Guys, welcome to this presentation on how to prepare for the USMLE. There's no right or wrong way. Well, there is a wrong way, but there's no right way to study. The most important thing is that when you study, you are assessing yourself and that you are seeing improvement in your study performance.
We'll go right into it. The way that this presentation is going to flow is because there are so many people studying at different levels. You have some people studying for Step 1, Step 2 CS CK, and then Step 3. What I'm going to be talking about is just the foundational principles that could be applicable for all these tests.
But this is primarily going to help the person that's starting to study for Step 1. I think that's the best person for this presentation because you have never taken the test before. You do not have an idea of what it's like. If you are able to get five pearls from this that you can use to transform the way that you approach the USMLE, you're guaranteed to do well.
So let's go in, like I said, there's no cookie cutter formula. This is just one of many methods and many styles of study. Everybody has a different way that they've learned to study over the course of time with medical school education being so long, we've all already become really ingrained in our patterns.
We have our habits, we know how we study some of us take notes when we study, some of us don't, some of us like to read, some of us don't prefer reading. We prefer more critical thinking. Everybody has a different format as to what they like, but I just want to challenge you a little bit to step away from what you like.
Adopt a growth mindset and try to do something that may actually produce better results. Meaning maybe it's not about what you like or it could be more about what can work for you. Let's just be a little bit more open. Throughout this presentation, if you have done some of these things, or if you study a little bit differently at the end of this, I would like to hear it.
I want to hear how you guys study. So what is the hype about Step 1 scores? Step 1, like I was talking about before we got on the call, on the presentation part of the call is, the hype about Step 1 is it's the most important part of the application. It's held in high regard by residency program directors.
It usually helps faculty evaluations when they're making determinations for whom to invite for interview or who to keep in a program and such. Unfortunately, people correlate your pass rate on USMLE with your future board pass rate. One of the reasons why, you'd hear those people would say, “Oh yes, you fail one of the exams. You don't stand the chance”, which is a fixed mindset. But the reason people are in that fixed mindset is because the fact behind it is some programs are worried because each program wants to graduate people that are eventually going to be board certified in that specialty. That's their goal. Once you finish residency, you're going to take boards and when you take boards, they want you to pass because they want to say, “Hey, we graduated 10 people that are board certified internists or board certified surgeons or board certified OBGYNs, board certified ER docs.” Now, the reason that's important is it helps maintain their validity, their accreditation as a teaching program.
They require or it's best if they have a hundred percent success rate eventually for the boards, then for them to have 50% because if they do, then ACGME is going to question them and say, “Hey, why are your residents underperforming?” When down the street, their residents are performing way better than yours.
Unfortunately, with the world being the way it is, we know standardized tests are not the only ways that you can prove someone’s medical knowledge, but that's the most objective way that we have. So usually programs, when they're looking at step scores, they're thinking if a person has struggled with Step 1, Step 2 and Step 3, their worry is that then board's going to be an issue.
But if they haven't struggled with any of those tests, then maybe they're more likely to pass the boards. But nobody would come up and admit that. But really that's what happens behind the scenes. The other thing is Step 1 greatly affects residency placement. US grads, a lot of them apply with only Step 1 scores. Because usually they'll do their application season during their fourth year. Most of them right now in their fourth year of medical school and then they're getting the applications ready. They already have a Step 1 score because they did it in their third year.
And now they're working on Step 2 so a lot of them are going to start taking CK this summer. They'll do CK in the summer and fall, they start interviewing even without CK scores in most cases. They get their scores midway while they're interviewing. And then they eventually, that's how, you need all your scores in your CS, CK and Step 1 in order to finalize your rank list.
It really affects residency placement because they're comparing you with people that have only done Step 1. If your application is incomplete and you only have your Step 1, then you're sort of at the same tier as US grad. A lot of them, they have higher scores and that kind of puts them over you, but if you have all your exams and you have a complete application, then at that point, you look appealing to the residency selection committee or like the people that sent out the invitations for interview.
Step 1 carries a lot of weight. There was a study done by the National Residency Match Program in 2014, it's actually a survey type of study, more of a cross sectional where they sent out information for program directors to fill out. They interviewed 8,700 program directors so almost 1800 program directors. That's a lot of programs. One person on an average, as an IMG, you may apply to anywhere from 30 programs to way more than that, depending on what your portfolio is.
And we talked about that when we did the How To Find IMG Friendly Programs. US grads have that point of diminishing returns where for them, they need fewer programs to be able to get to their program of choice. And after a certain number, no matter how many more that they apply into, they don't get any more interviews or it doesn't really increase their chance of matching.
For them, that point of diminishing returns is specialty specific. This was based out of another study done by the American Association of Medical Colleges, AAMC. They defined this as the point at which any additional application to your portfolio did not increase your chance of matching.
For US grads, they came up with a number of about 30. If they applied over 30, then adding program 31, 32, 33, 34 did not increase their chances of matching into that specialty. But then the biggest determinant that they found in that one study was if a person had higher Step 1 scores they only had to apply to fewer programs.
Those people with higher Step 1 scores were able to apply to under 30 programs, under 15 programs and target programs that they were eligible for. And they were able to get into the programs that they wanted to get into. The conclusion of that study was this, it was that Step 1 was the highest determining factor for a person's eligibility and it was the biggest facilitator for a person to match into residency.
Again, the limitations with the study would be that they did not study IMGs. It was completely US grads only from allopathic schools, so US MDs. That doesn't look at osteopathic schools and they didn't look at IMGs, but at least that one study, what it tells me is Step 1 is important.
If you have a high score on Step 1, you have a high chance of gathering many more residency interviews, irrespective of everything else in your packet. I had a student last year who just matched into internal medicine in Detroit this year. She did really well on Step 1, I don't remember what– I think she got like almost 240 something, and Step 2 was even higher than that. She was a visa applicant from Gambia, actually a visa applicant from Cameroon, which is from my country and then she had went to medical school in Gambia. But what was different about her application is even though she had a visa, even though she went to west African medical school and had a passport from another country, she got over 17 interviews.
But I think that was because one, her Step 1 score was good. Two, wrote a really good personal statement. I did a proofread for her and commented and critique. She took her time meticulously to fill out the ERAS form so that there wasn't any missing pieces of information. She really put in a lot of time and effort making sure that her packet was complete on the day that application started.
