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.

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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.

 So what do you do on the day of the examination? The day you sit for the USMLE is the culmination of months of preparation. It may seem unfair that no matter how well your performance were in those countless q banks and test simulation, the only performance that really counts is the one you do on exam day. Therefore, it makes sense to maximize your chances of performing well for that date.

 Your preparation should begin way before the date of your examination, when you schedule the examination. It is a known fact that during review, people do reach a plateau and the best time to take the exam is just before or just after you reach your peak. Earlier or later than that can result in lower scores. When you review, immediately after learning and memorizing your lessons, you immediately start forgetting. Normally, the amount of medical concepts you are memorizing and retaining is growing faster than you are forgetting them. However, there comes a time when you reach your peak and eventually plateaus. Afterwards you will go into decline and forget more than you are learning. Most people go into plateau in about 6 to 8 months, therefore the ideal review time is around that long. That is why my prep course is around 6 months long.

 The next question you have to ask yourself is when do you actually stop studying? Some make the mistake of studying right up to the night before the exam while others start relaxing  two weeks before the exam.

 What’s wrong with studying up to the last minute? Well to illustrate, imagine a marathon runner who the day before the marathon decides to do a marathon to see if he can win the marathon. The USMLE is an exhausting exam that will test your stamina  to the limit. Anyone who has taken the exam can tell you that their brains felt like mush and refuses to function properly in the last 2 blocks of the exam. I know, mine did. Therefore, it makes sense to rest as much as possible the day before the examination to regenerate your energy for the battle ahead. In fact I recommend to stop studying 2 days before the actual examination day.

 Now if resting is good, why shouldn’t I rest 1 week or two before the exam. Again, let’s use a sports example to answer this question. Professional boxers usually arrive a week or 2 before the bout to the venue where the bout will be held. By this time they’ve already finished their training. Any boxer, who has not finished training for the bout by that time is bound to lose the fight. And yet instead of painting the town red, they spend their time in the gym, practicing and sparring. The reason is so that they can maintain focus on the bout itself. Losing focus this late may mean losing the bout. The same holds true with preparing for the USMLE. The problem most old grad have is to start their review. They usually go through lots of false starts before their review start going smoothly. The main reason is that it’s been too long since they’ve studied and there are lots of things going on in their life that its hard to focus on the prep. Getting distracted and losing focus too early before the exam can cause you to perform at less than peak condition in the examination. You need to block off everything until you’ve finished the exam.

 So what should you be doing 1 to 2 weeks before the actual examination? Well definitely you should have finished the heavy lifting and not studying anything new. The reason is that your mind will tend to remember better the most recent things you have studied and if that is low yield new stuff (presuming you studied the higher yield stuff first), that is what you will remember better and unfortunately has less chances of appearing in the exam. Therefore the best thing to do at this point is try to cover the highest yield stuff. If you are in my course, you would be enrolled in the High Yield Fast Facts (HYFF) Course, a compilation of the highest yield test materials in electronic flashcard format. If you are reviewing on your own, you can use the Rapid Review section of First Aid at the back of the book. However, it is in table format which is less effective than in flashcard format. This way you remember the highest yield information best when you sit for the exam. (Did I mention that someone who got a 99/256 use my HYFF course two weeks before the exam? see here!)

 Another important thing to consider is how far you lived from the Prometric Center where you will be taking the exam. The exam is a high stress event. If you have to drive through traffic and you are 2 hours away, the stress can be tremendous. Worse, traffic may be unpredictable and you may get there late. In my case, I lived about 1 hour by car from the exam site. The route I have to travel is notorious for unpredictable traffic that could last for 2 to 3 hours. So instead of increasing my own stress. I booked myself into a hotel about 10 minute walk from the site the night before. I could take a cab (parking is also terrible) and be there in about 3 minutes including traffic light change. US$100, the price of one night in the hotel is small compared to the $800++ exam fees, $1000++ for books, qbanks, NBME, etc. and 7 months of prep time I had already invested so far. Cab fare is $5 plus tip. J

You can spend the last 2 days before the examination on anything to relax you. I watched a movie before my exam. A comedy, Ice Age 2. Then on the night before the exam, the most important thing is to get a good night’s rest. That involves a regular meal, not too heavy. Maybe a nice warm bath. Sleep early so you can wake up early. But do not take tranquilizers as that can cause you not to be in peak form the next day. Make sure everything you need is prepared beforehand. (Clothes, food, water, medicine, ID, Exam permit, etc.) Preparing it early in the morning just increases your stress level. In fact if you can prepare everything 2 days before so much the better.

