Physiology

Physiology is the medical school course that links cell biology, physics and biochemistry with the function of systems in the human organism. Under a classical curriculum, this course is usually presented second semeter of first year after biochemistry is completed. In a system-based and PBL-based curriculum, this course is presented system by system or topic by topic.

Physiology demands that the student have a thorough grounding in the basics of physics as much of this course revolves around cardiovascular functioning (plumbing), respiratory functioning (gas piping) or renal functioning (more plumbing). Often students have difficulty with physiology because of the math utilization requirements in terms of being able to understand diagrams and interpret graphical data. In terms of USMLE Step I, physiology is one of the heavily tested subjects and thus is the major course of first year that must be thoroughly mastered for a good USMLE Step I score.

The major components of physiology are Cardiovascular, Respiratory and Renal. The minor components are G.I, Endocrine/Reproductive and Musculo-skeletal. Many schools present Neurophysiology within the context of Neuroscience and thus this important component is out of the second semester physiology course and under its own course. USMLE Step I generally focuses on Cardio, Respiratory or Renal with plenty of diagrams for interpretation.

As with Biochemistry, it is vitally important not to fall behind in your physiology course. The best way to avoid falling behind is to organize your study of this discipline carefully at the beginning of the semester. Your syllabus is your first stop. As soon as you get the syllabus, look at the manner in which the course is divided. It is usually along the lines of Cardio, Respiratory/Renal and everything else. This usually follows first test, second test, third test and final.

• What is the subject matter headings for each lecture?
• How much material will be covered in each lecture?
• What are the objectives for each lecture?
• How much reading is expected for each lecture?

After you have looked at the topics, you need to make a list of any terms that you encounter in your reading and define them. Physiology will present loads of new terminology such as “homeostasis, positive-feedback systems, negative-feedback systems, futile cycle etc. You need to be thoroughly familiar with every term that you encouter in this subject and try to link function with structures that you studied in Gross Anatomy.

As with Biochemistry, you should prepare for each lecture. Physiology is one course that you really do not want to be going into lecture “cold”. In order to avoid this try doing the following before the lecture:

• Skim the syllabus and assigned reading noting topics, graphs and any tables.
• Look at the previous lecture and see how it ties into the material to be presented.
• Read the text and make a note of which topics are emphasized as outlined in the syllabus objectives for that reading.
• Listen to the lecture taking any notes and fill in any gaps as quickly as you can.
• Study your lecture on the evening after and repeat the above steps.
• On the weekend, review the entire week’s lectures with your main topic index next to your lecture notes. Answer the objectives out loud as you move along.
• If you have difficulty with a topic, make an appointment with your professor and have a list of specific questions or things that you do not understand.
• Try to organize a study group and meet together once a week so that you can test your understanding of the topics.
• If old exams are available to you, look at how the material is tested but do not memorize the old tests. Your study group is a good time to review old exams.

If you fall behind, go immediately to where the class is and do the above. Do not try to catch up during the week and you may fall further behind. If you fail a test, let that material go and move into the next block with even more resolve. You will get another chance (during your USMLE Step I study) to review and go over the material that you didn’t do so well on so let it go for the present.

Don’t make the mistake of believing that every student is “getting” physiology except yourself. Many medical students have difficulty with this course. Physiology can be burdensome as it is presented within the context of the rest of your coursework which is demanding. If you are having difficulty make sure that you are in the professor’s office during office hours and taking advantage of any tutorials that are available to you. There is always a course in medical school that is going to demand more attention at one time of another. It may be physiology this week but neuroscience next week and microanatomy the week after. Adjust your study up or down within the context of mastery of the material but do not neglect anything. Ask for help when you first think you need it and keep asking for help until you master the course.

Pay very close attention to the graphs and figures in your textbook. Often there are many nuggets of testable materials directly from these pictures, graphs and tables. Read the captions and make sure that you understand what is presented. Lecture the material back to yourself or make summary lectures/drill tapes (don’t re-listen to class lectures) that you can listen to while you work out. Having a discussion with yourself is a good method of mastering physiology.

Your physiology textbook can be a great asset. The major texts are Guyton & Hall , West, Berne & Levy or Tanner & Rhoades. They are all comparable but Guyton is the master of cardiovascular physiology, West is the master of Respiratory Physiology and Berne/Levey are masters of pretty much everything else especially neuro. If your text is difficult to understand at first, stick with it before you move to an alternate text. (Consult your instructor on this). Sometimes difficulty reading a textbook happens because you do not have a purpose in your reading. If you use your syllabus to organize your material before you go to your reading, you have purpose in your reading.

In terms of review books, you need to thoroughly master your coursework before you attempt to review. That being said, Costanza, BRS physiology or NMS Physiology can been helpful if you are having difficulty seeing the big picture. Do not substitute a review book for your coursework. You have to learn your coursework before you review for USMLE but having a solid review book like Costanza can be an excellent adjunct to your daily work.

Finally, don’t beat yourself up because you are stuggling with anything. Find any means that you can to get this material mastered within the context of your course. If Physiology is your “problem-child” at the time, give it more attention on the weekends but do not neglect your other courses during the week. Keep up with everything and organize, organize and do more organization. Time-management and organization are always the keys to the mastery of anything in medicine. Don’t talk yourself out of getting this subject matter under control. In the long run, you will find that a bit of struggle makes you that much stronger overall.

Preparing for United States Medical Licensing Examination (USMLE Step 1)

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 betweeen 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 quesitons 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.