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.

 In part 2, we discussed that the score you want to achieve not only dictates the review materials you choose, but also how much of those review materials should be mastered and not just read through. In part 3 we talked about the various materials you used for review and the need to go back to textbooks for concepts you do not know, since you cannot review concepts you do not know. You have to learn them first and you need textbooks for that.

 In part 4, we will discuss the two types of text reviewers you should be using for your review and how to use the concept of different types of recalls with the reviewers to maximize the amount of material you can store in your head for the exam.

 We know instinctively to write down notes when we attend lectures and even when we read textbooks. We know that not everything the lecturer mentions in his lecture nor all the concepts written in textbooks will come out in the examination. We also know that in order to retain concepts we need to revise them multiple times and revising whole textbooks or even whole lectures multiple times is not feasible.

 More so, if  we are dealing with board examinations where the amount of information you need to store in your head is literally tons more than the normal examination. Hence the concepts of study notes. Study notes are reviewers that are comprehensive enough to cover most of the concepts that will appear in the examination and yet are not textbooks. They are typically 25 to 40% the size of a typical textbook. They try to explain the concepts in more detail than most reviewers, however, not to the level of textbooks.

 As the name implies, you use the study notes primarily for studying without recourse to using textbooks, although there are exceptions. Therefore study notes must cover almost all the concepts that will appear in the examination. It must define most of the more difficult terms and concepts. It must give more exhaustive examples. It gives the most common causes and even the not so common causes. It contains interesting side notes that occasionally appear in the examination.

 An example of a study note in terms of scope of coverage is Kaplan Lecture notes although it has its weak points. And yet most people do not like to use it because its “too big”, “too much information”, etc. The NMS series are also study notes, although my main complaint with them is that they contain too many low yield topics that will never appear in the USMLE. Shelf exams maybe but never USMLE. The same could be said of reading textbooks, that is why even if you need to go to textbooks, you don’t read them from cover to cover, but use outline notes or even study notes to guide your reading.

 Levinson and Jawetz is a good study note for Microbiology and Immunology which I consider superior to Kaplan’s Microbiology and Immunology lecture notes. Kaplan’s Step 1 Lecture notes are better in terms of coverage of what you need to know than their Step 2 CK Lecture notes. But the lack of good study notes for Step 2 CK (even more so for Step 3) makes them currently the only really good choice. Step Up Medicine, is also a study note and covers some of the weak points of Kaplan’s Internal Medicine notes, but it has its own fatal weak points. So using them together can make up for each other’s weak points. The only exception is in Obstetric and Gynecology where Blueprints is far superior to Kaplan’s notes. All the other Blueprints editions though is again too lightweight. Their main benefit seems to be their diagnostic algorithms of which there are many and particularly useful for Step 2 CK and Step 3. Recall series for Step 2 CK has broad coverage, but severely lacking in details. That is I think deliberate as they were made for the wards rather than the boards.

If the study notes cover everything you need to know for the USMLE why even bother with the outline notes? Most of the exams we have done usually involves part of a subject or in the case of shelf exams, one whole subject. In most cases, although we try to store all the information covered in the examination in our brains, by the time the next examination comes, we can start to “forget” what was covered in the previous examination and concentrate on filling our brains with information on the next examination.

 In contrast, in the USMLE, you are required to keep in your head, information that took you 2 years to study for multiple subjects which you are not allowed to forget for the one day you will be sitting for that examination. There is just no way humanly possible to remember everything. Plus the exam is time-pressured such that you have barely a minute to extract those information, analyze them and come out with an answer, making it even harder since your brain has limited capacity in storing information in immediate recall.

 Therefore it makes sense to organize information in such a way, that you decide ahead of time what you should make sure to remember and never forget and information that you should also try to remember but is not as critical and therefore not as devastating in case you forget.

 The concept of the outline notes is to put information that are critical, and should not be forgotten for the examination for special attention. These are the so-called high yield information that are sure to be asked in the examination. They are a subset of the study notes. In other words, all the information in the outline notes can be found in the study notes, except that these concepts should be memorized and mastered more than the information not found in the outline notes.

So what information is left out of the outline notes? Well, of course lower yield topics that have a lower chance of appearing in the exam. Mind you some of them will appear in the exam, but most of them will not. Another thing is definition of terms. Certain terms once defined you should already know and don’t need to put into the outline notes. For example, Virchow’s node. Once you know it is a sentinel node that indicates visceral cancer, you don’t have to memorize the definition verbatim and therefore don’t need to know the definition by heart, just understand what it means. In contrast, the definition of Chronic bronchitis is exact and should be memorized verbatim, so the whole definition remains intact in the outline notes. Another good example is the Jones criteria for Rheumatic fever, everything verbatim.

 Now examples that illustrate concepts can also be safely left out of outline notes. You can have one or two examples leaving the more exhaustive list in the study notes. Most diseases have multiple causes, some more important than others. Again you may have an exhaustive list in the study notes, but the outline notes will contain only the most common ones.