 Remember, stress is additive. The examination itself is an extremely stressful event. Any other worries on the same day just adds to the stress. So prepare everything at least 2 to 3 days beforehand so that your only worry is the examination itself on that crucial day.

 Now a few things to remember on the day of the examination itself. The most important is to never leave a question blank. There is no penalty for a wrong answer. This is an MCQ exam and one answer is always correct. An unanswered question is a sure wrong, while a question answered even with a guess is a possible right. And just one additional right answer may mean the difference between a 74 and 75 or a 98 and 99. As sports great Wayne Gretzky said, “ You miss 100% of the shot you do not take.”

So what’s a method to make sure you do this. Well, you should allocate around 10 seconds per question to randomly pick the answer once your time runs out. At the two minute warning, it means you can randomly answer at least 12 questions. So if you have less than that to answer then you can start randomly answering the q’s that you have not finished. For example at the 2 minute warning, you have six questions unanswered. Continue answering as before, but at the one minute mark, just randomly guess an answer on the remaining unanswered questions.

Now for pacing in the actual examination. The best pacing schedule makes use of a couple of facts. One, you are more alert in the early morning than in the afternoon when the exam will have taken it’s toll. Therefore it makes sense to schedule more blocks before lunch. So 4, 3 would be good. For Step 2, no choice but 4, 4. Now you are sleepiest after lunch, because of the act of digestion, therefore schedule only 1 block after lunch then have a break afterward. Never take more than 2 blocks before you take a break with some food or sugared drink. Your sugar level starts falling after 2 hours (physiology of fasting) and sugar is the main fuel for your brain.

So best to schedule 2 blocks, 15 minute break, 2 blocks then 25 minute lunch, then 1 block, 10 minute break, then last 2 blocks.  (or 3 blocks if Step 2) You can take a break between the last 2 blocks if you feel you need it. Notice that the total break is 50 minutes. Reason is that the actual break will usually be longer than the time you scheduled it. Just logging in and out of the room will take 1.5 to 2 minutes. The rest room is usually two doors out (both the exam center in my home country and the one in San Francisco where I took Step 3 have the same layout. So I presume all Prometric centers have the same general layout) So you have to walk. If you just need a short break between blocks, just sit on your cubicle and rest for a minute or two before starting the next block. As I said logging in and out is a time waster.

Why create a study plan?

This is probably the question foremost in the mind of anyone who ever thought of tackling the USMLE. I remember when I was starting out, how this pre-occupied me a lot. Although studying for the USMLE is a big endeavor, studying how to study for the USMLE is no mean feat either. Just like an architect or engineer needs to plan out how to build a building before actually building it, we need to plan out how to prepare for the USMLE before we even begin studying.

Now some people can just jump right into reviewing and 3 to 5 months later take the exam and come out with a 99. I’m not one of those and so are I believe majority of those taking the USMLE. Some will start by applying and scheduling an exam 5 months later, only to find out that they’re not ready. So they extend their period of eligibility and still they’re not ready. Some will take the exam and fail or score so low that it amounts to the same thing. Some will forfeit the application fees and reapply later. Of those who do, some wind up getting good scores because they’ve learned their lesson and did better preparation this time, while for others the results are going to be poor because they did not change anything they’ve done before. Proper planning is crucial for proper preparation

Steps to creating a study plan.

Often, in forums, I’ve heard people refer to taking the USMLE in military terms. Going to War against the USMLE, they call it. Military generals never go to war without a thorough battle plan, that is if they expect to win and neither should you. We’ll be tackling this topic head on.

