The thespian’s exam: USMLE Step 2 CS preparation and thoughts

USMLE Step 2 CS is a fruitless sort of charade, but nevertheless it remains as a necessary component to becoming licensed. My school mandates a practice exam through Kaplan before taking the real exam. While I initially disliked this idea, it was a good primer and once you’ve gone through the thing once, the real one seems much more manageable. Here are some pearls:

  • Use First Aid Step 2 CS: This is a well-organized book that is probably overkill but once you go through it, you have the general gist of the idea. If you don’t have a partner, go through and do the mini-cases by covering the half of the page that shows the diagnoses and orders.
  • Practice with a partner: Either through Skype or in person, interaction is the best way to ease into the weird pseudo-clinical patient scenario. Practicing with another person lets you try your intro and closing in real time, which is probably the hardest part of the exam.
  • Have a script: I used a some sort of acronym to make sure I covered my bases in order to maximize the points I hit.
  • Have a plan: Probably the best change I made with my CS approach was to already have a list of three differentials before going into the room. This way you can ask question to rule thing in and out (pertinent positives and negatives) and include those tidbits in your note.

I took the exam fairly shortly after Step 2 CK and it’s good to know what to order and the sort of classic signs and symptoms because the obvious players show up on the real exam. Overall I’m one step closer to the goal.

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Persistence of memory: USMLE Step 2 CK preparation and thoughts

During the months of May and June, I had dedicated study time for my second board exam, USMLE Step 2 CK. Truthfully, preparation was ongoing throughout M3 year, and my dedicated prep started in March when I was studying for my Surgery shelf exam. I took the exam June 1, 2016.

I had one goal for USMLE Step 2; to beat my USMLE Step 1 score. If I could do that, I would be satisfied. Anything on top of that would be considered style points. I had a secondary goal of beating my score by 10.

In March, aside from general surgery review, I began redoing the IM portion of UWorld, and I completed the entire IM question bank during April, my FM rotation. After this, I began to redo the rest of the questions, subject by subject – Ob/Gyn, Peds, and Surgery. I also had my prior notes assembled for each subject’s shelf exam, which I reviewed in tandem with each subject. Whatever text I had used for the shelves were reviewed for contentious topics – Case files and Pestana for Surgery, Case files and APGO uWISE for Ob/Gyn, and MKSAP and Pretest for IM.

I did not review each text in its entirety – instead, whenever I missed a question and needed review, I looked it up (notably, the algorithms for workup of a thyroid nodule are different in Case files Surgery and UpToDate). Also, because I had not yet completed my Pediatric clerkship, I made particular effort to be thorough with that subject.

Aside from UWorld, which is the staple of preparation, I used the few other essential resources above and below for questions and reading. Similar to the prior board exam, here are my recommendations:

  • My first wisdom is to have a solid foundation. I completed UWorld once and the bulk of my shelf exams before starting review. Only after this should you reset your question bank.
  • My second wisdom is to re-build stamina. Just like Step 1, I timed my tests, simulated exams, and pushed myself to the limits of my concentration in order to ensure that I wouldn’t lose focus on the real deal.
    • This time, there was a week where I did 5 blocks a day (with review) in order to make sure I kept focus. It was rough, but necessary.
    • Because this exam was after Step 1 training, it wasn’t as hard to regain testing stamina because the muscle memory was there. Within 4 weeks of training I was at peak performance levels.
    • Overall I did about 5,500 q’s leading up to the exam.
    • Breakdown:
      • UWorld: 2,300
      • USMLE-Rx: 1,900
      • MKSAP for students: 500
      • Pre-test IM: 500
      • APGO uWISE: 50
      • NBME 4: 200
      • UWSA: 200
    • One note I’d like to make is that unlike for USMLE Step 1, I did not rely heavily on the NBME’s for predictive value or review. There are 4 available, and one of those doesn’t even have feedback.
      • The feedback is not particularly useful either.
      • When you have limited time, you want to be able to learn and digest rather than shock and awe.
      • I didn’t like NBME 4 and didn’t think it was a conducive use of my time, so I decided against buying more of them.
      • Also, the NBMEs for Step 2 are notoriously unpredictive and can easily give you false hope or burst your bubble of confidence.
  • My third wisdom is to use UpToDate. It is the most comprehensive resource that gives definitive management in a digestible summary form. Review texts are great, but U2D is the bread and butter for learning and review. I unofficially attend U2D SOM.

I got my score, 262, while on the beach with my fiancée. I am happy to say I achieved my primary goal, though was a bit shy of my secondary goal. Regardless, I am happy with my outcome.

