USMLE Preparation

1. USMLE Preparation Latha Chandran MD, MPH Associate Dean for Academic Affairs SUNY at Stony Brook

2. Our agenda • What is Step I? • Sample questions • Strategies to study • Resources • Sample schedules • CBSSA • Discussion with students

3. HANDOUTS • My ppt presentation • Sources to use • Sample study schedules • Performance check list • Feedback form

4. Final goal • Pass USMLE Step I, II and III • Pace yourself like a long distance runner- practice, practice and practice to build up endurance • Guard against procrastination

5. Lumpers vs splitters • How do you do your best thinking? • Talk it out (energizers) OR think it thru ( listeners) • What do you pay the most attention to? • Focus on “specifics” (describers) vs “the big picture” ( wonderers) • How do you make decisions? • Based on “my logic” (facts, impersonal) or “my values” (sensitive, personal) • How do you spend your time? • Joy of “closure” ( accomplishment oriented) OR joy of “discovery” (process oriented)

6. Linear vs integrative learning

7. You cant memorize understanding! • It is not what you know, it is HOW you think about what you know

8. Visual metaphors • Pictures • Charts • Tables • Algorithms • Bubble diagrams • Concept maps • DISCOVER relationships!

9. Step I exam • Designed “to determine if an examinee understands and can apply key concepts of biomedical science, with an emphasis of principles and mechanisms of health, disease and modes of therapy”

10. USMLE Questions • Three dimensions • Organizational level- molecule, cell, organ, person • Processes • Systems • Trend to add large clinically related stems to all steps including simulations

11. Questions to ponder • What to study?- books, questions • How to study?- alone, with others, study calendar • Where to study- home/ library/ group • When to study?- small/large blocks/ day/ night,

12. Useful books for Step I • Kaplan USMLE Step I review- Useful • First Aid- Essential • NMS Pathology, Appleton and Lange series • Micro made simple ( micro and immunology) • Lippincott Pharm ( pharm cards) • NMS Physiology, Underground clinical vignettes, High yield series

13. Question books for Step I • Free diagnostic test Kaplan • Board Simulator series • National medical series • USMLE Practice CD- very useful • Q bank - Kaplan 1m or 4 m • 60% of exam is Path- Pharm- Micro • Look at www.usmle.org for details

14. Useful resources for Step II • Secrets Step II • Boards and Wards • Kaplan Q bank • NMS Question Book • USMLE practice questions- very useful with answers free from Kaplan

15. Tools • Time AND study focus • Adequate time for all subjects • Develop a workable schedule • Note your progress ( lack of) • Use your own notes • Practice scanning large paragraphs for main ideas- useful skill to read large question stems

16. Practice questions • Answer in logical clusters (50)- don’t look each answer up • Use wrong answers as your diagnostic guide to identify gaps in knowledge • Study alone, with partner, with group • Study the hardest subject first at your high energy time • Train your biological clock to have high energy 8A- 5PM (exam time) • performance check list

17. Questions are powerful study aids • Look for topics in stem and answer choices • Understand correct answer • Understand wrong answers- powerful! • Make charts/entries for confusing areas • Rephrase the question-- more questions answered • Info not available in one place

18. Wrong answers • Requires an understanding of cause and effect relationships • Make logical connections between structures and their functions

19. Initial planning • Spend about 20 hrs reviewing all you need to know • Attention to labels, underlines • Do pretest/s pacing yourself correctly • Classify subject areas into “ know well”, “know somewhat” and “no clue” • Make a realistic schedule

20. Without a study schedule, you will run out of time before you run out of material!

26. Time allotment • Two thirds of time on” not too sure” topics • Weak areas need MORE time • Keep tabs of your progress in a large wall chart • Schedule small breaks between 1-2 hours of work • Make your own questions

27. Practice tests • Retake only AFTER reviewing material • Last three weeks- do organ system review • Study groups twice a week- two hours • Study partner with unlike learning style works best • At least two full length exams

28. Practice exams • http://www.usmle.org/step1/2005Step1.pdf • 200 questions in four hours • Request for accommodations early! • Familiarize with interface ( disc or website) • practice using white board

29. Tips for optimal learning • Create a realistic schedule and follow it • It is your best friend • Have positive thoughts (avoid neg self talk) • Say “Dr ---”- pep talk once an hour • Stop studying the day before the exam- do fun stuff

30. Stress reduction techniques • Breathing • Yoga • Stretching/ Exercise • Sensory imagery

31. Day of exam • Good sleep • Nourishments • Picture yourself as a competent doctor working in a beautiful place • Answer each question as it appears, check every 10 questions for time • No penalty for guessing

32. Actual test taking • 350 questions in 7 blocks • MONITOR you time • Mark on upper left hand side questions you are unsure of, to review later if possible • Keep all your wild guesses the same letter • Don’t get stuck in one question- move on after you answer

