For most people, preparing for an exam involves learning the material tested in the exam. After doing so, they feel that is enough for them to do well in the examination. For most short quizzes and even shelf exams, that is usually enough. But for examinations like the USMLE, it calls for a . . . → Read More: Why You Need Three Phases in USMLE Prep – I]]>

For most people, preparing for an exam involves learning the material tested in the exam. After doing so, they feel that is enough for them to do well in the examination. For most short quizzes and even shelf exams, that is usually enough. But for examinations like the USMLE, it calls for a different, more thorough approach.

There are people who can study for the USMLE the same way they have always studied and do well. The main reason is that these people already have good study habits and skills which they just carry on into their USMLE prep. They usually do very well in medical school due to these same skills. However, study habits and skills good enough for medical school will be inadequate because of the unique requirements of the USMLE.

The USMLE is different from all other exams for the following reasons

1. It’s coverage is very broad.
2. It’s a very long exam.
3. It’s a very clinical exam.
4. It’s a time-pressured exam.
5. It’s all or nothing

Let’s go over them in detail

The USMLE has Very Broad Coverage

Unlike most examinations we commonly encounter in medical school including shelf exams, the USMLE covers a lot of materials. For example, when you have a shelf exam for anatomy, you only need to remember anatomy until you finished the exam. Then you can start forgetting it while you prepare for the Physiology shelf exam.

In the USMLE Step 1, you need to know all 7 subjects at the same time and you need to be able to retain and recall all that information on the day of the examination. Therefore, it requires additional preparation in order to do well compared to the usual exams we encountered before.

The USMLE is a Very Long Exam

The USMLE Step 1 is 7 hours long with a 1 hour break totalling 8 hours. The USMLE Step 2 CK is  8 hours long with a 1-hour break totalling 9 hours. USMLE Step 3 covers 2 whole days. The most important problem you need to address here is fatigue. Believe me, by the time you hit the 5th block, your head refuses to work. You need to reread questions. You can’t think straight and it takes longer just to think of the answer.

The USMLE is a Very Clinical Exam

Lately, the USMLE has become more and more clinical, with over 50% of the questions in Clinical Vignette format. This adds a level of complexity to the exam which can impact negatively anyone unprepared for it. Therefore there is a need to make sure you can diagnose clinical cases even in USMLE Step 1 which is primarily Basic Sciences.

The USMLE is a Time Pressured Exam

The questions are long and you need to analyze the questions well before you can answer them. A lot of the questions require two to three step thinking which lengthens the amount of time you need to answer the questions properly. Therefore one of the biggest problems examinees have is finishing the exam within the time period provided. There is a need to take this into account during your USMLE prep and not just during the exam

The USMLE is All or Nothing

For the purpose of the USMLE, if you cannot answer the question, usually in about a minute, then you do not know it. It does not care if you forgot it. It does not care if you can’t just recall it. It does not care if you run out of time. If you can’t answer it, you don’t know it and you don’t get partial points. In medical school, we are used to being graded over our performance for the full semester or year. The USMLE does not care how much time you spent studying, how many sleepless nights you have gone through, nor how may questions you have practiced on. If you can’t answer it, you don’t know it. So again, there is a need to study a certain way to ensure you can answer those questions when the time comes.

We will continue discussion of the three phases of USMLE Prep on future posts.

Related Posts:

• Why You Need to Master the USMLE Step 1

• 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

It’s been over a year since I first published “NBME Self-assessment Tests and USMLE Review.” Little did I know it will become the most popular of my post with over 14,000 pageviews in the past year. Since that time a lot of things have changed, hence this update.

If you have not read . . . → Read More: NBME Self-assessment Tests and USMLE Review – An Update]]>

It’s been over a year since I first published “NBME Self-assessment Tests and USMLE Review.” Little did I know it will become the most popular of my post with over 14,000 pageviews in the past year. Since that time a lot of things have changed, hence this update.

If you have not read the previous two posts on this topic, please do so as I will not be repeating what I have said there in this post. You can access Part 1 here and Part 2 here.

How well does NBME predict your USMLE Score?

