If you have not read the previous two posts . . . → 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.

“Downloaded” NBME 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.

 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.

Failure to . . . → 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.

First, there is no real guarantee that if you study . . . → Read More: What to Study for the USMLE – Part II]]> We begin part 2 of our series on “What to Study for the USMLE”. For those just joining us, please refer to previous post here. Before we discuss the various criteria for selecting study materials for review, we need to clarify some concepts and discuss some limitations.

First, there is no real guarantee that if you study certain materials you will get a particular score. All you can be sure of is that you have a high probability of getting that score. The reason for this is varied and not all of them under your control. For example, since different exam sets are given to different examinees, the exam set you wind up with in the actual exam has a big impact on your final scores. It’s a universal fact that nobody can know every concept tested in the USMLE, therefore the more the exam set covers what you have studied and remembered, the higher your score will be. If it happens to cover a lot of materials you never read or do not remember then you are out of luck.

Second, two persons can study the same material, but what they remember, how much they remember, let alone how much and how complete their understanding of the material they’ve studied will vary. It seems everybody is studying the same material and doing the same Q Banks and yet the results vary from failing the examination to getting double high 99′s. Therefore, it is not enough to know that you have read Kaplan notes or First Aid, etc. You must know how much of what you have read, you understood and can recall.

Remember, for the purpose of the USMLE, what you cannot recall, usually in a minute or less, you do not know. In fact, the USMLE does not care whether you’ve read the concepts or understand it. You’ve to have read it, understood it and can recall it instantly in the examination. That is a stiff requirement. Therefore, it is not enough to have read the materials, you need to be able to understand and recall them. You need to read, understand and be able to recall at least 75 to 80% of Kaplan Notes to be able to pass the exam and yet most people just read them numerous times, hoping that that would be enough to pass the exam. You probably need to be able to recall 95 to 100% of Kaplan notes to score in the 90′s and depending on how much you were able to absorb from the qBanks have a small to average chance of getting 99′s.

Third, as I stated in my ebook “How to Create a Study Plan for the USMLE”. It is a universal truth that people usually miss their target therefore it always make good sense to over study a little bit. If you just want to pass, aim for an 80 so that you have enough allowance in case not everything go as planned. Therefore our recommendations will take that into consideration

If you haven’t read my other posts on high yield concepts, Mastery, know and familiar and information recall, please read them first. Then come back and join us in the discussion.

Dr. Goljan emphasized in his lectures that the more you read and know the higher your score will be in the USMLE. I will add something to that. The more you read, understand and can recall in the actual examination, the higher your score will be in the USMLE.

If you are aiming just to pass the examination, then you don’t have to read, understand and remember as much as someone who is aiming for a 99. However, it is still good policy to aim for an 80 or so, just to make sure you will pass, as too many variables not under your control can affect your final scores and the higher the score you actually aim for the lower the chance that you will fail.

There are 2 ways to achieve a passing score. One is to study only high yield stuff, ignoring lower yield ones. It requires mastery of high yield concepts, that is knowing enough details about high yield concepts that you will be able to answer the tough questions that is inevitably the form most high yield concepts will appear in the exam. This is because you will invariably miss a lot of low yield easier questions as you did not study them.

Two, is to study both high yield and low yield stuff. This way, you do not really need a high level of mastery of the high yield stuff as you can pick up points answering the lower yield stuff. The question now is how much detail you go into the high yield stuff and how much low yield concepts you need to know. Again this is a judgment call and not everyone is skilled in making this judgment on their own.

You also need to do q Banks even if you are just aiming to pass. This is mainly to familiarize yourself with CBT type of examination. Struggling with the computer software during the actual exam can lower your score significantly. However, using q Banks as a study tool is only advised if you are using the second strategy of studying both high and low yield stuff.

