Ever since I entered medicine, I have always been hearing rumors. Now most if not all these rumors are outright false and sometimes obnoxiously wrong. So I will fact check common rumors at Alfaisal University regarding the USMLE and some other topics. If you have heard anything and want to know if it is true or not, comment on this post and I will do my best to research and present you with the actual true facts inshAllah.
1. Rumor: Research will decide your fate in securing a residency (something that was said to my batch by a professor in our first week of medical school)
Verdict: Outright False
The Truth: As I have mentioned in a previous post, research is at the bottom when it comes to what program directors use to choose applicants for interviews. Unfortunately, our university over exaggerates and overrates research at times. This is not to say that research isn’t important, on the contrary, having an affinity to research is quite the noble trait. But when someone says that it will decide your fate; that is false. To put it simply, having research experience on your CV won’t harm you, but it will NOT help secure any residency positions if the more important criteria are weak (Step scores, LOR, electives, etc.)
2. Rumor: Studying for the Step 1 takes a year of dedicated studying of at least 16 hours per day, non-stop and nothing else should interrupt your studying.
Verdict: Laughably False
The Truth: What you should know is that there is no set time for studying that you have to do. Everyone is unique and for someone to say that it would take all of us a year to prepare for this exam is incorrect. Each person will take a different amount of time. I have colleagues in my batch with a range of studying periods. Some took a few months and some took longer. You decide on how long you need to study. If you are a weak student, you may take longer in preparing for your exam when compared to the higher achieving students. This isn’t something to be ashamed of, this is an exam you have to take your time in. So, don’t rush this exam, but at the same time, don’t be pressured into taking an obnoxiously long time because someone said you have to.
3. Rumor: It is best to take the step 1 after your internship.
Verdict: The Worst Mistake of Your Life
The Truth: Some people will tell you that taking a year off after internship to prepare your Step1 is the best choice to get higher marks. This could be the worst mistake in your life. This could cost you dearly. When you apply, your CV is closely scanned and if they find gaps in your medical education (a whole year off without clinical exposure), it will significantly weaken you application (look at #19 in the criteria program directors use to accept applicants for interviews, “Lack of Gaps in medical Education”). Studying for the Steps is not a legitimate excuse for a gap or clinical exposure. Also not to mention that those who apply a year after they complete their internship have a significantly lower chance at matching (programs are interested in accepting those fresh out of medical school). So, as many of us have mentioned before, complete the step 1 BEFORE internship.
4. Rumor: The step 1 exam is very difficult.
Verdict: Technically False
The Truth: The step 1 exam itself isn’t difficult. The preparation for the exam though is difficult. The enormous amount of material you have to prepare is the scary part. One of the resources that you MUST use is Uworld. Believe it or not, Uworld questions are considerably more difficult than the actual exam. Now if you go to the exam without properly preparing for it, then yes, the exam will be difficult and confusing as well. But with proper preparation, the exam will be easier than you expect. The hard part is also dedicating yourself to making the exam preparation a part of your daily life. This may seem easy, but after a while it gets frustrating and you just want to get it over with. What you should keep in mind is that continuous hard work always pays off and your hard work will not go to waste. So if you have properly prepared for the exam, then it shouldn’t be something that you are afraid of.
I will tackle other rumors every few weeks. If you have any specific rumor, please do mention it in a comment below.
The most dreaded subject for medical students. It's like laundry for those living alone. You should do it because if you don't, you're going to be depressingly unprepared later on, but you would rather hold off on it till the last possible moment.
Now many of us have mentioned when you should do it, how to prepare for it, what resources to use and where are the possible locations to do it. Yet no one has mentioned Why. First of all, if you want to go the US, it isn't up for debate, you have to do it, end of discussion. But my post isn't for those people who want to go to the US, it's for those who haven't decided on where to specialize or have decided but it isn't the US. So if you fit in one of those two groups, continue reading, because I want to illustrate why it's a good idea for you to study for the Step 1. There is an argument on why it isn't important for you to do it or why it's a waste of time to study for an exam that you won't use, and that is a very valid point. But for those who are unsure, listen to both sides and make a decision.