Think of this, IMG, full application packet on September 5th, when programs had to receive your information. Actually I think they receive your information September 15, but you submit September 5th. If you are a program reviewing an applicant that has a complete app, good scores, great layout, great personal– everything is just lining up.
And even if you had a US grad that had just step one score and incomplete app, you're more likely to say, “Hey, let me look at this IMG real quick. Let me just look at them a little bit in more detail.” It's important to have a high score because that's what program directors are looking for, one, that's their primary target. But then second, if everything else in the application is not good enough, at least you give people the chance to pull your application out of the pile.
Back to this NRMP program director survey from 2014. 94% of the program directors that were surveyed, they rated Step 1 as a 4.1 over five on an important scale. We looked at this study before, I think we looked at it when we did letters of recommendation because I think letters of recommendation, I don't want to quote the wrong thing, but I almost believe it was like a 4.1 as well, or a 4.5 right around there. So you can tell that those are the higher things that they're looking at Step 1, and looking at who's vouching for you. Most important factor in majority of cases, step 1.
Now that we've beat that horse to death, let's move on. Before you start studying, I want you to address a few things. First of all, there should be something called a dedicated study period.
I see some people study just passively for a year. They're just studying on the side, “When I get a chance I study.” And then, the boards come around and then they wonder why they performed a certain way. You should have what I call a longitudinal study period, which is throughout your medical education, you're studying.
The way that you would slip between your longitudinal study and your dedicated study period depends on the type of candidate that you are. The reason I put that on there is because there's two types of candidates. There are candidates that are in Caribbean medical schools, meaning that they just completed their basic sciences. Then you have candidates that are physicians from other countries, meaning that they already graduated with an MD degree. They may even practiced so they have some additional clinical experience as opposed to the person from a Caribbean school that doesn't have any clinical experience.
And then there are other things that you would consider before picking out these two phases, being your longitudinal study period, and your dedicated study period is assessing your personal study habits, figuring out what resources you use, and then you set a schedule with a timeline and a deadline.
You do a pretest before you even start your dedicated study period, and then you create your timeline based on your pretest. Once you start studying, then you're going to assess yourself periodically. This is what I call a post test. Here's what that looks like. If I was a Caribbean student again, my longitudinal studying starts when I start medical school on day one.
On day one at medical school, I'm not only studying for my classwork, but I'm studying, keep it in mind that the most important part of my education is going to be my Step 1 score. So everything I learned in school is dedicated to getting a 240 and over. What that would look like is from day one of basic sciences in a Caribbean school, while I do the coursework that my professors are giving me when I'm going through my first semester and we're reviewing anatomy simultaneously with my coursework, I am doing some type of question bank on anatomy.
It could be USMLE world. It could be Kaplan. It could be USMLE RX, whichever one you choose to use. Like I said, doesn't really matter, even though UWorld has shown to be superior to all the other ones, multiple times. But I would say if you were to use a UWorld, what you'd be doing is throughout that one semester of anatomy, you are constantly testing yourself behind the scenes with the QBank for anatomy from UWorld.
When you move to your second semester and you are doing biochem and molecular biology and ethics you're doing the questions from UWorld as well during that time frame. Over the course of two years, you would've completed all the questions in question bank X. And then at the same time you're studying for your schoolwork.
You wanted to be passing your classes as well, but then you're making extra time to pass and prepare for Step 1. The mistake I see is people wait until the dedicated study period to start to study for Step 1. Then you're under a time crunch and then all hell breaks loose and you don't do well. We're still on the Caribbean student, so the Caribbean student has finished his or her basic sciences. And now it's in their dedicated study period. Dedicated study periods vary per individual and per school. Some schools give you six weeks. Some schools give you less, some schools give you more and then some schools will not let you take the test until you pass a certain type of pretest, which is great.
I think that's a great filter, but your dedicated study period for a Caribbean student then looks like you have a deadline, which is I have to take Step 1 by this day. And then at that point, that's when you're putting in 5, 6, 7 hours a day of dedicated studying, phones turned off, Facebook is deactivated.
Instagram's turned off. I'm in my books the whole time. I take breaks, maybe every 60 minutes. Walk around the house, walk around the library, but I'm sitting down studying during that time period. That's what I call a dedicated study. But the problem with dedicated study is you can't just start it in six weeks and expect to just be great at it.
Because one thing I've noticed with the times where I've had US grads rotating with me though granted, those were osteopathic students. A lot of them came to rounds and they were doing UWorld simultaneously with their rotations. These were people studying for Step 2 more so. Because of course, clinical rotation is after Step 1, but it just tells me like these students are being ingrained and they're being taught to start doing practice questions way earlier in the game than the rest of us.
In a sense, we all have the same medical knowledge. But they may be better test takers just because they've been ingrained in the way that the test is structured in the way that the test is written, they've done tons and tons of active studying, which we’ll talk to you a little bit on that active as passive learning.
The next example we're going to highlight is the example of a foreign medical grad that has already completed medical school. I think this person has an advantage because they are able to see things 360. When I was in my preclinical years, I had not really had that clinical perspective to understand the way the USMLE structures questions because usually they've used a lot of patient scenarios to describe things. Sometimes, having that mundane knowledge of a basic clinical encounter really helps to facilitate how quickly you can understand the question staff. Because they do a good job of putting a lot of distractions in there. They'll put this long question stem, just to ask you one little thing at the very end.
The person who is a physician in another country, or who was a physician in another country already has so much medical experience on their own that reading that stem is not outlandish. Now what's different though, is that the system that they may have practiced in is very different from the system that we're in here, as far as there some of us that maybe went to medical schools in Africa where maybe their emergency system is not as structured in some parts of the continent, not every country, of course. But there are some parts where the emergency system may not be as structured like in my country.
Sometimes you don't have a fixed ER course. But then if I had a Cameroon physician going over a question that was talking about a 35 year old patient presented to the ER and was found to be complaining of chest pain, they were also diaphoretic, tachycardic. Usually they won't put it that way, they'll put like the numbers, put a low blood pressure and put this, and then they'll go off tangent and talk about the family history and the sister. Then they'll talk about this guy ate a mayonnaise salad the day before, and then they talk about something he had a trip to some long distance trip, and then they come back into the question stem and ask you, “What is the most likely mechanism of this patient's injury or cardiac injury?” or whatever, but they're trying to describe an MI. For a person that has been a physician in the past, when you look at that for Step 1 question, you have a broader perspective than someone who maybe has never been exposed to that in the past, but to the same token, to a person who did not have a robust emergency medicine experience, that could be new.