33. Generate your answer After you read the stem, think about the right answer • Then see if it is there • Read all options before you mark ( Js beware)

34. Other tips • Absolute terms- never,always, all • Read the directions- Ns beware • Read the lead in sentence first • What kind of a question is this? • Diagnosis/Management/ Prognosis/ Ethics etc

35. Other tips • Look for word associations • Longer/ more detailed answer usually correct • Frequency of elements • Middle choice may be correct with quantitative information • If pair wise confusion in matching questions, use same answer for both

36. Examples- I • What will the peripheral smear look like after one month of iron therapy for iron deficiency anemia? • Almost all larger than normal RBCs • Almost all normal RBCs • Almost all small, but not hypochromic • Almost all small, hypochromic RBCs • some small and some normal RBCs

37. Examples -II • A farmer develops acute attacks of fever, dyspnea, cough and leukocytosis when he works around wet harvested hay. Lung biopsy is likely to show • alveoli filled with dense, amorphous proteinaceous material • ferruginous bodies • Interstitial pneumonitis with eosinophils and interstitial fibrosis • Intersititial pneumonitis with lymphocytes, plasma cells and macrophages • Linear immune deposition along alveolar bast membrane

38. Examples -III • 33 year old woman develops a reducible mass of the groin, inferolateral to the pubic tubercle and medial to the femoral vein. The most likely diagnosis is • direct inguinal hernia • femoral hernia • incisional hernia • indirect inguinal hernia • umbilical hernia

39. Examples IV • 55 yr old female stopped menstruating three months ago. Her pregnancy test is negative. Which of the foll tests indicate that she is post menopausal? • Low LH, low FSH, high estrogen • Low LH, high FSH, low estrogen • High LH, low FSH, low estrogen • High LH, high FSH, low estrogen • High LH, high FSH, high estrogen

40. Types of questions • Factoids • Factoids as vignettes • Single jump ( what causes this problem?) • Double jump ( what is the problem and what happens because of this) • Triple jump- evaluate a situation based on knowledge

41. Triple jump question • A previously healthy 34 year old presents with fever and headache for one week. She has no history of exposure to illnesses and is on no medications. Her temperature is 39.3 (102.8 F) BP 135/88 HR 104/mt, RR24/mt. On exam, she is confused, oriented only to person. There is jaundice of the skin and conjunctivae and scattered petechiae over trunk and back. There is no lymphadenopathy. Stool is positive for occult blood

42. Triple jump question • Hct 32% with fragmented, nucleated RBCs • Leukocyte count: 12,500/mm3 • Platelets 20,000/mm3 • PT 10, PTT 30 sec • Fibrin split product Negative • BUN 35mg/dl, Creatinine 3 mg/dl • Total bilirubin 3/ 0.5 direct bili • LDH 1000 units/L • Blood and urine culture neg • CT head negative

43. Triple jump question • What is the most likely etiology of the patient’s symptoms? • Disseminated Intravasc Coagulation • Idiopathic Thrombocytopenic Purpura • Meningococcal Meningitis • Sarcoidosis • Systemic Lupus Erythematosus • Thrombotic thrombocytopenic purpura

44. Physiology question • An anesthetised patient is undergoing an operation under mechanical ventilation. His initial PCO2 was 40 mm Hg and Ph7.42. What would happen if his ventilation was decreased? • Decreased PCO2, increased pH • Decreased PCO2, decreased pH • Decreased PCO2, no change pH • Increased PCO2, increased pH • Increased PCO2, decreased pH • Increased PCO2, no change in pH

45. Another example • Lab tests from an edematous 35 y/o man shows normal serum complement, and increased serum cholesterol. Urinalysis shows 4+ protein, 0-5 WBCs/hpf and several hyaline casts. Examination of tissue after renal biopsy would most likely show • Post streptococcal glomerulonephritis • Membranoproliferative GN • Membranous glomerulonephritis • Minimal change disease • Rapidly progressive GN

46. Educated guesses • First choice is usually correct • Unless you read the question wrong- don’t change it!

47. Tennis game: Skill development • You want to improve your game for a match in six weeks • wait till the tournament, you know you are good • watch videos on tennis skills • watch all televised matches, with beer • take lessons and practice daily for two weeks • take lessons several times a wk, play with lots of partners, work on your weakest area the most

48. The message • Pace your study • Start ASAP • Study actively • Practice questions regularly • Get and use feedback

49. Some other resources • CBSSA exam- $45 each- correlation • Step I review courses- 1m-5m courses • Kaplan, Falcon Reviews, UMKC IPP, PASS • Student recommended website http://www.prep4usmle.com/step1/ • www. testprepreview.com

50. Final comments • No substitute for knowledge and its application • Follow your schedule strictly • Have positive thoughts • Take breaks and RELAX in between • Lots of good luck!