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Old 07-11-2012
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Arrow Journey thy name USMLE- My experience and advice.

Steve Jobs rightfully put in his ever famous Stanford commencement address in 2005: "Sometimes life hits you in the head with a brick. Don't lose faith. I'm convinced that the only thing that kept me going was that I loved what I did. You've got to find what you love. And that is as true for your work as it is for your lovers. Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven't found it yet, keep looking. Don't settle." If you have never listened to his speech before, put away your books for a while and head over to http://www.youtube.com/watch?feature...&v=UF8uR6Z6KLc and look what a dying, but successful man has to say about life.

This post includes my experience about the USMLEs and more importantly, philosophy and mindset you would want to develop while preparing for it and looking for a medical career in US.

Target audience: International medical students or international medical graduates (famously called IMGs) considering/taking USMLE-US residency path.

Philosophy, thought process and textbooks:

Many students tend to think of medical college's curriculum as disjointed pieces of a big puzzle of medicine. You need to realize that every small thing you read, hear or learn from your professors/patients has to fit into the "bigger picture". Let me give you a concrete example- In preclinical years, you would have learnt in physiology class that ACTH is synthesized from a precursor polypeptide called pro-opiomelanocortin (POMC). After post-translational modification (glycosylation, acetylation, etc- tie in of biochemistry) of this big fat POMC, it leads to smaller peptides, namely- ACTH, gamma-MSH and beta-lipoprotein. Further, ACTH is made up of beta-MSH and a small peptide called CLIP. Now, if you knew that it was beta-MSH which acts on peripheral receptors of our body to increase the skin pigmentation by upregulation of melanocytes, then, it should make perfect sense to you that in diseases causing increased secretion of ACTH (eg, primary adrenocortical insufficiency) AND ALSO ectopic ACTH production syndromes (classic example being that of SCLC- small cell lung cancer), you should expect to see skin hyperpigmentation (tie in of internal medicine and pathology). You knew this already? Good, then, make sure to do this mental exercise for each and every disease, that is- tie in with its possible correlation with anatomy, physiology, biochemistry and pathology. Never stop asking 'why' till you are satisfied.

At the very extreme end of above example, are obscure facts like thumb defects in patients with Fanconi anemia. Mechanism behind that is still unknown, but that being said, thumb defects with pancytopenia in a pediatric patient, should make you think of Fanconi. Please don't underestimate the importance of memorization in the field of medicine. It just proves that human body is too complex and way beyond our understanding to know mechanisms behind each and every symptomatology/signs of various diseases.

Why did I give you these two examples? Because this is what USMLE is exactly all about. Questions on USMLE (read: in real life too) involves the thought process I described in above examples. So if you are still in your early years of medical college, make sure to develop this thought process, which in turn, will make you see the 'bigger picture' of whatever you read/learn.

Read good books during your five and half years of medical college! Excellent textbooks like Gray's Anatomy FOR STUDENTS and B.D.Chaurasia for anatomy; Guyton and Ganong for physiology (definitely not Sembulingam); Robbins and Rapid Review (and not Harshmohan for good God's sake) for pathology; Lippincott review, Vasudevan and Harper for biochemistry; Katzung for pharmacology; Clinical Microbiology Made Ridiculously Simple (CMMRS) for microbiology; Harrison's for internal medicine; Love and Bailey for surgery; etc- will go a long way to stimulate your brain cells to learn rather than memorize everything. Books like Sembulingam and Harshmohan kill inquisitiveness one should have in medicine, and more scary- such books may not be accurate with their presented facts.

General advice for preparation for USMLE:

While in preclinical and clinical years of medical college:

1) Build concepts and try to learn obscure facts from first year of medical college by attending lectures (only good ones!) and reading textbooks mentioned above! If you don't, don't expect magic in the last year or while actually preparing for entrance exams like USMLE!

2) For weak subjects (for me, they are/were biochemistry, microbiology and Ob/Gyn)- read from various sources, rather than a single source- it will help to reinforce the facts and concepts much better.

3) Consider reading or just glancing through Kaplan Lecture Notes for Step 1 and 2 along with your textbooks. It will help you to get an early idea as to which areas are heavily tested on USMLEs.

4) Participate in online medical student forums to expand your thinking horizon and to expose yourself to how medical students function/think in US. Student Doctor Network- SDN (http://forums.studentdoctor.net/forumdisplay.php?f=189) is an excellent forum to participate into. Usmle-forums.com (http://www.usmle-forums.com/) would be another one. Prep4usmle.com used to be a good forum, but now its just filled up with spammers and their junk.