That has been the number one question asked of me since I wrote about this topic. My answer is still the same. Fairly well. Although correlation is never 100% more like 70 to 80%. However, certain development in the past few years have made the assessment tests less reliable for some people.

One of the reasons for this problem is that a lot of NBME questions, especially the earlier forms of step 1 have been discussed extensively in various forums. What’s more some of these posters did not even bother to warn people that what they are discussing are NBME form questions. Going into the NBME assessment tests knowing some of the answers already can invalidate the predictability of those assessment tests. In fact just knowing some of the questions beforehand can also invalidate the results. The reason is that knowing the questions ahead, means you’ve had time to consider the questions and possible answers before, not just the 1 minute or so that you will actually have in a real exam. That can skew your result.

It has also come to my attention that some NBME questions or variations of those questions have come out in online qbanks. That is bad news, too as it has the same effect of invalidating some of the questions in the NBME forms. Even if you did not get the answer, encountering the questions in the NBME form for the second time rather than the first time means you had more than the 1 minute allowed in the exam to think through the questions and look for the answers.

So what are the remedies for these problems that seem to have cropped up recently. Well first is to actively avoid discussing posted NBME questions in the forums. Of course since some posters do not have the courtesy of even warning people about it, avoid participating in any discussions on questions in forums unless you know for sure that they did not come from an NBME form.

Another solution is to try to use the later forms. In Step 1 this would be form 4. 5 and 6. NBME forms for Step 2CK does not suffer from the same problems as those in Step 1 as they are not discussed as often as those of Step 1.

Doing at least 2 forms instead of just 1 as I recommended before may also help. Just make sure one of the form is not the first 3.

What about the “Downloaded” NBME Self-assessment test version.

I can never understand the popularity of the so-called “downloaded” version of the NBME. IF saving a hundred dollars or so is worth scoring low or failing the USMLE altogether, then it is understandable. But ruining your long term career to save a couple of bucks is not a very intelligent move.

In earlier posts, I have said that the value in the NBME does not lie with the fact that the questions mimic the USMLE. In fact, in general, they are much easier than the USMLE. The main value of the NBME forms is that they are fairly reliable predictors of performance in the USMLE due to the correlation they’ve done with NBME results vs. actual USMLE performance.

However, recently, some posters in my blog have commented that they are able to “predict” their USMLE scores, since there are answer keys and correlation tables available with the downloaded version. So I decided to give it another look.

So what did I find out? Well, first, there is a problem with the answer keys. There were some answers that I completely disagree with. In some cases where I myself am not sure what the right answer is, I tried to verify the possible correct answer by researching them and I still cannot decide what the right answer is even after searching through textbooks and the internet. Therefore, there is a question of how accurate the raw score one is getting for each of those NBME forms are. And that is a major problem. In my case, anywhere from 2 to 8 answers in each form fall into this category and for me, an “unknown” of 4 to 16% in the raw scores completely shoots down any chance of actually knowing the exact raw score you should be getting.

A second major problem is that there is only one correlation table in existence, instead of the 6 correlation table I am expecting. That is one per form. There might be additional correlation tables out there, but the one I got is just 1. Why six tables? Because the forms are of different levels of difficulty, you expect the same person will get different number of questions right in the different forms depending on the level of difficulty. So you need a correlation table for each form to make them comparable. Having only one correlation table means we don’t even know to which form this correlation table belongs. See the problem, now.

A third really big problem is that people who used this downloaded forms has a tendency to keep on using them throughout their prep multiple times. Probably because it’s free. In fact, it was justified that since they did not try to look at the answer, they can redo the same form and expect it to still be accurate in predicting their scores. That is actually wrong. Again, one of the reasons why USMLE is hard is the time limit imposed in answering questions. When you go through the same question multiple times, you’ve had more than the 1 minute per question limit imposed by USMLE to think of the answer and therefore will tend to score higher. That skews the predictability of the NBME.

Therefore, again, do yourself a favor and use only the online NBME assessment tests and use them only when you feel you are ready for the USMLE, to confirm your readiness. The “downloaded” NBME forms may seem free, but it’s hidden costs may be greater than you are willing to pay.

