To further enhance the testing methods used in the Step 2 Clinical Skills (CS) examination, changes will be introduced in Step 2 CS for examinations and will be delivered beginning June 17, 2012.

The reporting schedule for examinees testing from June 17, 2012 through November 3, 2012 will be 2-3 weeks longer than . . . → Read More: Changes to the Step 2 Clinical Skills (CS) Examination]]>

To further enhance the testing methods used in the Step 2 Clinical Skills (CS) examination, changes will be introduced in Step 2 CS for examinations and will be delivered beginning June 17, 2012.

The reporting schedule for examinees testing from June 17, 2012 through November 3, 2012 will be 2-3 weeks longer than for examinees testing during other periods.

Below is the Step 2 CS Score reporting Schedule for 2012:

Changes to the assessment of Communication and Interpersonal Skills (CIS)
The CIS subcomponent of Step 2 CS has been redesigned to assess a fuller range of competencies.  The new approach divides communication skills into a series of functions. These functions have been further divided into sub-functions. Beginning June 17, 2012, the Communication and Interpersonal Skills (CIS) scale will focus on five functions:

1. Fostering the relationship
2. Gathering information
3. Providing information
4. Making decisions: basic
5. Supporting emotions: basic

Several additional functions are still under development; these include making decisions: advanced; supporting emotions: advanced; and helping patients with behavior change. A list of the functions and sub-functions is available.

Changes to the patient note
Also beginning June 17, 2012, a new patient note will be introduced. The patient note is completed by the Step 2 CS examinee after the encounter with the standardized patient. In the new note, examinees will continue to be asked to document relevant history and physical examination findings and to list initial diagnostic studies to be ordered. Examinees will also be asked to create a reasoned, focused differential (maximum of three diagnoses) listed in order of likelihood and to indicate the evidence obtained from the history and physical examination that supports (or refutes) each potential diagnosis. The new patient note provides examinees with an opportunity to document their analysis of a patient’s possible diagnoses. A sample of the new patient note is available for review.

Practice materials
Updated practice materials for Step 2 CS will be posted to the USMLE website in March 2012. These include the Step 2 CS Content Description and General Information Booklet, onsite orientation video, sample patient notes, and a simulation of the program for typing patient notes.

*You can also visit the ecfmg website for information on usmle news.

Related Posts:

• Askdoc’s USMLE Step 2 CS Prep Course Now Open for Enrollment

• Preparing for the USMLE Step 2 CS – Part III

• Preparing for the USMLE Step 2 CS – Part II

• Preparing for the USMLE Step 2 CS – Part I

• What to Study for the USMLE – Part I

• High Yield Concepts and the USMLE.

The USMLE Step 2 CS is probably the most neglected examination in the USMLE. It is usually taken as an afterthought, with very little preparation taken before the exam. And in relation to the other bigger exams, Step 1, Step 2 CK . . . → Read More: Askdoc’s USMLE Step 2 CS Prep Course Now Open for Enrollment]]> Click here to access Askdoc’s USMLE Step 2 CS Prep Course

The USMLE Step 2 CS is probably the most neglected examination in the USMLE. It is usually taken as an afterthought, with very little preparation taken before the exam. And in relation to the other bigger exams, Step 1, Step 2 CK and Step 3, maybe it is not as “important”.

Unlike its bigger cousins, USMLE Step 2 CS is a pass/fail exam. So performing really wells serves no other purpose than to feel good about yourself. Of course, over preparing can also insure that there is no chance you will fail. However, it is important to realize that although USMLE Step 2 CS is relatively simple, if you are unfamiliar with the methodology of the exam you can fail. For most AMGs this is not a problem since simulated patient exams are part of their normal curriculum. However, for most IMG’s it is a rather novel experience.

Therefore, the key to doing well in the Step 2 CS exam is to be so familiar with the methods that it becomes second nature to you. This includes doing a relevant medical interview, performing a focused physical examination and writing a legible and coherent patient note. All under time pressure. You also need to dress, act and speak in a professional manner. And all this takes practice.

The most important thing in preparing for Step 2 CS is practice. Practice, practice and more practice. Askdoc’s USMLE prep course currently consists of 30 practice cases that you can use to sharpen your mastery of the methods. An additional 30 cases will be finished in the next few days to bring the total number of cases you can practice on to 60.