Really, the only advantage to have, I think that you have there is that you are able to understand a clinical scenario from the viewpoint of having treated patients before and then now going back into how that connects with basic sciences. The only disadvantage though that FMG or IMG has, is that basic sciences for most people may have been like over six, seven years ago, because it was the first year as a medical school. Then you went into four plus years, some European systems where you do six years of medical school, your basic sciences are the first two years. It's really hard to remember your first three years, it's hard to remember some of those concepts. So that's the challenge is remembering the concepts from earlier on in your medical education.
But when it comes to understanding the question stem, I believe that you have an upper hand on that. When I talk about before you start studying to determine the type of candidate that you are, that's what I mean. I want you to look at yourself from the viewpoint of, “Do I understand clinical scenarios well? Do I understand basic sciences?” So a person from the Caribbean may just have completed basic sciences, so they may be sharper at it. But they may not understand how to interpret that in the sense of a clinical scenario. So that's where their challenge comes in and then they feel like, “Oh, I'm not a good test taker.”
It's really because you don't understand how to connect what you've studied into a clinical scenario. On the flip side, an IMG who has already practiced in Europe or Africa and Asia, or South America, that person has clinical experience so they understand that really well, but they don't remember the basic sciences.
You need to look about where your focus will be and figure out the type of candidate that you are so that you can know what your weakest area is. And then you're going to focus all your energy on improving your weaknesses. That's how you target your study.
The second thing we talk about is personal study habits. If you're the type of person that studies with music, I don't know. Goodluck to you. I'm not, I don't, I can't study with music. I feel like I need to sit in a quiet place and in my personal perspective, you need to have healthy study habits. Studying quiet, no distractions.
I think there was some article that floated around where it said, “Every time that you distract yourself, it takes your brain 15 minutes to get back to the point that you were at before.” So if you were studying right now, I'm looking in front of me. I have the MKSAP, which is a self assessment program for internal medicine and I use it to review stuff from my work.
So I'm looking at MKSAP, I have critical care. If I started studying chapter one in critical care and then I got distracted and went on Instagram because Instagram is my biggest distraction. Then I went on Instagram and I started reading through people's profiles. If I came back to study again, if it's going to take up to five minutes for my brain to reorient to what I was studying, that's a lot of time. Because if you get distracted multiple times an hour, say maybe if it's your kid that's walking around or your spouse is talking in the other room or a family member or something like that. If you keep getting distracted and interrupted, it's going to keep taking your brain more and more minutes throughout the day to reorient to what you're studying.
And really a lot of what you're studying, you need to memorize, but you don't need to memorize a blinding. You need an understanding of it. It's important to assess what your study habits are. What are the things that you're doing that are jeopardizing your study? Are you constantly distracted? Do you have a hard time sitting still?
Are you someone that maybe has been unfortunately diagnosed with ADHD in the past that you have attention deficit? Is this the prime time to go back and consult with the physician? Is this the prime time to be on medication so that you can be able to focus different things like that?
I'm not saying that everybody should be medicated necessarily, but if you have a true diagnosis, you may want to look into that. Now, if you have test anxiety and it's really not a problem of studying, there are tons of resources out there on how to handle test anxiety. There are psychologists, there are educational people, the educational PhD folk that focus on people that have test anxiety.
I have one resource that I'm working with to see if we can help people to feel maybe an example for, and have test anxiety on the next one. There are so many resources like that you can tap into to be able to tailor your personal study habits.
The next thing you're going to determine is, “What resources am I going to use?” Like I said, you don't need 10 books to study from. You really do not need to study from 10 books. If you study from three books, you should be okay if you really studied intensely. So UWorld and by books, I mean resources altogether. So if you're using UWorld, you're using First Aid, you’re using Pathoma, Goljan, I would say those are four resources already.
You don't need six more to diversify that unless you have a weak area. Say if you have a weak area, bio stats, and then you say, “Hey, I'm going to get a biostat book to focus on that.” Then that's different, but you don't need to be studying pathology from five different resources. If anything, you may need five methods of studying, meaning questions, video, audio, and text, which is actually four. But that again, should be your limit where you have one resource for questions, one resource for video, one resource for audio, one resource for text.
The next thing is you're going to set a schedule. So we talk about the people that are doing longitudinal studying with basic sciences, and then you're going to have the people that are going to be doing the dedicated study period.
Your dedicated study period may look like this. I am currently at this point in my career or my education and I say, “This is July 13th. I want to take Step 1 by December 1st. I want to have a past score by December 1st.” My dedicated study period varies if I feel like I have this study down and I take an MBME and I score really well, I may not need to study for too long. But what I recommend before you set up your dedicated study period, is that you do a pretest. You do one of the MBME forms to just assess your general knowledge. So this is for the FMG. This can apply to the Caribbean student and even a non Caribbean student.
You do one MBME before you start. The purpose of that MBME is not to tell you how you're going to do on Step 1. It's to determine your weakest area so you can put in all your effort in those areas. You do an MBME, you look at the score, not the score itself, but the score report and where your bars are closest to the left, the disciplines where your bars are closest to the left, meaning you scored lowest.
That's where you're going to put in all your initial effort and energy, the bars that are closest to the right. You can probably scale back on those and study those in a more passive manner. What that would look like is if I want to get my exam done December 1st, I'm going to start by doing an MBME today. Then based on my MBME, I'm going to create a schedule starting with the discipline that I scored the lowest on. If I did an MBME for Step 1 and I scored really low in anatomy, bio chem and pharmacology, that means I'm going to take the one with the lowest bar and say, “I'm going to start studying with pharmacology or bio chem or whatever.”
If you do an MBME and you're in that center, meaning everything's about the same. All your scores are on the lower end and all your scores are on the higher end. If you do that and that's what happens, then that means you don't have one area that's weaker than the others. It means you need to work on everything equally.