5) If your spoken/written english proficiency is not that good, please work on that. English is the only medium (spanish is distant second!) of communication in US and if you want to treat people there, you ought to know english well enough for clear and effective communication. There is no harm in joining a personality development course and spoken english proficiency course while being in your native country!

6) I strongly disapprove the idea of taking Step 1 immediately after second year of medical college, simply because of the way our curriculum is designed (especially in India). Step 1 requires clinical knowledge to be able to crack it. And, most of us, won't have even seen clinics/wards till second year of medical college or learnt disease symptomatology well enough. I also feel that taking Step 2 CK before Step 1 (even if you are not a fresh graduate) is not a great idea either, as Step 2 CK is based on Step 1 and not vice versa.

Length of prep for any of the Steps:

For this, first I want to talk about momentum and the bell shaped curve of your potential. Anytime you prepare for exams which require memorization and clarity of concepts, realize that what you read will fade away from memory as quickly as you read it! Concepts will stay, but it's not the only thing tested on the exam. I learnt this the hard way on my Step 1 and from some of my friends who actually practiced it.

Momentum- is basically the time when all you are doing in your life is reading for the Step (typically, around 12 hours/day). Length of this phase will and should vary according to your basic knowledge gained in your medical college years. But, once you have the ball rolling, it should end with you taking the exam, and NOT with taking a break for 15 days or so and restarting your prep!! Get it? I know many who took predictive exam (NBME) for Step 1 months before their actual exam. It's not a good idea. You will be surprised to know how much your test-taking skills will change in those months. For example, if you get a good/desired NBME score (especially, forms 12, 13 for Step 1) a month ago your exam, prepone your exam!!! It's called 'predictive' for a reason.

Bell shaped curve of your potential- There's a time in your prep when you will be at your peak potential. It's very difficult to find that time, but you have to! Taking the test before and after that could be detrimental- all that could happen to you is a lower score than you deserved/expected. This holds true for us- IMGs since we take around 4-6 months for preparing for Step 1. Feeling fatigued and 'just want to get rid of this exam' attitude is just a signal that you went overboard with your prep, and probably should have taken the test earlier.

Shortly, be your own judge as to how much and how long you want to prepare keeping in mind the above points.

Passo Uno- Step 1:

If you are one of those who feel or have been told that Steps are way easier than any equivalent entrance exams held in your respective country, you might want to reconsider that. Especially true for Step 1- it's a beast that remains to be tamed! 8 hours long exam requiring complete focus and clarity of concepts should not and can not be an easy task. On top of your medical knowledge, it tests your patience and willpower! So, I hope I made it clear that it's not easy and not worth taking lightly!

The big difference between Step 2 CK and Step 1 is that- Step 1 has a lot of seemingly obscure facts to be memorized. While this is definitely true, make sure you know as many mechanisms as possible for those seemingly obscure facts.

*Typical prep model*

All subjects except microbiology and pathology- Kalpan LN (Lecture Notes) along with videos. Videos were very helpful especially for biochemistry, physiology, anatomy, pharmocology, immunology, genetics and psychiatry. Kaplan LN for biochemistry is simply awesome. It's written with stress on the 'bigger picture'.

Microbiology- bacterial genetics from Kaplan LN and for everything else, I strongly recommend CMMRS (supplemented wherever deficient by Kaplan LN). It will help create a visual memory which will not fade for a long long time.

Pathology- Rapid Review Pathology (legal, much better, colored version of bootlegged "Goljan Notes") reviewed with Goljan audio. Goljan audio is phenomenal- more because its hilarious and keeps your mood rolling during intense prep. It's arguable (with no definite conclusion) if audios actually help in getting a better score! There's no denying that reading Rapid Review is an absolute must for Step 1. Pathology is super heavily tested on Step 1 and no other book integrates biochemistry, physiology and pathology so good as Rapid Review does.

A typical question asked by many is 'How many times should one read above stated books before exam?'. Answer- it depends!! You have to decide that for yourself, no one else can. Be your own judge; if you don't know then no one else would too.

Question banks: I can not stress enough the importance of question banks. It's numero uno predictor of your performance in the real deal. USMLEWorld (UW) is great and for many reasons- for starters, it's interface is pixel to pixel same as the real exam. After solving 50 blocks of UW, real exam will feel just like 7 more blocks of UW. UW has excellent explanations to answers. No other bank will make your concepts more clearer than UW. Make notes of difficult-to-remember points and classic presentation of various diseases from UW. Revise them sometime in the week before exam. Remember, there's a reason why a particular question is there in UW! It's a very high yield bank. Distant second choice for questions would be Kaplan qBank. It's really surprising that Kaplan has great videos and LN for step 1 but just not good enough question bank. If you have time, doing UW again would be more beneficial than doing Kaplan qBank.