You can use the course as a stand alone course for the USMLE Step 2 CS, or you can make use of the cases as additional practice if you are currently in another program. The price for 30 days access is reasonable at US$ 19.95. It is currently available at an introductory price of US$ 14.95 until June 30. If you want to check out sample cases you can go to the website and click on the sample cases section. You do not need to register to access the sample cases. If you want to enroll, you need to register first, then click on the course and enroll. You can pay for it via PayPal.

Click on the link to reach Askdoc’s USMLE Step 2 CS Prep Course.

Related Posts:

• Preparing for the USMLE Step 2 CS – Part I

• Preparing for the USMLE Step 2 CS – Part II

• Preparing for the USMLE Step 2 CS – Part III

We now come to Part III of our discussion on “Preparing for the Step 2 CS” In Part I, we discussed how to prepare for the medical interview part of the clinical encounter. In Part II, we discussed the physical examination part of the clinical encounter. We will now tackle the social aspects . . . → Read More: Preparing for the USMLE Step 2 CS – Part III]]>

We now come to Part III of our discussion on “Preparing for the Step 2 CS” In Part I, we discussed how to prepare for the medical interview part of the clinical encounter. In Part II, we discussed the physical examination part of the clinical encounter. We will now tackle the social aspects of the clinical encounter which is usually called bedside manners.

We can further divide the social aspects of the clinical encounter into two. Those that you do in every clinical encounter and those that you do in specific situations. We will start with the first one.

So what are the things you do in every clinical encounter?

When you are at your station, the doorway will contain the name and chief complaint of the patient inside. Take note of it, writing it on the upper right side of the page so you do not forget the patient’s name or get it wrong. Knock on the door, then open it. Greet your patient. Use good day or hello, rather than good morning or good afternoon to avoid making a mistake (wrong time of dayJ) Introduce yourself. It’s best to be formal like ” Hello, Mrs. Jones, I’m Dr. Uy, How may I help you?”  Then followed by a question. Other variants could include, “What brings you to the hospital today?” or ” What seems to be the problem?”  Try to use the phrase that is easier for you to pronounce.

If you got a patient who likes to joke and answers “The bus” or “by cab” when you ask them what brings them to the hospital today, Just give him or her your widest smile and rephrase the question, like “How can I help you today?” You should not ignore them, nor join in the joke but keep the interview going in the right direction.

Now where do you position yourself for the interview? It is important to make sure that you face the patient as much as possible during the interview. It is also important that you are either at the same level as your patient or lower. Usually the patient is sitting on the examination bed and it is alright to be standing up as you will be level with them. However, occasionally they’ll be sitting in a chair and it is advisable then to sit down too. Always look at them when speaking to them and do not let your eyes wander around as that is impolite. Avoid any situation where you tower over them and they are forced to look up at you as that is considered impolite. The only exception is during the physical examination when they are lying on the examination bed.

It is good practice to ask open-ended questions during the interview. The main reason is that, by asking open ended questions, the patient will volunteer information you might miss if you answered close-ended questions that could be answered yes or no or with short answers. For example, it would be better to ask her  “Could you describe the pain?” rather than ” Is the pain throbbing or stabbing?” etc. Only when she gives a vague answer, do you ask more close-ended questions. Although, I’ve read in some forums about patients going out of tangent when asked open-ended questions, my own experience is that they are professionals and would not deliberately waste your time by giving irrelevant long winded answers.

Never, hurry the patient, nor cut them short in their answers as that is rude and impolite. In the exceptional case where you have a patient who is giving you the run-around with their answers, then gently tell them that you would like to know more about this particular illness. Remember, in all probability when they do that, it is part of the test to see if you can recover gracefully when a patient starts talking about things irrelevant to their presenting case.

It is very important to show care and concern for the patient and empathize with them. For example, if the patient said something like, their parents had died, you should say ” I am sorry to hear that.” Or if they said that they missed playing golf because of their current ailment, you can say ” well, we’ll try our best to make you better, so you can go right on back to doing the things you like.”  There are a lot of other situations that can happen and we will talk about them in detail and the proper responses you can take later.

