How to make USMLE Step 1 when studying at Masaryk University

I am studying Medicine at Masaryk university in Brno, Czech rep., and my study curriculum as an european IMG (6 year) is a kind of different from the US. I first heard about USMLE on IFMSA Science exchange program at American University of Beirut (AUB). It was after my second year during the summer when I saw students cramming the First Aid for USMLE Step 1 in the library, and I started to toy with the idea of doing the USMLE Step 1 myself.

It took me some time to transform this idea to actually taking the Step 1. Last Friday, On the 23rd of November 2012, I finally made it. And although I don't know the results yet, I felt very well prepared and I am quite confident I passed. I would like to share some points for those who study in Europe or are considering studying at Masaryk Uni with the prospect of taking the USMLE Step 1 while at Masaryk Uni.

Comparison of regular class study and Step 1

• Similarities
  1. Although every person is an individual, there is one science, one evidence-based medicine.
  2. Almost all of the content asked I could figure out with the information from classes (if I remembered them :).
  3. Both examiners on oral exams and questions in the test are expecting you to know and understand key principles and concepts.
• Differences
  1. In Czech republic almost exams are from individual subjects consequtively and all exams are oral. You toss e.g. 3 questions from anatomy 300Q, and elaborate, describe the location and function. The teacher/examiner usually ask for more details and may ask you on whatever accross the subject. Through this discussion, one can see how deeply the student understand the material, but there is a potential for interindividual variance. This contrasts deeply with computer-based USMLE.
  2. The Czech (and most od european) study curriculum is bit different, some say more "classical". There is strong emphasis on anatomy, with close second physiology and pathology (microscopical and surgical pathology rather than clinical-vignette presentation).
  3. In the first 3 years in Czech medicine program, almost all of the subjects are theoretical. There is no patient with Tay-Sachs in biochem, there is no newborn with congenital adrenal hyperplasia in physiology. However, there is hexosaminidase A in the lipid degradation pathway, and there is 21-hydroxylase in the smooth endoplasmatic reticulum of the adrenal cortex. So in order to study for USMLE, you have to make a single another step in your reasoning or memorization and link a clinical presentation to a particular enzyme defect. E.g.:
     • Presentation: age: newborn; symptoms: hypotension, hyperkalemia - (think hypoldosteronism), dark skin folds - (think hypocortisolism => incr. ACTH); signs: ambiquous genitalia; tests: presence of Barr body, increased urine 17-ketosteroids
     • Enzyme: deficient 21-hydroxylase (most common cause of adrenogenital sy.)
     For USMLE, the basic features of clinical presentation must come second to you mind immediately after the underlying mechanism/pathophysiology.
  4. The subjects studied in class are examined consequtively one after another (Biochem after 1 year, Anatomy and Histology after 1,5 year, Physiology after 2 years, Microbio after 2,5years, Pathology+Pathophys after 3 years, Pharmacology after 3,5 years). This allows you to study and understand the subject well, but may have one pitfail: poor retention. Your examiner in pharmacology will not ask you on glycolytic pathway, but in USMLE, you will have a colourfull salad in one block.

If your goal is to have highest USMLE score possible, certainly US medical school curriculum is shaped more directly towards this goal. But if you direct yourself towards this goal, be sure you can make it while at Masaryk Uni.

Tips&tricks for scoring high in USMLE Step 1 for an IMG

Chronologicaly

• Decide. Studying for Step 1 will take you energy, time and money. However, if you want to do residency in US, this is the way. Be honest to yourself and make decision you will not regret.
• Make a plan. After 3,5 years, you are going to have covered all subjects needed for Step 1. I myself took the exam after 3 months of the 5th year, but taking the boards exam by the end of 4th year is a reasonable schedule, if you prepare yourself early.
• Study books recommended for USMLE for the subject you are going to take oral (called "high-yield" books). DO a LOT OF USMLE-style QUESTIONS as you are preparing for your oral exams. It takes a lot of time, but I cannot stress how important this is. Step 1 is a bunch of questions which floods you in 8hours. The best way how to prepare is practising by answering (and studying by reading explanations) of as many questions as possible. You can you either a Qbank, or Qbook for each subject separately (see below in detail). This will help you to address the differences 1. and 3. mentioned above.
• While studying, always ask yourself, the lecturer or colleagues WHY and try to answer with your knowledge from all other subjects. Many of the Step 1 questions ask you why. Building a net of causes and results in your mind (or drawing on a paper) will make your knowledge solid, and easily remembered. This is the best way to address difference No 4. When the answer to the why question is not known (and wikipedia or Goljan's pathology don't know either), then it's time to memorize it. Don't try to know it as a poem, but rather reinforce it by doing questions on that topic.
• Get yourself a First aid for USMLE, and read it briefly parallely with your class study. Make additional notes. This will make your future readings of First aid faster and you will recall more details from the classes easily. Also, when some point is not in the First Aid, you are not going to spend whole weekend studying it in a detail (leukemias or glomerulonephrites are example of this).
• Few months before the exam, practise questions as they will be presented in one exam block: random, timed. Try to review the questions on the same day, and do 50q per day (altogether it took me up to 5hrs/50q, but the speed is increasing as you practise).