First Aid for Step 1: Not reading (and *understanding* the mechanism/concepts behind the facts written) this book well enough is a pathognomonic feature of low step 1 score! This book is super super high yield for Step 1! Revise it very near your exam again. If you need a spoon fed journey for going over First Aid, following rapid review courses will help you do just that.

Rapid review online courses: Options include Doctors In Training (DIT), Kaplan Step 1 High-Yield and First Aid Express Review courses. All three of them, basically, spoon feed information in First Aid for Step 1 by going over First Aid page-by-page in videos. Which one is better? I don't know (may be DIT). Check the above mentioned forums for discussions and opinions. I recommend doing a rapid review course (if you have money to burn)- it goes a long way to put every high yield fact in your recent memory before you take the exam.

Mocks/predictors: I feel that NBME 12 and 13 are the best predictors (others have different opinions; use your own judgement). UWSA 1 and 2 are more of confidence-boosters than predictors, because they tend to over-predict. Take them to get feel-good-factor going along your way and for yet another 8 blocks of questions with explanations.

Passo Due Competenze- Step 2 CS:

Tricky, tricky! At the outset, failing this test has much worse impact on residency application than getting a low score on Step 1 or Step 2 CK. If you pass, no one cares; if you fail, every program director cares!

Success formula mix: Good (not necessarily exceptional) spoken and written English proficiency, decent typing speed on the computer keyboard, First Aid for Step 2 CS and a friend (preferably, one who has already cleared CS). There are also some notes flying around in the Internet space- Niraj, UW, etc.

Spoken English Proficiency: It's obvious, isn't it? Communicating with a standardized patient requires not only good command of English language, but also a good grip on the American accent and various small nuances of spoken English in US. How to improve it? Clinical rotation in US is the best way to improve it. If that's not possible for you, befriend a person who has! Most IMGs fail the Spoken English Proficiency (SEP) component of this test, so better get this sorted out and prevent a disaster.

Written English: The fact that you studied medicine in English for five and half years should help you here!! While you write patient notes on this test, make sure your Grammar is correct. I don't think it would be a reason to fail on Patient Note (PN) component of this test, but notes are checked by humans and not computers, so if you use horrible grammar, expect problems.

Typing speed: Starting mid 2011, its become mandatory to type the notes, instead of penning them down. Computers are imperative in American healthcare system, in deep contrast to India at least. It's surprising as to how many are still uncomfortable using a computer. Type whatever you want, but get your fingers moving on the keyboard smoothly before taking CS.

First Aid for CS and a friend: The ultimate combination. Practice each and every case in FA with your friend. Only doing 'Skype' practice is no good. You will need to get sense of time while you examine the patient. There's limited time for each case and knowing when to switch from history to physical examination to a nice closing statement is imperative.

In short, practice, practice and then? Practice!

And yes, please have enough self-confidence to not take any live practice course (worth thousands and thousands of dollars) for CS. You can do it; just make sure you practice well enough. Spend those dollars on a trip to Switzerland with your friend, after passing the test!

Passo Due Conoscenza- Step 2 CK:

Step 1 knowledge + longer questions (with tons of negative history) with the patient having atleast 4-5 chronic diseases + knowledge to tease out which chronic disease is the cause of current symptoms in the patient= Step 2 CK. As simple as that!

Taking Step 2 CK in around < 3-5 months after Step 1 will of great help; will require less time to go through and revise small subtle points which were covered on Step 1, but important for Step 2 CK too.

Again, it's a long exam- 9 hours! Stamina, patience, clarity of concepts (rather than rote memorization) will be deciding factors of your performance on this test.

While preparing for Step 2, it will be immediately apparent that there is no one good concise review book. Sad but true.

*Typical prep model*

Medicine (including preventive and emergency medicine), pediatrics, Ob/Gyn- Kaplan LN.

Psychiatry, Epidemiology/biostatistics, Ethics- UW only should be sufficient. But, if you do have time, going over Kaplan LN won't harm you.

Surgery- either of the two sections (theory, vignettes) in Kaplan LN. They have just printed same thing twice in that book! I did theory (first section) because it was shorter and I was running out of time.

