I know what it is like to be an old IMG, about to take the plunge into this challenging exam called the USMLE. I know about all the naysayers, who say that you are too old. Even if you pass, how can you match with a low score. I know about the anxiety, the fear of not being able to make the grade and to fail.

Therefore, I have decided to start a series of posts advising Old IMG’s on how to tackle the USMLE. How to evaluate what they need to do in order to be able to do well in this series of exam. Don’t get me wrong. The challenges for an Old IMG in taking the USMLE exam is enormous. But it is not insurmountable.

With patience, determination and proper study methodology, you can pass the USMLE exam. Some of you may also be able to ace it. So see you as we go on this journey of discovery and feel free to write me if you want me to write about a particular topic.

One of the biggest mistakes people make in prepping for the USMLE is underestimating the time it takes to finish the prep. It seems a lot of people start their USMLE prep by opening a book and then start reading. They have no estimate on how fast they have to go in order to finish the whole prep in the time they originally allotted for it.

Proper scheduling is very important in order to do well in the USMLE exam. The main reason is that after studying for some time, you will burn out. Your rate of learning will slow down while your rate of forgetting remain constant. This is called plateauing. When your rate of learning becomes slower than your rate of forgetting, you go into decline. And for most people optimum review time is 6 to 8 months.

Therefore it is very important to understand the steps we need to go through in order to prepare properly for the USMLE Step 1. This is a very long topic and it will take a series of post to cover everything.

Three Phases in USMLE Prep

There are three important phases in prepping for the USMLE exam

• Learning Phase: This is where you learn all the medical concepts tested in the USMLE. You cannot review what you do not know, you cannot master what you have not learned. At this stage the best resource to use are textbooks and lectures.
• Mastery Phase: This is where you try to memorize medical concepts tested in the USMLE in the right level of detail needed for the USMLE exam. You also need to make sure that you can recall them in a timely manner. The best resources to use are reviewers, study notes and flashcards.
• Test Preparation Phase: This is where you learn how to take USMLE type examination. The USMLE exam is unique in many aspects and you need to make sure you are ready to take this type of examination. The best resource to use is still online qbanks

It is very important to do the three phases in order as one phase builds on the other. Problems in the Learning phase affects Mastery and Test Preparation Phase. Problems in Mastery phase will affect Test Preparation phase. It is also important to use the proper resource for each phase as they are optimized for use in fulfilling the objective of each phase.

We will discuss all this in more detail in subsequent posts

This is one of the most common question that I usually encounter both in my blogs and in the various forums. And you have as many answers as there are NBME forms, in fact more. Various answers include the following

• Use all 7 NBME forms to track your progress
• Use at least 2 NBME forms and get the average
• Use NBME form 5 to 7 as they are harder
• Use NBME form 1 to 4 as they are easier
• Use NBME form (#) as they are most predictive

As you can see recommendations vary and reasons vary. My recommendation is to use at least 2 NBME forms, one from the easy set of NBME form 1 to 4 and the second one from the harder set of NBME form 5 to 7 and then get the average. If you want to know why, then read on.

What You Need to Know About the NBME Self Assessment Forms

In order to determine what NBME form you should use, you need to answer 2 questions.

1. What is the main purpose of using NBME self assessment tests for USMLE Step 1 Prep?
2. What is the difference between the various NBME forms if any?

I had written extensively about the NBME self assessment tests and how they should be used for USMLE Step 1 Prep. Those interested may read Part 1, Part 2 and Part 3 by clicking on the link.

For this discussion it is important for you to know the following,

1. The NBME question pool is different from the USMLE question pool and therefore the style of the questions are different although the content that they are testing is the same.
2. USMLE questions are more similar in style with the online qbanks than NBME.
3. The basis for using NBME self assessment tests to predict your probable USMLE score is due to the extensive correlation which NBME has done between both test results
4. Therefore, the best use of NBME self assessment test is to predict your probable USMLE score and decide the optimum time to take the exam
5. Although NBME self assessment tests can be use to assess your progress, there is some limitations. It measures your knowledge of USMLE content but it fails to detect any problem you have answering USMLE type questions.

