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.

Gross Anatomy

I thought I would write a short essay about my experience with Gross Anatomy class when I was in medical school. This class can cause some angst and turmoil for some freshman medical students because it generally requires the greatest adjustment in terms of study skills and habits.

First of all, Gross Anatomy does not require any great feats of intellectual insight. The material to be mastered takes diligent and systematic study. In short, there is NO substitute for just grinding through the process and taking the time to organize the material for study. At my school, Gross Anatomy also included Embryology which, made Gross Anatomy (GA) far easier to organize in my opinion.

During orientation, we were given a huge syllabus complete with objectives, lecture schedule and lab schedule arranged by topic. We were also given an exam schedule which allowed us to know exactly how much material each exam would cover and when the exams would be given. The breakdown was along the lines of Exam 1 – Extremities and Back Muscles, Exam 2- Thorax, Abdomen and Pelvis, Exam 3 – Head and Neck. This division made sense because dissection and study of the Back Muscles and Extremities requires far less manual precision than dissection of Head and Neck Structures. By the time we reached study of Head and Neck, we were old “pros” at dissection and finding structures.

My best tools for study of Back Muscles and Extremities were my embryology book and one of the skeletons. Our anatomy department had loads of bones and skeletons everywhere in the gross lab. My first approach was to sit down with the syllabus and look over what would be covered in lab and lecture. My next approach was to skim the material in the syllabus looking carefully at the objectives. This usually took less than 15 minutes tops and I was on to the reading making notes in the margins of the text that corresponded to material that was mentioned in the objectives.

My GA textbook was Moore’s Clinical Anatomy for Medical students. I had the binding removed from this book so that I could place the reading pages in a three ring binder. I always had something readily available for reading. My next step was to photocopy or scan the Netter plates that corresponded to the lecture that we would be covering. I would note with a pink highlighter, any structures that were mentioned in the syllabus. That was my prep for each lecture. After hearing the lecture, I would study my notes (or the noteservice notes) and do the same prep for the next lecture.

In prep for lab, I would take out my dissector and make a check sheet of every structure that were expected to observe in lab. I would organize them according to superficial, deep, nerve supply and blood supply. When it came to the muscles, I would list every origin and insertion and action on a sheet with a check list. Before I began dissection, I would visualize them on a skeleton and visualize the actions. I learned the nerve and blood supply at this point too. For example, let’s say that I was looking at the muscles of the back. My first task was to organize them into extrinsic back muscles (associated with the movement of limbs) and intrinsic back muscles (associated with movement of the spine). I would then organize them into superficial and deep layers.

My coverage of the anatomy of the back would have started with organizing the anatomy into surface anatomy (my fiance was a willing model for this stuff), bony anatomy (learning all of the vertebral bones), spinal cord anatomy and then the back muscles. Associated with all of these lectures were embryology lectures on development of the muscles, bones and nerves. But back to the my organization scheme. The embryology lectures took place before dissection so that we had that background before moving into the lab.

Let’s say that today’s lecture included the muscles of the back. I would have my Netter plates (with annotations) and my key words from the objectives in my folder for that lecture (the material that I had prepared the evening before). I would listen to the lecture taking notes as I needed them and adding notes to my plates or on paper. We would then head off to the lab where I would look at the skeleton and trace out every origin (medial attachement) and insertion (lateral attachement) for each of the back muscles. Lets look at the Latissimus dorsi for a specific example. The medial attachement is the spinous processes of the six most inferior thoracic vertebrae and the lumbar vertebrae, inferiorly: the iliac crest and the thoracolumbar fascia and the inferior 3 to 4 ribs. This muscle inserts on the floor of the intertubercular groove of the humerus. By locating the origins and insertions of a muscle, I would be able to picture the action of that muscle as it contracts. In the case of the latissimus dorsi, I knew for sure that this muscle was not an intrinsic back muscle but functioned primarily on the humerus (an arm bone).

I would also learn the blood and nerve supply as I studied the skeleton. The nerve supply is the Thoracodorsal nerve which can be found heading through the axilla and to this muscle. One of my instructors like to say that the extrinsic back muscles “crawled out onto the back and took their blood and nerve supply with them”. This statement easily explains why the thoracodorsal artery is a distal branch of the axillary artery and that I could trace the small branches on the anterior surface of the latissimus dorsi muscle back to the distal part of the axillary artery which is a continuation of the subclavian artery. The nerve system is the same as the thoracodorsal nerve is a branch off the posterior cord of the bracheal plexus which travels to the LD muscle that is located on the posterior, inferior portion of the superfical back. In short, by organizing the material before heading into the dissection lab, I knew where to look for nerves and vessels; the actions of the muscle and bony landmarks all at the same time.