USMLEWorld (UW)- Phenomenal and strikingly similar to actual test questions. Frankly, UW felt like a cheat sheet for CK. Know this bank in and out before appearing for CK. If you have time, go over it once more. Make notes! And revise them near your test date. Revising those 2000 points in your UW notes will go a long way to improve your score. Format of drug abstracts and case reports in this bank were similar to those on the real exam. In short, UW is the highest yield resource for CK. Note that I didn't even mention Kaplan qBank for step 2. It's a decent bank, but not representative of the actual test.

Rapid review course- there's only out there in the market- Doctors in Training (DIT). I used it mainly to supplement my weak areas- pediatrics, Ob/Gyn, neurology. Do it if you have time and money to spend. It will definitely help you bump up score by 4-5 points.

Review book for last week- Step 2 Secrets, by far, is the best one. I loathed Master the Boards (MTB) for its casual style of writing and innumerable errors. But to each, his own; compare these books before plunging for one. MTB has just enough information to make you pass the test, not excel it. Secrets, on the other hand, was a good add-on to UW and more importantly, a quick read.

Golden tips:

1) Revise UW rather than reading Kaplan LN again. One good read of Kaplan LN is sufficient, I think.

2) Patient demographics in question stem: While the following holds true for Step 1 also, it's all the more crucial in Step 2 CK. Learn correlations between various diseases and age, gender, ethnicity, immigrant status, which state/area he/she's coming from, *weight*, *BMI*, recent trips in/out of US to name a few. Patient demographics, which are usually in first sentence of the stem, should give you a hint of what the diagnosis could be. For eg., newborn with non-inflammatory hip pain and gross abnormality most likely has DDH (developmental dysplasia of hip), a 5 year old with same non-inflammatory hip pain most likely has Legg-Calvé-Perthes disease and an obese (weight in >=90th percentile) kid with similar hip pain with some subtle restricted hip motion has slipped capital femoral epiphysis! And yes, you guessed it right- all three would be in the options you have to choose from.

Mock/predictors: Check forums for latest news on these. I didn't do a single NBME. So won't be able to comment on that (but have heard that NBME 4 is a decent predictor). I used UWSA as a source of another 4 blocks of questions with explanations. Don't expect much of an accurate prediction like that of Step 1.

Closing remarks:

USMLEs or for that matter any exam you take, should make a better doctor out of you, nothing more and nothing less. If you take these tests just for the sake of it, it's no good. Learn to enjoy the process and loving what you do, rather than 'just another hurdle to cross for success'.

Be ethical in your work; many people's lives are and will be dependent on what you say or do to them. And instead of going for a facebook/street show against Satyamev Jayate's doctors' malpractice episode, sit back and remember how many times you were forced to be a partner in crime (of malpractice) while being an student/intern at your hospital; and make a firm decision never ever to pass on wrong information to your patients. Our profession has lot of responsibilities attached to it, and you have been chosen because a common man trusts you to carry those on your shoulders. With power, comes responsibility!

Tests will come and go, but what will stay is your passion for what you became a doctor. Don't lose that 'big picture'.

Enjoy life, go out with your girlfriend/boyfriend, be crazy, be an absolute idiot at times, but also be a responsible professional.

Best of luck!

-Shalin Kothari.
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Old 07-11-2012
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Great, great post!! One of the best step experiences there is.

Thank you for sharing this with us!

Congrats on finishing all the steps!
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Old 07-11-2012
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whoa!!!
very well put..you make it all look so easy

thanks a ton!
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Old 07-12-2012
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Star Great post

Amazing post man. You are awesome. Just pumped up me with adrenaline. Exactly what I needed Thank you so much for this. May God bless you.
GOODLUCK!
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Old 07-12-2012
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Star Wooooowwwwwww

i just love the last two lines...kudos man
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Matched!!!
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Old 07-13-2012
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wow, very detailed and helpful post. Love it. Thanks and congrats!
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Old 07-13-2012
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excellent post...
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Old 07-13-2012
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Thank you guys! Best of luck!! And questions are welcome..
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Old 07-14-2012
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A GREEEEAT POST...well written mate...
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I am not 'THE BEST', but I am not like 'THE REST'..
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Old 10-02-2012
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Congratulations !