What are the Difference in Difficulty Levels of the Various NBME Forms

There are differences in the difficulty level of the different NBME forms. The higher the NBME form number, the more difficult the questions. Therefore, NBME form 1 is the easiest while NBME form 7 is the toughest.

However, since all 7 NBME forms are normed and correlated to the same USMLE exam, the predictability of all 7 sets are fairly similar but not exact. In other words, even if the NBME form 7 is tougher than the other exam, the number of correct questions you need to get an equivalent score in the USMLE is actually lower.

I have also observed that the lower NBME forms tend to overestimate your actual USMLE score a little, while the higher NBME forms tend to underestimate your actual USMLE scores a little. But overall, they are still within the SD level of + or – 11 points on the 3 digit score.

So What is the Best NBME Form to Take for USMLE Step 1?

If the purpose is to predict the probable score you will get if you were to sit for the USMLE, then my recommendation will be to take two NBME forms and get the average score. One NBME form from the easy group Forms 1 to 4 and the second one for the harder group of NBME Forms 5 to 7.

If you only have the financial resource to take 1 form then either NBME form 4 or 5 will be a good choice as they are of intermediate difficulty.

What you should not do of course is to take the “downloaded” or “pdf” version as aside from issues of copyright, it is the predicted USMLE score that is important and not the actual percentage of correct answers you got.

If the purpose is to assess the progress of your USMLE Step 1 review, then my recommendation is not to use the NBME forms at all but use 4 blocks of UW or Kaplan Qbanks on a random, timed, mixed unused basis.

In the forums, you see a lot of people studying the same things in the same way and results range for high 99′s to failing. So something else must be at work to explain the variety of results achieve using what is essentially the same study plan. And that something is the level of mastery achieved by different people using the same plan. It has to do with the different methods people use to study the material. As some people have asked time and again. When you say you have revised the material 2 times, do you mean you have read the materials twice, or you have tried to memorize the material twice. And therein lies the difference in results.

For the purpose of the USMLE, what you cannot recall in a minute or so, you do not know.  It is not enough for you to have read Kaplan, or FA or whatever, but you should be able to recall what you have read. If you cannot answer a question, it is because:

1. you do not know the concept because you have not read it
2. you read the concept but you did not understand it
3. you read the concept and understood it but cannot recall it in the exam
4. you read the concept, understood it and can recall it in the exam given enough time, but of course since this is the USMLE, you never have enough time

In all 4 cases, you don’t get points as far as the USMLE is concerned.

Other reasons include,
1. you read it, understood it, can recall it in time, but the question is in clinical vignette format and you are poor in clinical vignettes
2. you read it, understood it, can recall it, but the question require more details than what you’ve actually read and understood, ie, it requires a higher level of mastery than you’ve prepped for
3. you read it, you thought you understood it, but actually you didn’t because you never tested your comprehension

In all these cases, you also don’t get points as far as the USMLE is concerned.

So you see, you could’ve studied and read all the right stuff, but you still don’t get points for them and you could still fail. So it’s not enough to study all the right things, you need to study the right way to insure that you covered all 7 situations stated above for everything you’ve read and studied. Studying the right stuff covers only situation number one.

Only by studying the right way, will you be able to achieve a level of mastery needed to do well in this exam. So the question arises what do you mean by mastering the concepts in the USMLE.

Well it means knowing enough details about the concepts tested so you know how to answer questions that require you to know that level of details. People who think Kaplan or Rapid Review are too detailed will probably not do well in the exam, because in my book, both reviewers lack detail to get you to 99′s much less high 99′s.

Next , you need to know those details at such a level that you can recall them in the limited time provided by the exam. And that is not easy. It requires studying a certain way to do that efficiently.