Subject-wise

US medical students usually stress the need to study by system (cardivascular, pulmonary, ...) for Step 1. However, due to the long time you study for one oral exam, I think it's wise to have o strong subject-based preparation for the USMLE. With emphasis on single gene disorders, pathophysiology, clinical presentation, you also addresses the difference No 2. (mentioned above).

1. Biochemistry. Throughout the class, study Lippincott's Illustrated Reviews (LIR): Biochemistry (not Harper!, though I-cell dissease is there better explained).
   • Assoc. prof. Tomandl is just great in making you think and arrive at things you wouldn't know you could figure out, his classes were perfect.
   • Favourite Step 1 questions are enzyme defficiencies, so make sure you get a bit deeper into lipidoses, mucopolysacharidoses (Hurler vs. Hunter sy.), urea cycle enzyme def. (Ornitine transcarbamoylase def. vs. Carbamoyl phosphate synthetase), glycogenoses, and porphyrias (Acute intermittent vs. Cutanea tarda). Don't see this rare diseases as something you have to learn and maybe never see such a patient, but as a striking examples of how the human system is malfunctioning when one enzyme/gene is deficient.
     • You may use Kaplan biochemistry lectures (and video) to study this for boards. It would be great to do it througout the class, but I did it during my overall review in the 4th year.
   • Kaplan Qbank or UsmleWorld or Qbook (Lippincott's Illustrated Q&A Review of Biochemistry was more than enough for me) to reinforce what have you learned.
2. Anatomy. Most of english-speaking students use Gray's or Clinically oriented anatomy. You are going to hammer every nerve, then dissect it yourself on a cadaver, and then be asked to show any important structure, so you are going to have an awesome knowledge base. In order to transfer it into applicable clinical knowledge,
   • Make sure you are not just memorizing nerve branches and their root origin. Visualize. At the end of the anatomy class, you must be able to imagine taking off a skin of a guy sitting opposite to you in the bus and see the bones, muscles, vessels, nerves. Zygotebody.com is great tool. For neuroanatomy, I used this virtual 3D brain model for visualizing difficult structures like Papez circle (usefullnes limited).
   • Discuss with your colleagues. There is a huge plenty of memorization, study group will help.
   • Link embryology knowledge (branchial arches 1 and 2) with anatomy (n. V3, n. VII) and neuroanatomy (branchial nuclei region in the brainstem) and function (physiology).
   • Link nerve (or nerve root) to muscle it innervates, and to it's function. Practise this on questions simulating USMLE. Use Kaplan Qbank or Qbook (I used Lippincott's Illustrated Q&A Review of Anatomy and Embryology) to reinforce the study material.
3. Histology. Don't be too afraid. Junqueira is more than enough. Link the microscopic structure (columnar eptithelium of the bronchi) to molecular (9+2 dynein arms), physiology (kinocilium elevator, mucus production by goblet cells) and basic pathology points (cystic fibrosis).
4. Physiology. I studied from Ganong, and it's a bit overkill. Guyton should be better. Consider reading through BRS Physiology when you studied that subject in class/Guyton. BRS Phys is a concentrated juice of knowledge testable on Step 1, you can drink it in one week.
   • Make sure you understand what you read. In Physiology almost everything makes sense and is well connected to every other subject. Explore these connections. Remember every channel, receptor and enyzme in BRS Phys, because there are drugs blocking or agonizing its function.
   • If you are able to proccess even more compressed material, read physiology chapters in First Aid (FA). This is usefull mostly because reffering to First Aid physiology when studying pathology and pharmacology is more convenient than searching through BRS Phys.
   • Associate clinical signs and symptoms and lab values with classic pathophysiology cases (hyper/hypo-thyroidism, -cortisolism, -aldosteronism). Again, Qbank will help you with this (although after Ganong, BRS and FA I was scoring above 80% in Kaplan Qbank, and there was no need to study more).
5. Microbiology. Throughout the class, I studied from our czech medical microbiology book (very complex but dense, found difficult to grip simple differences in bugs). I studied Medical Microbiology Made Ridiculously Simple (MMMRS) in boards prep, and found that just this book together with notes from classes and lectures would be well sufficient both for oral exam as for Step 1.
   • I found microbio very tough to memorize (it was fine in the actual exam). Finally, after reading MMMRS, I realized it's all about doing enough questions to recognize the nuances in classic presentation. Doing a plenty of questions will teach you that. Again, your main study material should be Qbank or Qbook (recommend Lippincott's Illustrated Q&A Review of Microbiology and Immunology).
   • Don't avoid 1st line antibiotics, aspecially for empirical Rx and prophylaxis. It's tough study, but it will pay off when doing pharmacology.
   • Tightly connect every knowledge to immunology.
6. Immunology. Cellular and Molecular Immunology by Abbas is recommended for the class (and is perfect for the boards, too), although I read Basic immunology by Horejsi (in Czech) and Clinical immunology by Chapel (that's a bit overkill for Step 1, but the frequently tested facts are adequately stressed and there are number of usefull clinical cases/presentations).