USMLE World Assessment Tests

I’ve had more time to gather information about this relatively new resource. So far based on talking to my students, posters in my blogs, people who have emailed me and reading various forums, my conclusion is that the UW assessment tests is just as good as the NBME assessment tests, so far.  Although there have been some observations that UW tend to be overestimate your scores in comparison to NBME, this does not seem to happen in all cases and the score difference is not too big. So all in all, I believe the UW assessment tests have enough track record by this time that we can safely say, they are fairly accurate in predicting USMLE scores. But as in all assessment tests, correlation is never 100%, therefore expect some deviation from predicted scores in the final result.

Related Posts:

• Which NBME Self Assessment Form to Use for USMLE Step 1

• NBME Self-Assessment Tests and USMLE Review – Part II

• NBME Self Assessment Tests and USMLE Review

• How to Create a Study Plan for the USMLE

• High Yield Fast Facts for the USMLE

• Guide to Self-Evaluation in USMLE Prep

Lately there had been too many . . . → Read More: Most Common Mistakes in Step 2 CK Prep]]> People have been badgering me for sometime now on writing more about how to prep for Step 2 CK. Some even wants me to start a Step 2 CK prep course. However, due to time constraints and the Step 1 Prep Course, it has not come to pass.

Lately there had been too many people asking questions about their Step 2 CK preparation and problems they are encountering. Although I still don’t have time to write a full article on it, I have decided to tackle the 4 most common reason that people do poorly in the Step 2 CK. I am also reposting an article about “What to do for Step 2 CK” an older post that needs some rewriting but is still relevant.

1. Not Studying Enough Detail. The most common mistake people make in studying for Step 2 CK is not studying enough detail. You see so many reviewers in the market that purport you can ace the exam by studying the little material it contains. That is a lot of bull. Medicine is a very broad subject and Step 2 CK covers all the most common and even some rare cases.Those little reviewer just does not give you enough detail to do well in this exam. An exception is Kaplan Notes. Very good detail. However, you need to know 85% of it in order to know enough to pass. Higher if you want a higher score. And that is impossible to do unless you do a minimum of 3 revisions. I will discuss the various study materials you can use in another post.

2. Difficulty with next best step in management type of questions. Next best step in managment type of questions acount for about 20% of Step 2 CK. This type of questions involve cases that describes the management done on the patient so far and asks what you think is the next best step in dealing with this particular patient. Remember the next best step depends on what was the result of a previous diagnostic workup or response to treatment. There is a big difference between knowing how to treat and managing a patient. There is also a big difference between knowing what lab tests to perform and working up a patient. Treating a patient  involves knowing what drugs and treatments to use. Managing a patient takes into consideration patient response, adverse reactions and other factors and altering the treatment accordingly. Working up a patient involves knowing implications of positive and negative results of previous tests and what lab or diagnostic test should be ordered next.

Most people study for step 2 CK by reading reviewers or books. And that is the appropriate way to study the clinical content for the Step 2 CK exam. But one needs to do the extra step of constructing algorithms in order to be able to master next best step in management style of questions. You can answer the next best step in management type of question without using algorithms but it will take longer and more analysis to be able to answer them. And as we know, in the USMLE time is what you lack. I will write more on how to write algorithms in another post

3. Knowing too little pathophysiology or mechanisms of diseases. One of the biggest reason why I emphasize pathology and pathophysiology in Step 1 aside from the fact that it is the biggest subject in Step 1 is that it is also very important in Step 2CK and Step 3. This accounts for 20% of Step 2 CK and covers mostly systems pathology unlike in Step 1 where the main emphasis is in general pathology. Also in Step 2, the pathophysiology tested are more clinical in nature, ie how they account for various signs and symptoms and complications of diseases. Cases will also include what I would call “Applied pathophysiology”. I have written examples of this in an earlier article. This is usually a problem for those older grads who decide to take Step 2 CK ahead of Step 1 and did not bother to brush up on pathology. Also for those who took Step 1 first but did poorly in pathology. The solution is therefore to make sure that you are solid in pathophysiology. Goljan’s Rapid Review for Pathology is a short but good book to brush up on pathophysiology, although it covers general pathology as well which is not needed in Step 2 CK.