The Steps to creating a study plan are:

1. Determine your objective
2. Know thy enemy
3. Know the learning process
4. Know the components of a good study plan
5. Know the factors that can affect your study plan
6. Scheduling
7. Importance of sleep, rest and recreation
8. Putting it all together

Determine your objective.

Just like all battle plans, you start out with what is your main objective.

1. Is it to pass the exam?
2. Get an average score?
3. Beat the mean?
4. Ace it?

High scores isn’t everything in the match. But it can make up for other deficiencies in your resume, like less than stellar grades in medical school, older grad, lack of USCE, etc. Often you see people in forums posting their study plans and asking if it is enough, but enough for what. Determining your objective is the first step in assessing whether your study plan is adequate or not.

So how high a score should you aim for? Well, it is a universal truth that most people do not achieve what they aim for so it is a good maxim to aim high. In the Greatest Salesman in the World, Og Mandino stated that

“It is better to aim for the moon and hit an eagle then to aim for the eagle and hit a rock.”

If you aim for a 75 and fail to reach it, you are in trouble. If you really want a 99 aim for a high 99 so you have points to spare in case not everything went as planned.

One word about setting objectives is to never set it in stone. As you finish your study plan and even as you begin your studies, you may find that your objective may change. Either you’ve underestimated yourself and have found out that you could do better, or your situation’s change, (e.g. your wife gets pregnant or you got pregnant, lost your job, got promoted, etc.) Do not be afraid to reset your objective, just be aware how it will impact your over-all chance in the match.

We’ve often heard about how people downgrade their objectives when they are unable to follow through on their plans. But how often have you heard of people who failed to upgrade their objectives when presented with the opportunity.

In 1863, on the first day of the Battle of Gettysburg, when Gen. Robert E. Lee’s Confederate Army defeated the Union Soldiers defending the three ridges south of Gettysburg, Lt. Gen. Robert Ewell refused to take Cemetery Hill, which wasn’t part of the original Battle Plan, even though it was lightly defended at that time. On days 2 and 3 after Cemetery Hill was reinforced by Union troops, the Confederates made numerous charges to take Cemetery Hill to no avail. This led to the famous Pickett’s charge by 12,500 Confederate troops on the 3^rd day of battle which was repulsed by union rifle and artillery fire at great loss to the Confederates. By refusing to upgrade his objective, Gen. Ewell missed an opportunity that could have changed the outcome of the war and the destiny of the United States.

Know thy enemy.

Now like all good Generals, we have decided on our main objective for the USMLE. The next step is to study the nature of the enemy, only then can we know how to defeat it.

Now someone might say, why don’t you just post a study plan and like good soldiers we will follow them. Well that would be easier for me, but I doubt it will work or be effective for a lot of you. You see, a plan presumes that there is an objective, takes into account where you are coming from, your skills and particular strengths and weaknesses and your particular condition. A one-size fits all plan presumes you have the same objective, the same skill sets, the same background and the same prevailing environment which is just not true.

Now normally when somebody asks you how to go to Times Square, you presume he is somewhere in NY. But in the internet, the person may be in San Francisco, Baltimore, London, Karachi or even Manila. And the answer would be different in each case.

So too must your study plan be different depending on your particular circumstances. Just as a doctor tailor makes his treatment plans depending on your circumstances (child, adult, geriatrics or healthy, immuno-compromised, debilitated) we must tailor make our study plans accordingly. But just as doctors have treatment guidelines to guide them in formulating a good treatment plan, so too does this book attempt to provide you with guidelines on how to study to help you formulate a good study plan.

Now a thorough analysis of the USMLE even just Step 1 is impossible in a short article such as this due to its complexity. For those who want more details, refer to my post here and here.

However,  the strategies during preparation is more effective than those you employ during the examination and therefore it makes sense to fix these problems before the actual examination day.

