Askdoc's USMLE Blog » USMLE Step 3

Why You Need Three Phases in USMLE Prep – I

askdoc — Tue, 05 Oct 2010 15:42:08 +0000

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

It’s coverage is very broad.
It’s a very long exam.
It’s a very clinical exam.
It’s a time-pressured exam.
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:

Three Phases of USMLE Prep

askdoc — Thu, 02 Sep 2010 09:07:48 +0000

Biggest Mistake in USMLE Prep

One of the biggest mistakes people make in prepping for the USMLE is underestimating the time it takes to finish the prep. It seems a lot of people start their USMLE prep by opening a book and then start reading. They have no estimate on how fast they have to go in order to finish the whole prep in the time they originally allotted for it.

Proper scheduling is very important in order to do well in the USMLE exam. The main reason is that after studying for some time, you will burn out. Your rate of learning will slow down while your rate of forgetting remain constant. This is called plateauing. When your rate of learning becomes slower than your rate of forgetting, you go into decline. And for most people optimum review time is 6 to 8 months.

Therefore it is very important to understand the steps we need to go through in order to prepare properly for the USMLE Step 1. This is a very long topic and it will take a series of post to cover everything.

Three Phases in USMLE Prep

There are three important phases in prepping for the USMLE exam

Learning Phase: This is where you learn all the medical concepts tested in the USMLE. You cannot review what you do not know, you cannot master what you have not learned. At this stage the best resource to use are textbooks and lectures.
Mastery Phase: This is where you try to memorize medical concepts tested in the USMLE in the right level of detail needed for the USMLE exam. You also need to make sure that you can recall them in a timely manner. The best resources to use are reviewers, study notes and flashcards.
Test Preparation Phase: This is where you learn how to take USMLE type examination. The USMLE exam is unique in many aspects and you need to make sure you are ready to take this type of examination. The best resource to use is still online qbanks

It is very important to do the three phases in order as one phase builds on the other. Problems in the Learning phase affects Mastery and Test Preparation Phase. Problems in Mastery phase will affect Test Preparation phase. It is also important to use the proper resource for each phase as they are optimized for use in fulfilling the objective of each phase.

We will discuss all this in more detail in subsequent posts.

Related Posts:

NBME Self-assessment Tests and USMLE Review – An Update

askdoc — Mon, 02 Aug 2010 15:58:14 +0000

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:

NBME Self Assessment Tests and USMLE Review

askdoc — Fri, 19 Jun 2009 12:37:17 +0000

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

What to Do on the Day of the USMLE Exam

askdoc — Fri, 13 Mar 2009 13:24:15 +0000

I wrote part of this post in answer to questions from my readers and students. After 2 emails and one answer to comments, I have decided to elaborate and write in more detail as a post that I will share with everyone.

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.

How to Create a Study Plan for the USMLE

askdoc — Sun, 26 Oct 2008 18:11:59 +0000

Note: This was initially published in 6 parts and was then consolidated into a downloadable ebook.

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:

Determine your objective
Know thy enemy
Know the learning process
Know the components of a good study plan
Know the factors that can affect your study plan
Scheduling
Importance of sleep, rest and recreation
Putting it all together

Determine your objective for the USMLE.

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

Is it to pass the exam?
Get an average score?
Beat the mean?
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.

Guide to Self-Evaluation in USMLE Prep

askdoc — Mon, 29 Sep 2008 14:34:01 +0000

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.

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What to Study for the USMLE – Part IV

askdoc — Mon, 15 Sep 2008 14:21:50 +0000

We begin part 4 of our series on “What to Study for the USMLE”. In Part I, we discussed the need to choose our review material based on what we want to achieve in the exam. We also discussed the use of substituted judgment when we rely on reviewers to know what to review for the examination, and the need to make sure that these judgments are based on the same goals we have with regards to passing, scoring well or acing the exam.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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What to Study for the USMLE – Part III

askdoc — Mon, 11 Aug 2008 11:47:54 +0000

We begin part 3 of our series on “What to Study for the USMLE”. For those just joining us, please refer to previous post here and here. Due to the sheer number of review materials available to examinees, we need to classify them in order to make it easier to choose and mix and match between them.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Why You Need Three Phases in USMLE Prep – I

What to Study for the USMLE – Part II

askdoc — Fri, 18 Jul 2008 14:05:07 +0000

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.

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Why You Need Three Phases in USMLE Prep – I