Now the first reason why you should do the Step 1 is because it's a backup plan in case your original plan doesn't work. This means that if you don't get accepted in your intended country or you decide to drop out from your program halfway through, you have a contingency plan. Most of you would be surprised on how many residents pull out of their program before they complete training. Now inshallah this doesn't happen to anyone and inshallah everyone goes to the program they always dreamed about and succeed in it. But you definitely don't want to be in a position where you cannot bare to continue down the path you chose and not have a backup plan on what to do. Think of it has money hidden away for a 'rainy day'. You don't have to use it and inshallah you won't ever have to, but it provides comfort and security knowing that you have it.
The second reason is the incredible knowledge that comes with it. To put it simply, the step 1 is an accelerated in depth review of the first 3 years of medicine and a good part of the 4th and 5th years as well. In other words, by efficiently studying for it, you review everything you took previously as well as learn new things. Believe it or not, this makes a huge difference in your final years of medicine and internship. It sets you apart from the rest of the crowd. So if someone is aiming for a residency position here in Saudi Arabia, studying for step 1 will get you noticed by most of the staff physicians (consultants, assistant consultants, registrars and specialists). This of course will help you get to your goal and give you an edge on other applicants.
Another reason is that when you finish your residency program, the US offers a wide variety of fellowship programs in each specialty. Say you finish a general surgery residency here in Saudi Arabia and you wish to do a fellowship in the US for further training. You will be required to do the Steps, including Step 1. But if you already have it finished, you don't have to worry about learning about all the basic subjects all over again (the Step 1 exam is valid for 7 years). So you may not use it now, but by completing it now you have made the process later on very much easier.
Also, any country you wish to specialize and train in has a medical entrance exam (Saudi Arabia for instance has the SMLE). The majority of these exams focus on clinical information more than the basics. Here some may point out that studying the basics won't help and there is merit to that point. However, throughout my clerkship years and internship, the majority of my consultants always tell me that if I want to truly grasp and understand a disease in the clinical sense, I have to have a solid foundation in the basics. I used to ignore that advice at the beginning, but now I see the wisdom in their words. Having a good foundation in my basic understanding of medicine (pathology, pharmacology, physiology, microbiology, etc.) has allowed me to better understand the clinical aspect of medicine and make it enormously easier as well. This makes studying for most board exams easier. I understand the basics, the rest makes logical sense.
Now the reasons on why it isn't necessary to study for the step 1 are numerous and valid as well. First, the exam is expensive (around a 1000$). If you don't want to pay for the exam, then don't, but my argument isn't only for you to take the exam, I am also advocating that you at least study it's material. Another reason is that it takes a lot of time. True, but that time you are using to study isn't wasted as you are learning medicine at the end.
This is just my point of view and honest advice to all my colleagues (senior and junior alike).
Let’s take a closer look on how to study for the step 1. I would first like to establish a ground rule: You are in charge for your step 1, you are the boss. You decide when to take it, how long to study for it, what resources to use and if you want to do it or not. Don’t be pressured into doing something because someone else did it. Instead, see what they did and let it help guide you. But just because someone did something doesn’t mean that it’s the only right way. It could be a great method for that person but for you it probably would be a complete waste of time. So see what other people are doing but make your own plan.
I believe the best thing to talk about is what resources are important (again, this is my opinion and view and should not be seen as law or fact). Take it with a pinch of salt.
In order of importance, these are the resources I used: Uworld, First Aid (FA), NBMEs, additional resources.
Uworld:This is THE question bank to get. It's a little expensive but it's well worth the money and then some. Uworld doesn't just provide questions and answers, it’s a resource by itself. Each question challenges a specific concept. After you answer, it tells you why this is the right answer and why each of the other answers are wrong. A single question needs anywhere from 5 minutes to an hour. All the information on it is high yield and it's explanations are easy to follow. It has simplified the most complex subjects in medicine for many students. If you don't use this resource to its full, then you won't score has high. This will take a long time to finish, so start early and try to finish it more than once (it has 2,500 questions). In my opinion, this resource should only be used after you have completed FA at least once. The questions in this question bank are more difficult than the questions on the actual Step 1. So if you can answer them, you can easily answer the majority of questions in the Step 1 itself inshallah. (I used Uworld in a very peculiar and weird way that I believe was very effective. It was extremely time consuming but I believe it was well worth it. I will explain this method in another week).
