23 March 2007

Preparing for USMLE (United States Medical Licensing Exam)

Medicial students (allopathic) who attend medical school in the United States will typically take the first step of the United States Medical Licensure Examination (USMLE Step 1) in the summer between their second and third year. This examination tests the pre-clinical science subjects and is supposed to test the readiness of a medical student for entering their clinical clerkships during third year. Students must register http://www.usmle.org/

This examination, along with USMLE Step II Clinical Knowledge and USMLE Step III are given on computer in a Thomson-Prometric Testing Center. Once you are eligible for each step, you may register and schedule these exams on a day of your choice. USMLE Step II Clinical Knowledge tests a medical student's readiness for the supervised practice of medicine i.e. internship. Most medical students in the United States will take this exam at some time during their fourth year. Step III is usually taken after graduation from medical school with application for permanent medical license at the time of Step III. Some states have a seven-year rule in that you must take and pass all three USMLE steps within seven years of taking USMLE Step I so keep your dates and years in mind. Optimally, get Step III out of the way as soon as you can.

In addition to USMLE Step II Clincal Knowledge, there is a USMLE Step II Clinical Skills (USMLE Step II CS) that must be taken. This Clinical Skills exam has been required of all graduating medical students since 2005. This exam is also staken during fourth year as it usually involves some travel to a specified testing center, Atlanta, Chicago, Los Angeles, Philadelphia and Houston on a specified date and hotel accomodations unless you have friends in this city that will put you up.

Now, for the "nuts-and-bolts" of USMLE Step I: First of all, the test is intergrated which means that each question block has subject matter from your all of your pre-clinical courses. The questions may test a specific type of subject matter but there are intergrated questions throughout the test. This means that you probably should not study for this test in a "subject-specific" manner but rather intergrate the materials. For example, a virus might attach the heart muscle and cause a myocarditis that leads to biventricular heart-failure. This may be presented to you in a case-scenario but you have to know the physiological and pathological effects of heart-failure along with the effects of myocarditis. This is why memorizing individual questions or attempting to study before you are done with your coursework is counter-productive.

Another popular USMLE Step exam technique is to ask secondary learning questions. A scenario might go like this: "A , neat and well-dressed young man comes to the office of your psychiatric practice. He states, ' I don't know why I am here but I came anyway. My friends seem to think that I have a problem but I don't think or see that I have a problem. It's just that when I see something out of place, I feel compelled to put it back in its place. I like things neat and orderly." A likely diagnosis for this patient is: A. Schizophrenia B. Acrophobia C. Obsessive-Compulsive Personality Disorder D. Obsessive-Compulsive Disorder.

In order to answer this question, you have to know something about the characterictics of the disorders in the answer choices and be able to differentiate between them. You also need to READ every answer choice and make distinctions between them especially the last two which, are the key to answering this question. Again, you just cannot memorize a bunch of facts and definitions without putting this information into the context of the disorder/pathology or entity that is presented in the case.

What about those expensive USMLE Prep Courses? What about using review books and memorzing them along with your course work? The problem with most of those expensive review courses is that they present the material by subject and the actual USMLE exams are intergrated. The problem with review books is that they are often superficial summaries of what you already have in your coursework. It is far better for you to organize and thoroughly master your coursework before you attempt a "review". You cannot "review" what you haven't thoroughly "learned" in the first place.

Most second-year medical students will take USMLE Step I the summer between second and third year. At my medical school, a passing grade was required on Step I before we could start our clinical rotations in September therefore USMLE Step I had to be taken before the third week in July so that the Dean had received our passing scores. Our coursework was completed at the end of April so that most people took Step I the second or third week of June.Those of us (myself included) who had summer fellowships were required to take our exams before June and thus had to be more efficient. I took Step I the third week in May.

Inevitably, those people who failed the exam, were among the later takers and thus were delayed in starting on the wards. If you took the exam early, you would have time to re-take and start one rotation into your third year but if you waited unti August and then failed, you would drop an entire year of medical school. Bottom line: Take that exam when you are thoroughly prepared and reviewed but don't wait too late.

How about USMLEWorld and Kaplan's Q-Bank? These are currently the best question resources available for students. They simulate the actual exam in terms of computer interface and can be used in both the "Test" and "Tutor" mode. The best way to use these resources is to work in 50-question blocks using "All Disciplines" rather than subject by subject. You can use the "Tutor" mode where you can review why the correct answers are correct and the wrong answers are wrong.Beware of feeling confident that if you have a specific percentage correct on USMLEWorld or Q-Bank that you are guaranteed a pass or a specific score. Also beware of memorizing the questions because the questions on the actual exam are different from either of these resources. Both of these on-line question sources have many questions that are more difficult and more specific than USMLE Step I.

These sites are nicely utilized with a study group too. You should do your review and then do a couple of question blocks discussing the answers with each other. You would be surprised how having these types of discussions can enhance your retention and understanding of the material.

Also beware of "one-source" reviews out there. USMLE Step I is an exam that is scheduled for 8-hours over one day. There is no audio "high-yield" review tape or single resource that will give you everything that you need for this exam. You need to practice questions and reveiw systematically.

After you have completed your second year coursework:

  1. Figure out when you are likely to be taking the test. Second or third week of June is generally the most popular dates.
  2. Figure out how you are going to review: Systems-based or subject based.
  3. Gather your resources meaning review books, on-line question systems.
  4. Set a study schedule and stick with it. Don't make the schedule so tight that you can't get everything accomplished. Be sure to put in some "down-time" so you can relax as you review.
  5. Use USMLEWorld or Q-Bank as measures of your progress and do not attempt to memorize these questions. For example, if you miss a question, use it again in under test conditons and see if you get it correct. If you miss it a third time, use one of your review books and review the subject matter of that test.
  6. Be wary of subject-based reviews as the actual tests are intergrated. If you do review by subject, be sure to question yourself in an intergrated manner.
  7. Try to have a study group where you can help each other and discuss the questions.


Anonymous said...



Anonymous said...

I just wanted to thank you for the blog. It's a great service for anyone who is thinking about medicine as a career, and can honestly say it's permanently altered the way I view the years ahead as I try to get into medicine, but in a positive way. Thanks.

Anonymous said...

I really appreciate your comments and I am realizing that it is alot easier to see the connections to the basic principles learned in the first year after going through the pathology and pathophysiology second year. However, I have a few points to make:

1. Some schools do not give as much time off to study as other schools. I go to a school where we only have five weeks to prepare for the test before the start of our third year.

2. I think it is possible to review during your second year as you go along if you do questions at the end of a block/sequence to see if you can answer the questions the way they are formatted on the boards. What I do is read from texts and review lecture notes as I go along and then at the end, I do boards style questions to test myself before taking my block exams.
3. I also think that going through case presentations of the material you are learning is a good way to start training yourself to recognize clinical patterns. I did this from the beginning of M2 and on the first test I was more prepared than my classmates who were cramming the notes.

4. Study groups are not for everyone. If you are a minority student in a majority school you may find it difficult to find people to study with if you don't initiate things yourself.

5. Lastly, USMLE step 1 secrets is a good guide to make sure that you understand certain concepts that will come back to haunt you on the boards. It's a small book that can to reviewed at the end of the block/sequence.

-Second Year Medical Student about to take the boards and long time reader of "Medicine from the Trenches."

MSIII said...

It would've been really nice to read a bit about preparing for Step 2 as well. Your post is very well thought and was written even better.