It is also very important to give proper medical advise when the patient gives you information about them. Example includes, smoking, drinking, safe sex, contraception, child safety, etc. We will discuss in more detail under specific circumstances. Now the question arises, when do you give medical advise? Although some people prefer to give it before closing the interview or even after the physical examination, personally, I think it is best to do it immediately after such condition comes up in the interview. For example, if the patient mentions she smokes, then give counseling immediately. The reason is so that you get the easy points immediately. If you wait for later, you risk the chance of forgetting or running out of time and lose easy points.

Throughout the interview process, it is important to use transitions sentences not only to ease the conversation along, but as a means of building rapport and showing concern for the patient. For example before proceeding with LIQORAAA, you may say, “I’d like to ask you more about your present problem, is that alright with you?” When transitioning to the Past Medical History (PAMHUGSFOSS), you can ask ” I need to know more about your past to better understand your current illness, is it OK if I ask you some questions?” Now, when going into the Personal and Social history as well as sexual history, you can say ” I am going to be asking you some personal questions about your lifestyle and sex life, is that alright?”  Doing these are just being polite. Now in real life, you will have patients who will object, but the simulated patients will always say yes. Even the supposedly depressed patient I had said yes, when I was expecting him to object.

Now the biggest transition is when you finish the clinical interview and would now be proceeding to the physical examination. It is important to take this opportunity to ask the patient if he would like to tell you anything. You could say something like this ” I am now going to examine you physically in a little while, is there anything that you would like to tell me, or I may have missed about your current condition?” Sometimes, you may be surprised when the patient gives you additional information you forgot to ask. You can then continue the interview a little while to make sure you completed the information. Now, if the patient says that you’ve covered everything, say “Thank You for your cooperation, I’ll just wash my hands and we’ll start the physical examination”

Now we come to the issue of hand washing. Now the question is, which is better, to wash your hands or to wear gloves? You will read in a lot of forums that people to chose to wash their hands because it is faster. However, in reality it isn’t and the time difference is not too much if you are experienced in wearing gloves. I wore gloves in all my cases.

Don’t get me wrong I started out with the intention of washing my hands. However, I took my CS on March in Los Angeles and the weather was quite cold. Being from a tropical country, I started peeling. It was especially bad on my hands. It was actually embarrassing as a co-examinee tried to wipe away what he thought was a piece of tissue from my cheek. Instead it was actually skin peeling. And so washing my hands would not only make it worse, but some parts of my hands were raw and my fingers bled easily with minimal trauma. So I wound up wearing gloves instead.  So instead of being tied to the sink, I would be walking back to the patient, giving him instruction on what to do while putting on the gloves.

Now, washing your hands also takes up a lot of time. First you wet your hands, then you put on soap. Next you have to wash off the soap completely. Then you have to dry your hands. Plus your hands will be cold and you need to warm them before touching the patient. That takes time. Some people advocate to just simulate the handwashing, Barely wetting your hand. Letting the soap fall to the sink instead of actually soaping your hands. Then wet your hands again, so it is easy to dry off. That will save time. But I do not know if they take off points if you do that.

But taking off the gloves again takes time, you say. Not really, in one case, I took the glove with me right out of the examination room and left it on the table while writing the patient notes. The proctor actually told me to just leave it on the table. So take it off only if you have time. If not just walk out with it.

Now what do you say to the patient in the moment that you are washing your hands or putting on your gloves? The silence can be awkward so it is better to fill it with conversation. If the patient is on a chair you can instruct him or her to sit on the examination bed. Most of the time, the patient will be on the examination bed and you can use the time in small conversation to increase rapport. For example, if the patient tells you he likes to play golf, ask what his handicap is. Or if she talks about her grandchildren, ask her how old they are and how they are doing.

We will continue next time on social manners during the physical examination including the all important draping procedures. We will then cover specific situations during the clinical encounter and what you should do about them. Then to patient notes.

Related Posts:

• Preparing for the USMLE Step 2 CS – Part I

• Preparing for the USMLE Step 2 CS – Part II

• High Yield Concepts and the USMLE.

We now come to Part II of our discussion on “Preparing for the USMLE Step 2 CS”.  In Part I, we discussed how to prepare for the medical interview part of the clinical encounter. We will now tackle the physical examination part of the clinical encounter,

To answer the first question on a . . . → Read More: Preparing for the USMLE Step 2 CS – Part II]]>

We now come to Part II of our discussion on “Preparing for the USMLE Step 2 CS”.  In Part I, we discussed how to prepare for the medical interview part of the clinical encounter. We will now tackle the physical examination part of the clinical encounter,

To answer the first question on a lot of people’s mind. No, you should not do the physical examination while conducting the medical interview. Not only is it rude, you miss the opportunity of building rapport with your “simulated patient”. A question your “patient” is asked is if they would want you to be their physician and depending on the source could be an additional 1 or 2 points for you.