My GA class also required that we study radiographs, CTs and MRIs in addition to our dissection. I studied the available materials along with my dissections. When I came to the dissection lab, I had a checklist of all of the materials that I wanted to review and master. I can tell you that I was in the dissection lab at least 10 hours per week outside of the dissection lab times. On the weekends, I would review the week’s materials which usually took three or so hours. This study was done with my study group. I also looked at every cadaver in the lab weekly in addition to my own. We kept a running list of excellent dissections (more likely to be tested) at different tanks. We always asked permission before entering another group”s tank.

Another thing my study group did was ask one of the instructors (usually the course director) to spend 30 minutes quizzing us a week before the lab practical. He was totally willing to work with a five-student group. We asked him to be picky and brutal. Usually these sessions made us go back and work a bit more on our identification of structures. Our instructor was very good about telling us how to identify structures on a lab practical. He always liked to show us great landmarks.

The most important aspect of GA study (any course study) in medical school, is not to get behind. If you miss something (illness) you need to go immediately to where the class in and catch up on the weekend. Some students get behind and attempt to catch up and never get there. Again, catch up on weekends (they don’t lecture on Saturdays and Sundays). Also, don’t underestimate how much your classmates can be great resources for you. I never found a classmate who wasn’t willing to review structures with me in the lab. The biggest gunner gets an extra boost by helping classmates who are struggling. Everytime I reviewed something, I learned it that much better.

Some caveats: You cannot organize the material for your classmates. Each person has to find their own system and each person has to learn the material for themselves. Working with a study group helps to reinforce the material but each person is responsible for their own learning. Don’t even try to work with a group until you have done a thorough mastery of the material for yourself. If you are isolated, you lose out on the great reinforcement so don’t isolate yourself. If you have a family and other outside obligations, schedule some study group time even if it is minimal. Medicine is not a solo activity and you will have to rely on your colleagues when you are in practice. Medical school is good practice for learning to work as a group.

Well, the above is the essence of my system for GA and embrylogy. I can tell you that I spent plenty of time in the Gross lab and working on GA. It was interesting and it helped me appreciate my classmates even more. We all worked together and we all learned together. GA is not a course that you can sit down, memorize and master in a vacuum. You need feedback and your instructors/classmates are great resources. While there is much to learn and master, it’s not all rote memorization. My classmates that were great rote memorizers did fine on the tests but crashed on USMLE Step I in most cases. The understanders and intergrator (like me) did equally well on the exams and on USMLE Step I. It takes both.

I would also say that GA is not a course to be feared but a course to be mastered. A full 75% of my class failed the first GA lecture exam but only about 2 people failed the course itself. In most schools, you are not penalized for getting off to a slow start as long as you figure out what you need to do to get your information mastered. For me, GA was daily study, preparation and mastery. I also forged a great relationship with the GA instruction staff (I was the class rep for this course) so that we all could do our best. The instructors were not there to “fail” us but to help us master this neat course. In the end, it worked out fine.

Interviewing for medical school

You have filled out that AMCAS or ACCOMAS application and you receive an invitation to interview from one of the medical schools that you have chosen to apply to. It has been a long wait but now you have moved closer to your goal by one step. Your next goal is to maximize your chances of acceptance now that you have received an interview.

First of all, you need to schedule your interview. Logistics should play a huge part in this process. Don’t schedule a medical school interview during exam week at your undergraduate institution. You will be under stress to do well on your exam and you don’t need the added stress of an important interveiw to add to this mix. Don’t schedule a medical school interview if you have planned any major dental or medical work either. You do not want to show up for an interveiw with cheeks that look like a chipmunk or not being able to speak clearly. Try to keep your major dental/medical procedures away from interview season.

You need to look at your means of travel to the interview site. My rule-of-thumb is that you should not drive unless the distance one-way is less than 100 miles. If the distance is between 100 and 200 miles, you should plan on taking a bus or train. If the distance is more than 300 miles, you should fly. If you have a driving trip of more than 100 miles, you will have more than 2 and 1/2 hours in the car with this trip. Even under the best of traffic circumstances, you may experience delays due to construction, motor vehicle collisions etc, that greatly add to the stress that you are already under. If you have the option, drive to the interview site the evening before and stay overnight.