So the way that I approach that would be a little bit different. I may not be disciplined specific. I could try to be organ system specific and see my lowest area there, or I can decide I'm just going to start from my foundational, which is my anatomy, biochem, histology and biology. Just like with the course of medical school. I always tell people the way that it teaches medical school, they did that for a reason. They started with anatomy, biochem, histo, embryo, because those were the foundational principles that we needed to understand before we got into molecular genetics, ethics, behavioral, and all these other things.
Then when they figured we got a hang of that, then they added micro, immuno, then they went into pharmacology, went into pathology, physiology. So there's a reason why they did that format was because you need to understand the basis of cell biology. Then you need to understand the basis of genetics. Then you need to understand the basis of behavioral.
You need to understand the basis of micro and immuno, and then they top that off with how that all comes together on the pathology. Then the cream of the cream is the path of these and how it all ties in day one of medical school to the last day of medical school. Your timeline would have to be focused on your weakest areas first and working your way into your stronger areas. The way that you'll do that is by doing your pretest. After you do your pretest and you start studying, then we'll come back to what to do for post test.
There are two types of learning. There's active learning, and there is passive learning. Active learning is when you apply critical thinking techniques to study. Passive learning is when there's no critical thinking. You're just reading to absorb and memorize. The best type of studying method for Step 1 is an active learning method, which is what everybody recommends using UWorld, UWorld, UWorld. The reason being, you do indeed know these concepts. You really do know, you do understand anatomy you've been in that class.
You know what they taught you. You understand it. The problem is, can you answer a question on it? The only way that you're going to do that on the USMLE itself is if you're able to have done that at home. So active learning really helps you apply some critical thinking skills because the questions on USMLE, man, I don’t know where they get them from.
But a lot of times they're written by well-meaning professors. They don't want to trick you. The intention is not to trick you. The answer is there, but they want to see if you can think critically enough to be a physician. That's why they make it that way. In a sense, the critical thinking piece is really what the test is about.
You're just not looking at the test for phase value or the questions for phase values like, “How can I think critically through this?” But what kills some people too, is that they start to overthink every question because they know that now, then they're overthinking every question and then they bypass the concept.
Two things, the USMLE is not out to trick you. USMLE is out to help you. What they're trying to do is assess your critical thinking skills. Don't ever think that the question is tricky. Again, mindset, right? Go back to thinking, “This is just an assessment of how good I am with critical thinking and understanding of medical concepts. There's nothing strange on this exam. I know everything that's on this exam. I've studied this material. I just need to calm down and read through.”
A lot of people start to get anxious when they're reading a question stem, and then that's when you really get messed up because you're drowning goes on high drive. You're not able to focus. You're not calm. You're not reasoning through it as well as you would have if you were in a controlled environment. So in that instance, what I tell people is if you find yourself, especially on test day and you're getting anxious, you need to stop and do some deep breathing exercises and you need to read the question out loud.
Reading the question to your own hearing, like under your breath helps you to not get distracted by the thoughts that are running you wild. Even at home, when you're doing your active learning, if you feel like you're getting tired, you're not focused. You need to read the questions out loud to yourself.
Passive learning is like basically taking a book, a review book, and just sitting on the couch and just reading through it. Even when you do your First Aid, you don't want to just be passively reading through it. You need to be highlighting. You need to be taking notes because when you take notes, what you're doing is you're activating your learning center in your brain.
It's connecting with your hand and you are writing now what you're learning. There's a lot more, it makes it more memorable for you because the act of sitting down and writing helps to connect one on one together. There's a theory in neuroscience that talks about how people learn and why writing is a more effective way in your learning process.
I don't remember the specifics of the study and I don't remember the brain center that they highlighted, but they did highlight a certain brain center. I'll find that study and share it with you guys by email. But it just really shows to how connected you need to be when you study. It's like when you go to the gym and you're working out, if you really want to be buff, the people that are buff, usually if you see them, they're standing over there by the mirror, curling that iron, like looking at the muscle, they're so focused. You can't break their focus.
The reason that I think body builders are able to get the muscle that they get is because they sit there, look at themselves in the mirror, make sure the form is right. They're focused on that muscle contraction. they're focused on the contraction, the relaxation it's 100% and then they drop the weight and then they'll chat with you.
But most often, why do we think that when it comes to studying and we're trying to build a learning muscle, we're trying to build a memory muscle. Not memory muscle in a sense, you're trying to memorize in your head and your brain, but then we feel like we can do that and be listening to music, or not be taking notes or be distracted.
You can't, you have to be 100% focused on what you're reading. You have to be talking to yourself. You have to be looking at your book and saying, “This is what this thing is trying to tell me. Oh, this is what this question is trying to ask me. But what is the educational objective behind this question?” Every time you see a question, you got to be thinking critically. Thinking critically is asking yourself about what you're learning and then answering that and reciting that to yourself until it makes sense to you. Critical thinking is connecting the dots. It's just not reading through something. It's putting one on one together.
Before you start, you definitely want to do your mindset work, meaning you have to embrace the fact that the USMLE is here to support you. I want you to take this and take it very seriously until the day I came to the realization that the USMLE was not meant to trick me.
It was not meant to become a stumbling block. It was not meant to weed me out of the lot, but it was meant to really help me think critically. Only then did I start to change my approach. I told you guys, it's the last seminar that we had. My Step 1 performance wasn't as good as my Step 2 performance, but then Step 1, I was a ball of nerves.
And with taking time out to say, “Hey, I can't let my nerves come in the way of my performance anymore. USMLE is not meant to trick me. It's meant to just assess my current knowledge level. And if I do really well on it, it gives me an upper hand in residency selection.” So at that point I set a goal. I'm like, “I want this score.” Every time I got anxious during my study period, I said, “USMLE is not meant to trick me. They're just trying to ask me things I should already know.” So my growth mindset in that moment was, “What do I need to learn that I don't know yet? What do I need to focus on that I don't know yet?”
That was my growth mindset that I had to adopt. It changed really my whole entire perspective and then I started to study and I'll listen to videos and audios and everything was making sense. And I thought, “Oh my God, how is it that missing out on this before?” It was all in my mindset because I would approach my books like, “Oh my God. Now I have to study for six hours. Oh my God. I have to study for seven hours. There's so much time I'm tired and I can't do this. I can't wait for this to be over blah, blah, blah.” Yes, you should want for this space to be over. But it shouldn't become the most crippling thing when you sit down to study.
