Prepare for the Boards in Six Weeks

March 27, 2007

All of this information is contained in the USMLE GUIDE.doc so that you can take it with you and not worry about your internet connection. I post all of it here for those that do not have Microsoft Word and so that people can find it through search engines. Hope it helps.


A word on this guide:

I just finished my second year at St. George’s University School of Medicine. Figuring out what you are going to do for the Boards is a pain in the ass and gets people nervous that they do not have a plan. Many of them sign on to Kaplan or Falcon for this reason. I would like to prevent as many people as possible from signing up for those courses for those reasons, as they are expensive and you are poor. I want you to have a plan, an idea of what to expect, and all of that free. I hope this helps.

A word on advice:

I am wary of most advice. It is often unqualified, and by this I mean that I do not know why I should believe in your expertise. Did you score well and are you willing to tell me the score behind this advice? Are you like me in that we learn, memorize, and study alike? What works for Peter may fail for Paul and it is good to keep this in the back of your mind as everyone begins to tell you what you should and should not do. The other problem that I have with a lot of advice is that I am not told the reason behind the conclusion. It is easy to say, “Just do questions”, but it is much harder to give a well thought out argument to support your advice. There may be an excellent reason, but many people do not think to ask for it or to give it. Also, it takes a fair bit of time.

If someone says that there is a lot of Embryo on the test, please kick him in the face. That sort of advice (even if it ends up being true) is worthless for planning. The most frustrating part of this whole experience is that n=1 and it is hard to draw conclusions from a sample size that small. You will wonder if you did it correctly, how you would have scored if you changed blah blah, and so on. That leads us to why I am writing this:

Medical school is great because it is the end of decisions. Decide to go to medical school. Three and a half years later: decide what kind of doctor to be. Three to five years later: decide which job to take. That is three decisions over ten years and medicine is great that way. I was so tired of making decision about how to study that I wished someone had done it all for me. This guide is meant to be a turn-off-your-brain and do-as-I-say outline so that you can save yourself from all of that. It is the guide that I wish someone had made for me.

A word on irony:

I am aware of the irony that I am writing a little guide filled with advice while not offering my score, telling you about myself, etc. What I can give is my reasons for each decision so that even if you do not end up following it, you at least see the problem of planning and studying as manageable. If you are interested, when I get my score I will post it and at that point, you can decide to continue using this guide or decide to forget everything written here. Deal? Now on with the show…

THE SCHEDULE

I am assuming that you are taking six weeks to study for this test. If it is shorter or longer, I have structured this so that it is easy to change according to your unique schedule. This schedule is built using the newest edition of the First Aid for the USMLE Step 1 (Systems based) as I think it is the best game in town and damn near everyone seems to own it. We need a calendar, and we need to divide it into two main sections: cramming and pre-cramming.

CRAMMING

Cramming is undervalued. I took an incredibly long time to prepare (9 weeks) so that I would not have to cram because (cue lame music) I wanted to really understand the material. Fair enough, but the last two weeks are for cramming. You can realistically cover two topics each day. Anything more and you are skimming. I have good reasons for each of these choices, but first you should just take a look at what we will call “the cramming”.

last-two-weeks.jpg

The day before the test, you will be tired of studying (more so). This is when you are most vulnerable to total mental collapse. A friend described it to me: “I opened up Micro to look over viruses once more before the test and I realized that I had forgotten how to read. It was as if my head had exploded onto the table and I could not pick it back up again. I postponed the test a week after that.” To avoid this, I advocate taking a half-day and seeing a movie. It was one of the few things that I did that worked.

Before you start this final sprint, take a day off. You have earned it. I think you should begin with Biochemistry because the meat of this subject is in the underpinnings of other diseases. A good look in the beginning will help you interpret things later on and will reinforce the pathways that actually matter. By putting this first, you effectively study it all week. It is a big topic, so it gets two days. Molecular genetics and Immuno cover some similar ground (signaling) and this is a nice lead in to Micro. I will make the same argument about Micro, that putting it this early means that you study it with every system to come, reinforcing the pathogens. It is big, so also earns two days.