FA: If Step 1 was a religion, then FA would be it's holy book. A little back story on this resource. FA is made in Yale Medical School. Every year, the FA sends out to medical students who have taken the step 1 and ask them about high-yield concepts they got in their exam. This isn't illegal as they don’t ask for questions or anything specific in the questions. Now for anyone who has opened FA, they will notice that's it isn't a textbook. It's a book with a lot of broken sentences and one word points. Great for memorization but very bad for understanding (understanding is for Uworld). FA will put two points together under one subject. Uworld helps you understand the connection. The Step 1 exam will challenge your understanding of the connection (Uworld) and expects you to have memorized that these two points are connected (FA). Some students may not understand FA, which is why at that point it becomes necessary to use other resources.
NBMEs: National Board of Medical Examiners Self-Assessment Exams (a mouthful). These are exams that help you see what level you are at. Each exam is around half the actual step 1 (150 questions) and it uses the same computer program that the Step 1 uses. The ones I did were 13, 15, 12, 16, 17, and 18, in that order (NBME 14 does not exist). Do you have to do them all? In my opinion yes. If you can't go through them all, at least get them offline and go over the questions as you may get a few of the NBME questions repeated in the actual Step 1 (the same people who write the Step 1 questions also write NBMEs). But the bottom line for this resource is that it helps asses your level. Most of us used it to track our progression in studying, to see whether or not we were improving. An honest piece of advice though, do NOT do any of them within one week of the exam. If you do bad in one of them, then it'll destroy your confidence. Even if you do well in, it will only marginally increase your confidence but you'll still be stressed out beyond belief.
Additional resources: It is in my opinion and view that if you understand FA, then using other resources isn't important. I only used other resources because I couldn't understand a thing in FA.
What other resource?
Pathology – Goljian
Pharmacology – Deja Review for Pharmacology
Physiology – BRS
Microbiology & Immunology – Deja Review for Microbiology and Immunology
Biochemistry – Rapid Review
Embryology, Anatomy, NeuroAnatomy & Behavioral Science – High Yield Series
Again, I only used them because I couldn't understand FA. But I never touched them after that. So don't waste too much time with these.
What about other resources?
Like videos, courses (Kaplan) and other question banks?
Videos: I honestly used them at the very beginning of my studying. I stopped a week later. I couldn't focus with the instructor and at end of the week I felt that I was wasting my time. A lot of my colleagues (who scored extremely well) used them, especially for Biochemistry and Behavioral Sciences. But for me, it is in my humble opinion that they are no better than the textbooks and waste your time. BUT, give them a try first. If you see that you are benefitting, use them to their fullest. If not, you decide what to do.
Courses: I never registered in one and cannot comment on it.
Other question banks: I only used Uworld so I cannot comment on any other qbanks (Kaplan, USMLE Rx, etc.).
Again, this is only my view and opinion. I know for a fact a lot of my colleagues would disagree with me on a lot of things I wrote. Take what I shared and what other have shared, make a plan that will fit you and then implement it. You will probably change it many times over your studying period, like most of us have done in the past. There is nothing wrong with that, it takes trial and error to find what best suits you. It may seem difficult now, but once you start to study for this exam in a serious manner, you will realize how achievable this exam this and inshallah this only makes you more enthusiastic to study and do better.
Last time we talked about resources for the Step 1. This week I was about to talk about studying methods, but I believe it’ll be a better idea to spend some time on how a step 1 question is written. By knowing how a question is written, you can better study for the exam and focus on what’s important and what’s not important.
The National Board of Medical Examiners (NBME, the board that writes the Steps) actually publishes a guide on how to write a perfect question. Now the problem is that it’s 95 pages long and if I post it here, no one will read it. So I am going to summarize what I believe are the important things you need to know. But here it is for anyone who is interested
According to the NBME, a perfect question is one that tests your recall of knowledge, how well you can integrate information, how you can synthesize (interpret) information provided to you and your final judgment. So a Step 1 question won’t ever ask you to recall a single fact. It will make you recall a number of facts (knowledge), makes you put them together (integration), then with the information you obtain from the question itself (synthesis) reach a final answer (judgment). Sounds difficult? That’s because it wasn’t made to be easy. But with proper preparation, the hardest questions will be a mild inconvenience to you that you will overcome with relative ease.
There are two types of questions: True/False and One-Best-Answer Items:
The NBME does not use true/false question format anymore. This is mostly due to the fact that these type of questions only make you recall a single fact but also these questions are usually ambiguous and the distinction in the answers themselves are unclear. The question writer may have something in mind but the examinee will be unable to decipher that with the information provided.