This is the best experience writeup I ever read!
So beautifully true!
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Old 10-02-2012
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Rattling post.Great experience
Best of luck for your scores
.
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Old 10-03-2012
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an outstanding post
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Old 10-23-2012
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Very well written post! Thank you very much for taking the time to do this! It is very inspiring!
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Awesome !!!!
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Old 11-23-2012
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Default Congratulations

Congratulations, Thank you for enjoying us with this slice of your life, I wish there are many people like you. I wish you the best life ever
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Old 11-24-2012
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Hello ...congratulations 4 ur success urs is the best post iv read so far..superb:-)inspiring in every way:-)im a IMG who took da sudden decision on USMLE.i had numero doubts regardin USMLE prep.iv evn posted a message in dis forum however no replies:-(ur post really helped me understand how to do abt by da prep in a simpler understandable way..thanq so much:-)U also seem 2 b a IMG so i hav a question.did u do any clerkship in da U.S.?n how much does it count later?if i hav 2 do it how do i go abt it?sorry 4 da long post.pls help me


Quote:
Originally Posted by kothari.shalin View Post
Steve Jobs rightfully put in his ever famous Stanford commencement address in 2005: "Sometimes life hits you in the head with a brick. Don't lose faith. I'm convinced that the only thing that kept me going was that I loved what I did. You've got to find what you love. And that is as true for your work as it is for your lovers. Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven't found it yet, keep looking. Don't settle." If you have never listened to his speech before, put away your books for a while and head over to http://www.youtube.com/watch?feature...&v=UF8uR6Z6KLc and look what a dying, but successful man has to say about life.

This post includes my experience about the USMLEs and more importantly, philosophy and mindset you would want to develop while preparing for it and looking for a medical career in US.

Target audience: International medical students or international medical graduates (famously called IMGs) considering/taking USMLE-US residency path.

Philosophy, thought process and textbooks:

Many students tend to think of medical college's curriculum as disjointed pieces of a big puzzle of medicine. You need to realize that every small thing you read, hear or learn from your professors/patients has to fit into the "bigger picture". Let me give you a concrete example- In preclinical years, you would have learnt in physiology class that ACTH is synthesized from a precursor polypeptide called pro-opiomelanocortin (POMC). After post-translational modification (glycosylation, acetylation, etc- tie in of biochemistry) of this big fat POMC, it leads to smaller peptides, namely- ACTH, gamma-MSH and beta-lipoprotein. Further, ACTH is made up of beta-MSH and a small peptide called CLIP. Now, if you knew that it was beta-MSH which acts on peripheral receptors of our body to increase the skin pigmentation by upregulation of melanocytes, then, it should make perfect sense to you that in diseases causing increased secretion of ACTH (eg, primary adrenocortical insufficiency) AND ALSO ectopic ACTH production syndromes (classic example being that of SCLC- small cell lung cancer), you should expect to see skin hyperpigmentation (tie in of internal medicine and pathology). You knew this already? Good, then, make sure to do this mental exercise for each and every disease, that is- tie in with its possible correlation with anatomy, physiology, biochemistry and pathology. Never stop asking 'why' till you are satisfied.

At the very extreme end of above example, are obscure facts like thumb defects in patients with Fanconi anemia. Mechanism behind that is still unknown, but that being said, thumb defects with pancytopenia in a pediatric patient, should make you think of Fanconi. Please don't underestimate the importance of memorization in the field of medicine. It just proves that human body is too complex and way beyond our understanding to know mechanisms behind each and every symptomatology/signs of various diseases.

Why did I give you these two examples? Because this is what USMLE is exactly all about. Questions on USMLE (read: in real life too) involves the thought process I described in above examples. So if you are still in your early years of medical college, make sure to develop this thought process, which in turn, will make you see the 'bigger picture' of whatever you read/learn.

Read good books during your five and half years of medical college! Excellent textbooks like Gray's Anatomy FOR STUDENTS and B.D.Chaurasia for anatomy; Guyton and Ganong for physiology (definitely not Sembulingam); Robbins and Rapid Review (and not Harshmohan for good God's sake) for pathology; Lippincott review, Vasudevan and Harper for biochemistry; Katzung for pharmacology; Clinical Microbiology Made Ridiculously Simple (CMMRS) for microbiology; Harrison's for internal medicine; Love and Bailey for surgery; etc- will go a long way to stimulate your brain cells to learn rather than memorize everything. Books like Sembulingam and Harshmohan kill inquisitiveness one should have in medicine, and more scary- such books may not be accurate with their presented facts.

General advice for preparation for USMLE:

While in preclinical and clinical years of medical college:

1) Build concepts and try to learn obscure facts from first year of medical college by attending lectures (only good ones!) and reading textbooks mentioned above! If you don't, don't expect magic in the last year or while actually preparing for entrance exams like USMLE!

2) For weak subjects (for me, they are/were biochemistry, microbiology and Ob/Gyn)- read from various sources, rather than a single source- it will help to reinforce the facts and concepts much better.

