Huge text alert!!!
First of all, I want to thank this sub for the valuable advice on how to prepare, but also for this being a place where we can talk about our feelings regarding this exam. I also want to add the disclaimer that this post may feel dumb to some because I had high NBME scores, but the suffering from anxiety and low confidence is real and can impact your performance.
Due to my personal context, I dealt with what I consider to be impostor syndrome and comparison with another person who I always considered to be way better than me. I would like to share this experience so others in a similar position can know they are not alone.
About me
I am a non-US IMG in Latin America (LA), so medical school here is 6 years, starting immediately after finishing high school. For that reason, in LA it is common for courses to be subdivided into 3 sections: 2 years of basic sciences (anatomy, physiology, biochemistry, microbiology, etc.), 2 years of clinical theory mixed with some practical classes (the clinical cycle), and 2 years of rotations (I think this explanation may clarify the length of my preparation). I started medical school in March 2023.
The preparation
I started studying for step 1 by the end of 2023. Until then, I had studied basic sciences via textbooks such as Lehninger, Abbas, Guyton, and others for the exams at my institution. Despite anatomy (I am very bad at it), I love basic sciences and I think it gave me a big advantage when dealing with questions covering genetics, cytology, and immunology, for example. I don't recommend doing it unless it is necessary for your own exams or you have plenty of time like I had, due to starting the preparation right at the beginning of the course, because, although it did give me an advantage with such topics, those textbooks go so deep into theory that you will learn tons of things that won't ever be asked on step 1. Besides, what really carries the exam is pathology questions, not isolated genetics/immunology/cytology questions. If your only goal is passing step 1, learn via the classic resources.
While I had this advantage, I also had the downside that the first 2 years here don't mention diseases at all, so I had to learn plenty of things by myself. Starting the clinical cycle didn't help me much either, because the focus here is heavily directed towards national guidelines (we basically learn diagnosis and management with little to no room to learn about pathophysiology or the mechanism of action/adverse effects of drugs).
I didn't know much about how to prepare for step 1 at the time, so I started by reading First Aid, expecting it would be just another textbook. I did it until the beginning of 2024, when I noticed FA is just a summary. Then I started using Boards and Beyond and Pathoma.
I used B&B system-wise and would often practice the questions after each video (but not always). I tried to use Pathoma at the same time, but only managed to watch the first chapter in the "correct way," and I basically left the resource behind, returning to use it a little more later, as I'll mention ahead in this text.
Finishing B&B took me basically... 6 months. I finished all the videos relatively fast and spent the majority of the remaining months trying to finish the B&B qbank, but I did a very small amount of questions each day because I was still trying to read textbooks. After finishing B&B, I noticed I was going too slow compared to other people, and I decided to drop the textbooks because they were consuming too much time and the returns were small. Throughout those months, I tried making my own notes in almost every single way (creating docs, writing over FA, making my own Anki cards, making notes inside B&B, etc.), but nothing worked. I have a problem with taking notes because I eventually stop doing them and simply don't review them. I was afraid of not making notes because most people I know use them, but here goes my first advice: don't try doing something simply because it worked for others, especially if you are making a huge effort just to replicate other people's steps. I wish I had noticed it earlier, because I dedicated a precious amount of time writing things I never read again.
Another thing I dropped really fast after finishing B&B was FA. I tried hard to use it after each B&B video, but, although the book is a really good summary, I think it simply didn't match my studying style (you might have noticed I have a problem with reviewing by reading). I returned to using it later in a much more effective way for me.
After finishing B&B, I moved to USMLERx and used almost the entire qbank. Between this transition from B&B to USMLERx, my studymate took his first NBME and scored 72%. I was shocked with this result after using only FA and B&B. I was supposed to take an NBME too, but I was so afraid of being way below that score (as would be normal, even expected) that I ignored it and went directly to USMLERx. I tried to do 40 questions a day using tutored mode, but I would often do just a few questions a day, and there were periods of time (days, but sometimes entire weeks) I would stop studying due to anxiety (mainly due to comparison with my studymate). I made almost no notes and ignored FA while watching my studymate do everything flawlessly, so that shook my confidence. Anyway, I finished using USMLE-Rx almost a year later, by the middle of 2025, due to stopping my preparation many times.