The NBME will only use One-Best-Answer Items (OBAI). Now what sets this apart from the former question type is that this allows the wrong answers to not be entirely incorrect. It allows the examinee to pick the best the best answer out of a group of answers that are all plausible. For instance, a question where the correct answer is pneumonia could also have other options such as chemical pneumonitis, pulmonary infarction, pulmonary embolism and lung cancer. All are differential diagnosis of each other and should be ruled out in a typical clinical scenario. This way, the NBME tests your understanding of multiple topics in one single question.
When writing an OBAI, there are 5 rules:
“Each item should focus on an important concept or testing point. “ What this means is that questions should be at the level of the examinee and test something clinically relevant. Here a blueprint is usually used. For example, let’s take the respiratory system. Questions can be either disease based (asthma, COPD, pneumonia, chemical pneumonitis, pulmonary embolism, pulmonary infarction, lung cancer, etc.) or task-based (interpretation of PFTs, radiology studies, history and physical exam interpretation, etc.). Let’s take asthma for instance, they won’t ask about the incidence of asthma in Djibouti, but they might ask about long-term complications, the mechanism of action of treatment or the signs typically seen in radiology studies. They will ask for relevant important information that you should know as an independent doctor.
“Each item should assess application of knowledge, not recall of an isolated fact.” As I mentioned, they’ll never ask you to recall one single fact, but multiple facts in order to test your understanding (application of knowledge). Everyone knows that nitrates and phosphodiesterase inhibitors shouldn’t be prescribed together, but the NBME will never ask you: “Which of the following is an absolute contraindication to nitrates” and have sildenafil as an option. It’ll give you a scenario where a patient took both and ask you why he suddenly collapsed (here you will need to know and understand the detailed physiological process of how the vasculature’s smooth muscles contract). The NBME here advises question writers to use actual real patient cases previously encountered (they won’t use them word by word as each case has a lot atypical features, but most questions are closely based on real encounters).
“The item lead-in should be focused, closed, and clear; the test-taker should be able to answer the item based on the stem and lead-in alone.” The “item lead-in” is the actual question after the clinical scenario they give you. The question will be “ Which of the following is the most likely diagnosis?”, not “The diagnosis in this patient is:”. Also, the examinee should be able to answer the question WITHOUT reading the options. So if you have properly studied, you could read the question and accurately answer it without looking at the possible answers. This makes sure that there is no ambiguity, no trick questions or question with multiple correct answers. Note, the answers may all be feasible, but in the Step 1, there will always be an answer that is obviously the answer with no doubt.
“All options should be homogeneous and plausible, to avoid cueing to the correct option.” If a question is about a man with shortness of breath and cough and the possible answers are: Pneumonia, pregnancy, fractured humerus, schizophrenia and invasive ductal carcinoma; the answer is sort of obvious and anyone who can understand the English language could answer it correctly. The options provided have to be related and one cannot stand out as an obvious incorrect answer. So a better list of options would be: Pneumonia, asthma, COPD, and pneumothorax. All are plausible and related. This is usually considered as the hard part of writing a question, providing options that could be right but can be ruled out based on the information provided in the question.
“Always review items to identify and remove technical flaws that add irrelevant difficulty or benefit savvy test-takers.” At the end, all questions are reviewed. The question bulk should be before the item lead-in. A knowledgeable test taker should be able to accurately answer the question without the options available. And last, all questions are reviewed to make sure that they hold up to the level of what NBME wants.
What I want to say is that by knowing what they ask for, you can better prepare. The step 1 isn’t just about memorizing FA or Uworld and it also isn’t just about understanding them. You need to study in a fashion that allows you to apply the knowledge you studied. In order to do that, you have to both memorize and understand as well as know why this is important and how it is used in real life scenarios (clinical relevance).
Unfortunately, our university doesn’t do this. The exam questions are nowhere near NBME standards. What I remember was that we had questions that mostly relied on our memorization skills, never the application of knowledge. This is not to mention the horrendous grammar, ambiguous wording of questions to purposely throw students off track and the countless errors in the questions themselves. This doesn't apply to all the questions obviously.
Next week, we will talk about studying methods keeping in mind how NBME questions are written. A last point to consider. My last post was my experience and definitely should not be taken as fact. This post is fact and should be taken in a literal sense.