Cardio and Heme/Onc are thrown together because of the pathology. For similar reasons, I have placed them next to Musculoskeletal. As you will find, the vasculitides are covered in Musculo, not in Cardio or Heme/Onc, so these three topics are overlapping in the First Aid which is why I have grouped them. Cardio, Heme/Onc, Gastro, and Musculo are also grouped because chances are that one of these topics is a strength for you, so going through that subject quickly allows a weakness in the others to expand into that day.

Neurology and Psychiatry are next to each other for the association. Neuro, unfortunately, is just too big to group with a second large topic, so this is as good a place as any to split up Behavioral with Psych (they pair naturally) and Biostats with Neuro. Renal and Respiratory are not as big as the other sections and this should make for a somewhat easier day. These are grouped together in hopes that you finally sit down and learn Acid/Base compensation. After two years, it is time.

Embryology is tricky. Most of it belongs with Reproduction and Endocrine while the rest is spread out among all the systems. The best advice I have is that you study the Embryology for each system in the morning before getting into the thick of each subject and save the Repro/Endocrine stuff for the end. That it is a hodgepodge also makes it a natural move to group it with Basic Pharmacology and Basic Pathology. These sections are short and represent a little bit of everything. If you give it a good read, it can pull topics from earlier in the week together and is not too stressful to be studying up to test day.

And with that, use the last day before the test to print out your permit, print out the directions to your testing center, and look over some topics that you had to skip. Try to force yourself to stop studying by midday and do something non-medical that night like watching a new movie with a friend. The night before my test I caught 300, and it was great to think about something other than pathways for at least those two hours.

PRE-CRAMMING

That was cramming. Now, onto pre-cramming. Since we have six weeks and I just stole the last two weeks for cramming, that gives us exactly 30 days to prepare. Remember that you are not preparing for the test during this period; you are preparing for “the cramming”. If you do not cover everything in a section in the time allotted, it will not be the end of the world. You will get another crack at it, at which point not getting to it will be the end of the world. Ready for the suck? Seriously, stay optimistic.

If you are a numbers person, we have 30 days to cover 329 pages of the First Aid, which works out nicely to 11 pages a day. This is a lazy way to weight things, but who cares? I have gone to the trouble of counting each page per section for you, and arranged the following. Here is the first two weeks.

first-two-weeks.jpg

We start out with something general and familiar: the basics. Most of the connections in this section went over my head and I did not pull them together until the end, but it is nice to have the early exposure and to ease into this whole thing before the real subjects start. This brings us to Biochemistry. It is big and intimidating for a lot of students and three days does not seem like enough, but it has to be just three days. First, we give it two full days in the last two weeks of cramming. Second, the other subjects need to be given time and are likely higher-yield.

It does not let up as Biochemistry feeds into Immunology and Microbiology. Again, three days is not enough to cover Microbiology, but the other subjects need to be covered and we give Micro two full days during cram week. Behavioral science and Biostatistics are meant to be your first break. The ground of Behavioral science will be touched again during Psych, and Biostatistics is not that big. You can either take half the day off or use the extra time on Micro. As always, make sure you are not seeing anything for the first time during “the cramming”.

Embryology is just not big enough to get its own day and should be learned in pieces with each system that follows. What is important for now is the developmental aspect. You can combine it with the first day of Endocrine (as I have done) or group it with Reproduction, does not really matter so long as you get to it. I think these three topics together makes each of them stronger, and this might be the first time you really understand the menstrual cycle.

second-two-weeks.jpg

The second two weeks begin the systems. I was taught subject-based, but for the type of thinking that makes for good test scores, the integration that comes with doing Anatomy, Physiology, Pathology, and Pharmacology together just cannot be beat. If your school taught this way then this is old hat for you, but for me it was a shock to see all the new connections.