 Another low yield info that is good to know, but need not be mastered are information that are usually used as clues in the stem, but will never be asked directly in the examination. A really good example are virus classifications and bacterial classification. People in forums often ask if they should bother to memorize the classifications of virus or bacteria. Well, you will never see a question in the USMLE asking you outright what the classification of the Hepatitis B virus is. However, they will be used as clues so you know that you are dealing with Hepatitis B and not Hepatitis C which has a lot of similar clinical features. However, as in most cases like this, you are given 2 to 3 distinguishing features and never just one so you probably can identify the disease based on the other features and not just on the viral classification. However, in case you forgot the other features, knowing the viral classification could save you. I can’t say how many times, knowing lower yield information usually used as clues in questions stems have saved me in the actual exam.

 We will discuss next time what are the different reviewers that can be used as outline notes and their strengths and weakness. We will also discuss how to put outline notes in immediate recall and the other information in aided recall to maximize the amount of information you can store in your head when you sit in the examination. We will also illustrate how study notes and outline notes that were specifically made to complement each other like in the notes being used in my prep course, differs from the commercially available reviewers that can be used as substitute and tweaks you need to make to insure that these commercially available reviewers can fit with each other better.

Broadly, we can classify our study materials into three. First are reading materials, mainly books and other written study aids, eg. Flashcards, etc. Second are Question Banks, which by themselves are very important and crucial study materials. Lastly and increasingly gaining importance are audio and visual resources like lectures both audio and video.

We can divide books into reviewers and textbooks. Simply, reviewers are for revising and textbooks are for learning. Often people complain of going through a reviewer and having a hard time remembering what they’ve read. They go through it a second time, thinking it’s a problem of retention (it isn’t) with the same disappointing result and poor performance in Q Banks. The problem is not with retention and recall but with understanding of the concepts. The right solution will be to go to textbooks. Reviewers assume you more or less know are familiar with the concepts and are just reviewing, so explanation of concept range from none to really succinct and concise explanations, using buzzwords and even acronyms. On the other hand, textbooks assume you know nothing and explain things in details. There are even complaints that textbooks tend to discuss the same concept in different parts of the same chapter, however, the main reason for that is that some concepts have slightly different importance in different contexts and the textbook is trying to make sure you understand that and leave it up to you (or your professor) to integrate the concepts.

It is maxim that you cannot review what do not know and therefore you cannot use reviewers to learn concepts you do not know. Learn them first using textbooks. Also you cannot use textbooks for revising because its too long. So the solution is to switch back to reviewers to revise the concepts once you’ve learned the concepts turning back to textbooks only if your understanding of the topic seems murky.

For most people, they can just pick up a reviewer, start revising and feel that there is no problem with their revising and that is probably true a lot of times. But sometimes, the problem is relatively small that they don’t feel the problem but actually enough to lower their scores a few points. So if you are going for a high score be aware of this. To illustrate, for example out of 100 concepts you need to know you don’t know more than half of it. So going through reviewers, you find it tough-going and have a hard time raising your q Bank scores, so you go through textbooks which solve your problem. However, if already learned 70% of the concepts and have problems with only 30%, your q Bank score will probably be good enough that you think you’re OK. In reality, if you’ve bothered to identify this 30% that you need to learn and went back to textbooks to actually learn the stuff before returning to reviewers, you would be scoring 90′s or even 99′s instead of 80′s. Even First Aid acknowledges this and asks its users to go to textbooks to “fill in” what they feel is missing in the reviewer.

And, to emphasize. I know textbooks are too large for revising and so after going through them to learn the concepts, GO BACK to reviewers to revise the material multiple times if required, but not afraid to go back to textbooks for concepts you remain iffy on.

Now reviewers themselves can be further divided into two types. What I call outline notes and study notes. Outline notes are shorter and more compact, while study notes contain more details. Good examples of outline notes are FA, HY and BRS. While good examples of Study notes are Kaplan Lecture notes, NMS, Blueprints (esp. OB-gyne, IM and Peds) and Recall series as well as Step UP.

The main reason we need two types of reviewers is the sheer amount of information we need to learn, retain and recall for the USMLE. In shelf exams, the amount of information you need to retain at the same time is smaller and therefore easier to manage.

In order to understand the need for both outline notes and study notes, we must understand how we retain and recall information we store in our heads. No matter how good your memory is, its capacity is finite. People differ in how much information they can absorb and retain and even differ in how fast they can absorb and retain information. So questions like is 3 months enough for revising has really no exact answer. You cannot increase your memory capacity, although you can improve the amount of material your memory can contain by organizing the information in your head. I wrote this in the comment section for someone who has problem retaining and recalling information and I am quoting verbatim

“The main reason you have problems with retaining and recalling information is that you do not organize the information you have acquired in your head. That is very important for good retention and recall. If you have not read my post on “Information Recall and the USMLE“, please read them first before continuing.

For some people, organizing information they have read or heard in their head comes naturally and without effort, just like me. However, for others it is far from natural and they need extra effort in order to do so. Most people can get through medical school with poor memory since the amount of information they need to retain per exam is small. But the boards is different and this weakness can be devastating.

