At Least Humor Is a Mature Defense Mechanism: An Unqualified Guide to USMLE® Step 1 Anxiety

Kayla Hicks
Published on May 29, 2020. Updated on Sep 15, 2020.

COVID-19 may have impacted USMLE® Step exams, but one thing that hasn't changed is the anxiety surrounding them—the butterflies in your stomach have simply morphed from one species into another. Today on the Osmosis blog, Osmosis Medical Education Fellow Kayla Hicks shares a humorous account of how she dealt with board exam stress leading up to her Step 1 exam.

Studying for Step 1. You’ve been at it for weeks—Osmosis, UWorld, Kaplan, Sketchy, First Aid, Pathoma, Anki—their words swirl ceaselessly and unintelligibly in your brain. Naegleria. Pseudotumor. Glioblastoma. Etanercept. Takotsubo. Metachromatic leukodystrophy. Pseudopseudohypoparathyroidism.

You’ve put in the work, you tell yourself—steeling for the moment when you push submit on your practice test. You feel the butterflies in your stomach—or is that gastric cancer? Let me check Virchow’s node real quick. You finally push "Submit" and it’s not what you expected. You spiral and crumple to the floor. Instead of garbled medical jargon, you hear your own voice in your head: Why? Why me? Failure. Failure. You’re not good enough, not smart enough. Failure, failure, failure. Your heart pounds in your chest like a kick drum. (Or is that hypertrophic cardiomyopathy? I DID have chest pain that one time!) As much as you’ve scratched and clawed to keep your head above water, the anxiety is creeping in and sinking your ship. You’ve never felt more vulnerable or more alone. But as cliché as it sounds, you are not alone.

Likely, anxiety has plagued everyone who decided to step on the long, winding, bumpy road that is medical school. It is an understatement to say that this situation is taxing emotionally, mentally and physically. For many, it will be the first time such a massive load of responsibility has been placed on our shoulders. Suddenly, we are the experts, if only in our parents’ eyes. We are entrusted with much more than many of us have ever undertaken. In seemingly one day, we have gone from skittering, quivering schoolchildren to healers. It’s enough to bring anyone to their knees. Couple those looming feelings with the acutely crushing, suffocating beast that is studying for Step 1, and you get a veritable perfect storm of anxiety. I’ve been that person. I collapsed to the floor and sobbed, as it was all just too much, as my own words swam in my head—not good enough, not smart enough, I’m going to fail, not good enough, not smart enough, failure failure failure—until the words ran together like the tears streaming down my face.

I hit my lowest low studying for Step 1, but I learned a lot. I learned about Naegleria, Takusubo, and Glioblastoma, but I also learned about myself. I came out a different person than who I was when I went in. It was a trial by fire, plagued by struggle and culminating in every students’ nightmare—my test being cancelled not once, but twice, by the testing center. Through it all, I emerged from that testing center three whole days after my scheduled test date, a grizzled, but gratified survivor of Step 1 anxiety. Having gone through so many challenges, I learned a lot about dealing with my anxiety. Here’s what you should know. 

Osmosis illustration of a medical student having nightmares about USMLE® Step 1.

Tip #1: Take at least a half-day off weekly, and an hour-off daily

I know the inclination that plagues every medical student—we didn’t get here because we tend to idle, and we’re definitely not going to start right before the biggest test of our lives. I can’t overstate the importance of taking this time for yourself during a period when simultaneously nothing and everything is about you. Talk to your mom, sit outside and get sunburnt, do some underwater basket-weaving. Whatever it takes for you to not study, then get back to it the next day, fresh. 

Osmosis illustration of a student taking a study break to do some underwater basket-weaving.

Tip #2: Learn to meditate (but do it your way)

I was skeptical too. There is something about meditation that has always felt a little too new age for me. In the depths of my anxiety, however, I was willing to do anything it took to pull me out of that spiral. At one point, I had 6 meditation apps downloaded. I did positive affirmations, journaling, and followed guided meditations 3 times per day, but it wasn’t working. If nothing else, I was MORE anxious. I realized that I was trying to shove myself into a "Meditation Mold," opting for a one-size-fits-all solution instead of searching for the solutions that would work best for me. I am constantly in my head, and meditation just allowed me to live there more deeply for a few minutes at a time. To get the most gain out of meditation without getting trapped in my head, I developed my own method of meditation that worked for me—a combination of deep yoga breathing and prayer. Always do what works for you. 

Tip #3: Wear your emotions on your sleeve

For me, the second-most concerning aspect of Step 1, aside from the looming fear of failure, was the thought of everyone discovering that I was a failure. My impostor syndrome creeping out like a specter, saying to me, “You’ve hid it this long, but they’re all about to find out.” Living that way is isolating and just leads to a spiral. You may feel that your classmates are beautiful, model geniuses who will cure the world of all famine and disease, but I promise that everyone has had that moment where they sobbed in their car, or the floor, or Walgreens (totally not based on a true story). 

Furthermore, a source of distress that is especially prevalent with future medical professionals is that if we admit our fear and anxiety, especially as it relates to testing, that we will be labeled as “damaged” or “fragile.” This is not the case. To the credit of my medical school, my classmates, my family, and my fiancé, when I arrived at their respective thresholds bawling, they circled the wagons and dragged me back to my feet. Do not suffer in silence—admitting that you are afraid allows you to take back your power.  

Tip #4: Be a good friend to yourself (and go see a therapist)

I saved the best, and arguably the most important, for last. One of the best decisions I’ve made in regards to preparation for Step 1 was reserving an hour every week to meet with a therapist. When I was being dragged down the whirlpool of my anxiety, the waves washing over my head and threatening to drown me, the initial two hours I spent sniffling and explaining to my therapist how I was feeling was a lifebuoy. In the weeks that I met with her, I felt able to love learning, and myself again. It always helps to have someone to vent to, who won’t pass judgement or offer practical solutions, because let’s face it—there comes a time for everyone where we just want someone to pat our shoulder and say, “I’m sorry, that sucks.” 

More importantly, my therapist called me out on the destructive behaviors that were contributing to my anxiety. One of the most important, and most influential things that she ever said to me came after I said, “I just feel stupid, like I don’t have the capacity to do this”. She looked me in the eye and said, “What if your very best friend said that to you. How would you feel?” I began to realize that I was arguably the worst friend to myself. We all have friends, family, mentors, but the one voice we hear in our heads day in and day out is our own. Be a good friend to yourself, and if all else fails, pat yourself on the shoulder and say, “I’m sorry, that sucks.”

Osmosis illustration of a student's support network.

About Kayla

Kayla Hicks is a first generation medical student from Kentucky, and a current participant in the Osmosis Medical Education Fellowship program. She will be starting her third year at Case Western Reserve University School of Medicine. Her specialty is undecided but she is interested in pediatric general surgery, pediatric otolaryngology, and maternal-fetal medicine. Kayla enjoys cooking, dogs, medical history, true crime podcasts, and Broadway musicals. 

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