If you are taking the bus, train or plane, you should definitely plan on an overnight stay. While the expense of a hotel room adds to the costs of application, this is money well spent. If you arrive the evening before, make sure that you KNOW the route to the interview location. Do a MapQuest, MSN Maps or Google Map search (satellite photos too) and know the route from your hotel to the site. You also need to know how long the trip will take so that you can allow extra time for increased traffic (especially a problem in urban areas) and your cabbie getting lost. Pack your maps in your carry-on baggage so they will be with you.

If you make plane, bus or train reservations, be sure that you do not schedule your return trip so tight that you are rushed during the interview day. Walking into the interview site with the demands that you have to be done in time to catch a flight creates a very negative impression. If you end up having to stay an extra day, then you won’t risk your career over an airline, train or bus schedule. Beware of discount air fares and scheduling. Put more laxity into your schedule not less. Again, know how long it takes to get to the airport, train station or bus station from your hotel or from where ever you are leaving and allow for things like “rush” hour or construction. (Boston & DC are notorious for these hang-ups).

If you did not drive and you have an extra day, you can use that extra day to unwind and relax. Even if you drove, it’s not a bad idea to stay overnight, rest from the stress, take some extra time to look around the city and then drive home in the morning when you are rested, informed and refreshed. There is no substitute for keeping your mental health in order throughout this process.

Once you have decided on your transportation, decide on your attire. Your attire should be business attire. This means suit and tie for men and professional (suit, business dress or pantsuit) for women. Women should wear no heel higher than 1 and 1/2 inches and shoes should be well “broken-in”. Most interviews involve a walking tour which becomes downright hazardous if you are teetering around on 3-inch heels. Use a check-off list as you pack and don’t forget things like small stud earrings (for women), nice conservative cufflinks for men, clean hankerchief and conservative tie. (Men-take the diamond stud out of your ear; women-no dangly earrings and take the stud/ring out of your nose) For both, get rid of the tongue ring.

If you travel by air, curb/runway check your interview suit. This means that your garment bag will go in the plane just before you get on and will be waiting at the entrance of the jetway as you get off. DO NOT “counter-check” your interview attire and do not crush your suit in a small carry-on bag. You may find that you cannot remove wrinkles if you stuff your suit into anything. Carefully pack your entire outfit (use a check list), toiletries in doubly-wrapped small containers placed in a toiletries bag and an extra shirt, underwear and socks into your garment bag. You can pack a separate bag with fitness clothing, travel clothing etc. Also, check the airline regulations in terms of what you can pack and carry on.

You should travel in the most comfortable clothing possible. For me, that is jeans or scrubs, running shoes and a T-shirt. Your interview clothing should NOT be your traveling attire even if you are making the drive to the site in the morning. You should arrive, change into your suit and then attend your interview. Nothing can ruin your day like spilling coffee or dripping something onto your interview clothing. You can also scuff your shoes if you drive in them. Again, if you can arrive the night before the interview, you will have plenty of time to make sure that your suit is pressed, clean and ready to go.

Men should be well groomed with beard or moustache neatly trimmed. You should invest in a professional haircut or style (if you wear dreds, pull them back neatly). You should NOT wear any cologne as your interviewer may be allergic. Use rubbing alcohol or ice-water if you can’t live without aftershave. Make sure that you have no dandruff flakes or lint on that nice conservative suit.

Women should have a conservative hair style. If you have hair that reaches your collar, put your hair up. While three feet of hair may be your signature, fussing with it on an interview makes you look instantly unprofessional. If you have braids or dreds, pull them back and get them off of your collar. If you wear a head dress (for religous reasons), then make sure that it is neat. As I said above, no dangly earrings, nose rings or tongue rings. Try to make sure that your tatoos are covered. Keep your hair out of your face (get a good cut or style) and don’t fuss with your hair. Nail polish should be a conservative color (not black) or clear. Keep rings to a minimum along with other jewelry. Watch, conservative earrings and wedding/engagement rings are enough. Keep the cologne to a minimum (none is best), keep make-up to small amount of foundation, powder and lipstick with NO eyeshadow or mascara). Check your make-up in front of a window in daylight. If you can see make-up, you are wearing too much. Also, put on your makeup before you put on your blouse. Makeup is difficult to remove from a white blouse or shirt. Don’t wear a short, short skirt that shows too much when you sit.

Things to bring with you: A COPY of all correspondence that you have sent this school. If anything is missing, you can provide your return receipt and your copy. A copy of your personal statement and secondary – often interview questions will come from these documents. Bring these items in a folder along with an index card where you can write the names of anyone (office staff, dean of admissions, interviewer etc) that was especially helpful to you for thank-you notes. You should write your thank-you note to the Dean of Admissions with courtesy copies to everyone who helped you out on interview day especially current medical students and office staff.