You need to study the materials in a certain way that insure you did your analysis during the review and not during the exam. There are methods of doing this which is emphasized in my course. The reason for doing the analysis during review rather than during the exam is that the exam is timed and the additional time you need to analyze the facts in order to answer the questions, may be what will cause you to fail or do badly in the exam. In contrast to the actual exam, you can do the analysis during the review where you have all the time in the world to do so. So the question, instead of requiring you to recall facts, analyze then answer, now only requires you to recall the analysis you did during the review, thus insuring faster recall, faster time to answer the question concerned and consequently higher scores.

Therefore it is not enough to have just read through the materials a couple of times. You need to master the USMLE in order to do well in the exam. There are study methods to help you do this consistently throughout your review. If you want to know more about How to Master the USMLE Step 1, Watch my 15 minute introductory video, How to Master the USMLE Step 1 – An Introduction

What is Askdoc’s USMLE Step 1 Live Lectures?

Unlike other courses, my live lectures concentrate on teaching you how to study for the USMLE Step 1, rather than what to study. It is composed of 6 1.5 hour lectures, presented live over the web. The lectures includes the following:

1. How to Master the USMLE Step 1: This lecture discusses and explains the basis for the study methodologies in the course. It discusses what is unique about the USMLE, why you need to study a certain way to do well. It outlines basic principles you need to consider in designing your review, how long you need to study, what you need to study, how much you need to study, understanding how test questions are designed and how that should impact your study and much much more.

2. How to Review Pathology: This discusses in more detail the study methodologies covered in the first lecture using Pathology as an example. It also covers certain methodologies unique to studying Pathology and the way the USMLE asks questions in Pathology

3. Scheduling your Prep: Too many people do not know how to schedule their prep. In fact some have a hard time keeping to a schedule or even tracking their progress and adjusting the schedule accordingly. No schedule is written in stone and should be adjusted according to your own capacity to learn and time you can allot for the review. Explains the prep schedule for the online course and how to use Askdoc’s USMLE Step 1 Schedule Organizer to plan your schedule and keep track of your progress. Download the suggested prep schedule for participants in the online course here.

4. How to Review Microbiology and Pharmacology: Discuss how the study methodologies are applied in reviewing Microbiology and Pharmacology. Includes discussions on methods unique to studying both subjects including how to create and use flashcards which are most effective for this two subjects.

5. How to Review the Minor 4 Subjects: The minor 4 subjects includes Anatomy, Physiology, Biochemistry and Behavioral Sciences. There are special problems and methods for studying these topics. Plus there is a need to integrate this topics with the more advanced subjects of Pathology, Microbiology and Pharmacology since questions will usually focus on this integration.

6. Test Preparation Strategies:. This lecture focuses not only on test-taking strategies or the so-called tips and tricks. It covers all aspect for taking the USMLE exam, including correcting bad habits and thought processes that negatively impact your ability to get the right answers, speed building to help you finish each block ahead of time and much much more. You could know all the medical concepts tested in the USMLE and still get a low score.

If you want to see a sample of what we generally discuss in the lecture sessions, please refer to my earlier post with an introductory video to the first lecture. How to Master the USMLE Step 1 – An Introduction.

To  enroll in the lectures or find out more about them, please go to http://main.askdoc-usmle.com.

The purpose of this post is to help people prepare for Step 2 CK. I purposefully did not title this as ‘How to get a 99 in Step 2 CK’ even though I got one using these preparation techniques. The reason is that it takes more than knowing how to prepare to get a 99. How much sacrifice and effort you put into your preparation is most important.