The main challenge in clinical vignettes is to be able to diagnose the case as fast as possible. As a medical student, the way we learned clinical cases starts with a diagnosis, say Myocardial Infarction. Then we study the signs and symptoms that accompany myocardial infarction followed by laboratory tests that suggest or confirm the diagnosis. Lastly we study therapeutic interventions. That is how clinical vignettes are presented in Underground Clinical Vignettes, which is fine for medical students having their first taste of medical cases. Unfortunately for most people who are ready to take the USMLE, they’ve already gone through that process and will probably need only a short review and it will still not help them with diagnosing clinical vignettes. The reason is that clinical vignettes are presented the other way around with signs and symptoms as clues while you come up with the diagnosis.

Which is why when you start your clinical rounds, you are taught a good method for diagnosing cases which is through the use of differential diagnosis. Doing differential diagnosis is an effective way of tackling any clinical case and coming up with a diagnosis. But for the purpose of answering the USMLE clinical vignettes, it may not be a good strategy. The reason mainly being the extraordinary amount of time it takes to build and run through a series of differentials and come out with the diagnosis. The USMLE gives you around a minute to do that and still come up with an answer to the question itself. Don’t get me wrong, you need to learn how to do differentials to be effective in diagnosing clinical cases, but for the purpose of the USMLE, it is not enough.

You must be able to do what experienced clinicians usually do in clinical practice. It is called pattern recognition. Contrary to expectations, most experienced clinicians do not do differential diagnosis when they are faced with a clinical case, they recognize a pattern of signs and symptoms and jump to the diagnosis in most cases. However, it does not mean they do not know or never do differentials. For difficult and unfamiliar cases, they do revert to doing differentials, but since about 90 to 95% of clinical practice deals with common cases, they rarely do differentials in actual clinical practice.

So how do you get to the point of doing differentials to being able to do pattern recognition, reserving differentials for more difficult and rarer cases? For most clinicians, it is usually secondary to experience. After year of seeing thousands of cases, they can easily see the patterns of signs and symptoms that indicate a particular diagnosis. However, relying on pattern recognition alone in clinical practice can result in malpractice and even fatalities. It is one of the most common reasons why extremely competent and experienced doctors can fail miserably and misdiagnose cases. This is especially true in critical cases. For example, suspected cases of Acute MI must always be differentiated from dissecting aortic aneurysm. Failing to do so can prove fatal as in the case of actor John Ritter. I have a family friend who is a pediatrician who died of undiagnosed acute MI despite the fact that she was in the hospital at that time being treated for acute cholecystitis under the care of a team of physicians one of whom is the top cardiologists in my country.

Being able to use pattern recognition is also dependent on the prevalence of a disease in your practice. In the case of the USMLE, it also means how common a particular case will appear in the examination, i.e. how high yield that particular topic is, which is different for Step 1, Step 2 CK and Step 3. As I have stated in other posts, high yield topics in Step 1 includes cases which may not be common but illustrates important basic science principles. For example, oat cell carcinoma of the lungs is more important in step 1 than squamous cell carcinoma because oat cell carcinoma demonstrates the important principle of paraneoplastic syndrome. In Step 2 CK and Step 3, the reverse is true with squamous cell  carcinoma more important because it is more common.

Which is why, some of those medical questions asked during residency interview can be so ridiculous. In one interview, I was told to diagnose a theoretical case they will give me by asking relevant questions on history and physical examination findings. I was specifically told that this case is fairly common in the hospital and there is no reason that I would not have encountered this in practice. The case was a female, who had a prolonged partial thromboplastin time. Of course the first thing that comes to mind are intrinsic coagulation factor deficiency of which the most common is factor VIII. However, being female eliminates Factor VIII and IX. So I thought of anti-phospholipid syndrome. However, all other findings were normal, no history of thrombosis or even failed pregnancy. If I were probably a student without clinical experience and the interviewer had not emphasized it was a common medical condition, I would have run through all coagulation factors in the intrinsic pathway, all of whom are quite rare. So when he finally announced it was a case of factor XII deficiency, I can’t help but feel either he is very, very stupid, or very, very sadistic. Factor XII deficiency has an incidence of 1 in 1,000,000. Therefore, there will be at most 300 cases in the whole of US. Now even if all the cases is concentrated in Brooklyn, New York. 1 in 10,000 does not make it fairly common. However, the incident is not reflective of my competence as a physician, but on him and the institution he represents.