If you are aiming to score average to above average (85 and above) again it is advisable to aim for 90′s. You must study the high yield stuff and master the proper amount of detail. But it is also imperative that you cover lower yield stuff. You can use q Bank, especially UW to cover the lower yield stuff, but you must take notes and reread those notes at least a couple of times. Goljan’s Pathology lectures can help you achieve the right level of mastery at least in pathology to help you score above average. Goljan also covers the other subject albeit not as comprehensively in his notes. Kaplan notes have the required level of detail to score average to above average scores but you must be able to recall at least 95% of the details in the notes to do so.

Aiming for 99′s is much, much more difficult. You need to cover not only the high yield stuff and master them, you need to cover a lot of low yield stuff, plus you cannot have a weak subject. Since you need to make sure you score high in all sections of the examination, having a weak point in a subject can cause you points you need to reach 99 or high 99. In fact the higher the 99 you are aiming for, the more you cannot afford any weak point. Whereas, you can afford to cover major subjects only if you are aiming for above average scores, eg. mastering only Pathology, Microbiology and Pharmacology in Step 1 or Internal Medicine in Step 2 CK and Step 3 while just skimming through the rest. You have to master almost all subjects if you are going for 99′s. Kaplan notes is not enough for 99′s in Step 1 even with UW q Bank or Kaplan q Bank, your chance for a 99 is low to average. You need at least Goljan or Robbin’s Basic Pathology for Pathology, Jawetz and Levinson’s Microbiology and Immunolgy as supplement to increase your chances of a 99. For Step 2CK, Kaplan notes, mastered at 95 to 100% + UW q Bank at 80 to 90% is minimum if you want a good chance of getting a 99. In Step 3, doing well in the MCQ section is not enough, you need to do well in CCS section too as it is 25% of your score.

Remember, you can study less than what I have stated and still get the score you desired, however your chance of doing so is much lower and your chance of failing to reach them is much higher. In sports, records are considered broken only if it is achieved during competition and not during practice. Therefore athletes aiming to break world records, break those records numerous times during practice to insure that they have a high chance of doing so during actual competition. Otherwise, they can break records only through pure luck. The same goes with the USMLE. You must consistently score high during practice and review to insure that you will get the score you desire and not depend on luck.

We will stop here and continue our discussion next time. We will give more detailed discussion of the various resources you need to use for each of the above scenario for Step 1, Step 2 CK and Step 3. We will then continue on to discuss individual resource and their pros and cons in achieving your objective in the USMLE.

Previously we talked about what Q Banks to use and when to use them for review. We will now talk about how to use Q banks as study . . . → Read More: Using Q Banks Effectively for USMLE Review – II]]> We now come to the second part of our discussion of “Using Q Banks effectively for USMLE Review”. For those just joining us, please review the previous post here.

Previously we talked about what Q Banks to use and when to use them for review. We will now talk about how to use Q banks as study tools and how to use them for review and assessment.

Q banks like USMLE World and Kaplan are most effective in helping you score well in the USMLE whereas other Q Banks are more effective at increasing your mastery of particular subjects. Q Banks dealing with specific subject usually tackles the subject in more detail and testing how thorough you’ve mastered the subject, while UW and Kaplan concentrates more on concepts tested on the examination, giving different weights to different subject depending on its importance in the USMLE. To learn more about UW and Kaplan Q Bank please read my post on “USMLE World vs. Kaplan Q Bank, which one?”

We will now discuss the difference on how to use Q Banks as study tools and Q banks for assessment and test preparation concentrating of UW and Kaplan. Although both Q banks may be used for either purpose, UW is better as a study tool and Kaplan better as an assessment and Test prep tool. There is also a difference between Step 1 prep and Step 2 CK prep. There is less difference with Step 3 prep vs. Step 2 CK.

First question, Should I take down notes? Of course, you should. It is a good idea to take down notes in all aspects of your review not just when doing Q Banks. One of the things I noted in my conversation with other double 99ers during the course of my interviews is how they take down notes made a big difference in their review. I’ll deal with that in a future posts. You should be taking a lot more notes when you are using Q banks as a study tool. If you find yourself still taking copious notes by the time you are using Q banks for assessment and test preparation, then there was a problem during your initial review and you may need to evaluate your readiness to take the examination.