Some of you may already know me, from my post on how to prepare for step 1. I posted it in answer to a question on ‘What to Do’ in Step 1, and it’s purpose is to guide people in how to prepare for step 1 rather than how to get a 99 even though, again, I got one using those prep techniques. I’m posting a link to that thread:

For those who don’t. I am an Old IMG from the Philippines. Graduated way back in 1989 at the top medical college in my country. I took Step 1 last April 24, 2006 and got a 99/256. Took Step 2 CK last November 20, 2006 and got 99/258. Back in late 2004, when I started this journey and like most of you dreaming of 99′s, whenever, I see someone posting that they got 99′s, 2 things always pop up in my mind, wishing that it was me and wondering how it’s done. And always, when I read what they write about how they did it, it talks of what books they read, what lecture they listened to and what QBanks they used. Of course, the problem was, everybody seems to be doing the same things and most of them are not getting 99′s and some are even failing. So the only conclusion I can make is the secret does not lie in the preparation materials rather in how you used the preparation materials. And since different people have different starting points and different capabilities, their preparations and the materials they used must be adjusted accordingly.

Someone once asked in this forum if the reason I know so much about USMLE is I had taken it before. The answer is no, this is the first time I am taking all Steps. The reason I seem to know a lot about it is that it has always in my nature to know as much as I can about any task set before me. I have never failed an exam in my life and even though USMLE is supposed to be really tough especially for old Grads, I’m not about to let this be my first time. So, I set out to discover as much as I can about the exam, analyzing it and planning out what I hoped was a coherent well thought out study plan taking into consideration my special situation (a very old graduate) and my own prep capabilities.

It is not enough to study hard, one has to study smart too. I believe that with proper prep and hard work, anyone can pass this exam, hence this “what to do”. It is also my belief that with proper prep and really hard work, most can get high 80′s and even 90′s. Someday I’ll probably write a post about how to get double 99′s but for now I’ll stick to proper preparation for Step 2 CK.

So How do you prep for Step 2 CK? Well, for one thing, most of what I wrote on how to prep for Step 1 still applies to step 2. KA, KR, TP still applies, although some details differ. What to Master, Know and Be Familiar with still applies although the emphasis is radically different. There is enough differences that if you prepare for both steps in exactly the same way without adjustments, you will tend to do better in one than the other. Explains why double 99′s are uncommon though.

When I started my own review, I was approaching Step 2 CK in exactly the same way I was approaching Step 1. I chose books using the same criteria, looking for books that discussed important concepts in more details rather than just using review books. It wasn’t until 6 weeks into my review that I realized my error. There is a difference.

Firstly, in Step 2 CK you have to master the horses rather than the zebras. You have to know the variations in presentations of common cases their workup in detail and their treatment, including diagnostic criterias that determine whether treatment is even advised or not. Zebras still are important but they are as rare as in real life. Most cases will be typical appearance of common diseases. Atypical appearances of common disease are also common and responsible for a lot of the vagueness. As for zebras, you just have to know enough that you don’t mistake them for horses.

In Step 1, there usually are more zebras than in step 2. The reason is that in Step 1, you are studying important basic medical science concepts and sometimes, these concepts are best illustrated by rare cases. For example, Prader Willi Syndrome is rare and yet illustrates a very important principle in genetics, namely imprinting.  Another example, Lung CA in Step 1 will probably be Small Cell due to para-neoplastic syndrome, rather than AdenoCA and Squamous Cell which you expect to be more common in Step 2.

Next, whereas Step 1 emphasizes facts, Step 2 CK emphasizes decision making. Where Step 1 tests how much you know and understand about medicine, Step 2 concentrates primarily on your ability to use what you know and understand about medicine in decision making. 60% of what you need to know in Step 2 CK, you’ve learned when you did Step 1. But the 40% you don’t is just as important(Which means unless you are a fairly recent grad, you still have to read Texts). Then you have to show that you have the ability to use what you know in clinical decision making.

In Step 2 CK  75% of the Q’s deal with Diagnosis, Work-up and Treatment. The other 25% covers Pathophysio, Preventive Medicine, Biostatistics and Ethics.

The most important skill one should develop is the ability to diagnose the case presented even if the clinical presentation is vague. Even though most of the question will deal with Work-up and Treatment and occasionally pathophysiology, you still must be able to diagnose the case BEFORE you can even begin to think about Work-up and Treatment.