Next, you need to be able to write down the information in the medical history on paper or risk forgetting it. However, it is unsanitary if you have washed your hand or wear your gloves to examine the patient and hold the paper and pen at the same time. Third, you don’t have time to do a complete physical examination and a good clinical history can point you to what areas to concentrate your examination on. Last, unless you are really good at multitasking, doing both at the same time can distract you and lead you to do things less than perfect. Remember, you are being judged on the process, and not the result. By doing them separately, you are better able to concentrate on doing each of them correctly.

That is not to say that you cannot ask questions you forgot to ask in the medical interview during the physical examination part. If you realized you forgot to ask something, by all means as them as you do the PE. If it’s short and not too many, you could just try to remember it and write it down later. Just don’t make it your standard operating procedure.

There are a couple of issues we have to tackle when you do the PE part. If the patient has a particular complaint focused on a particular system, then you should do a thorough examination on those part. However, you should not forget to the following in all your patient regardless of the chief complaint or other complaints that you were able to gather from the interview.

Always listen to the lungs. You don’t have to do a full PE of the lung unless the patient had any respiratory related complaints. Just listen to the six areas at the back and at least the two area in front below the breast. (The middle lobe of the right lung can only be heard in the front of the chest while the posterior lobe at the back.) Then always listen to the 4 auscultatory areas of the heart corresponding to the 4 valves. You should always make sure you do a complete PE on those parts that corresponds to your patient’s chief complaint and other complaints. For example if your patient complains of abdominal pain, you should auscultate, inspect, percuss and palpate all four quadrants of the abdomen.

What if you have a patient with vague, generalized systemic complaint, like fever, myalgia, etc. Or coming in for pre-employment or annual physical examination? How should you conduct your PE. If the patient has no localized complaint, these are the minimum examination you should do. First examine the conjuctivae, sclera for icterus then pupillary reaction to light. Examine the mouth for erythema, (say aaah) then just rub your fingers near their ear and ask if they can hear the sound. Palpate the lymph nodes on the submandibular, anterior and posterior triangle area including the posterior auricular area. Listen to the lungs and heart as mentioned above. Do percussion and palpation of the abdomen. You may cursorily inspect the extremities. That’s it.

Here are some tips for specific parts of the examination that you should take note of.

Ask the patients to look at a spot far behind your shoulder when you are testing the pupillary light reflex and not to look at the light. Make sure you dim the lights.

Tell the patient to stick out his tongue and say aaah aloud when examining his throat not when examining the oral cavity.

When palpating the lymph nodes, stay on the patients back and use both hands to palpate both sides simultaneously. Start on the submandibular area, palpating down the anterior triangle up to the clavicle, then the posterior triangle until the posterior auricular nodes.

When using the stethoscope, make sure it’s warm. Use your hands. You can place the bell of the stethoscope in your pocket to keep it warm. Your patient will appreciate it. Also, always make sure the bell or diaphragm is touching bare skin and not pieces of clothing because that will cause you extra points.

When examining the abdomen, remember that unlike all the other parts of the body, you should start with inspection, then auscultation, then percussion and lastly palpation. The reason is that any manipulation of the abdomen can alter the bowel sounds, so you should do the auscultation first. Another thing to note while doing the abdominal examination, is to ask tha patient to pull up his knees and rest his feet on the bed. This is to relax the abdominal muscles for palpation. You lost points if you forgot to ask the patient to do this.

Two more points, when eliciting Murphy’s sign, place the tips of your fingers just below the costal margin on the right. Just place them gently. Do not dig them in. When specifally percussing and palpating for the spleen, ask the patient to roll onto his right side and palpate the left side of the abdomen, not just the front left.

Additional general tips.

Try to come up with a sequence that minimizes the effort of the patient like sitting up, lying down and removing their gown. Group examinations together so the patient only sit up, lie down and remove parts of their gowns only once.

Make sure the patient is covered at all times. Practice draping techniques until it becomes second nature to you. You could lose points doing this poorly.