3) Consider reading or just glancing through Kaplan Lecture Notes for Step 1 and 2 along with your textbooks. It will help you to get an early idea as to which areas are heavily tested on USMLEs.

4) Participate in online medical student forums to expand your thinking horizon and to expose yourself to how medical students function/think in US. Student Doctor Network- SDN (http://forums.studentdoctor.net/forumdisplay.php?f=189) is an excellent forum to participate into. Usmle-forums.com (http://www.usmle-forums.com/) would be another one. Prep4usmle.com used to be a good forum, but now its just filled up with spammers and their junk.

5) If your spoken/written english proficiency is not that good, please work on that. English is the only medium (spanish is distant second!) of communication in US and if you want to treat people there, you ought to know english well enough for clear and effective communication. There is no harm in joining a personality development course and spoken english proficiency course while being in your native country!

6) I strongly disapprove the idea of taking Step 1 immediately after second year of medical college, simply because of the way our curriculum is designed (especially in India). Step 1 requires clinical knowledge to be able to crack it. And, most of us, won't have even seen clinics/wards till second year of medical college or learnt disease symptomatology well enough. I also feel that taking Step 2 CK before Step 1 (even if you are not a fresh graduate) is not a great idea either, as Step 2 CK is based on Step 1 and not vice versa.

Length of prep for any of the Steps:

For this, first I want to talk about momentum and the bell shaped curve of your potential. Anytime you prepare for exams which require memorization and clarity of concepts, realize that what you read will fade away from memory as quickly as you read it! Concepts will stay, but it's not the only thing tested on the exam. I learnt this the hard way on my Step 1 and from some of my friends who actually practiced it.

Momentum- is basically the time when all you are doing in your life is reading for the Step (typically, around 12 hours/day). Length of this phase will and should vary according to your basic knowledge gained in your medical college years. But, once you have the ball rolling, it should end with you taking the exam, and NOT with taking a break for 15 days or so and restarting your prep!! Get it? I know many who took predictive exam (NBME) for Step 1 months before their actual exam. It's not a good idea. You will be surprised to know how much your test-taking skills will change in those months. For example, if you get a good/desired NBME score (especially, forms 12, 13 for Step 1) a month ago your exam, prepone your exam!!! It's called 'predictive' for a reason.

Bell shaped curve of your potential- There's a time in your prep when you will be at your peak potential. It's very difficult to find that time, but you have to! Taking the test before and after that could be detrimental- all that could happen to you is a lower score than you deserved/expected. This holds true for us- IMGs since we take around 4-6 months for preparing for Step 1. Feeling fatigued and 'just want to get rid of this exam' attitude is just a signal that you went overboard with your prep, and probably should have taken the test earlier.

Shortly, be your own judge as to how much and how long you want to prepare keeping in mind the above points.

Passo Uno- Step 1:

If you are one of those who feel or have been told that Steps are way easier than any equivalent entrance exams held in your respective country, you might want to reconsider that. Especially true for Step 1- it's a beast that remains to be tamed! 8 hours long exam requiring complete focus and clarity of concepts should not and can not be an easy task. On top of your medical knowledge, it tests your patience and willpower! So, I hope I made it clear that it's not easy and not worth taking lightly!

The big difference between Step 2 CK and Step 1 is that- Step 1 has a lot of seemingly obscure facts to be memorized. While this is definitely true, make sure you know as many mechanisms as possible for those seemingly obscure facts.

*Typical prep model*

All subjects except microbiology and pathology- Kalpan LN (Lecture Notes) along with videos. Videos were very helpful especially for biochemistry, physiology, anatomy, pharmocology, immunology, genetics and psychiatry. Kaplan LN for biochemistry is simply awesome. It's written with stress on the 'bigger picture'.

Microbiology- bacterial genetics from Kaplan LN and for everything else, I strongly recommend CMMRS (supplemented wherever deficient by Kaplan LN). It will help create a visual memory which will not fade for a long long time.

Pathology- Rapid Review Pathology (legal, much better, colored version of bootlegged "Goljan Notes") reviewed with Goljan audio. Goljan audio is phenomenal- more because its hilarious and keeps your mood rolling during intense prep. It's arguable (with no definite conclusion) if audios actually help in getting a better score! There's no denying that reading Rapid Review is an absolute must for Step 1. Pathology is super heavily tested on Step 1 and no other book integrates biochemistry, physiology and pathology so good as Rapid Review does.