4. Atypical presentation of common diseases. According to Cecil’s Textbook of Medicine, there are four types of cases you normally encounter in clinical practice. In order of frequency, they are (1) common diseases with typical presentation, (2) common diseases with atypical presentation, (3) rare disease with typical presentation and (4) rare diseases with atypical presentation. They also occur roughly in the same number in Step 2 CK with slightly more type 2 cases than normal

In Step 1, most of the cases you encounter presents classically. But in real life you rarely see classical cases where all the key signs and symptoms are present. Even in Type 1 cases, not all the signs and symptoms will be there. However, enough will be present so diagnosis is not so difficult. The big problem in Step 2 CK for most people is type 2 cases where common diseases presents atypically. For example, although sarcoidosis is most common in young, black female. They do occur in males, older people and other races. So in Step 2CK a sarcoidosis patient may be an old, white male instead. You need to be able to diagnoses the case even with atypical presentation or you won’t be able to answer the questions. These is usually a problem with medical students with limited clinical experience and old grads who have not practiced medicine for some time.

Other ways clinical cases are tougher in Step 2 CK is the addition on both relevant and irrelevant normal findings. The addition of irrelevant abnormal findings that will not change the diagnosis. You need to be able to discern what facts are important and what are not. Remember in an actual live patient, they may present with symptoms that is irrelevant to their main complaint and you need to decide what is relevant and what is not.

The best way to correct this problem is to study classical cases and know what symptoms and signs are absolutely essential in making a diagnosis. When doing qbanks and you misdiagnose a case, it may make sense to find out where you got it wrong and write down the minimum symptoms and signs you need to make the diagnose, so you don’t make the same mistake again.

These 4 are the most common reason for getting low score. Although there are other less common weak points that can cause lower score, they will be discussed in another post.

Related Posts:

• Three Phases of USMLE Prep

• What to Do in Step 2 CK

• NBME Self Assessment Tests and USMLE Review

• Guide to Self-Evaluation in USMLE Prep

• What to Study for the USMLE – Part IV

Today, we will talk more about the NBME self-assessment tests. We previously discussed what the NBME self-assessment tests are and how they impact your USMLE review. You can read the posts here. Now we will cover three important topics. When to use the NBME self-assessment tests, how to use the NBME self-assessment tests . . . → Read More: NBME Self-Assessment Tests and USMLE Review – Part II]]>

Today, we will talk more about the NBME self-assessment tests. We previously discussed what the NBME self-assessment tests are and how they impact your USMLE review. You can read the posts here. Now we will cover three important topics. When to use the NBME self-assessment tests, how to use the NBME self-assessment tests and how wise it is to use the USMLE World self-assessment tests instead.

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.

How to use the NBME Self-assessment tests

Best time to take the NBME Self-assessment tests

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 USMLE 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 Q Bank or Kaplan Q Bank as a screening test.

Use NBME Self-assessment Tests to assess readiness, not identify weak points

The practice of many to take the NBME Self assessment tests to identify weak points and measure progress in review is not very practical. First, there are only 7 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 USMLE 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 USMLE 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 assessment test scored 700, way above what I needed for a 99.

Timed NBME Self-assessment Tests for best results

Another common question is whether to take the NBME examination timed or self-paced. Since you are trying to test your actual readiness for the USMLE 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 self assessment test. 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 USMLE 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.

What about the USMLE World Self-assessment tests

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.

Related Posts:

• Which NBME Self Assessment Form to Use for USMLE Step 1

• NBME Self-assessment Tests and USMLE Review – An Update

• NBME Self Assessment Tests and USMLE Review

The NBME self assessment test is another of those tools that I feel is responsible for the increasingly high scores in the USMLE. It is a great tool that allows the test-taker to assess his or her readiness for the exam. To a certain extent, if used properly, it is also a useful . . . → Read More: NBME Self Assessment Tests and USMLE Review]]>

The NBME self assessment test is another of those tools that I feel is responsible for the increasingly high scores in the USMLE. It is a great tool that allows the test-taker to assess his or her readiness for the exam. To a certain extent, if used properly, it is also a useful tool for the examinee to target a certain score, even 99′s and achieve it.