   • Don't get confused by the ILs. Draw a schematic use of every of them (e.g. IL-4 secreted by Th2 cell when also presenting CD40L to B cell, illustrating class switch), don't study their function just by reading a table ("IL-4 increases IgE").
   • Keep checking immunology chapter in FA as you study in the class. Turn to immune deficiencies and try to figure out as many patient's Sx as possible, when particular molecule is missing. Compare these presentations (e.g. NADPH oxidase def. vs. Myeloperoxidase def. vs. Chediaki-Higashi sy.).
   • Review nucleotide synthesis and salvage when studying ADA def (one cause of SCID).
   • Refer to wikipedia or more clinical sources (Up to date, Chapel's Clinical imunology) when unsure about understanding a disease.
   • Don't spend too much time memorizing every antibody (Ab) associated with a disease, pick maximally one sensitive and one specific anough. Again, do rather questions, which presents the disease in a complex patient, not an Ab profile.
7. Pathology. Pathology is high yield, but in my opinion is too stressed by US students, because it's one of the last subjects before the test. According to my experience (and also resources review in FA), the most useful for boards are Goljan's pathology and WebPath. In order to do well in class examination, you have to add more surgical pathology and microscopical pathology, these can be covered by class notes and MUNI's microscopic pathology atlas.
   • Don't go too much into detail, if you understand Goljan, recognize the microscopic appearance in atlas, you should be able to answer the questions right.
   • Study throughout the class. If you are strong, read the chapter in Goljan, then go through images in webpath. You may add review of microscopic images in the evening and Goljan's audio to your weekend jog.
   • There are tons of pathology questions in Webpath (free) and Qbanks (my choice), but if you have time, do also questions in good Qbooks (Red Robbins, Lippincott's Q&A Review of Rubin's Pathology). Put down the facts tested in the Qs into FA or separate sheet, and review it before oral exam.
   • When you answer question wrong, check the disease in FA, if you don't recall it confidently, look into Goljan. If you cannot sleep because you don't understand the pathology, look into wikipedia.
   • Don't memorize the classification for leukemias for Step 1, know the most typical causes:
     • Follicular (non-Hodkin's) lymphoma, B cell neoplasm, t(14,18), amplification of bcl-2 antiapoptotic gene.
     • CML: usually 40-60 y/o, blasts usually <10% (always <30%) in peripheral blood, low leukocyte alkaline phosphatase, no Auer rods, Philadelphia chr. t(9,22), bcr-abl fuse gene (abl is tyrosine kinase), Rx: imatinib.
8. Pharmacology. For the class exam, LIR: Pharmacology is the book of choice. There is everything needed in this book, really, but some important points may be missed when viewed together with low-yield facts. Together with this book, I also studied Kaplan's Pharmacology notes (KLN) and videos. These lectures basically covers everything necessary for boards, and are well presented and explained.
   • The sequence I did: LIR Pharm, making cards with drugs, MOA and side effects, then turning to Kaplan's lectures.
   • The sequence I recommend: chapter in Kaplan's lectures together with class, then reading the chapter (or at least looking up unsure points) in LIR Pharm. Then cards and questions.
   • When you cannot keep the pace of class and Kaplan lectures with LIR Pharm, let the LIR for final study before oral exam. If you have watched the lectures, read carefully LIR Pharm, review FA pharmacology once and turn to questions and do them as much as possible.
   • For Step 1, UsmleWorld pharmacology questions were the best to me.
   • Don't memorize too many drus from the same class.
   • Don't memorize too many side-effects. If they aren't in FA nor in KLN, they probably aren't important. Rather imagine this side effect in a patient with the disease for which this drug is indicated.
   • Build long logical sequences of pathology (origin - risk factors, epidemiology - age, sex), progression, microscopic appearance, underlying molecular, physiological & immunological proccesses, symptoms (pathophysiology, internal and surgical propedeutic), treatment options, 1st line treatment side effects.
   • After pharmacology, you are ready to answer questions from random subject. Practise this by answering Qbank in random, NMS Qbook, simulated step 1 (either in Qbook or Qbank) and NBME.
9. Behavioral science. This "subject of exclusion" covers some ethics, psychology, and statistics. Don't be scared, but don't underestimate this. The result from Step 1 is a single number, and Behavioral weight about 1/8 in this score. Get yourself BRS Behavioral Science or KLN Behavioral and read these books and practise Qs as you approach statistics, medical psychology and ethics in your class.
   • When I was reading BRS Behavioral for the first time, I was in a pain. It was totally different from other subjects, and there were so many diseases which presented with thought disorders (schizotypal or schizoaffective personality disorder, brief psychotic disorder, schizophrenia, delirium), that I got easily confused. The key is again in practising cases and questions, which both reinforces your memory and stresses differences between these diseases.
   • Questions in BRS and one Qbank should be enough.

