USMLE Preparation USMLE Preparation

Latha Chandran MD, MPHLatha Chandran MD, MPHAssociate Dean for Academic Associate Dean for Academic AffairsAffairsSUNY at Stony BrookSUNY at Stony Brook

Our agendaOur agenda

What is Step I?What is Step I? Sample questionsSample questions Strategies to studyStrategies to study ResourcesResources Sample schedulesSample schedules CBSSACBSSA Discussion with studentsDiscussion with students

HANDOUTSHANDOUTS

My ppt presentationMy ppt presentation Sources to useSources to use Sample study schedulesSample study schedules Performance check listPerformance check list Feedback formFeedback form

Final goalFinal goal

Pass USMLE Step I, II and IIIPass USMLE Step I, II and III Pace yourself like a long distance Pace yourself like a long distance

runner- practice, practice and runner- practice, practice and practice to build up endurancepractice to build up endurance

Guard against procrastinationGuard against procrastination

Lumpers vs splittersLumpers vs splitters

How do you do your best thinking?How do you do your best thinking?• Talk it out (energizers) OR think it thru ( listeners)Talk it out (energizers) OR think it thru ( listeners)

What do you pay the most attention to?What do you pay the most attention to?• Focus on “specifics” (describers) vs “the big Focus on “specifics” (describers) vs “the big

picture” ( wonderers)picture” ( wonderers) How do you make decisions?How do you make decisions?

• Based on “my logic” (facts, impersonal) or “my Based on “my logic” (facts, impersonal) or “my values” (sensitive, personal)values” (sensitive, personal)

How do you spend your time?How do you spend your time?• Joy of “closure” ( accomplishment oriented) OR joy Joy of “closure” ( accomplishment oriented) OR joy

of “discovery” (process oriented)of “discovery” (process oriented)

Linear vs integrative learningLinear vs integrative learning

You cant memorize You cant memorize understanding!understanding!

It is not what you know, it is HOW It is not what you know, it is HOW you think about what you knowyou think about what you know

Visual metaphorsVisual metaphors

PicturesPictures ChartsCharts TablesTables AlgorithmsAlgorithms Bubble diagramsBubble diagrams Concept mapsConcept maps DISCOVER relationships!DISCOVER relationships!

Step I examStep I exam

Designed “to determine if an Designed “to determine if an examinee examinee understands understands and canand can apply key concepts apply key concepts of biomedical of biomedical science, with an emphasis of science, with an emphasis of principles and mechanisms of principles and mechanisms of health, disease and modes of health, disease and modes of therapy”therapy”

USMLE QuestionsUSMLE Questions

Three dimensionsThree dimensions Organizational level- molecule, cell, Organizational level- molecule, cell,

organ, personorgan, person ProcessesProcesses SystemsSystems Trend to add large clinically related Trend to add large clinically related

stems to all steps including stems to all steps including simulationssimulations

Questions to ponderQuestions to ponder

What to study?- books, questionsWhat to study?- books, questions How to study?- alone, with others, How to study?- alone, with others,

study calendarstudy calendar Where to study- home/ library/ Where to study- home/ library/

groupgroup When to study?- small/large When to study?- small/large

blocks/ day/ night,blocks/ day/ night,

Useful books for Step I Useful books for Step I

Kaplan USMLE Step I review- UsefulKaplan USMLE Step I review- Useful First Aid- EssentialFirst Aid- Essential NMS Pathology, Appleton and Lange NMS Pathology, Appleton and Lange

seriesseries Micro made simple ( micro and Micro made simple ( micro and

immunology)immunology) Lippincott Pharm ( pharm cards)Lippincott Pharm ( pharm cards) NMS Physiology, Underground clinical NMS Physiology, Underground clinical

vignettes, High yield seriesvignettes, High yield series

Question books for Step IQuestion books for Step I

Free diagnostic test KaplanFree diagnostic test Kaplan Board Simulator seriesBoard Simulator series National medical seriesNational medical series USMLE Practice CD- very usefulUSMLE Practice CD- very useful Q bank - Kaplan 1m or 4 mQ bank - Kaplan 1m or 4 m 60% of exam is Path- Pharm- Micro60% of exam is Path- Pharm- Micro Look at www.usmle.org for detailsLook at www.usmle.org for details

Useful resources for Step II Useful resources for Step II

Secrets Step IISecrets Step II Boards and WardsBoards and Wards Kaplan Q bankKaplan Q bank NMS Question BookNMS Question Book USMLE practice questions- very USMLE practice questions- very

useful with answers free from useful with answers free from KaplanKaplan

ToolsTools

Time AND study focusTime AND study focus Adequate time for all subjectsAdequate time for all subjects Develop a workable scheduleDevelop a workable schedule Note your progress ( lack of)Note your progress ( lack of) Use your own notesUse your own notes Practice scanning large paragraphs Practice scanning large paragraphs

for main ideas- useful skill to read for main ideas- useful skill to read large question stemslarge question stems

Practice questionsPractice questions

Answer in logical clusters (50)- don’t look Answer in logical clusters (50)- don’t look each answer upeach answer up

Use wrong answers as your diagnostic guide Use wrong answers as your diagnostic guide to identify gaps in knowledgeto identify gaps in knowledge

Study alone, with partner, with groupStudy alone, with partner, with group Study the hardest subject first at your high Study the hardest subject first at your high

energy timeenergy time Train your biological clock to have high Train your biological clock to have high

energy 8A- 5PM (exam time)energy 8A- 5PM (exam time) performance check listperformance check list

Questions are powerful study Questions are powerful study aidsaids

Look for Look for topicstopics in stem and answer in stem and answer choiceschoices

Understand correct answer Understand correct answer Understand wrong answers- powerful!Understand wrong answers- powerful!