I think you'll do a lot better if you were so excited to go study. The only thing that would keep you excited is if you start to look at the outcome as something good as something that's making you better. I tell you, the studying that I put in when I did Step 2 and Step 3, after I did Step 1. The way that I approached my studying then really made a big difference for me because I started to like what I was learning and it became exciting.
I would remember I would study something and when I finally understood like the RAS system, I was like, “Oh my God, I was so excited because finally, it makes sense.” When you really start to enjoy studying, then you learn a lot easier. You really capture what you're supposed to capture. I know this sounds really outlandish, but it's very possible to enjoy some parts of studying.
Yes, it's going to be stressful sitting in seven, eight hours. That's very true. I had a hard time sitting in the same spot for so long. It's really stressful, but you need to be able to say, “Hey, it's stressful, but I can do it. It's stressful. But tons of other people have done it before me. It's stressful but if I can enjoy some parts of it wouldn't be as stressful anymore.” Growth mindset.
Then, you're going to start early. So those of you that are still studying for Step 1, perfect timing because you can start early. Study now and target not this cycle of residency in September, but next September.
But all this information that you're getting right now, hopefully is putting you in a position where you'll be in a better place to perform well and to really have a different approach to this whole process. I think you should allocate time as if this is a full time job, meaning you should give it at least six, seven hours a day during your dedicated period.
Because if you think about it, when you go to work for six, seven hours, what do you get? You get a paycheck, right? What's your paycheck? Your paycheck is your reward for work well done. If you go to work and you're not productive, you're not going to get a paycheck because you get fired. So it's the same thing. If you are studying for USMLE, it's a full time job.
If you put in six, seven hours a day, you get a paycheck. The only difference is your paycheck is an increase in your USMLE world performance, your NBME performance. Eventually your UWorld performance. But if you go to work every day and you're not focused, you're doing other people's work in the middle of your work.
It's you're not treating it like a full time gig. Guess what? You're going to get halftime pay because you did not put in full time work. So you need to put in full-time work. By full-time work I mean you're completely dedicated to this process. One of the things that limits that is like finances, some people have to work between these.
They have to family to keep up and such, but at some point it's important to see if your family or other people can step in so you can just sit back and focus on your dedicated study period.
Assessment, you want to assess your current knowledge within NBME or the US grad. Some of them have the CBSE, which is what they do at the end of each rotation.
It helps you to determine your weakest area. Like I said, you're going to start with an NBME to determine your weaker areas. Then you're going to set your question bank based on your weakest area first and work your way up into your best discipline. The next thing would be after you've done your assessment. You're going to go into your question back of choice. So UWorld, like I said, is like the gungho. It's like everybody swears by UWorld, but there's different ways to use it. What I usually recommend is if you don't do well on your NBME, then you should start in a tutor mode. Tutor mode meaning you're going to start with one block a day or two blocks a day.
You answer each question and once you answer the question, then the result shows up on your screen, if you got it right or wrong and you can work your way through it. But when you do UWorld, I want you to focus on those educational objectives because the rule test is not going to be all UWorld verbatim, but it's going to be all those educational objectives because the people that wrote that test, what they're trying to tell you is this is a content that has been tested on the USMLE and continues to be tested on the USMLE. So irrespective of how I presented the question to you in this USMLE world question bank, it's up to you to understand the objective of this question. The objective means the reason behind. The [unintelligible: 00:41:44] like, “Why is this important?” It's important because it's always going to be tested on the boards, but they won't test you on the same thing. They'll test you on different things.
For example, you can always guarantee if you're studying for Step 1, that they're always going to ask you about the stages of myocardial injury to infarct. That's a given, you know why? Because every day in America, the most leading cause of death is cardiac disease. That's why cardiology carries like 38% of your QBank.
Every day in America, there's a new person. There's hundreds of people being diagnosed with high blood pressure. That's why they'll ask you all the questions about their RAS system. They'll ask you all the questions about every single type of pharmacology agent, like loop diuretics, your thiazide diuretics.
Your aldosterone antagonists, your ACE inhibitors, the Bradykinin system. The reason they dig deep into that is because millions of people walk around needing those medicines to survive. The educational objective of each question is because it's an important issue. If you start to look at your studying like that and look at your studying in the context of that altruistic individual that you are, that shows this career path, then it becomes a little bit more exciting.
I'm not going to lie. There are some things that I learned the most when I was studying for boards that I never forgot till today. When I'm starting a patient on a new medication now, and I'm just thinking, “Man, the reason I understand the mechanism of action of this medication is because I remember studying it day in, day out. Alpha 1 antagonist, alpha 1 agonist, when it comes to vasopressors and things, and the mechanism, pharmacology was just like oh my God, this is the bane of my existence.”
But it ended up being one of the best things I ever did was to sit down and put some extra time on my pharmacology question banks or the pharmacology section of my question bank, because I ended up understanding everyone and I never forgot it. It's really important to not focus on the question, but focus on the educational objective. The way that I do UWorld, or I recommend people to UWorld is so you start in this tutor mode, say you did your MBME assessment and you scored really low in biochem. You're going to start in tutor mode on biochem. I challenge people to do this. I challenge people to take the UWorld question bank. If you go to your UWorld question bank, you probably have, I don't know, 2,300-something questions to start off with, let's just say, 2,500. So if I say there's 2,500 questions in UWorld, and my weakest error is anatomy and I have six months before me, or three months or two months, or one month before I study. Say I have one month to study, I would say, “If I split 2,500 by 30 days, it means on average, I need to do 83 questions a day to complete this QBank.”
But it's just not about numbers. It's not a number game. It's not about how fast you go to the question bank. It's how much you learn from the question bank. Technically every day, if I did two blocks of 45 questions or more, I can get through the QBank in one month, but you don't want to just get through the QBank and not learn anything.
That's where I say everybody's time frame is different. But say I did six weeks, say I decided, “Hey, it's going to be 45 days. The 2,500 questions divided by 45. That puts me about 55 questions a day.” Let's say I bought a QBank, one QBank a day. And then I say, “I'm going to start with my weakest area.” My lowest score was biostat and I go to the QBank and actually see biostat only has 40 questions. I'm going to set those 40 questions on my QBank and I'm going to set it in tutor mode. I'm going to get me a small exercise book, the spiral notebooks, the one that you can flip back and forth really easy. And I start with tutor mode.
