What to Study for the USMLE – Part IV

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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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8 thoughts on “What to Study for the USMLE – Part IV

  • July 30, 2009 at 3:03 pm
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    Hi again Doc!

    I’m aiming for doing very well in the USMLE, but if that is not possible, then at least above average. I’m thinking about pediatrics as a specialty, i know it’s not as competitive as other areas, but still want to do well. I’m a mexican IMG, and I bought BRS Pathology for my review, but I realize that some of the mechanisms of disease will be missing there. Do you think that that book and my Robbins review and textbook to fill in those lagoons is a fair game?

    Many thanks! Truly appreciate all your advice!

  • August 8, 2009 at 6:03 am
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    Hi Francisco,
    Personally I used Robbin’s textbook, since I was aiming for a really high score. However, Goljan’s Rapid Review of Pathology have good discussion on pathophysiology. If you are not aiming very high, it’s shorter and easier to read.

    Askdoc

  • May 9, 2010 at 11:26 pm
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    askdoc, after using Robbins, did you get a high score? Because even I’m aiming for a really high score (90+). Thanks.

  • May 14, 2010 at 11:01 am
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    Hi Rahul,

    My score for USMLE Step 1 is 99/256 and I do credit Robbins as one of the reasons I was able to get a high score, but not the only reason. However, I do not recommend you use Robbin’s entirely for your review of Pathology unless you have a large memory capacity and you know how to chose what is important vs. what is trivial. Otherwise, since you can’t remember everything you have read, you might end up reviewing the wrong things and get an even lower score. That is why in my course, I was forced to write notes for the use of my students. They just refer to Robbin’s for additional details so they know what to study and how much to study.

    Askdoc

  • May 18, 2010 at 7:53 pm
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    Thanks Askdoc,

    I usually supplement Kaplan/BRS path with Robbins (I love the mechanisms and diagrams in Robbins). I’ll keep you posted on my progress.

    PS: Totally love your blog – keep up the good work!

  • June 3, 2010 at 10:27 pm
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    Hi, Askdoc.

    First of all, thank you for your excellent advice. I just stumbled upon your website while doing some research for study methods and I have found your blog to be very inspiring.

    I am a recently graduated mexican IMG and my objective is to ace my Step 1, since I am aiming for a pathology residency. Curiously enough, I have used precisely the materials you have recommended for the “Big 3” subjects and I feel very confident on them. I think it helps they were my best subjects in school, but who knows. 😛 However, I have noticed that there are not a lot of recommendations on what materials to study for biochem, cell bio, histo and anatomy, this last one being my weakness (this meaning, even tho I had a very good grade in my school I mostly memorized everything and by now I have no clue where to begin again). I am really dreading anatomy and I am so desperate that I am literally thinking of studying Gray’s Anatomy for Students from cover to cover. I was wondering if you have any pointers on this and any other of the less tested items on the exam. For biochem I have studied Lippincott’s, and for histo I have pretty much read all of Gartner’s. I have 6 months until my test and I really want to fine tune my study methods in order to achieve my goal.

    Anyways, any advice you might offer will be greatly appreciated and again thank you very much for taking the time to write this. Live long and prosper!!! 😛

  • June 7, 2010 at 1:30 pm
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    Hi Joey,

    First, the reason why not too many recommendations other than the big 3 is that the other subjects are not as crucial in doing well in Step 1. However, if you are aiming for a 99, then that’s a different story. You need to be strong on all subjects. You still have to be strongest in the big 3 but you can’t have weak points. Most important for Anatomy and Neuroanatomy is study them clinically. If it is important clinically, it will come out. For example, anatomy related to trauma – brachial plexus, lumbar plexus, the knee, etc. and important surgical cases like inguinal hernia are high yield. In neuroanatomy, you need to understand the pathology of the different syndromes, etc. For biochem, Lippincott is good to understand the basic, but lacks advanced topics especially in Molecular biology. You need to supplement with Kaplan notes or BRS Biochemistry and Molecular Biology. Histology, just know cell biology primarily and normal histology vs. pathology. For physiology, use BRS physiology. Supplement with Guyton or Ganong for acid-base disorders. Concentrate on pathophysiology, esp. endocrine, spirometry, etc. Hope that helps.

    Askdoc

  • June 28, 2010 at 5:15 pm
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    Thank you Askdoc! I will be sure to include your recommendations in my study plan! Thanks again for this awesome website! It has really helped me a lot to put things into perspective.

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