A good metaphor is if you have around 20 items and you place them in a desk. Since the number of items are small, you can just place them anywhere and you can easily find them. But imagine if you have enough items to fill that desk 3 feet deep. If you just place them on top of each other without organizing them, you know that…

1. It’ll probably take you a long time to find any item you need, unless you’re lucky enough that it’s on top

2. That if any item got lost (it fell out of the pile) you may not even realize it.

3. That there is a good chance you will not find the item you need even if its in the pile because its just too disorganize

That’s the reason you get confused when you read other books, since they just make your pile deeper and more disorganized therefore more confusing. Doing qBanks and taking notes do not help much either because you’ll just pile those information into your head without organizing them into meaningful relationships for easy retrieval.”

That’s why superbly organized outline notes like BRS and Goljan Rapid Review for Pathology helps a lot of people remember and retain more information, then more poorly organized ones like First Aid.

We will stop here. Next time, we will continue discussing the two types of reviewers and we will revisit the different types of recall and how to take advantage of them to vastly increase the amount of information you can store in your head at any one time. To paraphrase Dr. Goljan, the more concepts you read, remember and can recall at the time of the examination, the higher your score will be.

We now know that the NBME self-assessment tests are accurate in predicting actual USMLE performance. And we also know that the main reason for this accuracy is the correlation study done by NBME between the two tests using AMGs performance in both tests rather than to any real similarity between the 2 tests. This correlation has also been borne out by most test takers who narrated their experience in forums. It can be used to gauge whether you will pass the examination and even if you have a good chance of achieving the score you are aiming for.

So when is the best time to take the NBME? The best time is when you think that you are ready for the USMLE. When all parameters indicate that you are probably ready for the examination, you take the NBME to confirm that you are ready for the examination. In other words, use the NBME as a diagnostic or confirmatory test, instead of a screening test. You can use your performance in USMLE World or Kaplan Q Bank as a screening test.

The practice of many to take the NBME to identify weak points and measure progress in review is not very practical. First, there are only 6 NBME tests (for Step 1) and second, you can take it only once. Taking it more than once invalidates the correlation and therefore its accuracy in predicting actual USMLE performance. Therefore, what do you do if you are still not ready after taking all six tests? You just used up your most valuable tool for predicting your actual performance in the USMLE.

Personally, I used the NBME exam to confirm my readiness to achieve my targeted score of 99. In preparing for Step 1, when my Kaplan scores were hitting 84 and above, I felt I was ready for the test. I took NBME form 1 only and 740 confirmed my readiness for the exam since I was aiming for a 99. 600 was enough for a 99, but I would have postponed if I got less than 660. Why? Since I decided I want only a 99, I was giving myself a 10 point leeway (600=240 and 660=250) to make sure I make it to a 99 no ifs, ands, or buts. The same thing holds true for Step 2 CK, I took the exam when my one and only NBME test scored 700, way above what I needed for a 99.

Another common question is whether to take the examination timed or self-paced. Since you are trying to test your actual readiness for the examination, it is best to simulate actual exam conditions. In my case, I took self-paced but finished everything in the 1 hour allotted for it. I may look over the questions after 1 hour, but I will not change them so as not to alter the score predictability too much. Make sure everyone in the house knows not to disturb you while doing this. Although you can pause the exam, it is not recommended. Also I do not recommend you do it in a public library. There was one person who took the USMLE despite getting a low score in NBME. He attributed it to the fact that he took it in a noisy public library and “upward adjusted” his predicted score. He failed. So, take it properly and trust the score. One warning, though, correlation is not 100% therefore always give yourself some leeway in case things do not go too well. Never, ever go for the examination if you scored 400 or less. Your chances of failing is too high and even if you passed 75 and 76 are with you for life.

Recently, USMLE World started offering their own assessment tests for US$ 30 each, US$ 15 cheaper than NBME’s assessment tests. The question foremost in everyone’s mind is, can I switch to UW assessments tests instead of NBME’s. How wise is a decision like that?

The reason for using assessment tests is to make sure you are ready for the USMLE and to lessen the risk of getting an adverse score. NBME has proven throughout the years, after thousands of test takers, that it is a reliable predictor of your actual score in the USMLE. It is also backed up by correlation studies that have been published in journals. Now, although USMLE World’s assessment test may also be a reliable predictor of your actual USMLE performance, all we have is their word for it. No study has been cited or provided to independently verify such claim. And not enough empirical evidence from test taker’s experience forums allow us to make any judgment on its accuracy at all. Surveying forum after forum reveals variable experience with the tests as of now.

My take is that since you only have one shot at the USMLE, it is better to go with what is proven and tested rather than take a risk. Although, you can retake the USMLE if you fail, that failure is recorded and counted against you. If you pass, the score is with you the rest of your professional life. If you chose to, maybe you can use the UW assessment tests as a screening tool. Just be sure to use the NBME assessment test, whatever form to confirm your readiness before actually sitting for the USMLE.