A typical question asked by many is 'How many times should one read above stated books before exam?'. Answer- it depends!! You have to decide that for yourself, no one else can. Be your own judge; if you don't know then no one else would too.

Question banks: I can not stress enough the importance of question banks. It's numero uno predictor of your performance in the real deal. USMLEWorld (UW) is great and for many reasons- for starters, it's interface is pixel to pixel same as the real exam. After solving 50 blocks of UW, real exam will feel just like 7 more blocks of UW. UW has excellent explanations to answers. No other bank will make your concepts more clearer than UW. Make notes of difficult-to-remember points and classic presentation of various diseases from UW. Revise them sometime in the week before exam. Remember, there's a reason why a particular question is there in UW! It's a very high yield bank. Distant second choice for questions would be Kaplan qBank. It's really surprising that Kaplan has great videos and LN for step 1 but just not good enough question bank. If you have time, doing UW again would be more beneficial than doing Kaplan qBank.

First Aid for Step 1: Not reading (and *understanding* the mechanism/concepts behind the facts written) this book well enough is a pathognomonic feature of low step 1 score! This book is super super high yield for Step 1! Revise it very near your exam again. If you need a spoon fed journey for going over First Aid, following rapid review courses will help you do just that.

Rapid review online courses: Options include Doctors In Training (DIT), Kaplan Step 1 High-Yield and First Aid Express Review courses. All three of them, basically, spoon feed information in First Aid for Step 1 by going over First Aid page-by-page in videos. Which one is better? I don't know (may be DIT). Check the above mentioned forums for discussions and opinions. I recommend doing a rapid review course (if you have money to burn)- it goes a long way to put every high yield fact in your recent memory before you take the exam.

Mocks/predictors: I feel that NBME 12 and 13 are the best predictors (others have different opinions; use your own judgement). UWSA 1 and 2 are more of confidence-boosters than predictors, because they tend to over-predict. Take them to get feel-good-factor going along your way and for yet another 8 blocks of questions with explanations.

Passo Due Competenze- Step 2 CS:

Tricky, tricky! At the outset, failing this test has much worse impact on residency application than getting a low score on Step 1 or Step 2 CK. If you pass, no one cares; if you fail, every program director cares!

Success formula mix: Good (not necessarily exceptional) spoken and written English proficiency, decent typing speed on the computer keyboard, First Aid for Step 2 CS and a friend (preferably, one who has already cleared CS). There are also some notes flying around in the Internet space- Niraj, UW, etc.

Spoken English Proficiency: It's obvious, isn't it? Communicating with a standardized patient requires not only good command of English language, but also a good grip on the American accent and various small nuances of spoken English in US. How to improve it? Clinical rotation in US is the best way to improve it. If that's not possible for you, befriend a person who has! Most IMGs fail the Spoken English Proficiency (SEP) component of this test, so better get this sorted out and prevent a disaster.

Written English: The fact that you studied medicine in English for five and half years should help you here!! While you write patient notes on this test, make sure your Grammar is correct. I don't think it would be a reason to fail on Patient Note (PN) component of this test, but notes are checked by humans and not computers, so if you use horrible grammar, expect problems.

Typing speed: Starting mid 2011, its become mandatory to type the notes, instead of penning them down. Computers are imperative in American healthcare system, in deep contrast to India at least. It's surprising as to how many are still uncomfortable using a computer. Type whatever you want, but get your fingers moving on the keyboard smoothly before taking CS.

First Aid for CS and a friend: The ultimate combination. Practice each and every case in FA with your friend. Only doing 'Skype' practice is no good. You will need to get sense of time while you examine the patient. There's limited time for each case and knowing when to switch from history to physical examination to a nice closing statement is imperative.

In short, practice, practice and then? Practice!

And yes, please have enough self-confidence to not take any live practice course (worth thousands and thousands of dollars) for CS. You can do it; just make sure you practice well enough. Spend those dollars on a trip to Switzerland with your friend, after passing the test!

Passo Due Conoscenza- Step 2 CK:

Step 1 knowledge + longer questions (with tons of negative history) with the patient having atleast 4-5 chronic diseases + knowledge to tease out which chronic disease is the cause of current symptoms in the patient= Step 2 CK. As simple as that!

Taking Step 2 CK in around < 3-5 months after Step 1 will of great help; will require less time to go through and revise small subtle points which were covered on Step 1, but important for Step 2 CK too.

Again, it's a long exam- 9 hours! Stamina, patience, clarity of concepts (rather than rote memorization) will be deciding factors of your performance on this test.