Finally, a relief: USMLE Step 1 preparation and thoughts

USMLE scores are released every Wednesday, and mine just got in. I was relieved that my score was in the predicted range of my practice tests and that my prep had not gone in vain. This post will outline my preparation strategy, advice, and my scores leading up the real one.

Firstly, my philosophy in preparing for any exam – USMLE, block exam, NBME shelf – is to leave no stone unturned. As a physician, I want to know what’s going on with my patients without doubt. Hence, I like to go through all the material, know all the material, and be able to explain all the material. If I can do that, I’m confident in my knowledge. With that mindset, I approached basic sciences, so I had a solid foundation of all the coursework I had completed. Without this, prepping for the USMLE Step 1 is pointless.

  • My first wisdom is to solidify that knowledge base of basic science. There are many ways to do this; this is the point of taking a review course.
    • I started my preparation at the start of my 5th semester (early September 2014) rather than waiting until my courses finished
    • It was strenuous to juggle classes, exams, and preparation, but I persevered because I wanted to do the best that I personally could
    • To solidify my knowledge base, I reviewed slides from my courses and used:
      • Doctors in Training
      • Kaplan Physiology and Pharmacology
      • Pathoma (note that I think Pathoma is phenomenal after reading big Robbins fully)
  • My second wisdom is to do questions, even if you don’t think you’re capable. I started the Kaplan q-bank doing 46 questions a day when I started my prep. My scores were initially abysmal, but slowly they climbed. Every 2 weeks was a solid 5-10% increase until I hit a fluctuating plateau.
    • About halfway through 5th semester I finished Kaplan q-bank and switched to the USMLE-Rx q-bank. By December I was done with that one. I did 2 blocks a day until about 3 weeks before my exit exam (NBME Basic Science Shelf), where I had full days of dedicated studying. I then did 3 blocks a day.
    • After the exit exam and a few festivities on the island, I started studying again at home with USMLE World in December.
    • I had honed testing to an art form; my timing, my pace, my breaks, and, most critically, my review methods at this point were all efficient. I made index cards on questions and concepts I missed or got right by good guessing. I reviewed these cards. I got up for 5 minutes for a break every time. I had a pre-exam fact sheet memorized. Everything was done for a reason.
  • My third, and final, wisdom is to build up stamina. Starting when I began studying, every Saturday (with the exception of weekends with block exams), I forced myself to take 4 hour-long exam simulations.
    • I was unable to focus properly for the first one and was mentally and physically drained. After the second and third, I was able to get through all 4 hours, but barely. Eventually I could get through the exam with ease. By the time the exit came around, I was able to not only take 4 blocks, but review all 4 blocks in the same day.
    • When I returned home, I knew I wanted to double the time of focus, so I began training in the same way. All in all, there were 2 days where I took 7 hour practice exams, and one draining day where I took an 8 hour exam (NBME 16 + UWSA 2) – about 3 days before the real exam on February 9, 2015

So, what material did I get through? The list below is the order of material I went through, and the number of questions is approximate, with my performance given:

  • Kaplan q-bank and miscellanea: 2500 questions – 75%
  • USMLE-Rx qbank: 2300 questions – 81%
  • BRS Physiology, Pharmacology, Biochemistry, Pathology: 800 questions
  • Lippincott’s Pathology Q&A: 200 questions (not completed)
  • NBME 15 : 200 questions – 251 predicted
  • NBME Pathology Shelf: 200 questions – 99th percentile
  • NBME Basic Science Shelf: 200 questions – 96th percentile – 260+ predicted
  • Free questions on USMLE.org: 150 questions (don’t remember % correct)
  • USMLE World: 2300 questions – 80%
  • NBME 13: 200 questions – 260 predicted
  • NBME 7: 200 questions – 254 predicted
  • NBME 11: 200 questions – 249 predicted
  • NBME 12: 200 questions – 262 predicted
  • USMLE World Self Assessment 1: 184 questions – 265 predicted
  • NBME 16: 200 questions – 260 predicted
  • USMLE World Self Assessment 2: 184 questions – 265 predicted
  • ——————
  • Total practice questions done questions: 10,000+; real score 259

Overall, the real exam felt like just another practice test. There were some bizarre questions that no amount of preparation can ready you for, and there were some nit-picky level of detail questions, but overall, I was satisfied with it. I didn’t walk out of the examination center elated, but I  wasn’t discouraged or depressed either. I knew it was done, and, now that I have my score, I can say it was worth going through all the extra material.

The conclusion of my time on-isle

On Wednesday, December 3, 2014, I took the exit examination at Saba University School of Medicine, also known as the NBME Comprehensive Basic Science Shelf.