We begin with the Cardio/Heme/Onc/Musculoskeletal combination for the reason I described earlier. Cardio looks big in the First Aid and the pharmacology of Heme/Onc can be intimidating. Just remember that “screw it, I’m just not going to know that” is a perfectly good assessment for some of the material and if you can make peace with that, you will be less stressed. It probably will not be on your test anyway. Or you fly through these sections and earn a day off.

Gastrointestinal is there because where else would you put it? Renal and Respiratory go together with their acids and bases, and this brings us to the skull. Psychiatry is a new section with the First Aid and I think they have done a good job. It may bleed over into Neuro (as far as BRS and other review books go) but the two of them together get four days now and two more days during “the cramming”.

All together now:

all-6-weeks.jpg

If you are taking less time or more time, you simply shave or add a day here and there from one of the blocks in the first four weeks. I do not think it is a good idea to steal or add days from “the cramming” as this is a period favored by the gods. Why not add? “The cramming” is the period where you realize that everything you are reading is the last time you will get to see it before the test, and this is a shocker if you have not prepared for it. Cramming is also useful in the short term, and once you extend that period past two weeks, I think it is a hard argument that your short-term memory is still holding onto the lessons in the first days. Just my advice, but then again I could have done poorly and you should ignore all of this. You can access this calendar online. The dates used are from May 20th, 2007 – June 30th.

QUESTIONS

Which QBank is the best? USMLE WORLD. But that would be shitty advice, right? I could just cut and past the whole thing here, but I would like to keep this file manageable. Please read my evaluation of free questions and Qbanks available online.

BOOKS

Everyone is chasing after that magic bullet: the high-yield book. My experience was that few books can pull this off well and that most try to be miniature textbooks and are unmanageable in the time you have (HY Cell and Molecular by Dudek, HY Neuroanatomy by Fix) or are bare bones and do not help you make many connections (BRS Path). After spending a good chunk of change on these review books, I should have just covered the material in the First Aid using my own textbooks. Most of what you read you will not have to look up (because you learned it) and the things you do look up will be surrounded with full explanations. Anything less than a full answer is annoying and wastes time (if, like me, you tend to dwell). If you have played it correctly, you should also have old review notes from your courses and it is always easier to remember what you used to know instead of starting from scratch with everything. By the end, I was using Golan’s Principles of Pharmacology, Robbins’ Basic Pathology, and the Merck Manual. The Pathology BRS by Schneider and Szanto was useful as an outline (which I used to focus on Robbins) but the questions for each chapter are absolute crap. Costanza’s Physiology BRS was good in parts and her questions were reasonable, but there are a few uncovered topics.

first-aid-binder-page.jpg

FIRST AID

I tip my hat to Graham Azon of Over!My!Med!Body! for this piece of advice: put the First Aid in a binder. I took my copy to an Office Max, had the spine cut off and the book three-hole-punched, and put it into a 1.5” binder. Best move I ever made. I was able to take separate notes and include them exactly where I needed them and I was able to take my notes from previous courses and include them (my roommate expanded the book to fill two 1.5” binders). It is hard to overstate the advantage of having everything you need in one place.

THE EXAM ITSELF

It is hard to anticipate the pace of this test. When doing timed questions in preparation, there were instances where I would finish with 10 or 20 minutes left. I thought to myself, “Self, you’re going to have plenty of time to look over questions in each block”. I was wrong. On test day, I had around 10 questions marked per block that I wanted to give a second look and two minutes to do it. It was unexpected and unsettling, and for this reason I wished that I had taken the NBME practice test at the center. It is worth it just to remove the final few unknowns for test day.

The clock counts down for each block while you move up the list of questions. Unless you are willing to do the calculation (even subtraction can be stressful), it is hard to know how fast you need to move to finish. For pacing purposes, I ended up starting each block with question #50 and ending with #1. This way I knew exactly how many extra minutes I had to devote to problems as I went along and it helped me gauge whether I had to come up with an answer now (because I was falling behind) or could mark it for later (since I had a seven minute cushion). I would do this again.