• Make charts/entries for confusing areasMake charts/entries for confusing areas Rephrase the question-- more Rephrase the question-- more

questions answeredquestions answered Info not available in one placeInfo not available in one place

Wrong answersWrong answers

Requires an understanding of Requires an understanding of cause and effect relationshipscause and effect relationships

Make logical connections between Make logical connections between structures and their functionsstructures and their functions

Initial planningInitial planning

Spend about 20 hrs reviewing all you Spend about 20 hrs reviewing all you need to knowneed to know

Attention to labels, underlinesAttention to labels, underlines Do pretest/s pacing yourself correctlyDo pretest/s pacing yourself correctly Classify subject areas into “ know Classify subject areas into “ know

well”, “know somewhat” and “no clue”well”, “know somewhat” and “no clue” Make a realistic scheduleMake a realistic schedule

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

Time allotmentTime allotment

Two thirds of time on” not too sure” Two thirds of time on” not too sure” topicstopics

Weak areas need MORE timeWeak areas need MORE time Keep tabs of your progress in a Keep tabs of your progress in a

large wall chartlarge wall chart Schedule small breaks between 1-2 Schedule small breaks between 1-2

hours of workhours of work Make your own questionsMake your own questions

Practice testsPractice tests

Retake only AFTER reviewing materialRetake only AFTER reviewing material Last three weeks- do organ system Last three weeks- do organ system

reviewreview Study groups twice a week- two hoursStudy groups twice a week- two hours Study partner with unlike learning Study partner with unlike learning

style works beststyle works best At least two full length examsAt least two full length exams

Practice examsPractice exams

http://www.usmle.org/http://www.usmle.org/step1/2005Step1.pdfstep1/2005Step1.pdf

200 questions in four hours200 questions in four hours Request for accommodations early!Request for accommodations early! Familiarize with interface ( disc or Familiarize with interface ( disc or

website)website) practice using white boardpractice using white board

Tips for optimal learningTips for optimal learning

Create a realistic schedule and Create a realistic schedule and follow itfollow it

It is your best friendIt is your best friend Have positive thoughts (avoid neg Have positive thoughts (avoid neg

self talk)self talk) Say “Dr ---”- pep talk once an hourSay “Dr ---”- pep talk once an hour Stop studying the day before the Stop studying the day before the

exam- do fun stuffexam- do fun stuff

Stress reduction techniquesStress reduction techniques

Breathing Breathing YogaYoga Stretching/ ExerciseStretching/ Exercise Sensory imagerySensory imagery

Day of examDay of exam

Good sleep Good sleep NourishmentsNourishments Picture yourself as a competent Picture yourself as a competent

doctor working in a beautiful placedoctor working in a beautiful place Answer each question as it appears, Answer each question as it appears,

check every 10 questions for timecheck every 10 questions for time No penalty for guessingNo penalty for guessing

Actual test takingActual test taking

350 questions in 7 blocks350 questions in 7 blocks MONITOR you timeMONITOR you time Mark on upper left hand side questions Mark on upper left hand side questions

you are unsure of, to review later if you are unsure of, to review later if possiblepossible

Keep all your wild guesses the same Keep all your wild guesses the same letterletter

Don’t get stuck in one question- move on Don’t get stuck in one question- move on after you answerafter you answer

Generate your answerGenerate your answer

After you read the stem, think about After you read the stem, think about the right answerthe right answer

Then see if it is thereThen see if it is there Read all options before you mark Read all options before you mark

( Js beware)( Js beware)

Other tipsOther tips

Absolute terms- never,always, allAbsolute terms- never,always, all Read the directions- Ns bewareRead the directions- Ns beware Read the lead in sentence firstRead the lead in sentence first

• What kind of a question is this?What kind of a question is this?• Diagnosis/Management/ Diagnosis/Management/

Prognosis/ Ethics etcPrognosis/ Ethics etc

Other tipsOther tips

Look for word associations Look for word associations Longer/ more detailed answer usually Longer/ more detailed answer usually

correctcorrect Frequency of elementsFrequency of elements Middle choice may be correct with Middle choice may be correct with

quantitative informationquantitative information If pair wise confusion in matching If pair wise confusion in matching

questions, use same answer for bothquestions, use same answer for both

Examples- IExamples- I

What will the peripheral smear look What will the peripheral smear look like after one month of iron like after one month of iron therapy for iron deficiency anemia?therapy for iron deficiency anemia?• Almost all larger than normal RBCsAlmost all larger than normal RBCs• Almost all normal RBCsAlmost all normal RBCs• Almost all small, but not hypochromicAlmost all small, but not hypochromic• Almost all small, hypochromic RBCsAlmost all small, hypochromic RBCs• some small and some normal RBCssome small and some normal RBCs