I start with question one at the same time I have my audio resource and my video resource, which could be like a Kaplan video. So I start question one and I'm going through, I do the question, I answer it. If I get it right, I read through the educational objective. I make a note in my book as to what the objective is, because when I go back to First Aid, that's the concept that I want to make sure I understand 100%, the objective of that question.
So when I see to my First Aid, I'm going to highlight it. I'm going to make notes next to it. That's later on. Now I go to the next question, I get that question wrong. What do I do? I read through the question, read through the answers. I try to figure out why I got the question wrong.
And then I say, “This is a question about negative predictive value, and maybe I've never really understood what negative predictive value is.” So I go back, I pause my QBank. I go back to my video on biostats and I look for the section where they talk about negative predictive values and positive predictive values.
I watch that section. It may be 30 minutes, 45 minutes. I watch that section entirely making a distinction between a negative and a positive predictive value, understanding the key concepts. And at that point I'm taking notes in my notebook. When I come back to that question and say, “Now I've gone through this concept. Let me see why I got this question wrong.” And then I read it again. And then I'm like, “Oh yes, so now I understand. I thought about it differently.” I talk through to myself. So this is me thinking critically out loud to myself. Once I have a summary of what I got wrong or why I got it wrong, then I make myself another note for the educational objective and I move on.
That is time consuming. So you may end up doing just one block a day. But even if you did one block a day, you can finish that in two months. Then you're going to have to do it again. I usually recommend you do question banks at least twice so you do UWorld like two rounds. If you did the second round, then you're going to go timed mode. Because the second round is timed mode, it's random because you're trying to simulate the test. Because simulating the test is very, very, very important. The reason being the test environment is one of the most stressful days of your life. You need to be able to calm your own anxiety by already practicing to sit still in a timed mode, random selection.
Your second go round should be timed mode, random selection. Just like each form should be a true representation of what the test could potentially look like. So that's for the question bank.
We'll move into how to use your question bank. Like I said I already explained this, how to break down your question bank, identify the total number of questions, you identify the total number of days you have to study and you break them down to one to three blocks per day.
If you have 60 days to study, you may be able to do one block a day. If you have 60 days to study, you may have to do two blocks beause you have to go through it twice. If you do one block a day, you may only get through it one and a half times. So you want to give yourself time.
But when you first start, you're going to go through your tutor mode. When you complete that, you go through your UWorld again in timed mode. Keep yourself review notes. Your notes that you keep for yourself is what you're going to review before you go to sleep at night. If you have a long commute on a train or something, you take your notes with you.
It's always good to have. Myself and some of my friends who studied together, we used to carry around like the Goljan audios in our MP3 players back in the day. Or even now you have Pathoma videos, I don't know if those come in audios anywhere, but being able to listen to those passively when you're not working.
So if you're in the kitchen trying to fix dinner for your mom and you have kids, and every evening you have to make dinner, you could be listening to Pathoma in the background. Instead of listening to the television, while listening to Pathoma, instead of listening to music, when you're in the shower, but wanting to turn on some Pathoma or some Goljan or something, that way you're always learning something.
But I would probably make sure that if I did a QBank on anatomy today, and I was making dinner later in the evening, I'll probably be listening to the same section of anatomy that I just learned. I'll try to make sure that I'm listening to something that I just studied about so that it's reinforcing concepts in my head.
Then your First Aid, which is going to be your next best resource, you're going to use that simultaneously with your own personal notes. Hopefully that gives sunlight as to how to utilize the question banks that you have.
And then like we talked about, we talked about the type of candidate before I sort of jumped ahead so I'll just skip this slide. Then the limitations that you may have, it’s good to recognize them because it helps you tailor your studying to what's important. Those that have distant, basic science education are usually a non-Caribbean medical students. So you may want to focus a lot of time on Step 1 study, but Step 2 study may not be as complex for you and vice versa. Those that are in Caribbean schools. They just need to focus on Step 1, because Step 2, they're going to learn when they get to clinicals.
Moving on to the next slide, does it really matter where you studied from? You can use any resource. I know for sure, the highly rated resources are Ufap + G.
So U-F-A-P plus G, which is USMLE World, First Aid, Pathoma and Goljan for Step 1. And then, most people supplement that with Kaplan videos and audios. But the best way that I think to use Kaplan is just not sit down, listen to them passively. But the best way, in my opinion to use Kaplan is, when you do your UWorld question, you find that section in Kaplan and you watch it again.
Because at that point you've already had a question in your head that needed an answer. So when you're reviewing the audio or the video in Kaplan and looking at the notes, you are applying critical thinking by asking or answering a question that is imposed to you, as opposed to just sitting there.
When you're just sitting there looking at the Kaplan videos, you don't know what's important and what isn't, so it's just that it doesn't make sense. Using questions really helps to tie it in together. Talked about the different types of resources. So UFAP + G, UWorld, First Aid, Pathoma and Goljan. There's so many other ones on this table, as you can see it is incomplete because there's just so many programs that you can use.
Some people say “Hey, I don't like Kaplan. I'm going to use Goljan, DIT, I'm going to use the PASS program.” Again to me, doesn't matter what resource you use. Just use it the same way. Use it in the manner that you use it as a reference source while you do a lot of questions. Questions, questions, questions, that's what's going to help you or your revision, a summary book, like a First Aid or Master The Boards always helps.
So your pretest, we talked about picking out how to do your NBME. It's really the first one's not about the score. It's just to help you identify your baseline weaknesses, then it helps you make your schedule thereafter. And like I said, your schedule has to be like the schedule of a fulltime job. So you're putting 6 to 7 hours a day, however long you need to get your work done. You have a schedule a week ahead, even a month ahead. This week, I'm going to be doing anatomy. I'm going to go through all 300 questions. I'm going to split them out into timed mode. So on Monday, I'm doing 50 questions. Tuesday, I'm doing this number however way you want to do it. Next week, I'm doing biochem next week. The follow week, I do micro. You need to have a schedule because you need to keep yourself accountable. You can't just keep studying. And say “Whenever I finish anatomy, I'm just going to move to biochem.” You're never going to finish anatomy.