When you palpate the patient, palpate gently even if you need to do deep palpation. In fact just touch them while telling them loudly that you are palpating their liver, etc. They will appreciate it. This simulated patients have to endure from 12 to 24 clumsy examiners everyday. 5 days a week. You could imagine how you feel if that were you. So be gentle,

Always make sure the light is dimmed when you do any eye examination that requires response to light.

If you see something marked on the skin of the patient do not ignore it. Usually, their make-up department does a good job of simulating bruises, although not always. For example, patient had linea negra on her abdomen, However, I wasn’t sure if there was any attempt to simulate a CS scar. So I asked the patient if she had undergone CS while pointing to her abdomen. She looked at me askance and said it was normal. I shrugged my shoulder and proceeded. As I said, they may try to simulate certain signs and symptoms and may not be that accurate. For example, a supposedly inflammed knee looks like a painted knee.

Now this covers our discussion on physical examination. We will discuss next the social aspects of the clinical encounter, then on to the patient notes.

Related Posts:

• How to Create a Study Plan for the USMLE

• Answering USMLE Type Questions – Part I

• Preparing for the USMLE Step 2 CS – Part III

• Preparing for the USMLE Step 2 CS – Part I

• What to Study for the USMLE – Part I

For the past few months, I’ve written articles that deal with all the different Steps except for Step 2 CS. So this will cover preparations for Step 2 CS.

Like most IMGs, I felt really anxious preparing for the Step 2 Clinical Skills. This was primarily due to the novelty of the examination . . . → Read More: Preparing for the USMLE Step 2 CS – Part I]]>

For the past few months, I’ve written articles that deal with all the different Steps except for Step 2 CS. So this will cover preparations for Step 2 CS.

Like most IMGs, I felt really anxious preparing for the Step 2 Clinical Skills. This was primarily due to the novelty of the examination method. (simulated patients, etc.) Although, we had a type of clinical skill exam in training, we had actual patients which we examined rather than a simulated patient and what was graded was more on did we get the diagnosis and treatment right, rather than how we did the interview or physical examination. In other words, on the results rather than the process.

Meanwhile for AMGs they feel the whole exercise is a waste of time and money, since simulated patients are part of their normal curriculum. Which of course makes this exam to them just another exam they’ve done countless times before.

It is important to realize that in Step 2 CS, unlike all the other steps, the process is more important than the result. How you do the interview, your physical examination and a good differential is more important than nailing the diagnosis. In fact you will encounter cases where there is no clear diagnosis.

In my own exam, of the 12 cases I encountered, 4 had clear-cut diagnosis, another 4 had less clear cut but highly probable diagnosis, while 4 others have no real diagnosis and could be any of the differentials. You could imagine how disconcerting it was to encounter the latter as my first case. I ran into overtime and it was only after the 4th case when I encountered another case with no possible specific diagnosis, did I realize my first case did not have one either.

In forums, you find people asking whether using USMLE World is better of First Aid. For me (I used both) either one will do as well. What is not needed is the really expensive Step 2 CS course of Kaplan. USMLE World has more cases than First Aid but what is more important is to practice the cases in real live format. The process must be second nature to you as in the actual examination, with the pressure to perform well in limited time, you have no leeway to make too many mistakes or to call a time out to rethink your approach.

So how do you practice for the clinical encounter. Well, the clinical encounter can be divided into 2 major parts. The clinical part and the social part. The clinical part can be further divided into 2, which is the medical interview and the physical examination. The social part has to do with bedside manners like greeting the patient, introducing yourself, washing your hands, etc. The social part must be intertwined with the clinical part and done while doing the clinical part. We will first discuss the clinical part, then list down all the things you need to do in the social part and when we should do each of them in the clinical part of the encounter.

The 2 most important thing to remember during the medical interview are LIQORAAA and PAMHUGSFOSS. Although some of you may know about this already from the different forums and prep courses, I would like to emphasize its importance. You not only have to know them, but you must be able to do them in your sleep. When I forgot what to do or somehow went astray during the clinical encounter, LIQORAAA and PAMHUGSFOSS keeps me focus on what I need to ask even if all the patient answers is I don’t know or normal. So what does this two acronym mean.

