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.

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

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

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

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

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

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

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

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

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

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

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

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

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

Additional general tips.

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

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

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

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

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

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

 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.

I would like to announce that Askdoc’s Method of USMLE Review for Step 1 is now available at my prep forum at http://forums.askdoc-usmle.com. As I promised to some of you before, it contains more or less the same instructions available to the participants in my prep course. It includes suggested alternate reviewers and q Books you could use for your review. If you have any questions about the review methods, feel free to post your questions there.

The prep course participants are currently revising pathology so only the pathology review methods are outlined. Once they’ve reached the other subjects, probably around 1st week of October, instruction for the other subjects will be posted there too.

The prep forum is currently limited to Step 1 and Step 2 CS only as it will take time before I can write up enough materials to fill them. However, one feature it has which members may like is a Groups section where members can form themselves into groups and have a place where they can do their group discussion and learning in privacy. Only group members can enter and post in their forum. They could also limit visibility of the forum to their own group. Groups wanting to have their own forum section should sign up at Askdoc’s USMLE prep forum and submit the names of all group members and the name of their group (which will the name of their forum under the Groups forum) via personal message to me. Please include if you want to keep it invisible to the public. Your group is good for 30 days. You can extend it twice at 30 days each time for a total of 90 days by sending me a personal message before the 30 days expire.

Small private groups are handy for discussing Step 1 concepts and even Step 2 CS cases.

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


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

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

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

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

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

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

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

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

Use PAMHUGSFOSS to finish the rest of the interview.

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

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

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

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

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.

Now 4 years later, with a double 99 in my belt, I feel bad whenever, I read about people failing the examination. If I can make it, they should be able to make it, too. 2 years ago I wrote an advise to someone who had failed already thrice and was plaintively asking people “What to do”. I’m happy she eventually passed her exam with an 82. Since that time, I am happy to note that a lot of people have passed and raised their scores and even got 99’s using that advise. A couple of them had the opportunity to catch me between Steps and was couched by me through emails to raise their scores with varying results. However, since that time, hundreds of people still failed. Some had read my advise but were doing exactly opposite of what I had written. Others, I found out did not understand how to implement what I had written.

As I wrote recently in my post “Milestone”, I learned that for some people, you just need to show them how to study and they can do so on their own with excellent results. These are the people helped most by my blog and posts in the forums. Then there are people who need to have study tools and taught how to use them. So recently, I’ve tried to analyze the different study tools and tried to teach people to use them, writing mostly in my blog. I’m also trying to build one through the USMLE Wiki Project. Then, there are those who needs couching in order to get anywhere with their review. Their only choice seem to be expensive prep courses whether “live” or not that are essentially cookie cutter courses made for the average reviewee. However, if these people are really average, they should’ve been able to pass the USMLE already. They need special couching. It is for this group of people that I am starting this course

I would like to announce that I would be starting a free USMLE Step 1 Prep course starting hopefully on September 1, 2008., which is to last from 3 to 6 months. It will of course be called Askdoc’s USMLE Step 1 Prep course. I will be accepting initially 6 participants to this program. The main criteria for acceptance being that you have failed the Step 1 at least once in the past 2 years. Only if less than 6 applicants have failed Step 1 will I consider applicants who have not failed Step 1. The main reason for this is that they need help the most and also to prove to others that with proper preparation, anyone who is able to finish medical school and pass their countries’ medical board should be able to pass the USMLE.

If you are interested in applying for the course, you will need to submit the following information:

Your Name:
Your preferred nickname or callsign
Year of Graduation
Country of Medical School:
Country of Origin
Country currently residing (ie. where you will be reviewing)
Sex (only so I don’t make a mistake of addressing you wrongly)
Age: (only if you want to, however, I may have to make adjustment to how to couch you depending on whether you are older or younger, so if you don’t want to state actual age, give me an idea more or less)
Year Step 1 Taken (if more than once then indicate all years)
Step 1 Scores (if more than once indicate all scores)
Have you taken Step 2 CK (if yes indicate year and scores)

Please submit scanned image of of your Step 1 Scores (all if taken multiple times). Try to make the files small by using JPEG compression. (I have limited mailbox size) You may cover your USMLE number and street address, but I need your name to match what you submitted, exam dates and country as proof you failed the examination. You will also be asked to submit your perfomance profile at the back of your score report but only if you are accepted as a participant in the prep course

Please submit them to this email address: applications@askdoc-usmle.com.

Do not email anything else to this email address as you will not receive any reply.

If you are going to this year’s match, please be aware that the earliest I expect any participant to take Step 1 is December with January to February being more likely. So plan accordingly.

Other Terms and conditions you must agree to is as follows:

1. commit to finish the program in the appointed time,
2. willing to purchase, borrow and/or acquire one way or the other the study materials needed for the review. although study material provided by me will be free
3. willing to follow the prescribed schedule and course materials. You can supplement but not subtract from them.
4. will follow instruction and be able to follow all meeting schedule including chat sessions that may be implemented weekly or even more frequently
5. active participation in discussions of medical concepts and practice questions, etc.
6. set a goal of 85 or higher and will not register for the actual examination until advised by me of their readiness
7. will not duplicate and/or sell or distribute study materials developed by me for the sessions
8. will not provide access to any website used for preparation to individuals not in the program by providing them your user name and password, or allowing them access through your account
9.should also have not applied for the next examination schedule yet or are willing to drop it if it conflicts with 3 to 6 month review schedule,ie. September-February.
10. should not have any ongoing family or personal problem that can affect their ability to follow the review schedule as prescribed.