So, if you have extensive clinical experience and have been in practice for quite some time, you should have superb pattern recognition skills and minimal difficulty with clinical vignettes. If you are a medical student with very limited clinical experience, you may still be struggling with doing differentials and therefore, clinical vignettes can be a significant source of difficulty for you. Most people are probably somewhere in between.

The basis for both differential diagnosis and pattern recognition are what I call key words, or words that will evoke a diagnosis or a group of diagnosis for consideration. For example, given microcytic anemia, you will think about all disease process that presents with microcytic anemia. Then if you encounter a second key word for example blood loss or equivalents of blood loss (young women without iron supplementation or old guy with signs and symptoms of colonic CA, which can be +FOBT, alternating constipation and diarrhea or even a family history of polyps) this should evoke iron deficiency anemia. The presence of increased Hgb A2 should bring to mind thalassemia trait. In pattern recognition, you take in the different signs and symptoms and together you are able to pinpoint a specific diagnosis without going through the step by step process in differential diagnosis which is time consuming.

In the USMLE where you have limited time to make a diagnosis and then answer the question which is usually about pathophysiologic mechanisms or other basic science concept related to the disease concerned, doing differentials is too time consuming. In my own experience, I was doing pattern recognition in about 80% of clinical vignette cases, resorting only to differentials in less than 20% of clinical vignette cases. That can save an inordinate amount of time.

So what are the steps you can take to prepare yourself to better able to handle clinical vignettes? Actually we will follow the natural steps we take in becoming competent in handling clinical cases as we outlined above. However, we have to consciously drill ourselves using study tools instead of depending on time and experience to teach us the skill.

The first step is to know the signs, symptoms and relevant laboratory results that define a disease entity. In medical school, we usually encounter these as we study individual diseases in pathology and microbiology and immunology in basic science as well as in the clinical sciences. For the purpose of the USMLE, you need to accelerate the process. However, your only choice currently is to either make your own study tools, or use Underground Clinical Vignettes which at between US$ 16.95 to US$ 19.95 per book with a total of 9 books for Step 1 is quite steep and outrageously expensive. Which is why I am building a High Yield Clinical Vignette course in my prep site at http://prep.askdoc-usmle.com. As of this writing, this portion of the course is still being constructed. Look to my blog for future announcement. It will eventually cover over 900 disease process with their clinical description.

Therefore, I always make it a point to test their knowledge base first. This is usually done by testing them using straightforward questions that test knowledge and recall without the common tricks that accompany USMLE type questions.

Now as you may know, I have an online prep site at http://prep.askdoc-usmle.com.  The prep site contains all the courses available to course participants of my USMLE Step 1 prep course. There is a demo prep course for Review of Pathology which features the first chapter  out of 25 total chapters of Review of Pathology. It covers cell pathology. The online quiz is a straightforward quiz which directly tests recall and does not use USMLE type question. Do well there and it proves you do not have a knowledge base problem.

It is surprising though that out of almost 2 dozen people who had this problem and asked for help and was advised by me to take the test in order to evaluate their problem, only 4, yes 4 people actually took the test. That is quite bothersome and may explain why despite numerous articles I have written on how to prepare for the USMLE, too many people are still failing. It seems over 80% of people seek advice in order to confirm what they want to do rather than find out what they need to do to pass this exam. That is part of the reason that I prefer to just post articles rather than do one-on-ones as 80% of the time, people won’t follow my advise anyway and one-on-one advise is too time-consuming.

So how did the 4 who took the quiz go? Well if they had scored over 70% here, it means they have no problems with concepts or their knowledge base. between 60 to 70% means there are some problems with their knowledge although tough questions may be contributory to their low score. Anything below 60% means that they don’t know enough concepts to pass the USMLE.

Out of the 4, 3 got below 60%. The actual score was 2 with 50% and 1 51%. And these are people who have reviewed from 4 to 6 months already and was scheduled to take Step 1 in a month or so. The one who passed, scored a very high 80%, which means her main problem is really answering tough USMLE type questions rather than any knowledge deficit. It is for her that I started writing this answer which is now long enough to become an article.