First, LIQORAAA is done when discussing the History of Present Illness. The chief complaint is already given on the door before you enter the room (although you still have to ask, “How can I help you today?” ” Or “What seems to be the problem”)

L = Location of symptom (e.g. stomach, head,etc.)
I = Intensity of symptom (e.g. mild, moderat, severe, or scale 1-10)
Q = Quality of symptom (if pain, pulsating, throbbin, burning, sharp, etc.)
O = Onset of symptom (when it started, continuous or intermittent, etc.)
R = Radiation of symptom ( to other parts of the body – jaw, leg, etc.)
A = Associated symptoms (shortness of breath, palpitation, fainting spells, etc.)
A = Alleviating factors ( rubbing makes it better, burping relieves pain,  etc.)
A = Aggravating factors (walking makes it worse or starts the pain, etc.)

Use PAMHUGSFOSS to finish the rest of the interview.

P = Past Medical History
A = Allergies
M = Medications
H = Hospitalizations – previous illness, surgeries
U = Urinary complaints (polyuria, dysuria, etc.)
G = Gastrointestinal complaints (change in diet, bowel movements)
S = Sleep habits – any changes, insomnia, early morning awakenings, etc.
F = Family history of any illnes, esp. similar to chief complaint
O = Ob/Gyne history (females only) like LMP, parity, abortions, etc.
S =  Sexual History (preferences, activity, STD, etc.)
S = Social History – occupation, tobacco, alcohol, etc.

It is best to practice this multiple times, coming up with actual questions for each part until asking them becomes second nature to you. For example, for medications you can ask “Are you currently taking any medications or drugs?” For allergies, you can ask “Have you ever had an allergic reaction to any food or medication before?” It is important to choose words that are easy for you to pronounce and sounds natural for you when you enunciate them.

You can also skip some of the letters as needed. For example, no need to ask Ob-gyne history if patient is male. Also, you should be flexible enough depending on the case. For example, if the chief complaint is diarrhea, obviously intensity would be more of amount of diarrhea and frequency rather than the level of pain. Plus an associated symptom like abdominal pain, may deserve its own LIQORAAA.

We will deal with physical examination, social aspect of the examination and the very important patient notes next time.

note: Part II on physical examination and Part III on bedside manners now available.

Related Posts:

This is a really big topic and would probably take at least a dozen posts maybe even two to finish. However, we have to begin somewhere. This is actually the most common question asked in forums. When people ask whether First Aid is enough, should I do Q Banks, do I need Goljan, . . . → Read More: What to Study for the USMLE – Part I]]>

This is a really big topic and would probably take at least a dozen posts maybe even two to finish. However, we have to begin somewhere. This is actually the most common question asked in forums. When people ask whether First Aid is enough, should I do Q Banks, do I need Goljan, etc. the question they are really asking is, what should I study for the USMLE. When they scour through exam experiences in forums, spend money on bootlegged CDs or DVDs or decide whether to use the extremely expensive UCV (you know its my pet peeve ), etc. what they really are concerned about what to study for the USMLE.

The USMLE published guidelines on exam content just adds to the confusion as the list is so comprehensive that you’re better off opening your medical textbooks and starting from there. Then, there’s the occasional low yield question not found in textbooks like the PARKIN gene or HPV vaccination that can only be found either in journals or by searching the Internet.

So in come the reviewers. At first, I shied away from writing about what to study for the USMLE due to the abundance of reviewers. However, I’ve come to realize that the sheer abundance of review material is itself becoming a problem as the poor examinee struggle to decide what review material to use. As it is impossible to go through all available review material (that would be worse than going through textbooks for everything), deciding what to use is becoming a major issue. Even if the examinee knows what he is looking for in a good reviewer (you’d be surprise that a lot do not), he needs to be able to read them first before knowing if its any good, which of course brings us back to the problem of having to go through everything.

Then come reviews of different review materials as pioneered by First Aid and the forums, where examinees ask other examinees what reviewers they should use. Of course, that is still a problem, since all First Aid does is give a rating on reviewers without saying how the rating is done. So it works for some but not for others. Meanwhile, most advise in the forums come from people who have only used one reviewer and in reality is not in the best position to give comparative reviews. Plus different people have different objectives and different criteria on what constitute a good reviewer and so compounds the problem and adds to the confusion.