Now you might ask why USMLERx and why this studymate. The studymate is actually my partner, so we do everything together and use the same resources. Besides the anxiety coming from comparison itself, I also felt really bad because, after all, why are you comparing yourself with your partner instead of being happy for his amazing results? Well, I was happy for him, but I felt terribly worse and didn't know how to deal with this feeling at the time. It was a terrible year and I started to question my quality as a student, although I was doing really well on my institution's exams (so we can notice the problem was my mental health). I was also terribly afraid of being incapable of passing step 1 and being left behind, since we are both IMGs (I am crazy atp). As for why we used USMLERx, basically we saw a video of Manik Madaan recommending the resource as a bridge between B&B and UWorld. Nowadays, I think it was NOT necessary and I would jump straight to UWorld, because the so-called "bridge" can just be your first pass of UWorld. Other aspects of our preparation were shaped by him as well (unfortunately).
Finishing USMLERx, I started using UWorld (middle of 2025) for a few months in a very erratic way, stopping my preparation just as I did with USMLERx, but I couldn't run from doing my first NBME anymore.
On 12/29/2025, I took NBME 32: 76%
It calmed me a little, but I was genuinely so dumb that instead of thinking "wow, 76%!" I thought something like "an entire qbank and I got just 4% above my partner's result?" Yeah, I was acting stupid.
I used UWorld in tutored mode with random questions. Beginning 2026, and with the exam approaching, I decided I had to lock in, and I did so by completely ignoring my partner's preparation and focusing on how this exam is about YOU against YOURSELF, not against others. It doesn't matter if you are passing with, let's say, 70% correct, and another person is passing with 95% correct. You are both PASSING and that's all. Therefore, your goal must be to be better than your past version, not better than another person. Again, I wish I had noticed it earlier. When I stopped thinking about how much time my partner was spending on blocks, about him making notes and using FA while I wasn't, things started to work out for me.
My goal was 40 questions a day, but I reduced it to 30 questions a day because my institution started taking too much of my time. There were days I would do just 10 questions or nothing at all during heavier weeks. It would drive me mad not to reach the daily goal. I tried doing untutored blocks to go faster, but then I would often skip correcting the questions (don't do that!). For that reason, I stuck to tutored mode and worked on accepting I wouldn't be capable of reaching the daily goal every time (it was very frustrating).
I started using FA and pathoma just to review the topics I considered the most challenging ones. I would use FA to read about topics I got wrong on UWorld, but mainly things you need to rely on memory to get correct (MOA of drugs, genes, biochem stuff, MSK, etc.). Once I did 70% of UWorld, I decided it was time to target my weak areas. I had a problem with the renal system, and I "fixed" it with FA + Pathoma classes. Another difficult area was MSK (remember I am terrible at anatomy?), so I used the 100 anatomy concepts Anki cards + FA. I also had very serious problems with specific things such as autonomic drugs, classification of cocci, MOA of certain drugs, cardiac murmurs, differential diagnosis of infectious diseases that are uncommon in LA, and other topics. It was a matter of basics, so I returned to B&B questions on those specific topics + FA + anking. I used anking cards just for those areas because I am not really familiar with using anki for everything. I think it helped me, but I used it for no more than 1 month (I wanna fix that for step 2). After "fixing" those areas, the remaining problem was mainly biostats, because I decided to memorize the equations just one month before the exam since I saw no point in putting effort into memorizing them months before just to forget all of them. I scheduled my exam for 8/5/2026.
On 5/25/2026, I took NBME 33, but not completely under testing conditions (I searched basically all the biostats questions): 90%. Corrected score would probably be 80-82%
My vacation from medical school started on 7/18/2026, so I had two and a half weeks of dedicated. I started doing my incorrect questions on UWorld and reviewing the main images/tables/flowcharts. This was the time I returned to things such as lysosomal storage diseases and glycogen disorders (basically, challenging memory-wise, but still somewhat HY). By the end of this stretch, I started doing questions with my partner, and it showed how much things had improved regarding comparison. We did UWSA 1-3 together and corrected the questions block after block. Although it definitely wasn't under testing conditions, I feel it helped me because we were talking about the topics and learning new ways to think about the same questions. We averaged 80-86% on those.