I am thankful for the advice I received from a stranger: “You are going to walk out of the test with incredible relief that it is over. This will be mixed with some despair since you will think that you failed. It is over. You did not fail. Everyone feels that way.” He was right, and every one of my friends has echoed it. I went from relief, to defeat, to anger that I had not done better. A week later, I feel “okay”. When you go through it, remember that you are not the first, not the last, and it is normal.

Hope it helps, topher.


How to Prepare for the USMLE: USMLE WORLD

January 26, 2007

When choosing a QBank, I went with USMLE WORLD (UW). It is much cheaper than the competitors Kaplan and USMLE Rx, it gets higher reviews from students that have used more than one QBank, and everything else (interface, online stats) was equal. Something of a no-brainer.

After using it for almost a month, I can say a few non-comparative things.

It’s fair. I haven’t had a question yet where I felt the wording was ambiguous or the answer was a stretch. Every time that I have looked at the options and thought to myself, “I have no idea,” it was because I really didn’t know (instead of knowing the answer and not knowing how to apply it).

It’s interesting. Each question has a full explanation (usually with an illustration or table) for right and wrong choices with a summary “Learning Objective” at the bottom. This is just a smart thing for the company to do, as every wrong answer leads to a new concept learned. I regularly go through my incorrect responses and copy down the new objective into my notes.

It’s hard. While at SGU, my favorite tests were in Pathology. Whoever wrote those tests was a sadist of the fourth order. For example:

  1. The test stem would have symptoms. [appendicitis with Hx of appendectomy]
  2. You’d have to figure out the disease. [Crohn’s]
  3. You’d then have to realize what the appropriate treatment was. [Cortisol]
  4. You’d have to know the side effects of that treatment. [abd striae, bull neck]
  5. Finally, you can answer the question: Given this patient’s symptoms, what is the most likely side effect of his treatment? [weight gain]

Everyone complained about how hard those tests were, but I had been waiting for that type of challenge in a course my whole life. I loved those tests, and for similar reasons, I love the questions in the UW Qbank. There have been a few times where, after reading a question and figuring out the answer have thought, “That was the coolest way I have ever seen that asked.” I couldn’t give it higher praise.

If you’ve decided to use UW and are working through the questions, it might help to know how you’re doing. With each question, it will tell you the percentage of people that answer it correctly. With each subject, it will tell you your percentile against other test takers. Useful, right? I’m having a few problems with this.

The stat for “percentage that answer correctly” doesn’t say if that is on the first try or includes all attempts, including repeats. I wish there was a separate statistic for this. Your overall percentile is based on your test average against the mob, but again this can be manipulated by taking the same questions over and over (I’ve tested this myself). For the person going through the questions once without repeating, you may feel that your percentile is a little low (or just hope that it is).

Here are my percentiles on first past through all the available questions in a section. I will expand this list as I continue to cover material. You’ll notice that the scores are very low. As I mentioned before, these aren’t true percentiles as they are not compared against the mob’s first attempt and I list them here just so that people don’t feel so defeated when they take the questions themselves.

  • Biostatistics (74th) – I felt very well prepared
  • Behavioral Science (waiting to do Psych until later)
  • Embryology (71st) – I felt well prepared
  • Genetics (48th) – Curse you, Dudek and your horrible book.
  • Biochemistry (79th) – I felt very well prepared
  • Immunology (70th) – I felt well prepared
  • Histology (32nd) – I wrote this off. Maybe I should look at it.
  • Anatomy (74th) – Just for fun. I’m an Anatomy geek.

ADDENDUM: I sent an email to the USMLE WORLD team about these questions and I was pleasently surprised to see them respond the next day.

The “percentage that answer correctly” only records the first attempt of the user if the question in taken in the unused mode.

The cumulative performance is based on the entire test percentage and you are correct in assuming that the percentile might be manipulated if a person repeatedly takes the test and answers all the questions correctly. However for the percentile to skew greatly, a large number of users will have to “cheat” the system this way by repeatedly taking the same questions.