I’ll try to come up with some guidelines on how to pick the reviewer that is right for you. Plus, I’ll be covering some review materials, of course separately for Step 1, Step 2 CK, CS and Step 3 and their pros and cons. This is a very large topic and I don’t claim to be the expert or have the last word on the subject, but I hope I can help you get off to a good start.

Deciding what to study should be part of your study plan. And as I said in my ebook about “How to Prepare a Study Plan for the the USMLE” (download here) the first thing you need to decide is your objective. Your objective determines what you need to study for the USMLE. What you need to study if you want to just pass the USMLE is different from what you need to study if you are aiming for a 99. So asking around in forums is a bit futile, as depending on the objective of the advice giver, their advice may or may not be suitable for you. When I posted my study advice in prep4usmle (“What to do?”) some people felt that some of what I recommended was overkill, and they were right if you where just planning to pass the exam, but not if you were aiming high. So advice are only just as good as the objective on which the advice is based.

In order to follow the discussion, you need to know what you need to study to score high and what you need if you just want to pass. Please read my posts on “High Yield Content and the USMLE“, “Mastery, Know and Familiar in USMLE Content” and “Mastery, Know and Familiar applied to USMLE review” before continuing if you haven’t read them yet.

The most complete source of concepts are textbooks, which contain most of the concepts tested in the USMLE both high yield and low yield and in the right amount of details needed to master them. If you just want to pass the exams, then study the high yield stuff. However, the question arises, what are considered high yield concepts? The next question, is what concepts do I need to Master, know or be familiar with. Although some really good students are able to judge accurately which concepts to concentrate, unfortunately many do not.

I remember in medical school, during lectures, there was a mad scramble to take notes, with tape recorders overflowing the lectern. Eventually it was agreed that one tape recorder will be placed on the lectern, the notes transcribed and we will just pay to have it photocopied. In fact, the notes were very complete and done professionally. However, before long a lot of us opted to photocopy instead the more incomplete notes written up by a classmate, who eventually became our class valedictorian. Her notes, were incomplete, but you can bet that what she wrote down has a high chance of appearing in the exams and what she did not usually did not. And she always got it in the right amount of detail. So we actually preferred her incomplete notes to the more complete ones. We substituted her judgment for ours, because she is just that much better at it.

So all those review materials we are using are actually a form of substituted judgment, even the Q Banks. We use reviewers to find out what other experts consider high yield and study them, using their judgments instead of ours. Of course, the question is, how reliable is their judgment and second what is the basis for their judgment. For example, First Aid is quite reliable, except their objective is to help you pass the exam, not to ace it, therefore if your goal is to score above average or ace the exam, you just chose the wrong reviewer. First Aid contains most of the concepts tested in the USMLE, both high and low yield, however, it does not contain enough detail for you to master those concepts and you need to do that if you want to score high.

So it is important for you to first decide what is your objective in the exam, and find reviewers that will help you achieve that objective. For example boards and wards, secrets, high yield series, etc. cover only high yield stuff, mostly in minimal details, good enough to pass but not good enough to score high or ace the exam. You read in forums, people recommending materials as good if they’re short and not too detailed and bad if they are long and quite detailed. Such recommendations reflect their own objectives for the exam and you should carefully examine whether such recommendation should apply to you at all depending on your objective. If you just want to pass the exam, recommendations by most real 99ers (I don’t doubt that there are a lot of fake ones) will usually be a bit of overkill.

We will discuss the ideal criteria for choosing reviewers depending on your objectives next time. The criteria are different if you just want to pass, you want to score above average or you want to ace the examination.

Related Posts:

• What to Study for the USMLE – Part II

• Why You Need Three Phases in USMLE Prep – I

• NBME Self Assessment Tests and USMLE Review

• How to Create a Study Plan for the USMLE

• Answering USMLE Type Questions – Part II

• Guide to Self-Evaluation in USMLE Prep

• What to Study for the USMLE – Part IV

“Study the High yield stuff”. “Don’t bother with that because it’s low yield”. When I was just starting my review, these are the most common advice I get from “experts” in forums and books about reviewing for the USMLE. The question is how good is this advice. If you are just aiming to . . . → Read More: High Yield Concepts and the USMLE.]]>

“Study the High yield stuff”. “Don’t bother with that because it’s low yield”. When I was just starting my review, these are the most common advice I get from “experts” in forums and books about reviewing for the USMLE. The question is how good is this advice. If you are just aiming to pass the exam or get average scores, it is very good advice, but if you are aiming to ace the exam then watch out as it could bite you.