How the NBME self assessment tests were designed.

The questions for the NBME self assessment tests were taken from a pool originally designed for the shelf exams of American Medical Student. As such it covers the most important concepts that AMGs are required to know before passing to the next level. It covers the same topics that will be covered in the actual USMLE examination.

The NBME self assessment tests are very good at predicting the score you will get at the USMLE. In fact I read somewhere (unfortunately, I can’t seem to find the site now though) that at least for Step 1 the 1^st exam set has a correlation as high as + 0.89, while the others range from + 0.72 to + 0.85. If you go to most of the forums, you will find that the correlation for most examinees is very good.

Difference between NBME and USMLE.

Although the topics covered in both the NBME and the USMLE is more or less the same, there is a tremendous difference between them.

First, the NBME questions are much, much more straightforward than the USMLE questions. The NBME has precious little tough questions. Therefore a low score in the NBME is more indicative of lack of knowledge of the topics covered in both exams rather than a lack of mastery of those same topics. Although the latter exam sets have tougher questions than the first sets, they still are not as tough as the tougher parts of the USMLE, plus, they actually have lower correlation with USMLE scores than the first exam set.

Second, the NBME questions total less than the actual USMLE exam and therefore will cover less lower-yield stuff than the actual USMLE exam.

Third, you can have up to 4 hours to answer the examination. Part of the toughness of the USMLE is the time constraint imposed on the examinee.

Fourth, you can take the blocks at a time of your own choosing, usually during periods where you are at your peak effectiveness. The actual examination does not give you such luxury.

Fifth, you have to take the USMLE blocks, 7 to 8 at one time with minimal breaks, which can take its toll, believe me. By the fifth or sixth block, your mind tends to stop functioning. You have only 4 blocks in the NBME and you can take it at your leisure.

NBME self assessment tests is a good predictor of USMLE performance.

So despite the obvious difference between the 2, why is the NBME such a good predictor of USMLE performance? The answer lies in the fact that the NBME has taken the time to correlate the results of hundreds of thousands of AMGs with their actual performance in the USMLE. This correlation has taken into account the difference in test conditions and actual content of the examination and that this difference although apparent is not very significant as can be shown by the correlation of + 0.72 to + 0.89 between the various NBME exam sets and the USMLE.

Ineffective use of NBME self assessment tests

So the practice of using the “downloaded” version of the NBME tests effectively wipes out the predictability of the exam set itself. It’s effectiveness lies in the statistical analysis they’ve done for the results and not the results themselves.

Another ineffective practice, is studying the NBME test questions to improve your score. This will be effective only if your original review is so poor that you have not covered the required high yield topics tested in the USMLE properly. Otherwise you are better off studying the questions in USMLE world and Kaplan Q Bank to understand how to answer tough questions and low yield stuff that are more likely to appear in the USMLE.

Another common error is repeating the exact same exam set. The correlation holds only if you take the exam once and only once. Repeating it will raise your score in the NBME which will not be carried over to the USMLE. Therefore, I suggest reserving at least one set to be taken only if you are ready to do the USMLE.

Used properly, the NBME tests can be an effective tool for self-review. So do yourself a favor, use the NBME self assessment tests properly as an assessment tool rather than a study tool. And take the online form rather than downloading them, which is also subject to copyright issues. The NBME self assessment site is here.

*note: Part II deals with When and How to use the NBME self-assessment tests and whether it is wise to use USMLE World self-assessment tests instead. Part III is an update of this article.

Related Posts:

• NBME Self-assessment Tests and USMLE Review – An Update

• Which NBME Self Assessment Form to Use for USMLE Step 1

• NBME Self-Assessment Tests and USMLE Review – Part II

• How to Create a Study Plan for the USMLE

• High Yield Fast Facts for the USMLE

• Guide to Self-Evaluation in USMLE Prep

Be at Your Best on the Day of the USMLE Exam.