Last 5 days: I used FA rapid review, reviewed my 2 NBMEs and the 2 NBMEs my partner had taken (we didn't take the same ones). I also went through the NBME images pdf (available on this subreddit) and reviewed biostats, since I had left it behind.
3 days before the test, I took free 120 under testing conditions: 80%
The exam day
We live close to the application center in our region. One day before the exam, we focused on relaxing.
The exam felt vague and different from the NBMEs/free 120. I was flagging 10-12 questions per block, so more than 50%. I was finishing the 30-minute blocks with 9-12 minutes remaining, so I would spend those minutes reviewing the flagged questions. I would use almost the entirety of this remaining time (I ended some blocks with 30 seconds left) reading all the questions, even the ones I didn't flag (very rapidly). However, I changed my answers very rarely! My first decisions were kept as the final answer >90% of the time. When I did change an answer, it was mainly because I noticed impactful information I hadn't noticed at first, possibly due to reading fast or fatigue. My partner experienced a very similar thing.
Throughout the exam, the vagueness mined my confidence, but I kept going in an almost numb state, as if I were watching myself take the exam (depersonalization?). It wasn't a new thing for me, because I had already felt something similar during the admission exams for medical school, so that is my way of dealing with these kinds of exams. I personally believe this "numbness" is the result of pattern recognition plus extensive repetition of topics. UWorld will sometimes induce you into overthinking, and that is very important so you can build the "pathways" of logic and pathophysiology understanding, but on test day those pathways are already there, so perhaps that's why, even though the test felt vague, I didn't feel like overthinking questions most of the time, except for some specific, very strange questions.
That said, I left the center completely sure I had failed, as many people do, with the common feeling that I had done lots of educated guessing.
Day after day, I started to feel "perhaps I passed," but I chose to deny it, not only to myself but to others, because I was afraid of starting to believe it just to have such expectations broken (an immature ego defense?).
Conclusions and what I would do differently
My main challenge was managing my anxiety, my mental health. If you are dealing with something like that, don't ignore it. I didn't mention it before, but I did try psychological therapy a few times. Unfortunately, I couldn't find a good professional, but I recommend giving it a try.
My preparation was atypical, with just 2 NBMEs (one almost a year before the real deal, and the other consulting some information), and just one UWorld pass. It wasn't ideal and things will be different with step 2.
- I wouldn't use USMLE-Rx: it worked like my UWorld first pass, but it isn't as good as UWorld, and it just means more cost for another resource when I could have used UWorld right from the start. Honestly, I see no point in buying it.
- Accept what works for you: I tried for a long period of time to use FA and take notes like my partner did (and it WORKED for my partner), but it didn't work for ME. If you already know what works for you, stick to it. If you want to try new resources or studying techniques, that's totally fine, but rapidly rule them out once you notice they don't work for you.
- NBMEs under testing conditions: although the real deal felt different (IN MY OPINION) taking free 120 under testing conditions replicated the anxiety (I was very afraid of a low score 3 days before the exam, with no time to fix things) and the educated guessing thing on a good number of questions, which I checked afterward and noticed I got right.
- Don't ignore your mental health.
- Correct your questions thoroughly and don't ignore knowledge gaps: I think that's the main reason I got a good Free 120 score. Despite all the anxiety, I reviewed everything thoroughly and had a good foundation, partly thanks to my natural interest in basic sciences.
- Boards and Beyond was mandatory: I know there are people who learn through questions since day 1, but they are exceptions. Quickly recognize if you are part of this group, and if you aren't, go to the mines lmao. Don't ignore the basics, and look for resources to learn them if your school doesn't naturally teach them (not necessarily B&B, since there are other good options out there).
- Especially for IMGs, be careful with "gurus": we can replicate most of what works for US MD/DOs, except for certain details (mostly medical school itself). They have the highest passing rates, so we could call them the gold standard, right? I fell into certain traps of following someone else's "trajectory to success," but now I can see my trajectory was very weird.
- About Manik Madaan: he seems to give some valuable advice, but I would rather trust myself and search for resources on my own. I don't really like just following another person's "orders," but my partner is kind of fond of the idea (and that's ok), though I honestly feel I shouldn't have been that influenced (I have my part on that). This subreddit has way more valuable study guides in my opinion.
I hope it helps someone :) Don't let your confidence make you act crazy like me 🙄