If you don't set a deadline, it's scheduled for yourself. That's just the way our minds work. What happens when your professor says you needed to submit your homework assignment before the 22nd? A lot of us wait until the 21st night and we start to do it because guess what? We're going to do it for the 22nd.
But if you don't psych your own self into creating a deadline and say, “Hey, I'm going to take Step 1 on October 1st. So whatever happens, I need to have gone through UWorld twice by the end of August.” If that's your goal, you go for it. But you have to have deadlines. You need to get a calendar and put things down on paper. I'm going to do the 30 questions of UWorld every day for the next week, starting with anatomy. And then you put that on paper and then each day you cross it off when you finish.
This was another nice paper I found. I thought I would share that with you. It basically looked at the resources that US students used to study. Of course, the studies are all based on US grad. And we know that of course, medical schools are different in how they teach and how they train students. So it may not 100% apply to us, but you can make inferences from a study, right? You may not be able to make statistically significant conclusions, but you can make inferences from a study.
This was a survey. Again, not a clinical base, it's more of a retro retrospective survey. The mean age of the people that took this survey were 25 years of age. And they studied on average about 40 days for the test. They scored a mean of 240. So meaning the average score was 240 on Step 1 and all these people, again, US grads, younger, like 25 of age, at least younger compared to me.
On average study, about 40 days. So a little bit over a month of studying they used, UWorld QBank as a primary or secondary source. They used First Aid as a primary or secondary source. And they studied only half the time in group. So a lot of it was individual study, meaning it was a dedicated study period.
It was putting my 100% down in on making this a full time gig for 40 days and then scored 240. Again, the relook at the resources that they use. Yes, you can say, “Other factors may apply Dr. Lum, such as their medical school and how they were taught in school.” Some there I don’t know those of you that follow me on Instagram, the other day, I put up a post about medical schools and there are some medical schools that are Caribbean that really need to be shut down, honestly, because they're ripping students off and not providing them good quality education.
Then there's tons of other ones that are very successful and have been around for decades, even 30, 20, 40 plus years. So it's important to realize that yes, if you're basic sciences weren't strong enough when you first started, you may need more time to catch up. You may need more time to get up to speed, but if you felt like you had a pretty strong background of basic sciences and it wasn't dodgy or sketchy, then you may not need that a whole lot time.
I think nobody should be studying for USMLE for a year. It is just no way. You shouldn't be doing that. You should be able to have either a focus period where you're like, “I'm going to do this in six months.” If I'm a graduate from a foreign school and I'm currently in the states, you need to have a timeline. set a timeline, set a deadline. I think the best way to set a deadline is to say when you want to apply. If you are going to apply September 1, 2020 then perfect. Start now because you're over a year out. So you can actually do Step 1, Step 2 CS and CK over the next year.
In this one year, you can get your US clinical experience. You can even do research. You can get strong letter writers through the connections and networking that you do. You can study for Step 1, Step 2, CS, CK, all, and have your results before August of 2020. Guaranteed. And this is July in one year. You can do all of that. You just need to treat it like a full-time gig. That's all.
Like I said, I think I've been going ahead of the slides, but create your timeline. There's no guideline because everybody has different conditions in which they live in and in different family dynamics, but always start with the end in mind.
Another thing that I've noticed is a big limitation is the financial constraints. A lot of people have a lot of financial stress and that cannot be disregarded because actually in this study that I was talking about even though it was only US grads, they did mention something that I thought was very powerful, but they said the students from their survey, again, the small number, so a low power study, only 82 people, but the students within that group they found out that their Step 1 scores correlated well with the lack of financial need.
So people that didn't have any worries about where their next rent was going to come from or where their next meal was going to come from, or they didn't have financial problems per se. They did a lot better. And to me, that just correlates to the level of anxiety, because they don't have as much anxiety.
They're not easily distracted because you have all your resources in place. If we know that's the case, then maybe before we start a dedicated study period, maybe we can reach out for help. Maybe it's the time to move in with somebody else that can vouch for you or help you be sheltered from your own problems.
But then, it'll be a short thing. “Few months, can I live with you? I'm not going to pay a rent. I'm just going to stay in this one room and kind of figure some things out”, use whatever you need to do. I remember actually I went to live with a friend and I was studying just because she lived in the most remote area ever.
And I just needed a place to run away from the buzz of Maryland. I used to live in Maryland at the time, from the buzz of Maryland because it was so busy. So I went off to this suburban area to the Maryland, but there was no one, there was no one for me to be distracted. I didn't know people in the community.
All I had to do was study. In this study, what they showed was people that had a lack of a financial need. They scored about an average of 230 compared to those who didn't have any financial problems in the 240 and over. That's a significant 10 point difference, so your emotional state does matter, which goes back again to mindset. You need to be able to find a way to counteract them.
On the day of your test you're going to have to sit seven, eight hours. I recommend people take breaks between but before that you need to be able to be sitting the same amount of time at home for at least two weeks prior, like simulating tests environment so that on that day, it's not like, “Now I have to sit for 78 hours and I've never done that before.”
Other tricks you can use is consider reading the question line first and then back to the stem. The last line always has a question in it. If you get the question and then you go back in the stem really quickly, all this happens within a few seconds.
You get back into the stem of the question and then you find the answer or you can think of the answer first and try to find it in the options, if you are unsure of a question, you can always mark it and move on and come back to it. So you spend less time on the questions that you know because you just keep moving on and then you mark the ones that you're unsure of. Then you come back and use your leftover time to finish it. You want to get good night rest the night before, at least eight hours of sleep, you want to eat a balanced side, tons of water, tons of vegetables because your brain needs that to work. Usually, I don't know, my brain works better on carbs. I'm just saying, you figure out what works well for you, but you eat a balanced side. You don't need to be hypoglycemic during a test or constipated during a test. Those things are not necessary. Anxiety can make or break your test. If you don't already have a way to counteract anxiety, you can try some deep breathing exercises.
Your faith can help you. You can create a mantra like we did with the mindset class. Every time you feel like, “This test is difficult, I can't do it.” You have to recite whatever you wrote for yourself as your counteracting thought to be able to combat that fear. I like to use, I use this app called Headspace.