First, we must understand that Medicine, whether Basic or Clinical Science is a very vast field with many important concepts necessary for its practice. It is so vast that medical specialties arose because it is impossible for any one person to know everything. However, the USMLE has to be able to assess if you know enough about Medicine in 350 q’s or so per Step. Therefore, certain concepts will be more commonly tested than others will and high yield concepts will be tested more often than low yield ones.

However, although a high yield concept will appear more often, it is not 100%. On the other hand, many low yield concepts will probably not appear in the exam but again it is not 0%.

To illustrate, for example, say for Step 1 there are 3000 medical concepts that can appear in the exam. (The USMLE has a list of topics that can be tested in the exam) Let’s say about 200 concepts can be considered high yield, 400 concepts medium yield and 2400 concepts low yield. (These are not actual figures, just used for easier illustration and dividing concepts into high, medium and low yield is arbitrary but again needed for illustration purposes)

Out of the 350 q’s in step 1, let’s say around 140 will consist of high yield questions. Therefore, 140 of the 200 high yield concepts will appear in the exam giving each concept of a 70% chance of the question appearing in the exam. Now the next 100 questions will feature the 400 medium yield concepts giving a 25% chance of that concept appearing in the exam. If it takes an hour ( a day, a week or a month, whatever) for you to study 200 concepts, it is better to spend that hour learning high yield stuff as you can get 140 q’s correct, while studying medium yield stuff for the same time interval will get you only 50q’s (100 concepts divided by 2). And so it goes down the line.

Therefore, it does make sense to study high yield stuff. And if you just want to pass or get an average score, this is the best approach. Remember not all high yield stuff will appear in a specific set of exam. However, for any large group of examinees, all the high yield stuff will eventually appear in the exam. On the other hand, low yield topics will not appear all the time, but some of them will show up in the individual examinations. If you want to score high, you not only have to know all the high yield stuff, but every low yield stuff you know will be crucial to scoring high.

Further example. In Step 1, anatomy is considered low yield stuff. Why? Because although the subject is vast with lots of information to memorize, probably only 15 to 20 questions will appear in the exam, making it low yield. But 15 to 20 questions still count to your score and it may mean the difference between a mid 90′s vs. 99 or even low 99 vs. high 99.

Of course, it does not make sense to fill your head with low yield concepts at the expense of high yield stuff. There is a danger of failing the exam altogether if you do this. If you lack time for review, or have a poor memory, you should stick to high yield stuff. But if you have time and good memory and really want to score high, then go for the low yield concepts too, so long as you make sure it is not at the expense of remembering the high yield concepts.

Most reviewers contain only high yield stuff, therefore is ideal for people who only want to pass or get average scores. Textbooks have both high yield and low yield stuff, but also too much low yield stuff that won’t ever appear in the exam. Remember, USMLE will have to come up with questions even for low-yield stuff and therefore it does not have an endless pool of questions. Some concepts will be too obscure or specialized to ever be tested in the USMLE. There are very few reviewers that contain not only High yield stuff but enough low yield material that it is possible to use them to ace the exam. Usually the only way to ace the exam is to occasionally go to textbooks or for pathology, listen to Goljan’s lectures.

Now one of the reasons USMLE World Qbanks are more difficult than Kaplan’s (though not the only reason) is because UW tends to test more low yield concepts, correctly guessing that most people have reviewed the high yield stuff already and need to be drilled more on the low yield stuff to score high. I will talk on the difference between UW Qbanks and Kaplan Qbanks in another post.

So in conclusion, if you just want to pass the exam or get average scores, stick to high yield concepts. If you want to ace the exam, learn as many low yield concepts as you can without sacrificing high yield concepts. Even among low yield concepts there are some more high yield than others. Example, brachial plexus in anatomy. If you have limited time, or you know you just can’t remember that much, then stick to high yield concepts, better to pass or get average scores than to fail.

Related Posts:

• How to Master the USMLE Step 1 – an Introduction

• Why You Need Three Phases in USMLE Prep – I

• NBME Self Assessment Tests and USMLE Review

• What are High Yield Topics?

• USMLE FAQ

• High Yield Fast Facts