How to Prepare for the USMLE: Statement of Goals

What you want to do with this test, with this opportunity, is up to you. However, if you’ve googled the topic and are reading things like this, chances are you’re not looking to coast with a modest passing score. I, sure as shit, am not. I want to keep as many doors open as I can for my residency interviews and I know that coming from the Caribbean puts me at a disadvantage.

People come down to the school to tell us things like, “The passing score is now 185. If you want a residency program that has empty slots each year like Internal Med or Family Practice, that score is fine. But if you want anything even mildly competitive, don’t show up with anything below 215. Don’t even bother applying. At that point, your best bet will be to sign outside of the match. Remember that there is a difference between having a score good enough for a residency and having a score good enough for a competitive program in that residency. It is always better to have a better score, regardless of your goals.”

In light of all of this, I’m going to state my goals and try to put everything that I’ve written about my preparation into context. When I say that the BRS questions are weak or that for a certain book the topic was covered superficially, I mean that it was weak and superficial for what I want to do. I do not want to just pass the Boards. I don’t even want a high pass. I am locking myself in a library every day to score above the 95th percentile. If you glazed over a subject, feel weak in it, and could use a stepping stool to competency, then the BRS Path (for example) is fine. But if you’re reaching for the brass ring, you should just sit down with Pocket Robbins or the Merck Manual and take the time to really get into it.

Yes. I know that you know a guy that barely studied and got a 99. Yes. There was a guy that did nothing but review the First Aid and he also got a 99. If you’re going to be the kind of doctor whose decisions are swayed by anecdotes like this, then you probably need to review Epidemiology and Study design. As far as I go, I’m not willing to follow their examples because, regardless of what they accomplished, I’m not that guy and you probably aren’t either. So let’s just dispense with the bare bones approach.

Reviewing this stuff (cramming) without achieving deep understanding at each level (internalizing) is like renting an apartment for a month at a time when you know you’re living in the neighborhood for the next ten years. Why waste your money? Instead of paying just enough each month, it’s worth it to go into debt (time-wise) to own it. Every day after that, the investment pays for itself, but you have to make it that first time. I’m not here to rent the knowledge; I’m here to own it, and every criticism I ever make of review materials is in that light.

There are books that I’m going to really like because of their incredible (but necessary) detail or because they are exceptionally well-written. There will be books that I trash for being riddled with errors and grammar mistakes or for being superficial to the point of uselessness. But whatever conclusions I reach, yours may be different because of time constraints (I have the luxury of two months) or learning style (in the eyes and it stays, in the ears and its out the other).

State your goals. Have a plan. Set a Schedule. Buy your books. Pick a QBank. Don’t crack. Have fun.

***

I think it’s now worth saying that of all the things I’ve done so far, bringing the Merck Manual to the library every day has been the best decision. I left it at home one day because it was taking up too much space. I am never doing that again. Pound for pound, I don’t own anything more useful. In fact, I’ve decided that from now on I will rate everything in units of Merck. Let’s establish a scale:

18th Ed. Merck Manual = 100 Mercks = highest rating.

Dudeck’s HY Cell and Molecular Biology = 1 Merck

“Dudeck” might be its own scale, sort of an inverse to utility… like a feacalith.

Return to USMLE Step 1 page.

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How to Prepare for the USMLE: USMLE WORLD

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?

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.