I use the free version and it just helps to do some deep breathing exercises and just calm your mind in the morning or whenever you can always consider using one of those kind of apps that I will call calm. There's so many apps out there to just help you with how to do deep breathing exercises and such.
For Step 2 CS, I recommend that you find a practice partner. I think the people that feel Step 2 CS, it's not that they don't know the concept, usually it's because they haven't practiced enough. Or they didn't practice in the right way. So your First Aid has all those clinical scenarios that you can practice from, but you need a physical human partner to practice with. A lot of people and again, Step 2 CS, if you really think about it, it's all the cases that we see everyday, chest pain, stroke, diabetes, mental health condition, depression. So they'll always give you the things that are every day, bread and butter, American medicine. You're not going to see something that's outlandish. You can always guarantee that they're going to give you one per system.
They're going to give you something from cardiology. Cardiology, they're probably going to give you two like stroke and chest pain. They're going to give you something from GI, like abdominal pain. They're going to give you something from neurology, like seizure. They're going to give you something from psych, like depression, because that's very common or someone with suicidal ideation.
Just debunk it, demystify the test. Listen, guys, the USMLE is just asking questions of things that we see every day in clinical practice, which is another reason why for those of you that are just starting out for Step 1, it's good if you can secure like a rotation and make it a light rotation, like a light clinical experience where you just go in one day, a week or twice a week while you're doing your intense, dedicated study period, just so that you can see some of those scenarios that you're seeing on your QBank.
It makes it really interesting when you go in and you're shadowing your doctor, and then they have a clinical case that you just saw on your QBank. At that point, when you get back to it at home, it just all makes sense. But back to CS, you want to rehearse all the cases that are available on the first one, whatever study resource you're on the first eight or whatever study resource that you choose to use.
You rehearse all those cases with a live partner. You can use your family members to be your standardized patient or you can use, I know some people do Skype practice at places that you can find a partner. Like on this e-course, this would be a perfect place for you. If you're doing CS prep and there's somebody else that's doing CS prep, you team together and you do it, or you can go on any of the other USMLE forms and you find someone that's also doing CS prep and you work together.
The other things that make international graduates fail CS is what I would call cultural differences and by cultural differences, I mean not understanding the need for personal space, not being excessively polite, not being excessively explicit in what you're doing. So you're supposed to tell the patient everything that you do before you do it.
You need to be respectful. So you're going to say, “Ma'am, I would like to examine your heart. Can I go ahead?” And then they'll give you the permission and then you'll say, “I'll need you to unveil your gown” and then they do that. And then if you're going to do an exam, you're going to drape them. Draping is very important because you have to protect patient privacy. Those are laws that have to be kept. But if you don't drape a patient, the standardized patient's going to file you. You may have your clinical concept down and you go back out and you write a good differential and you fail the test and you're like, “Why did I fail that test?” I think it was cultural differences. Then the other thing is the master of the English language, but you don't need to be like a pro. You just need to know how to ask open ended questions. They usually say “You don't ask suggested questions.” So if you ask suggested questions, you're already failing your test, but you need to be open ended in the way that you ask your questions, give the person the opportunity to answer honestly. You need to offer reassurance and education.
Usually that's a key part that they test you on, counseling. “Did you counsel the patient?” That's a very important point in CS. I actually heard that was one of the most important things that they're looking for is you say, “I think you have high blood pressure and high blood pressure is a disorder of thickening of the blood vessels. And we can treat it with this medication” or, “I think you're having a stroke. A stroke is a condition where there's decreased flow to your brain and it's causing this left arm weakness. We will get you to the ER, I'll write you some orders for aspirin, a CT scan of the head. To be given after your CT and such.”
You need to be offering counseling for the patient, and then you need to be reassuring the patient, “I'll do everything to take care of you.” Those little things go a long way in CS because they want compassionate physicians. They want professional physicians. Like I mentioned, in one of our previous sessions, the ACGME core competencies call for professionalism. It calls for medical knowledge. You need to be able to display that, but then be very professional, be very polite. Offer education, offer counseling and reassurance. Do not disregard the patient's body language. I just noticed it's a type of my patients, but you should have a tea there, but do not disregard the patient's body language.
If a patient feels uncomfortable, you're being too close, they're going to fail you. Keep a healthy distance. Those rooms are really small to keep a healthy distance. I guess I tell the patient what you're going to do before you do it. Drape the patient, respect privacy, always knock on the door before you enter.
And when you enter, you introduce yourself. Wash your hands, hand hygiene. Because if you enter the room and you don't wash your hands or you don't clean your hands and just go ahead and start touching the patient, they're going to fail you because you did not practice hand hygiene. So knock on the door, introduce yourself, watch your hands, tell the patient what you're doing.
Even when you step over to get a glove from the glove compartment. “I'm going to get a glove here so I can examine you. I'm going to sit down so we can talk.” You tell the patient what you're doing every step of the way that is reassuring your patient. That is calming your patient's own anxiety. That is what we do in clinical practice day in, day out.
We're compassionate to our patients. We are professional to our patients. Above all things, find a practice partner that you can do this with over and over again. Step three it's often not needed to match, but most IMGs, I think that the way that it helps in IMG is to just get their packet complete, especially if you had a gap year, most people will use that to pass Step 3.
It just helps because especially, if you had a failure before, then the program knows, “Okay, you wouldn't have a problem getting a medical license because for most states you need a Step 3 score to get your medical license.” I think if in all states, if I'm not mistaken, that's another limitation before the boards.
We talked about boards being something that programs worry about because they want a hundred percent board pass rate. But before that, you need to get a medical license after. In Kentucky, it's after your intern year and some other states you apply for your license during your intern year like at the start of it.
So either way it's important for your licensure so getting it out of the way, just gives you an upper hand for the program to know, “Hey, I wouldn't have to worry about this person passing, especially if they have one or two failures in the past”, so if you come in with a full app, it just makes it more trustworthy.
It only influences your application really, if your performance is off the charts, if it's just way out the park, because residency is really where they teach you about the concepts that are tested in Step 3. The residency is the place where you're going to learn about your Step 3 clinical skill being an intern and such.
They're hoping to teach you that information, but if you pass Step 3 before then good for you. So I think that brings us to the end of our presentation.
