Ok one thing that I would like to ask someone in this forum

[Darth _Vader Sidious_Maul]

Ok one thing that I would like to ask someone in this forum is:
what’s the best sequence? Meaning if you’re preparing for the USMLE step1 should you do biochemistry or start with anatomy…?
You get my drift?
Some people have different opinions…!
What you think is the best one out there to be followed that you might have heard or not, please share it with us?
I am talking about the subjects that one should follow in order to like make sure that he or she will not forget stuff or at least maximize learning because of the sequencing that he or she is following at the time?
As one friend from another forum very nicely wrote the following to me:
The sequence should be biochemistry first; as organisms start from the molecular levels not from anatomical ones. The review books for biochemistry are written for medical student not for biochemistry specialists. The USMLE-1 exam is design in a way that you should know biochemistry very well. You see biochemistry in pathology, pharmacology, microbiology and other subjects…
Start from biochemistry and u will feel u r learning other subject easily… One other friend very nicely put it: I suggest that you start with pathophysiology (and pathology), because it touches almost all the other subjects, gives you a pretty good foundation on which you can build upon. Moreover, most Qs have clinical stems that require you to make a diagnosis before proceeding…
After this stage, you are on uncharted waters: Just do the other subjects in the order that U want. Draw a good plan that will allow you adequate time for revision. I suggest that U start with the subjects you find difficult (while your brain is still fresh) and review them again at the end. Also, leave the “crammable” stuff close to your exam date (I don’t believe that most of us have memories with very long half-lives)
As U go along, try to do as many Qs as possible. Start this from the very beginning as it would help U consolidate what U r currently reading. Anyone please let me know what you think of these two different opinions as I know that there are many others…
Any sequence in particular that some of already tried?
Let me give you an example of what I am talking about:
You think that biochemistry should be done review with in the middle your prep or at the end since its all just memorization? Or since it might be the hardest things because it involves genetics as well as those weird metabolic diseases should also be the first thing that one goes through? As you are with the highest level of stamina when starting preps and stuff…
If you respond yes please let me know why you think that is.
Different opinions are welcomed of course…
So that’s what I am meaning by a sequence to be followed in your prep.
Hope that some one helps me to understand how and why…
Thx for your time…
Van Horrus.
Some one else also wrote this in another forum and I hope that this will help some of you out there like me on the growing path:
USMLE Review