While preparing for Step 2, it will be immediately apparent that there is no one good concise review book. Sad but true.

*Typical prep model*

Medicine (including preventive and emergency medicine), pediatrics, Ob/Gyn- Kaplan LN.

Psychiatry, Epidemiology/biostatistics, Ethics- UW only should be sufficient. But, if you do have time, going over Kaplan LN won't harm you.

Surgery- either of the two sections (theory, vignettes) in Kaplan LN. They have just printed same thing twice in that book! I did theory (first section) because it was shorter and I was running out of time.

USMLEWorld (UW)- Phenomenal and strikingly similar to actual test questions. Frankly, UW felt like a cheat sheet for CK. Know this bank in and out before appearing for CK. If you have time, go over it once more. Make notes! And revise them near your test date. Revising those 2000 points in your UW notes will go a long way to improve your score. Format of drug abstracts and case reports in this bank were similar to those on the real exam. In short, UW is the highest yield resource for CK. Note that I didn't even mention Kaplan qBank for step 2. It's a decent bank, but not representative of the actual test.

Rapid review course- there's only out there in the market- Doctors in Training (DIT). I used it mainly to supplement my weak areas- pediatrics, Ob/Gyn, neurology. Do it if you have time and money to spend. It will definitely help you bump up score by 4-5 points.

Review book for last week- Step 2 Secrets, by far, is the best one. I loathed Master the Boards (MTB) for its casual style of writing and innumerable errors. But to each, his own; compare these books before plunging for one. MTB has just enough information to make you pass the test, not excel it. Secrets, on the other hand, was a good add-on to UW and more importantly, a quick read.

Golden tips:

1) Revise UW rather than reading Kaplan LN again. One good read of Kaplan LN is sufficient, I think.

2) Patient demographics in question stem: While the following holds true for Step 1 also, it's all the more crucial in Step 2 CK. Learn correlations between various diseases and age, gender, ethnicity, immigrant status, which state/area he/she's coming from, *weight*, *BMI*, recent trips in/out of US to name a few. Patient demographics, which are usually in first sentence of the stem, should give you a hint of what the diagnosis could be. For eg., newborn with non-inflammatory hip pain and gross abnormality most likely has DDH (developmental dysplasia of hip), a 5 year old with same non-inflammatory hip pain most likely has Legg-Calvé-Perthes disease and an obese (weight in >=90th percentile) kid with similar hip pain with some subtle restricted hip motion has slipped capital femoral epiphysis! And yes, you guessed it right- all three would be in the options you have to choose from.

Mock/predictors: Check forums for latest news on these. I didn't do a single NBME. So won't be able to comment on that (but have heard that NBME 4 is a decent predictor). I used UWSA as a source of another 4 blocks of questions with explanations. Don't expect much of an accurate prediction like that of Step 1.

Closing remarks:

USMLEs or for that matter any exam you take, should make a better doctor out of you, nothing more and nothing less. If you take these tests just for the sake of it, it's no good. Learn to enjoy the process and loving what you do, rather than 'just another hurdle to cross for success'.

Be ethical in your work; many people's lives are and will be dependent on what you say or do to them. And instead of going for a facebook/street show against Satyamev Jayate's doctors' malpractice episode, sit back and remember how many times you were forced to be a partner in crime (of malpractice) while being an student/intern at your hospital; and make a firm decision never ever to pass on wrong information to your patients. Our profession has lot of responsibilities attached to it, and you have been chosen because a common man trusts you to carry those on your shoulders. With power, comes responsibility!

Tests will come and go, but what will stay is your passion for what you became a doctor. Don't lose that 'big picture'.

Enjoy life, go out with your girlfriend/boyfriend, be crazy, be an absolute idiot at times, but also be a responsible professional.

Best of luck!

-Shalin Kothari.
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  #17  
Old 11-24-2012
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Hello..congratulationswonderful post iv read so far..inspiring in every way.im a IMG took a sudden decision to go 4 USMLE..hav not much idea abt da xam.iv evn posted a msg in dis forum for advice no replies however:-(ur post helped me how 2 go abt preparin for da xam.thanq so much.AS ur also a IMG i hav a question..did u do a clerkship here b4 goin 4 da test?hw much does it count in da future n if i have 2 do it how do i go abt it?pls help me

Last edited by harrie; 11-24-2012 at 08:28 AM.
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  #18  
Old 12-01-2012
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please I need Master the boards Usmle step ck2 and step 3 , I need it urgent, my email is dr_azeezah@hotmail.com , and I need any important notes for step 1 and step 2 ck
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