I have yet to write an article dealing with Test Preparation or TP and answering USMLE type question is one of them. TP deals with all preparation to ready oneself for a specific type of examination. Preparing for essay or enumeration type questions is different from preparing for Multiple Choice Questions. Which is why Step 2 CS prep is so very different from the other Steps.

The most common reason for the increasing toughness of USMLE type question is the use of case-based questions or clinical vignettes. This is especially true for Step 1, primarily for those exam takers who lack clinical experience. These includes 2nd year medical students taking step 1 prior to going to third year and medical graduates of medical schools that provide little clinical training until internship or even residency.

To illustrate.

1. A patient was diagnosed with disseminated intravascular coagulopathy. The most characteristic laboratory abnormality for this condition is

A. increased bleeding time

B. elevated fibrin split products

C. deficiency of von Willebrand factor

D. increased plasma fibrinogen

E. thrombocytosis

Now instead if the question look like this,

1. A 45 year old female who was hospitalized for severe community acquired pneumonia, developed septicemia and hypotension on the fifth day of her confinement. Over the course of the next few days her condition worsened and was observed to have decreasing renal and hepatic function. She was bleeding from  the endotracheal tube, IV lines and foley catheter. She finally died of shock a few days later. At autopsy, microthrombi was found in the arterioles and capillaries of the brain, liver, adrenals and kidney. The most characteristic laboratory abnormality for this condition is

A. increased bleeding time

B. elevated fibrin split products

C. deficiency of von Willebrand factor

D. increased plasma fibrinogen

E. thrombocytosis

Even though the two questions are asking the same thing, the first question is so much easier to answer than the second one. In fact this clinical vignette is really a very straightforward one. To make this question tougher, instead of telling you the patient had pneumonia, I would just give signs and symptoms of pneumonia e.g. fever, rales, dyspnea and signs of lung consolidation. I would give a low blood pressure reading instead of saying she is hypotensive. I would give the results of BUN and creatinine tests as well as protime, etc. instead of decreasing renal and hepatic function. I would add a few  unimportant findings like normal triglyceride, numerically. This is how you get those kilometric questions that people are complaining about.

If you cannot answer even the first question, it shows a lack of knowledge of concepts being tested in the USMLE and there is no way you can answer the second tougher question, which is basically asking the same question except in a tougher way.

When I took my Step 1 in 2006, around half the questions were in the form of clinical vignettes. As I understood it, the USMLE will continue to increase the percentage of Step 1 questions in clinical vignette format. Therefore difficulty with clinical vignettes can impact your score severely.

The solution really is to be able to diagnose quickly that the patient has DIC and then to rephrase the question to: This patient died of DIC. What is the most characteristic laboratory abnormality in DIC, which is exactly how the first question is phrased. You would be surprised to know that many people have trouble doing that or was too slow to figure that out and fail the exam or get really low scores. There are various ways to remedy this and we’ll discuss it later.

Another common problem is the two to three-step thinking question. The two to three step thinking questions arose directly from the fact that the USMLE uses multiple choice questions. The weakness of multiple choice questions has to do with the fact that the answer choices themselves gives clues to the right answer. This is also the same reason for increasing use of distractors in the answer choices, which is the third problem we will discuss.

I was fortunate that I graduated so long ago that exams then not only use multiple choice questions but other formats as well. Fill in the blanks and Enumeration require you to memorize the concepts since if you did not memorize them you cannot answer those questions. The advent of multiple choice question only examination made full memorization unnecessary. You only have to be familiar with the concepts and you have a good chance of answering a multiple choice question since the answer choices act as hints to the right answer.

You could try this to see if you tend to do this. Whenever, you encounter a question, can you answer it immediately without looking at the choices or do you tend to look at the choice first before coming out with the answer. The more often you need to see the choices first to come out with the answer, the more chances you will fall victim to the two to three step thinking questions and distractors. In my Step 1, I tend to know the answer 70% of the time without looking at the answer choices. Which means I depend on the answer choices 30% of the time. I am not immune to distractors and two to three step questions so I got them right less than half the time. Which me give me average scores of about 80%++ right.