The major complaint of a lot of people (including me) about Step 2 CK is the “vagueness” of the questions. And the reason for the vagueness of the questions is the way the q’s are constructed. Clinical cases are almost never presented classically in Step 2 CK which is so unlike Step 1, where almost all clinical case presentation is classical.

Someone who prepares a Step 2 CK clinical case will usually begin by writing down all the classic signs, symptoms and laboratory results for a certain diagnosis (as is done in Step 1). In the second pass, he will eliminate or alter a lot of signs, symptoms and laboratory result from the presenting case so long as it does not alter the final diagnosis, ie. If you really look at it long and hard, you will realize the diagnosis remains the same. Now to make it even more difficult, on a third pass, he will add signs, symptom and laboratory results that although positive will not really alter your main diagnosis. To make it even harder, he will put on even more irrelevant positives and negatives so you have those kilometric case, that’s so hard to read, understand and clearly time-killers.

Why do this? To test if you can decide which diagnostic clues are relevant and irrelevant. In actual medical practice, patients never present classically, and part of being a good diagnostician is the ability to flesh out relevant and irrelevant facts. Which is one of the reasons why people with longer clinical experience tend to do better in Step 2, since we usually study classic clinical presentations in med school. Whereas, people with longer clinical experience tends to experience a lot of atypical cases.

For example, whereas, the classic presentation of Sarcoidosis is a black, female, in Step 2 CK don’t be surprise if the patient is a white male instead. SLE is possible in males, although classically , patients are females. Not all patients with Lyme Disease will present with rash. Therefore, being able to diagnosis properly despite missing or over-abundant information is crucial to doing well. Atypical presentations abound, but they still will be common cases, therefore be careful not to mistake them for zebras.

Next, for every diagnosis, it is important to know how to work it up and treat them. However, for common cases, one should know in what order work up and treatment should be done, what steps to do depending on diagnostic test results and what to do next depending on the outcome of treatment already done. For some cases, time since presentation, is an important factor in what actions one should take. I’ll illustrate this further next time.

Actually I wanted to finish the whole of part I first before posting this, however, my step 2 CS is on March 23 already and between reviewing, trip preparation and work, there is limited time to write this all down before I leave for LA. Since, I’ve received lots of PM’s on when this will be posted, I’ve decided to post this. I’ll try to finish them by April. There are 3 Parts, Part 1 deals with the difference between Step 1 and Step 2 CK as well as things to note about Step 2 CK. Part II which deals with preparation materials (Kaplan Notes still the best, not because it is really great but others are just not that good) and Part III, which deals with specific prep problems on Step 2 and how to deal with them. I’ve chosen not to rewrite preparation methods common to both Step 1 and Step 2 and advise people to just read my Step 1 post instead.

I would  also like to apologize to everybody whose q’s I’ve failed to answer, or took a long time in answering due to time constraint.

Anyway, if anyone has any questions, I will be back after the Holy Week (fon non-christians, Holy Week is first week of April) and unless you’re in LA at the Hacienda Hotel between 16 and 24, I will be seeing you then.

———————————————————————————————————————————————

Sorry for the late posts. Took an extended vacation. However, now I’m back and we’ll continue the discussion.
Let’s take an example of a case, say Acute Cholecystitis. You have to know how to diagnose it first. If diagnostic workup have not yet been done then, UTZ Abdomen is next and depending on findings either further diagnostic workup is needed or therapy. Now for therapy choice is cholecystectomy or cool it down first with fluids and anti-biotics. Here time of presentation is important. First 72 hours after start of symptom, you operate (laparoscopic cholecystectomy first choice), after 72 hours, cool down inflammation (with fluids, antibiotics) before scheduling elective cholecystectomy 5 to 6 weeks later. (Of course this is not complete as depending on diagnostic findings and therapeutic outcomes, other course of action may be needed. but this will suffice for illustration purposes only.)