…and any other conditions that may be implemented as necessary to insure that the prep session go properly and be successful.

Although this program have been conducted in part before informally, this is the first time I will be doing this formally. As such, I expect, it will not go smoothly. There will be startup pains and missteps. Nevertheless, although previous participants have used this system to raise their scores, some even getting 99’s some have not reported back and the possibility that they actually failed the exam could not be discounted.

Therefore, although I will try my best to help you pass this exam, I think you know that I can’t guarantee that you will pass for the simple reason that only you can guarantee that you’ll pass this exam since only you can do the studying needed to pass this exam. All I can do is guide you and help you.

The deadline for submission of your application is August 10, 11.59 pm EDT Sunday. Names of those accepted will be announced subsequently.

Whether or not there will be future prep courses will depend on how this first one turns out. Certain parts of this prep course will be made available to others so that they may be able to see how the participants have progressed in their review. However, some portions of the prep site will only be available to participants.

All discussions and teaching session will be held at the forums: http://forums.askdoc-usmle.com. Quizzes and other study tools will be available at http://prep.askdoc-usmle.com. Both sites are of course still empty and closed although the necessary software to run the sites has been setup. phpBB3 for forums and Moodle (an educational program) for prep website.

Again, I hope this project is successful and I can help more people achieve their dream of a medical career in the US.

note: Marlene, sara, sara9999 and others, hi. you can now start applying.

After 4 months (as of July 27, 2008)

Total posts: 30
Number of pageviews: 7,046 - 4,439 in July alone
Number of Visitors: 2,290 - 1,528 in July alone
Number of Countries: 87 from 812 cities
Top 5 countries: United States: 1, 548; Canada: 122; India:117; Philippines:86; Pakistan: 48
Number of downloads of my ebook “How to Create a Study Plan for the USMLE”: 524
Alexa top rank for all websites: 3 month average rank: 2,852.091 (8,600,000 6 weeks ago)
1 week average rank: 751,712

All in all not bad for a blog that’s just celebrating its 4th month. And I have to thank you my audience for this success. Of course, I would also like to thank prep4usmle, usmleforum, prep4md, usmlemd, mdin2009 and southerndoc for their support. Now if I could only get people to click on my adsense ads, my life would be complete.

After all this what have I learned. Well, First it is not easy to run a website, even something as simple as a blog. So kudos to those who’ve paved the way. Whereas before, I just plow through forums and blogs, now I take the time to click on those ads to show my support, although I still tend to forget sometimes . Second, no matter how careful and logical you are in writing, there are still people who don’t believe you. If they fail, then they come back, ready to listen. But I guess those who pass with low scores never realize that they’ve missed the opportunity to score higher. You never miss what you never had. Third, that although for some people it is enough to teach them how to study and they can go on to review on their own, not everyone can do it. Some people need to have study tools given to them and taught how to use them. Some will need close couching in order to get any review done. So there will always be a need for reviewers and review schools.

So what’s in store for the future for Askdoc. Well, I’ll continue writing my blog to help people achieve their dream and pass the USMLE. There’s still a lot to write about. Different people have different skills and different needs. Some have poor memory, others have excellent ones. Some read slowly, some read quite fast. Some are better informed about the USMLE, some aren’t. I strive to write solutions for different situations for different people.

I’ve already started the USMLE Wiki Project at http://usmlewiki.org. It will be officially announced in my blog once I’ve finished writing the pathology section. It will be equivalent to the Kaplan Lecture Notes plus additional information needed for people who want to go for 90++ or even 99’s. Although printable, it will be easier to use it online as there will be built in links to different sections of the Wiki. For example, related topics in Nutritional Pathology will be linked to Nutrition section of biochemistry in one click. You can be reading cardiovascular pathology and cardiovascular anatomy, physiology and pharmacology will be one click away. It will also contain hundreds of high yield photographs eventually organized in two ways. In appropriate sections of the Wiki and as a collection of high-yield images with captions you can review exclusively. As always, you can go to appropriate sections of the Wiki discussing the image concerned in one click. Once Step 2 CK is finished, there’ll be appropriate links to Step 1 topics needed in step 2, for example menstrual physiology in OB. You may or not use the link, but it’ll be there for quick review if you chose to do so.

As I’ve noted, there are people who seem to need couching in order to make it through this exam and it seems their only alternative is to spend thousands of dollars in review courses that are made for the average examinee and not tailormade to their particular needs. My take is, if they are the average examinee, they should’ve no problem passing this exam. They need special couching. So I am starting, hopefully by September, a prep course for USMLE Step 1 online. It will be free initially but due to limited resources, both time and financial in my case will be limited to 6 positions. I will be developing study materials for the course that would concentrate on increasing retention and recall of information which seems to be the biggest problem of this group of examinees. However, since probably the only way for me to keep this prep course going let alone expanding it is additional financial resource, I may have to charge for it eventually. Look for the official announcement hopefully by the end of this week, latest next week.

So that’s how it is 4 months into Askdoc’s USMLE Blog. Hope you all pass and with a good score. Happy prepping.

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

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

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

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

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

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

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

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

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.