Also, as I mentioned above, place your Driving Directions from hotel, your index card, your documents, your tickets, your hotel reservation confirmation numbers and any other vital information in your folder which you will carry in a portfolio or case. Include any important phone numbers on this folder such as Number to the Office of Admissions (you can call if there is an emergency delay), number to the hotel etc. I also liked to place a schedule of the day, if you have received this information. For most schools, you can download a campus map (great for getting around) which should be in your interview day folder.

When I arrived at the medical school, I went to the ladies (mens) room, checked my shoes, checked my hose and popped in a breath mint (no gum please). I also checked back and front of my suit, checked my make-up (just a bit of powder and lipstick). Do a last minute check of the hair and head into your interview confident and energetic.

Be early, I repeat, be early. This is not an interview to be late. If the school is late, be early. Rushing into an interview looks unprepared and very unprofessional. Be cordial to your fellow interviewees and to all staff (especially the cleaning personnel). Hold doors for people who come in behind you. Guys do not need to hold chairs for women but holding a door for anyone is just common politeness. Don’t forget to speak to everyone but don’t be “overly” friendly or formal. Your fellow interviewees are not your buddies nor are they your competition.

Nerves are very much a part of this process. Another good reason for arriving at the interview the night before, is that you can go down to the hotel’s fitness center and “work off” some of your nerves. Don’t let your nerves cause you to: chatter too much, bite your fingernails, fuss with your hair, chew gum, constantly clear your throat (get a sip of water if all of your saliva is drying up) or get depressed. A small amount of stress can make you appear energetic but too much can make you appear frantic. Before you leave home, look at yourself sitting, standing and walking. Observe how you hold your head, hands and shoulders. Guys, do the old “anchorman’s trick” and pull your suit jacket down so that it doesn’t ride up at the shoulders when you sit down. Practice calming yourself in front of the mirror.

Don’t eat or drink anything that has the potential to spill. If you are ravenous, have breakfast before you leave the hotel so that you are not covered with powdered sugar from the donuts when you enter the interviewers office. Avoid coffee or if you must have coffee, fill the cup half-full and be very, very careful. Avoid spaghetti or foods like fried chicken, that must be eaten with your hands. Avoid anything with spill potential. Check your teeth after lunch. You can always nibble at lunch and have a good meal on your own later after the interview. Avoid sugary sodas and energy drinks too. These can cause a caffeine/sugar rush followed by a huge depression if you over-indulge.

Your medical school interview is a time for the interviewer to get to know you. Your individual interviews will “sell” you to the rest of the committee. Don’t make the mistake of trying to anticipate what you believe the interview “wants” to hear. Answer each question truthfully and carefully. Take your time and don’t blurt out anything. BE sure to shake hands with the interviewer upon entering the office (unless you have been greeted elsewhere) and when you leave. Make eye-contact and don’t be put off if your interviewer is rude or rushes. Being able to redirect is a good characteristic. Redirect if the interview gets off course.

When your day is done, try to relax. Resist the urge to re-play the entire interview in your mind. You are far too subjective to have good recall and you always have the tendancy to believe that the interview went worse than it actually did. If you are taking a plane, train or bus, you can relax and enjoy the scenery. If you are driving, relax a bit before you drive home. Even better is to change into your comfortable traveling clothes and relax before attempting to drive home. Don’t drive home in your interview suit (you may need it for your next interview). Be sure to prepare for the weather where you will be interviewing by checking Accuweather http://www.accuweather.com any other national weather service like The Weather Channel.

On a final note, if you are staying with a student host, bring along a small gift. This can be Starbuck’s gift certificates, Bed, Bath and Beyond gift certificates, any restaurant chain gift certificate or something small for the house or apartment. (Remember that they are saving you to cost of a hotel room so make the gift of appropriate value.) Bring your own towels and soaps and clean up after yourself. Check your host’s schedule and make sure that you do not interfere with their study routine. Offer to take them to dinner or breakfast if possible and be sure to write a “thank-you letter” (with a courtesy copy to the Dean of Admissions). Do not expect your student host to entertain you but you should have some questions for your host and ask when they have a bit of time to answer them. Plan on providing your own transportation to and from the interview site, the airport etc. It’s nice if they offer but don’t plan on your host being your cabbie.

Finally, enjoy your interview. This is an opportunity for you to get the “feel” of the medical school. Take some time (outside of the interview day schedule), walk around, talk to students and get the feel of the campus. Are there plenty of safe and comfortable places to study? Do the students have social events? Do you NEED a car? Where do students live? Find out what you need to spend three years (fourth year is often away electives) in this place.