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TitlePhloston - USMLE Step1 Experience
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Q: When you and others who have taken the test say the exam is different from NBMEs and UWorld in

that the questions there put you in places where you have not gone before and makes you think

hypothetical situations, what exactly do you mean?

Could you give me examples of such questions? Is it something like this is this pathway, what will

happen if this gene is missing or if we add this miraculous drug that only blocks this enzyme, etc? If so,

that's alright for biochem where most stuff is pathways and already follows a logical progression but

how can that work for other subjects like micro, systems, etc?

A: I'm not entirely sure what you mean, but it seems like you're already aware that you need to know

various mechanisms well enough to be able to manipulate or extrapolate from them. I would say this

applies best to your cell signaling pathways (e.g. G-protein, MAP kinase) and the lac operon.

Q: Yeah I meant about just that. I remember you posting something about the questions on the real

thing are a lot harder than the NBME because it required a lot of manipulation. I was just wondering

where all this applies, apart from the biochem pathways.

A: The harder questions will integrate many concepts, particularly endocrine. For instance, they might

ask you about a gene knockout that affects calcium-sensing on bone but not on enterocytes, and then

they might also tell you that the patient has a long Hx of uncontrolled diabetes (so you'd need to infer

secondary hyperparathyroidism); then they'd possibly show you some table asking you, with arrows,

about how calcidiol, cholecalciferol, (24R)-hydroxycalcidiol, phosphate, and ALP would all be expected

to change based on the mutation. Now it's not that this question would necessarily be exceedingly

difficult as much as it is that you just need to know vitamin-D and Ca-PO4-PTH mechanisms really really

well, and then be able to understand how the arrows would change based on the knockout they give.

Most often, you'll actually get a much more simple question than the above one, where they'll merely

just ask you for Ca, PO4 and ALP levels (with arrows) in secondary hyperparathyroidism (which you'd

have to infer based on the pt's presentation), but the caveat is that they'd then throw in an additional

variable that most people likely haven't heard of before (e.g. osteocalcin, osteoahderin, DMP-1), and it

will come down to you literally having to know that variable, and there's no way out. You either know it

or you don't, and it's not in FA. This is an example of where low-yield info can come rushing up out of


Q: Pardon my manners, happy new years. What do you recommend for sleeping the night before? How

was workout schedule like?

A: Two cups of chamomile tea with milk and honey, one hour apart, but not within one hour of bed (if

you take them too close to bed, you'll have to wake up in the middle of the night to micturate). Don't

use any medications, etc. I averaged probably ~4 days/wk at the gym during my final two weeks.

Definitely work out if you can.

Q: Did you go over the all of NBME wrong answers a day before the real exam?

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