So what do you do on the day of the USMLE 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 USMLE examination, when you schedule the examination. It is a known fact that during review, people do reach a plateau and the best time to sit for the USMLE exam is just before or just after you reach your peak. Earlier or later than that can result in lower scores. During review, immediately after learning and memorizing your lessons, you start forgetting right away. 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 for the USMLE is around that long. That is why my USMLE Step 1 prep course is around 6 months long.

Stop Studying for the USMLE Exam at the Right Time

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 they sit for the USMLE exam while others start relaxingtwo weeks before their scheduled USMLE 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 staminato the limit. Anyone who has taken the USMLE exam can tell you that their brains felt like mush and refuses to function properly in the last 2 blocks of the USMLE 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 day of your USMLE examination.

Now if resting is good, why shouldn’t I rest 1 or two weeks before my scheduled USMLE 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 USMLE 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 actual USMLE examination. You need to block off everything until you’ve finished the exam.

What to Do 1 to 2 Weeks Before the Actual USMLE 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!)

What to Do the Last 2 Days Before the USMLE Exam

Another important thing to consider is how far you lived from the Prometric Center where you will be taking your USMLE 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 Prometric 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.

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 USMLE 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.

What to Do on the Day of USMLE Exam Itself

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. The USMLE 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 for USMLE Step 1,  4, 3 would be good. For USMLE 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 for the USMLE?

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 USMLE 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 for the USMLE.

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.

This started out as a reply to a question asked by dr patel on my blog on how to evaluate one’s readiness for the USMLE and avoid making the mistake of taking the examination and failing it. However, it got a little bit too long, so I have decided to rewrite it into . . . → Read More: Guide to Self-Evaluation in USMLE Prep]]>

This started out as a reply to a question asked by dr patel on my blog on how to evaluate one’s readiness for the USMLE and avoid making the mistake of taking the examination and failing it. However, it got a little bit too long, so I have decided to rewrite it into an article.

Failure to properly evaluate one’s readiness for the examination and one’s progress during the whole USMLE preparation process may be one of the most crucial reason not only for failing the USMLE but also for failure to achieve a less than stellar score.

Proper self-evaluation involves not only how to do the evaluation, using the right tool to measure the right parameter but also when to do the measuring to insure maximal effectiveness. Most failures in self-evaluation can be divided into these 2 broad categories.

Whenever, we mention evaluation, most people think of the NBME self-assessment tests primarily or the online q Banks like UW and Kaplan. These are very useful assessment and evaluation tools, but they are not the only ones and not necessarily applicable in all situations. Used the right way, they are extremely effective, but the propensity of most people to use them in all kinds of situation is not necessarily a good idea. The right tool used for the right situation is very effective. Using the right tool for the wrong situations makes it less effective.

You see people using NBME to evaluate themselves at various stages of their review rather than at the end, to gauge their final readiness for the USMLE is an example of an expensive misuse of a great tool. I wonder what you would think of your anatomy professor if after finishing upper extremities, he uses the USMLE Step 1 to test how well you are doing so far. Ridiculous and yet that is what most people are actually doing during their prep.

The MRI may be one of the biggest breakthrough in medicine in recent years, but it is a tool with a specific function. Using it to measure blood glucose level is ridiculous. So use the right tool for the right situation. We’ll talk about that more later.

The second area where most people commit a big mistake in self-evaluation is when to take it. One of the primary reasons being the myth that only online q Banks will do as evaluation tools for the USMLE which is far from the truth. A myth perpetrated by a lot of posters in forums and of course encouraged by online q Bank providers for obvious reasons. Again as stated before, proper tools for proper situations will provide excellent results. But for other situations other tools are better.