To summarize all I wrote below in one (long) paragraph: I don't think the
goal of studying for USMLE is to get all the questions right. That's
virtually impossible, and the score is scaled (related more to the
relative performance of your group than to absolute number of correct
answers). If you are trying to get them all correct it would make sense to
go over embryology and memorize all the branches of every artery, just in
case one question asks you to name all the carotid branches in order. But
can anyone really know all anatomy and microbiology in depth, just to pick
two topics out of many? Each is a several year course at the masters
level. Well, I sure can't. I'll admit I didn't even try cause I find them
boring, but I couldn't anyways, and I'm not the dumbest person you'll meet
in medicine. I made an effort to memorize class notes and got the highest
or almost highest scores in my class of 220 students on every midterm and
final for two years - but I forgot it all a week later. And never
rememorized it either. This stuff simply never comes up in clinical
practice, and if it does you can look it up. What I did concentrate on is
being able to recognize as many diseases as possible from a typical boards
presentation (i.e. one paragraph with several classic "keywords"), and
some labs and treatments that may be applicable. This I knew cold, and
even today I don't have to reach for a book when writing orders on a
patient, I know it. This contrasts to many of my colleagues that proudly
remember some obscure anatomical fact yet still find DKA or MI in the ER
confusing, many months into their residency. I also understood human
physiology, and it's hard for me to see a question I can't figure out from
basic concepts I understood long ago - I don't have to memorize how the
heart reacts in various situations, it makes sense to me. When you study
detailed anatomy you are wasting time and brain cells that could be used
to review pathophysiology. Personally I think it's enjoyable to get those
two embryology questions wrong on your exam when you know you saved a
hundred hours by never bothering to rememorize that topic. You can be
certain you will do very well just with pathophysiology, pharmacology,
behavioral science and some clinical micro, genetics, immunology, etc -
all topics that are enjoyable and useful for your future. There will be
few dozen questions out of 800 on the other topics, and you'll get a good
bunch of those right without any review. But the time and effort you save
by not spending months memorizing every muscle attachment etc is
priceless. Like I said I couldn't remember anything from anatomy midterms
when I was taking the finals (our tests where not cumulative) so how was I
going to know it two years later? Today's exams are overwhelmingly
clinical and even the basic science Step 1 is presented in a very clinical
setting. NO QUESTIONS ON WHICH STEP OF THE KREBS CYCLE HAS WHAT ENZYME,
AND NO QUESTIONS ON ANYTHING THAT LOOKS LIKE THE KREBS CYCLE, i.e. pure
basic science with no clinical application. I think you get what I mean
All topics are NOT tested equally, you have a finite period of time to
review = therefore you must prioritize and spend the bulk of you time
reviewing the more important topics, perhaps ignoring others altogether at
the cost of a few question that won't affect your score.
Here are some of my thoughts on the USMLE (United States Medical Licensing
Examination). When I think back to my fears and expectations before taking
these exams and what I know now the difference is amazing. Mostly the
secret is in only studying certain topics and completely ignoring the
endless details, unless you have a photographic memory. Actually, even a
real photographic memory will not work, these tests are a classic example
of how idiot savants can memorize all of Shakespeare including the
position of words on every page yet are unable to add 2 and 2 together. I
mean the USMLE questions do not test raw recall, and the classic mnemonic
devices (using imagery, arranging a list of drugs that affect P450 so that
their first letters spell something, etc) are useless - not one question
asks you for these things. They test decision-making ability, but of
course that ability rests on knowing (memorizing) a few points about every
disease.
I think that most medical students expect that these exams won’t test the
common things, that they must be very difficult and concentrate on the
rare and obscure. Therefore they feel compelled to buy endless review
texts and worst of all try to cram until the last minute unmemorizable
info - all drug side effects, which enzyme deficiency goes with which
genetic defect, all the steps of the Krebs cycle, etc. The book companies
support this image to make profits by scaring students with their huge
point-form review books.
In my school half the students were always sitting in the lecture hall and
study rooms, 1 am on a Saturday night, while I was out having some beers
and playing pool. They sat there with a giant pile of books, like three
different anatomy texts at the same time, plus their recordings of
lectures and the typed lecture notes they bought, and they were writing
their own longhand notes. They did this for two years. It’s really a
mystery because most of them still did average on exams and when I later
met them on the wards they couldn’t say anything too intelligent about
simple patient management issues. When I took the USMLE I remembered very
few details of anything, I never knew any anatomy, biochem etc, (except
for the mid-term and finals at school - I literally forgot everything one
day later). Even though I got A-grades throughout, which is at my school
was just about impossible, I would have gotten zero if I had to retake a
midterm anatomy exam a month later, however I could think clearly and just
had a good feeling of what makes medical sense in any situation. I was
very afraid going in that I made a terrible mistake by not memorizing the
details - but YES the exams test reasoning and not memorization of the
bones of the hand in order.
The truth is the exam is very fair. You are asked to give back some
memorized fact only a few times per 100 questions. The exam tests logic
and common medical sense.
A lot of questions are soft - what to say to a patient, easy psychiatry,
easy statistics, ethics.
Every single patient presentation is simple and easy - it tells you many
classic keywords and labs to recognize the exact diagnosis
That does not mean you’ll be able to answer the actual question however.
Here are the problems:
The presentations are very long, and give a lot of useless normal signs
and symptoms and other info. You have to be very quick, only 60 seconds
per question.
Most questions on step 1 and 2 have more than 5 answers - they go to h,