However, most of our users take the test first in unused mode and then they use other modes like incorrect or marked questions if they have sufficient time left. This might skew their overall percent by 2-3 % but over a significantly large data set this offset becomes negligible.

Hence, the presented percentile should only be used as a rough indication of where the user stands and preferably should be ignored during the initial tests.

Return to USMLE Step 1 page.


How to Prepare for the USMLE: Which QBank is the Best?

January 18, 2007

I’m just going to assume that I feel the way most people do about the unknown: I don’t like it. Even though I’ve known about this test for two years, it still feels like it’s springing up on me and I’m frantically trying to prepare.

What’s on it? Where there a lot of Biochem questions or was Neuro more stressed? Were the Path questions hard? And on, and on.

For most of us, it’s also the first time we’ve ever taken a test like this on a computer. Like most, I have my habits of underlining key words in a question stem, putting *’s by things that I have to skip now but may get later, putting an “X” next to a question that I could never answer correctly, etc. That I’ll be staring at a mouse, keyboard and glowing screen on test day is an unnerving thought.

To get over all of this, we look for practice questions. The good news is that there are thousands of practice questions on Al Gore’s internet and the companies worth their salt have some great supporting software. There are free questions and expensive questions and you get what you pay for. Let’s look at some free/semi-free sources first.

Free/Semi-free sites

  • Official USMLE tutorial and practice questions (2007)
    • Gives you four blocks of 50 questions for practice with the testing interface FRED. No explanations for answers and reviewing your questions is awkward.
  • Tulane’s Medical Pharmacology Exams
    • I wish I had known about this site when I took Pharmacology. The questions are broken down by subject with explanations of all answer choices. Straightforward multiple choice and great for review.
  • Web Path
    • I used this site religiously when I took Path and it was an enourmous help. I recommend it to anyone and everyone. Great questions, great pictures, great format.
  • Anatomy at University of Michigan
    • I used this site throughout anatomy and I still give thanks to this site.  Surface anatomy, gross anatomy, radiology, and Anatomy Jeopardy. After the Boards, I owe these guys a bottle of wine and a nice card.
  • Lipincott Williams and Wilkins
    • 350-question comprehensive USMLE test, available to anyone that has registered with the site. If you have bought one of their books (Physio BRS), there is an access code in the jacket.
  • Student Consult
    • I have access to this because of the two Rapid Review books that I bought (Gross and Developmental Anatomy, Microbiology and Immunology). This site also has 350-question tests for you to use (with the scratch-off code, of course).
  • Facts in a Flash
    • Not USMLE format, but if you like working on flashcard questions without the rubberbands and mess, this might be for you.

So after looking at those sites you decide that, while very good for your normal review, you need some professional help for the Boards. You need this enough that you’ll part with some loan money. Whichever company you choose, you should look for the following:

  1. Their question bank (QBank) should have enough questions for you to give yourself a fair evaluation, there should not be so many questions that you could not comfortably do them all, and the quality of the questions should be more important than the quantity.
  2. The questions are given in the FRED computer format that you are going to see on the USMLE, complete with question marking, annotation, highlighting and strikethrough.
  3. Detailed explanations for right and wrong responses.
  4. Questions broken down by both subject and system, i.e. Cardiovascular Pharmacology.
  5. The software shows your strengths, weaknesses, progress, and performance against all other students using the same questions.
  6. THE HOLY GRAIL: The questions are of equal or greater difficulty compared to those on the USMLE.