Summary

• You studied all subjects needed for Step 1 after 3,5 years of 6 year programme General Medicine at Masaryk Uni (similar to other european universities)
• Reasonable schedule is to take the exam in the end of the 4th year. This gives you 6 months for boards prep (along with another classes, though).
• USMLE Step 1 exam is about reading and understanding fast and selecting single best correct answer. Masaryk Uni will not prepare for this. Practise a lot of questions.
• Apply what you learn throughout the study on vignette-style questions. Before your oral exams, practise subject-based USMLE questions. Step 1 facts are usually high yield enough to be asked on your oral exam. Use either
  • Subject-specific Qbook. Lippincott's Illustrated Q&A series, or get Kaplan Qbook and Lange Step 1 Q&A and use chapters dedicated for a particular subject.
  • In Qbank, you can select Qs only from particular subject. Kaplan Qbank is cheaper for 1 year, and is more detailed. Thus I would prefer it for deep-knowledge oral exam of one subject. On the other hand, Usmle World is more high yield for the Step 1.
• Look up things in FA, use it as a reference and recall what's there and your notes on the margin.
• When are you ready for the exam?
  • When you have done all exams on each subject and answered about 4000 questions and read explanations for your wrong answers. You should have done all Qs in UW Qbank.
  • Or you are ready, when you score more than 80% correct in any qbank or questionbook (Kaplan Qbank is the toughest).
• Some people read FA 3 time form front to back. I did find it boring. To be honest, I haven't read the whole FA once from front to back.
  • Only did questions, and reviewed the page which covered answer to the particular questions. Overall, I read each page in FA about 3 times, but never front to back. I think that by reading it hrough, I would not recall details which were in my hippocampus by doing Qs, and my knowledge may "flatten".
• When doing questions, do them in blocks of 50q timed for 1hour. Reviewing the answers and explanations (esp. UW) may take up to 3hrs per block.
• The closer to the exam you are, the more % of your study time should be answering questions, and the more convenient FA (with your notes) should be for reviewing the answers.

My scores

My aim was to beat the mean, and my goal in doing Qs was to reach 80% correct in random, timed mode.

• 150q from NMS Qbook: 75%, other Qs from books with similar score
• Kaplan Qbank average (did 52% of questions, mostly subject-wise, timed): 70%
• UW Qs (subject-wise, timed, almost 2000q): 70-85%
• Simulated step 1 (Sept 2012): 226/322 = 70% (helped to focus on weaker subjects: BS, Anat, Pathophys, Pharm)
• Simulated step 2 (one week prior): 267/322 = 83%
• NBME
  • 7: 175/200
  • 12: 173/200
  • 13: 189/200

As soon as I receive my score, I will update it here.

UPDATE 2012-12-12: After long several weeks, here it comes... 257/88! Happy, confident, and at least for a while perfectly relaxed.
Goal reached (mean 224, SD 22 => 1,5 SD above the mean represents roughly 92 percentile), although the way was long and tough. Many thanks to all supporters and those who tolerated my pre-test ignorance :)
Going to play laser-game this evening to celebrate the result of this (altogether) almost 2 year effort. See ya!

Useful links:

• www.usmle-forums.com/polls.php
• wikipedia.org
• valuable learning documents freely available online

27.11.2012

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