodically I would take a practice test, a soul-sucking exercise in self-flagellation that I, of course, also wrote about

I am still on the fence over which is worse – the MCAT or Step 1. Step 1 is certainly harder, and longer, but at least it is sometimes relevant to the future practice of medicine. Step 1 also realistically determines how many residencies are open to you. Or closed. No big deal.


I take Step 1 this coming Saturday, and every week for the past month I’ve spent Sunday morning locked away taking a practice test. The practice tests are 200 questions, run about 4 hours, cost $60 each, and provide little more than a score at the end.

My routine is to wake up, take the practice test, and then spend the remainder of Sunday eating my sorrows away by consuming as much sugar as I possibly can. Sunday is Cheat Day.

This is what it’s like.

6:00: Wake up. Make coffee and breakfast while awaiting Tiller’s realization that I am awake and possibly in possession of food. This is Tiller.


6:30Finish breakfast, let dog out, perform once-daily whiparound of social media to stoke personal Fear Of Missing Out. (Normally I would do the millennial thing and shorten this to FOMO. But 45% of my blog readership is constituted by my mother, known to the comments section here as Bringer of Life, and my grandma, known here for anonymous comments she believes are emails directly to my account.)

7:00: Log on to website and open test.

The first question is a straightforward one about a black woman with a cough. If you read my previous post, you already know the answer is “sarcoidosis.” It still does not matter why. I check the box next to sarcoidosis and move on.

Hey! This isn’t so bad!

Question six is a biochemistry question. I hate biochemistry. I am bad at it and I never learned it because I am a stubborn ass. I do not know what the malate shuttle is, nor do I care. This is problematic only because the question is specifically asking for an enzyme that “participates” in the malate shuttle.

I’ve found that when all else fails, the right answer to biochem questions is usually the longest one. I check the box next to “Increased ratio of NADH/oxaloacetate multiplied by the gradient coefficient of uridyl-D-transferase cheese processor.”

(That one turned out to be wrong).

The questions grew harder. Harder and longer. The NBME (the National Board of Medical Examiners, aka tormentors of medical students) loves writing insanely long questions with curveballs at the end:

“7. A 41-year-old woman with a past medical history significant for hyperlipidemia and hypertension presents with a 3-day history of right upper quadrant pain, anorexia, and nausea. She weighs 190 lbs and is 5’2”. She describes the pain as constant and radiating to her shoulder, worsened when she eats a meal high in fat such as a Chipotle burrito containing only steak, sour cream, and cheese. She is tearful in the office and appears to be in distress. She has recently discovered that her pet watermelon is terminally ill with metastatic melonoma. Her mother is alive and well but calls the patient on the phone seven times a day to complain that they do not converse frequently enough.

2_nps_sunsafety_dec2013[By now, 2 full minutes have elapsed just reading the question.]

“On physical exam, the patient is irritable and fat. She has a fever to 100.7F, pulse of 76, BP of 130/70, and RR of 12. Her lungs are clear to auscultation. She has several tattoos of flaming skulls on her flank. She abruptly stops breathing when the right upper quadrant is palpated.”

[To those of you who are nonmedical, this is a classic case of having an impacted gallstone, minus the flaming skulls. As I read, I was already thinking, “take out the gallbladder! The Sphincter of Oddi! Cholesterol!” and other stupid things they might ask me on Step. I scanned the answer choices for cholesterol-related things and saw nothing of the sort.

Oh – the question keeps going.]

“Given this patient’s presentation, if the average flow through a sewage pipe in Nairobi is 30 L/hr and the toilets in 12 separate households are simultaneously utilized by a single madman with a raging case of explosive diarrhea, what is the predicted flush capacity of one toilet?

A. The knee bone is connected to the thigh bone
B. Hypoxanthine-guanine phosphoribosyltransferase
C. Forty-two
D. “Tell me more about your feelings about your mother’s phone habits.”
E. You Can’t Handle The Truth!”

Speed is the name of the game, if the name of the game is “finish as quickly as possible so you can eat unlimited peanut M&M’s.” I chose the hardest-sounding one, which I later found out is an enzyme still unrelated to the malate shuttle, and moved on.

The test continued in this vein for the next three hours, with the odd softball thrown in.

The payoff comes at the end. I submitted my test, now with a mild headache and blood trickling out of one nostril, and played with the dog for a few minutes. On returning I clicked through to the next page, which contained good news and bad news.

The score report includes an estimated Step 1 score, which is scored on an incredibly obtuse grading curve from something like LOL to 300, with a 192 a passing score. I think. I think if you slip the attendant a $20 the passing score probably drops to 185.

Regardless, I passed. That’s good to hear, considering I take the test in six days. The bad news is that the score report also contains a “PERFORMANCE PROFILE,” which is a breakdown by topic. A bar chart shows you your strengths and weaknesses. Most of my bars were about in the middle, consistent with an average performance.

BIOCHEMISTRY and EMBRYOLOGY were way off to the bottom side of the screen with little stars next to them. I had to look at the legend: “An asterisk indicates that your performance extends beyond the range of the scale.”

I’m off the charts!

…the wrong way, but I still have a week to shore up my knowledge of the malate shuttle. Right? RIGHT?

…Here is another picture of my dog. It makes me feel better about the whole thing.


PS: how great was the melonoma joke? Come on, you snickered. Don’t lie.

3 thoughts on “Taking a (Practice) Step 1 Exam

  1. Pingback: Helpful Posts | Laughter is the Best Medicine

  2. Pingback: Helpful Posts | Laughter is the Best Medicine

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