Examples -IIExamples -II A farmer develops acute attacks of fever, A farmer develops acute attacks of fever,

dyspnea, cough and leukocytosis when he dyspnea, cough and leukocytosis when he works around wet harvested hay. Lung biopsy works around wet harvested hay. Lung biopsy is likely to showis likely to show• alveoli filled with dense, amorphous proteinaceous alveoli filled with dense, amorphous proteinaceous

materialmaterial• ferruginous bodiesferruginous bodies• Interstitial pneumonitis with eosinophils and interstitial Interstitial pneumonitis with eosinophils and interstitial

fibrosisfibrosis• Intersititial pneumonitis with lymphocytes, plasma cells Intersititial pneumonitis with lymphocytes, plasma cells

and macrophagesand macrophages• Linear immune deposition along alveolar bast membraneLinear immune deposition along alveolar bast membrane

Examples -IIIExamples -III

33 year old woman develops a reducible 33 year old woman develops a reducible mass of the groin, inferolateral to the mass of the groin, inferolateral to the pubic tubercle and medial to the femoral pubic tubercle and medial to the femoral vein. The most likely diagnosis isvein. The most likely diagnosis is• direct inguinal herniadirect inguinal hernia• femoral herniafemoral hernia• incisional herniaincisional hernia• indirect inguinal herniaindirect inguinal hernia• umbilical herniaumbilical hernia

Examples IVExamples IV

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

Types of questionsTypes of questions

FactoidsFactoids Factoids as vignettesFactoids as vignettes Single jump ( what causes this Single jump ( what causes this

problem?)problem?) Double jump ( what is the problem Double jump ( what is the problem

and what happens because of this)and what happens because of this) Triple jump- evaluate a situation Triple jump- evaluate a situation

based on knowledgebased on knowledge

Triple jump questionTriple jump question

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

Triple jump questionTriple jump question

Hct 32% with fragmented, nucleated RBCsHct 32% with fragmented, nucleated RBCs Leukocyte count: 12,500/mm3Leukocyte count: 12,500/mm3 Platelets 20,000/mm3Platelets 20,000/mm3 PT 10, PTT 30 secPT 10, PTT 30 sec Fibrin split product NegativeFibrin split product Negative BUN 35mg/dl, Creatinine 3 mg/dlBUN 35mg/dl, Creatinine 3 mg/dl Total bilirubin 3/ 0.5 direct biliTotal bilirubin 3/ 0.5 direct bili LDH 1000 units/LLDH 1000 units/L Blood and urine culture negBlood and urine culture neg CT head negativeCT head negative

Triple jump questionTriple jump question

What is the most likely etiology of What is the most likely etiology of the patient’s symptoms?the patient’s symptoms?• Disseminated Intravasc CoagulationDisseminated Intravasc Coagulation• Idiopathic Thrombocytopenic PurpuraIdiopathic Thrombocytopenic Purpura• Meningococcal MeningitisMeningococcal Meningitis• SarcoidosisSarcoidosis• Systemic Lupus ErythematosusSystemic Lupus Erythematosus• Thrombotic thrombocytopenic Thrombotic thrombocytopenic

purpurapurpura

Physiology questionPhysiology question

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

Another exampleAnother example

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

Educated guessesEducated guesses

First choice is usually correctFirst choice is usually correct Unless you read the question Unless you read the question

wrong- don’t change it!wrong- don’t change it!

Tennis game: Skill Tennis game: Skill developmentdevelopment

You want to improve your game for You want to improve your game for a match in six weeksa match in six weeks• wait till the tournament, you know you are wait till the tournament, you know you are

goodgood• watch videos on tennis skillswatch videos on tennis skills• watch all televised matches, with beerwatch all televised matches, with beer• take lessons and practice daily for two weekstake lessons and practice daily for two weeks• take lessons several times a wk, play with take lessons several times a wk, play with

lots of partners, work on your weakest area lots of partners, work on your weakest area the most the most

The messageThe message

Pace your studyPace your study Start ASAPStart ASAP Study activelyStudy actively Practice questions regularlyPractice questions regularly Get and use feedbackGet and use feedback

Some other resourcesSome other resources

CBSSA exam- $45 each- correlationCBSSA exam- $45 each- correlation Step I review courses- 1m-5m coursesStep I review courses- 1m-5m courses

• Kaplan, Falcon Reviews, UMKC IPP, PASSKaplan, Falcon Reviews, UMKC IPP, PASS Student recommended website Student recommended website

http://www.prep4usmle.com/step1/http://www.prep4usmle.com/step1/ www. testprepreview.comwww. testprepreview.com

Final commentsFinal comments

No substitute for knowledge and No substitute for knowledge and its applicationits application

Follow your schedule strictlyFollow your schedule strictly Have positive thoughtsHave positive thoughts Take breaks and RELAX in betweenTake breaks and RELAX in between Lots of good luck!Lots of good luck!