The actual case presentation may end anywhere in this narrative and you are expected to know what to do next. But first you have to be able to diagnose the case since it will be presented as a case with no diagnosis.
Another example is Acetaminophen poisoning. Here time of presentation is crucial. On first 2 hour, gastric lavage, 2-4 hours activated charcoal, at 4 hour draw blood levels to decide if will use acetylcysteine. This case, time of presentation is most important criteria to decide what to do. (This case actually illustrates another problem with Step 2 CK since other sources will insists that lavage and activated charcoal is only effective first 24 hours. Will discuss this further later)
Now don’t get me wrong, only about 20 to 25% of the q’s will be of this type, the rest will be more straightforward and they will mostly be the more common cases. However, since we don’t know how common a case should be for USMLE to consider it common, the more cases you know how to handle this way, the higher the probability you will score high, since you’ll be able to answer these types of questions and still be able to answer the more straightforward question. Another advantage is that a bigger proportion of Step 3 questions will be this way and it will help you to have a leg up when you prepare for that.

So the best way to study for Step 2CK is to find diagnostic algorithms and therapeutic protocols whenever they exist. Kaplan Notes have good protocols but not complete. Step Up Medicine have some protocols, but others are just lists of diagnostic and therapeutics done for a specific case (no indication of which comes first). Blueprints also have a lot of them. I’ll discuss them in more detail in part 2. You can also learn them in UW and Kaplan QBank although usually it is not presented in complete detail since the q’s are focused on certain aspects of each case. The best way is to know them beforehand and see how they apply when you answer the QBanks.

If given a specific case, say acute pancreatitis, you know step by step workup and treatment, then you have mastered that case correctly.

Now another reason for the complaint of vagueness of the exam has to do with the fact that even when you have diagnosed the case correctly, one or two variables in the presentation can alter management acutely. For example, Primary Hyperparathyroidism is managed surgically except when patient is over 50 and asymptomatic. Another example, a patient you have diagnosed with hepatitis may be fulminant or suffering from hepatic encephalopathy, which changes your therapeutic and diagnostic options, and you have to be able to recognize them clinically, since the case will not tell you outright. If you noticed that all answer choices seem correct, you may have failed to notice tiny details that changes the clinical picture entirely. In contrast in Step 1, once you get the diagnosis, that’s it.

One way to cover this is to know diagnostic criteria for interventions. For example, Thrombolytic therapy can only be done if there is an ST-segment elevation in 2 contiguous leads on a patient with pain onset within six hours. Failure to meet this criteria even if the case points strongly to a diagnosis of MI means you don’t do thrombolytic therapy.

Now, around 15% of Step 2 CK is pathophysiology, hence if you did step one and mastered pathophysio, you have an advantage in Step 2 CK. Kaplan Medicine is not heavy on pathophysio, so Step Up Medicine is a good supplement to cover this. (It’s not complete, but short of going back to Step 1 Patho or Harrison’s and Cecil, this will do.) Although most pathophysio questions will be straightforward (After an appropriate clinical case presentation which you have to diagnose first), there are what I would call “Applied Pathophysiology”.

To illustrate:

Patient has acute shortness of breath and xray show whiteout of both lungs. You know it’s either Left Heart Failure or ARDS. The case presentation will be vague enough that you will not be able to pinpoint if it’s one or the other. The question asks you what to do next. Knowing pathophysio of Left heart failure is increased pressure in left heart causing backflow of fluid to lungs, vs. ARDS where fluid in lungs is secondary increased capillary permeability, answer should be Pulmonary Capillary Wedge Pressure or PCWP.

Another case:

Patient have recurrent episodes of gout. You are asked what to do next. You already know that you don’t treat hyperuricemia on a single attack of gout. The list includes treatment with probenecid and treatment with allopurinol, and treatment with colchicine. Of course the right answer would be to measure 24 hour urine uric acid and if high give allopurinol and if low give probenecid. Colchicine is used for acute attacks. Knowing pathophysiology is important in answering this question.

Now we will pause here and will continue with Part 2 next time.