The last 4 months were spent preparing for both the exit and the USMLE Step 1. Now that the exit exam is done and I’ve successfully passed, I can take the Step. I was pleased with the mark I received on the exit, and I know if I put in another month and a half of work I can really sharpen my knowledge base.

In completing the exit exam, I finished my 5th and final academic semester in the basic science portion of my medical education. My next week will be spent packing up the last 19 months of my life and flying back home to Louisiana.

There are many places and sources of advice on how to prepare for such a colossal exam, so I’ll keep mine brief. Firstly, you need to know yourself. Only on an existential level do you know what you know and what you don’t. After that, it’s simple: systematically address your weaknesses until you have as few as possible.

Personally, I knew I was a variable test taker. I knocked the socks off the SAT but did average on the MCAT. This was my personal weakness. So, every day, I tried to simulate testing conditions and pressures so that I could increase my capacity for focus. This was rough, but I am very proud of myself for the improvements I made. Every morning, at the same time, was the same ritual, the same breakfast, the same pre-question formula sheet, the same number of questions.

Every Saturday (except for when we had exams), I would do 4 blocks of questions. The first time I did this, I was mentally fried after the questions. I couldn’t do anything else that day. By the time around, I was able to review some of the questions the same day of the test. Eventually, I was able to focus for the whole exam, do well, and review all the questions in a single day, albeit from 8AM to 5PM.

The sources I used varied, but I liked:

  • First Aid 2014
  • Kaplan CV Physiology
  • BRS Path, Physio, Pharm
  • DIT
  • Sketchy Micro
  • Slides from courses (best if profound review needed)

Without a doubt, the bulk of my studying came from questions; thus far I’ve finished both the Kaplan question bank and the USMLE-Rx bank. I’m saving UWorld for when I get back home.

So that’s that. Now for a long awaited break.

At the cusp

Before I was actually a medical student, I was asked a very pointed series of questions in an interview for medical school. I like to think of myself as a good interviewee, and rarely do I get a question that leaves me at a loss. Since I am nearing the end of my basic science curriculum portion of my medical education, I thought it might be relevant to share my thoughts.

The questions were in this line of thought, about two-thirds of the way through the interview:

Interviewer: You are starting medical school, and after the first quarter, you find yourself in the bottom 10% of your class. How would you proceed?

Me: I would look at my study strategies and try to find a method better suited to my strengths.

Interviewer: Good. So let’s continue this scenario. You change your study habits for the next quarter. Time passes and at the end of the quarter you again find yourself at the bottom 10%. What would you do?

Me: Again, I’d look at my performance and assess what I did this quarter and compare it to the first quarter. After that I’d try and find a study method outside of these first two approaches I took and apply it to hopefully better my scores.

Interviewer: Ok, so you try that. Again, the quarter passes and you’re in the lower 10%. How would you approach the next quarter?

Me: (at this point I’m stuck. I can’t say the same thing for a third time. I’m sitting there and I know he’s looking for something, but I just don’t know what. I can’t leave too big of a pause, though, because that’s just awkward.) Well, again, I’d reassess and figure ou-

Interviewer: You tried that. Is there anything else you’d do or think in our scenario?

Me: (I know I missed it, but I have to say something) I think it’s important to learn from the mistakes I made and try new things until I figure something out.

Interviewer: Yes, very true. (moves to another topic)

It’s not something I think about every day, but from time to time I remember that scenario. Now that I’m at the end of my basic sciences and have mulled it over enough, I think I understand what he was getting at.

I think he was trying to make a broader point about having the wisdom to tell the difference between things you can and cannot change. The ideal third response in that interview, I’m pretty sure, would have been something like: “Well, if I’m trying my hardest and am still in the bottom 10%, maybe I should continue working hard and be happy that I’m passing.”

The point being made by the interviewer was that it’s important to be happy that you’ve passed rather than to be happy that you’re in a certain standard deviation of performance on a test. In other words, be happy about getting through medical school rather that beating other people at a numerical game. The metric you choose to measure yourself against should be internal, not external. External metrics can be references to what is possible; internal metrics are those you are aiming to beat.

I think my time in the basic science curriculum at SUSOM certainly made me realize that, and I am better for it. As my time on the island is swiftly coming to an end, I have been focusing my hardest on overcoming my personal limitations when it comes to test taking. Specifically, I’ve been building my stamina of focus so I can be as sharp as I can throughout a 5-6 hour testing period. I definitely notice improvements. Anyway, as far as preparation for the USMLE1 and NBME Basic Science SHELF ago, I’ll have a separate post after outlining what I did and what I learned.