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

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

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

My scores

My aim was to beat the mean, and my goal in doing Qs was to reach 80% correct in random, timed mode. 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: 27.11.2012

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