k or even all the way to z. Guessing is not going to work.
Even when you read a case and recognize the Dx immediately don’t get
excited, you’re only halfway there. The question is almost never “what
does this patient have”. They always go a few steps beyond to ask
something about the disease, e.g. treatment, labs to be ordered, etc,
without ever naming the actual disease. All the wrong answers
(distracters) make sense and are the appropriate steps if the patient
actually had a different disease in the differential of the presentation.
If you don’t know the Dx before reading any of the answers you won’t be
able to guess. The questions are “tricky” and extremely well designed to
eliminate rote recall of facts. They really do test your ability to make
common sense medical decisions in a real setting. They only give a few
bits of information for every patient, while in a hospital you would
actually get a lot more in the first minutes to narrow the Dx.
The vast majority of questions deal with very common everyday diseases,
there very few questions on obscure genetic problems, porphyria, etc. All
the cases have a simple Dx as may be found in the Schneider’s Red BRS
Pathology book - Addison’s, Graves, MS, etc. There are no complicated
multiple problems that would take days to figure out in real life
hospital. The distribution is very equal - pulmonary, heart, endo, GI,
it’s all there. Even in Step 3 you do NOT need to know the sort of stuff
found in Internal Medicine boards - all SLE criteria, exact heart failure
categories, etc. It’s still the same diseases you learned in pathology. Do
not learn ICU management, ventilator settings, details of surgeries, etc.
Completely useless.
The best way to prepare for these exams is to IGNORE all the stuff that
you could barely remember in first year and forgot immediately after the
finals. Do not study any anatomy, neuroanatomy, biochemical pathways,
histology, embryology, etc. You will only lose a few points even if you
don’t know what the thigh bone is called.
What is vital is to have on instant recall all the classic diseases found
in the BRS Pathology book. First of all you must be able to immediately
recognize the diagnosis from a classic patient presentation, i.e. buffalo
hump + stria = Cushing's, petechia + hematuria & belly pain = HSP, etc.
All the cases make it obvious what the Dx is, there are no tricks. If you
can’t do this before even looking at the answers you’ll get nowhere. Do
this for several hundred diseases. When I say the Dx is obvious I mean it
was obvious to me, I'm sure it was super confusing to many others. Even
then answering the question was a fair challenge. CONCENTRATE ON PATIENT
PRESENTATIONS.
Then just learn one thing you would do to test for this disease and a
couple of first line treatments. Anyone can do this, but you must know
this as you do your own name, clearly and instantaneously. The problem is
when you try to memorize each disease in detail - pathology, genetics,
epidemiology, everything - it becomes impossible. There is no limit to the
depth of detail you can go to (why not just memorize the entire
Harrison’s), and when you end up at the exam you’ll still be unsure what
drug and test go for Graves while you remember a lot of crap about enzyme
synthesis, thyroid anatomy, etc. Remember you’ll only have seconds to put
down your answer, if your knowledge is at a level that you have to stop
and strain to recall something about treatment that you vaguely remember
- you are lost. It is much better to have rock solid knowledge of just a
few facts on most diseases and also being able to instantly recognize the
disease from a classic presentation than to have knowledge that is even
slightly vague but covers dozens of facts per disease. Such a goal is
achievable while it is impossible to know where to stop with the details
(every disease has a hundred+ page text devoted just to it). But I think
students are convinced that on the boards the questions will concentrate
on the most obscure detail of a disease - NOT TRUE.
Overall if you did well in med school you can walk in without studying and
pass - 94% of American students do and some of them are as dumb as they
get. This is because you only need to answer 60% or so correctly to pass
and at least 30% of the questions are incredibly easy. Another 30% can be
answered with some very basic knowledge. The problem is, for IMGs, just
passing is worthless. You must get a high score, and now you come up
against the rest of the questions, which are difficult. You can get some
of them again simply by having the ability to recognize classic
presentations and knowing with certainty the common diagnostic workup and
treatment. Unfortunately the rest of the questions are classic boards
material - not found in real life, not found in review texts, worded
confusingly, and you just go “how the hell did they come up with that?”.
Some of them no-one can answer, but you still must answer some to do well,
and I think some of the stuff I’ve used is very effective.
What’s the solution? First and very important is not to waste time on
topics that are rarely tested and concentrate on things that are.
NOT TESTED: Anatomy, histology, detailed neuroanatomy and pathways,
embryology, hard-core basic science microbiology & virology (clinical
micro is tested), parasitology, all biochemistry, nutrition. There is
very little hard-core pathology, but plenty of pathophysiology. If you
know absolutely nothing about any of these subject you will lose only a
few points.
IS TESTED: All 3 exams are very politically correct and contain an
absolutely incredible amount of talking to patients, ethics, &
behavioral science. Step 3 only has a very large amount of statistics &
epidemiology - Chi Square, positive predictive value, relative risk,
everything.
Steps 1 & 2 have a lot of immunology, molecular biology and genetics.
Steps 2 and 3 have a very equal distribution of the 5 clinical
disciplines, but MOSTLY it’s inpatient adult medicine, followed by Peds
and Ob/Gyn, LOTS of psychiatry (easy basic questions) and very little
surgery.
Finally all steps are overwhelmingly clinical in nature. I mean
virtually every single last question gives a full patient presentation
of some sort. Here pharmacology comes in with a bunch of pathophysiology
basic science concepts
There are very few photos of any sort.
I remember before starting the clinical years I knew a bunch of pathology
but had a great problems putting down the diagnosis from a patient
presentation. When I heard a patient described no disease names popped up
in my head, even though if somebody named one of the possible diseases I
could give a nice lecture about it. If this is true for you too, you’re in
for a world of hurt, you’ll never pass. Get the Underground Clinical