More important still is to know what notes to take down. As noted on my post “What to Study for the USMLE”, not everyone knows how to take good notes or judge what is important or not. Hence the need for substituted judgment. The good thing about UW and Kaplan is that all the questions really give good coverage to what is important at the right level of detail. They may not cover everything (hence, you can’t just use Q banks alone without other study tools and expect to get high scores). But you know what they cover have a good chance of coming out in the examination.

Of course, facts on questions you answered wrong should always be noted. But even if you got the answer right, if it was for the wrong reason, take note of this fact too. Ditto for questions whose answer you were not absolutely sure of even if you eventually got it right or questions you got right but took you too long to answer, since this shows lack of full mastery of the topic. If the same concept is presented in the actual exam in a slightly different way, this lack of mastery may cost you. You must also make a decision whether to supplement this notes with additional reading, especially on topics you should have mastered already in your readings.

There are also differences depending on what steps you are taking. In Step 1, any facts, even if low yield, should be taken down. Step 1 tests Basic Science facts. Even pathophysiology, Goljan’s mechanisms, mechanisms, mechanisms are facts. Step 2 CK presupposes you know the facts and would like to know if you know how to use those facts in clinical decision-making. Therefore, it is important to note the basis for deciding a therapeutic course of action, or a diagnostic test to favor in a specific case not just simple fact. Also note down any atypical presentations of signs and symptoms in individual cases, since Step 2 CK cases tend to be less typical, eg. male with Temporal arteritis (typically old female) or white male with sarcoidosis (typically black female) Same things generally holds true for Step 3 as in Step 2 CK. However, for Step 3 also note down the Treatment of Choice and the next alternative treatment of choice of all common diseases. For example, Co-trimoxazole for simple cystitis and amoxicillin only if pregnant. Very important to take notes of all ethics questions too in Step 3.

The next most commonly asked question is should I take it in blocks of 50 (48 now for Step 1). If you are using Q Banks as a study tool, you don’t have to take it in blocks of 50 (or 48, or 46, etc.) and it may not even be desirable. However, if you are using it for assessment and test prepartion, it is best to simulate the exam and take it in appropriate blocks with time limits.

The reason you avoid doing full 1-hour blocks when using Q banks as a study tool is that there is a limit to the sharpness of your attention span and for most people this is around an hour or so. If you spent that hour answering questions, you may not be fully alert when you are studying the answers and taking down notes. Better to do 20 ++ q’s in 30 minute intervals and spend the next 30 minutes in reviewing the answers and taking notes. Rest a bit then go to next block. The alternative is to study the questions another time, but you don’t get the benefit of noting down any problems in your thought process as you were answering the particular questions.

When using Q Banks for assessment and test prep, not only is it important to do it in appropriate blocks with time limits, you must also work yourself up to doing it at 7 or 8 blocks per day (depending on steps) with the same rest limits as the actual examination. That is of course the ideal, but going as close to it as possible is just as well. I do not recommend doing full day simulation a few days before actual examination as the simulation can drain you and may even affect your performance on the day of the actual examination.

As I stated in a previous post, blocks in the actual USMLE exam are balanced in that it is a mixture of easy and tough questions as well as long and short ones, mindful of the time limits imposed. In Q banks since blocks are generated randomly, it is possible to get predominantly tough questions in a block or predominantly easy ones. Ditto for long and short questions. These can be a problem when doing exam simulations with time limits. I noticed that Kaplan tends to give more balanced questions in blocks while UW can have really tough questions all in one block. You can note this by looking at the percent of users who got questions right. There is a much wider variation between blocks in UW than Kaplan. That is part of the reason why I recommend Kaplan for assessment and test preparation rather than UW.

I’ll stop here. Til next time.