Usually you have people studying for 3 or 4 months, reading the various subjects, Anatomy, Physiology, etc. for step 1 and Internal Medicine, etc for step 2 CK and step 3. Then they enroll in the online q Bank, the first time they will actually test what they have been able to retain in their readings for the past 4 months. Then shock when they are scoring 40 to 50% followed by panic since they realized that they have 2 months left before their scheduled exam and that after 4 months of efforts, they’ve only come so far. So they searched the forum looking for answers that tell them all is not lost and reject anything that says otherwise. Most of the time, they take the suggestion which they so want to be true, that by just doing q Banks for a month or so, they will raise their scores. Yeah, right probably by 5% or less so unless they are already scoring borderline scores, doing that will not help. Their only choice really is to restart their review, this time doing them the right way. Don’t get me wrong, doing q Banks can raise your scores. However, there seems to be a pattern. The higher your starting q Banks scores, the more help doing q Banks will be to raise your scores. Below a certain level, doing q Banks will not help. People just fail.

All of this could’ve been avoided if proper self-evaluation have been instituted right from the start of their prep process. Self-evaluation is important to insure that you are prepping the proper way and that your prep is effective. That is why I’ve always advocated that people should use Subject specific q Banks right from the start. They don’t have to be USMLE type questions, since the main objective is to see if you know the subject, not in how good you are at answering tough, USMLE type questions. You need to know the subject well, before you can answer the tougher questions. You need to learn basic arithmetic before you can answer algebra or trigonometry. In my prep course, the course participants have a quiz per chapter (comprehensive quiz with 30 to 65 questions per chapter) to insure they know the topic before moving to the next one. Any problem is solved on the spot. So they don’t have to wait until 4 months later to realize something is wrong with their prep and they have to do them all over again.

Even in medical school, everyone knows you should evaluate performance at regular intervals to insure that people are learning. Imagine if your dean tells you that due to the huge success this method of evaluation is among people prepping for the USMLE. They will now only give one evaluation examination at the end of 4^th year to test whether you will become an MD or not. That’s not very realistic is it and yet that  is what most people do when they prep for the USMLE.

So how do you go about doing your self-evaluation? In the beginning, when revising the subjects, you should be prepared to test yourself chapter by chapter to insure that you know your stuff before moving on. When you finished each subject. Test yourself using by subject q Books. You use online q Banks after you’ve finished your first round of review, both to assess how much you know and help raise your scores. Then just before the examination, you use NBME to confirm your actual readiness for the exam and if you are going for a certain score, whether you will make it or not.

For example you are preparing for Step 1. You can use Robbin’s Review of Pathology q Book as a chapter by chapter quiz for Pathology. It is important that the chapter quiz is comprehensive and not the short ones usually found in the end of Kaplan notes chapters or BRS Pathology chapters. For an example, you can go to my prep site at http://prep.askdoc-usmle.com. Log in and enroll into the Pathdemo program to access the quiz. Compare how comprehensive the Cell Pathology quiz is to the Cell Pathology Study Notes provided or even the Cell Pathology notes in Kaplan lecture notes. That is how comprehensive the chapter quiz should be. For Microbiology and Immunology, Levinson and Jawetz have a very good chapter by chapter quiz. My prep course will also develop its own as it is finished. For Pharmacology, Trevor and Katzung also have a comprehensive chapter by chapter quiz. For the other 4 subjects, there is no comprehensive chapter by chapter quiz q Book that exists, although, the Kaplan q Book which covers by the subject may be an adequate substitute.

For Step 2 CK and Step 3, no adequate chapter by chapter quiz exists. Harrisons q Book contains too many low yield stuff and may be more helpful for ABIM rather than Step 2 CK or Step 3. Good subject exams include the Kaplan Q Book and the Blueprints q books.

Although I have chapter by chapter quizzes in my prep courses, only Review of Pathology is available and will take 6 to 9 months to finish the rest. However, good commercial chapter by chapter quizzes are available for Pathology, Microbiology and Immunology and Pharmacology as stated above and I would suggest you make use of them right from the start of your review.

If anyone knows of other chapter by chapter q Books available, I would appreciate it if you can bring it to my attention, especially for the other subjects, so I can evaluate them and make recommendations.

Related Posts:

• Which NBME Self Assessment Form to Use for USMLE Step 1

• NBME Self-assessment Tests and USMLE Review – An Update

• Why You Need to Master the USMLE Step 1

• Most Common Mistakes in Step 2 CK Prep

• What to Do in Step 2 CK

• How to Master the USMLE Step 1 – an Introduction