Question Bank Subscriptions

  • KAPLAN ($279, 3 months, 2100 Qs, FRED)
    • This was likely the first company that sprang to mind. Kaplan runs review courses where you live in a hotel for 6 weeks cramming, they have online course content, video lectures, on and on. This company has worked the USMLE inside and out, and it seems a right of passage that students slog through the 2100+ questions before sitting for the exam. I was a little wary of this company, though, as people told me that by the end of the course, they were scoring in the 90s on each block and that the actual USMLE was much harder.
  • USMLE WORLD ($110, 3 months, 1730 Qs, FRED)
    • I had never heard of this program, but three people that I consider intelligent (each scored 95+) told me that UW’s questions were more difficult than the actual USMLE. Each of them also subscribed to Kaplan, used its program, and found the programs to offer the same features. After hearing this, visiting their site, and considering the prices, I had to take them seriously. It seemed like a great deal (less than half of Kaplan with a higher rating). The reviews at Prep4Usmle were positive as well. I also like that UW let’s you try their product for a month and if you like it, you can buy more months at a discount. My review of UW Qbank.
  • USMLE Rx ($199, 3 months, 2000 Qs, FRED)
    • Written by the same authors of the First Aid for the USMLE. On glance, they seem to be doing everything correctly. They let you test their product and they offer integration between their online product and the First Aid book. The reviews that I have found put it on par with Kaplan. I’m intrigued.
  • SCORE 95 ($99, 3 months, 4300 Qs, FRED?)
    • That this site is slick and has a string of testimonials (which read like a third grader’s homework assignment) is not impressing me. I am also having a lot of trouble actually learning about their program (does it run off your computer, what features does it have, etc.). What I am impressed with is their accompanying note set, that they show you the breakdown of their questions, and that they offer a daily podcast to anyone that wants to listen to a new subject each day. The reviews I was able to find online say that the program is poor and the questions are disappointing. Quantity > Quality. In fact, the number of questions scared me off well before my research. 4,300 questions comes to 360 questions a week for 12 weeks. I currently average 150, and that pace is keeping me busy. I cannot fathom the amount of work it would take to complete these questions, so why have them?
  • EXAM MASTER ($179, CD, 8,700 Qs)
    • Absolutely not. On first glance: no. After reading reviews: no. If this program helps your score, it’s probably a placebo effect.

So where does that leave us? If you’re going to start doing questions 3 months before the exam, anything more than 2500 questions isn’t practical. You have to realize that you’ll be spending all day learning the material, and that it might take 3 days to cover a topic. At a reasonable pace, you can expect to do 150-200 a week (which will take you 3 hours and 15 minutes, remember). Anything more than this might burn you. So let’s just throw Exam Master and Score95 right out.

If you believe the worst reviews of the anonymous, Kaplan, UW and Usmle Rx are the same difficulty. If that’s true, then you should go with the cheapest program: UW. If you believe the best of the reviews, UW is harder than Kaplan and Rx, and you should go with UW. Though it has fewer questions, I got the strong feeling that the Quality >>> Quantity, and since I only have so much time to devote to questions, I want them to challenege me and teach me something new. I dropped the $110 and am incredibly happy with it. The questions are stout, and with all my over-preparing for each section, I have yet to crack an 85% in any discipline. This was a good choice for me.

However, if you don’t have much time, are planning on putting all your eggs in the First Aid basket, and would benefit more from reasonably challenging questions (whereas harder Qs might hurt your confidence more than help your score), then I can see a strong case for buying the Rx. It’s twice as expensive as UW, but the formats are indistinguishable and the integration with the First Aid book is appealing. If this wasn’t priced at $199, I might have bought this after finishing UW.

I’m sorry to beat up on Kaplan here, but after going through their QBook and the questions in their Lecture Notes, I’m just not impressed. I have consistently felt that the questions were either written to make me feel good about owning the notes, or that the notes were written to prepare me for those exact questions. Either way, I never had the feeling that Kaplan’s questions were independently difficult (if that makes sense) and from what I’ve read and heard from others, my concerns have merit. And for $279! Get over yourself, Kaplan.

So those are my thoughts on picking a QBank. I assure you that all the research was anecdotal and supplemented with gossip. I suggest heading over to the forums at prep4usmle to read for yourself, and if you have any comments on these products, I’d love to hear them.

Hope it helps, topher.

Return to USMLE Step 1 page.