Vignettes and similar books until you can do it. It’s a learned skill, and
if you just read the NMS texts or whatever you’ll have problems. I
remember once I concentrated on it I could shout out the Dx after the
first few words of a typical “Patient, sex, race, age presents with…” read
to me. I guarantee you this skill is the basis for my success.
THERE ARE NO QUESTIONS THAT GO “All of the following statements about
nephrotic syndrome are true except…”. That you could easily answer from
your pathology days, however in the exam you will only see a patient with
edema and some history of cancer, medications or whatever, the words
"nephrotic" or even kidney never appear anywhere, and the question will
ask something about maybe getting lipid levels or giving steroids, worded
in a tricky manner. Most people will think of anything but nephrotic, even
if they know a whole bunch of facts about it, and laugh off these
(actually correct) answers and fall for some attractive distracter answer.
Believe me - under pressure, in a few seconds, it is impossible to
mentally come up with a differential for edema (what is it, a hundred
things?) and go down the list eliminating each. Somewhere in the question
will be a clue or two, age, sex, previous medical history or whatever lost
in three giant paragraphs of normal useless data. There is no way to pick
up on this unless you’ve developed the skill to say the classic “boards”
Dx (not real life, you don’t have all the data available as you would in a
hospital) after a couple of sentences of a presentation. Like I keep
saying, without this skill, even if you are a professor of pharmacology
you won’t answer a simple drug question because every damn one begins with
a patient presentation.
Finally what about the 35%-40% of questions which are classic boards
material? They haven’t changed these for decades. Every lecture I ever
heard the doctor would say something about a classic boards question.
Although the boards HAVE gotten a lot more fair and you can pass them just
with common basic useful medical knowledge you cannot do very well, since
a lot of questions will be about stuff you never see emphasized in
textbooks and never encounter or study in the wards. The typical PreTest
or similar review book you find has a few pearls but it’s hopelessly lost
among hundreds of too detailed questions which are never found on the
boards, they might make you feel good about being so smart but that’s all.
Please read about the stuff I’m selling. I'm not claiming it's all you
need to pass, but I'm sure it is very high-yield for classic board
questions.
TO SUMMARIZE:
All three steps are quite fair: though the questions are long and
confusing, they are asking about simple things that every doctor really
must know. The majority of the exam has nothing to do with obscure
details, difficult to memorize lists, or advanced management that only
senior residents and specialists are involved in. It’s all first line
family practice stuff. It’s possible for the vast majority of American med
students, no matter how badly they did in school, to walk in with no
review whatsoever and pass. This is due to a fair number of joke questions
plus another part that’s quite easy. Getting a high grade however is a
different story and obviously not guaranteed no matter what you do. But
for sure taking 6 months off to re-memorize everything learned in basic
sciences or studying advanced subspecialty texts will raise your grade not
at all or maybe by 2%. Going over favorite board topics, if you know what
they are, only takes a few weeks and can raise your score to 260 for all I
know. I got 245s and it was easy. When I came up against the 1 question in
5 that I did not know, I could smile and just guess, because I knew I was
getting a lot of the others right. These exams have grammatical mistakes,
they repeat the same question three time in one block, it’s a real mess,
but the same topics keep cropping up again and again.
The last point is that every question begins “A patient, age, sex, blah
blah ” and goes on for quite a while. It’s the same as the classic “A
common complication of disease X is a, b, c, d, or e”, but here disease X
is described in a patient format and never mentioned by name, and the
question will be “The best advice to give your patient at this point is:”
(referring to the common complication, but again the word “complication”
is never mentioned). If you have to read the presentation twice, make
little notes, strain your brain about the differential you’ll get nowhere,
it takes 45 seconds just to scan thru all the writing on the screen. But
after really trying for a few months to think about everything in terms of
what it looks like on a patient as typically presented on the boards YOU
WILL know which disease they are describing and you’ll know the answer
before even reading the choices.
USMLE Step 3
I got my Step 3 result: 206/83 (177 is pass). I got 245/96 and 245/92 on
steps 1 and 2. I did not study for this test. Not even for ten minutes.
Just practiced the CCS software for a few hours. I would advise folks not
to worry about it, and take it ASAP if needed for H-1B. You do not need a
year of residency or outpatient experience or anything else for this test.
Just the usual Step 2 stuff with emphasis on treatment. At least 50% of
the questions cannot be studied for, they are common sense and not found
in textbooks, e.g. what to say to a patient, simple epidemiology, ethics.
No need to study ventilator settings, advanced EKG, photo atlases, and so
on, all the questions are 5 answer multiple-guess format amazingly similar
to Step 2, and worded so strangely that I think that the people who wrote
them would have trouble being 100% sure of the answer with an open
Harrison's in front of them. The CCS component - all I can say is,
practice a lot with the sample software. The cases are easy but the
software is hard to figure out, plus it tends to crash every 30 minutes.
If you can get 215 on Step 2 you can pass this the next day. There is no
basic science on step 3. Of course it's possible to raise your grade
greatly by knowing in detail the management of common diseases, but why
bother? This is the easiest of all steps, just take it as soon as you get
your ECFMG certificate, at least this is the one Step you just need to
pass instead of worrying how much over 200 you need to get to be
competitive.



[/size][/color]

[Ozlem]

You have a great insight !

I'm an IMG and I feel the same way you do for USMLE.

Many thanks for your amazingly great explanations and encouraging honest, brave approach!

Best Wishes & Regards

Ozlem

[rogerforever]

yup...all he said has been taken from the advices an IMG gives in a web page....nice copy anyway
roger