I cannot stress how important the United States Medical License Examinations are. You always hear of people with double 99s or triple 99s. They are not as rare as you may think. Every year, more and more applicants are coming in with perfect scores, showing that this test is only the first screening measure for IMGs. Once you get 99s, what more do you have to offer? Clinical experience, research or publications, awards or rankings, LORs from distinguished faculty? Jumping beyond such measures, this guide will tell you how to study to get those 99s. They are not as hard as you may think; anything is possible with hard work and dedication.

Schedule

If your medical school gives you some time off to take your Step 1 after your second year (basic subjects), you should try to get it done in that time while the knowledge is still fresh. Step 1 is without a doubt the hardest of the three exams and completing it early will make the rest a breeze. If your medical school does not complete all the subjects covered in Step 1 by the end of your second year, or simply does not give any time off to study and take it, you will have to do it after graduation. Studying for your Step 2 CK while studying for your finals is the smartest and fastest way to complete your steps in time. There is no disadvantage of giving the CK before Step 1; both are very similar tests and can be given in any order of preference. The CK subjects are the same as final year subjects, covering Medicine, Surgery, OBGYN, Pediatrics, Psychiatry, and Preventive Medicine. If you truly study hard for the Step 2 CK, you are guaranteed passing your finals. The schedule made earlier does just that, starting CK studying four months before your finals. Once you finish your finals, keep taking NBMEs and redo the Qbank online. Once you achieve the score you are looking for in a practice exam, you are ready for the real test.

Moving to a studying schedule, everyone studies at different paces. If you are working or doing research, its much harder to put 6-12 hours a day in studying. But if you have the luxury of studying full time with no other obligations or responsibilities, it’s that much easier to focus and complete. I personally started with 6 hours of studying a day in the first month. Do more if you’d like, just don’t tire yourself and take it easy the first month learning concepts and familiarizing yourself with questions and formats. In the second month, I studied 8 hours a day, half of the time spent reading and the other half doing questions and studying the answers. In the last month, I went up to 10 hours a day, majority of my time on questions or practice exams, leaving a couple hours to review notes quickly. Make a schedule for each day (certain amount of reading and number of questions) and make sure to complete what you set out to do that day. Also try to sleep at least 8 hours every night, just to rest from all that studying. That last month of studying is the hardest and most intense. In those four weeks, I did 4 blocks of questions daily (~200) for 2 days and every 3rd day a practice exam (200). So in 1 month I completed 9 practice tests (7 NBME + 2 Uworld for Step 1) and covered the entire 3rd time through the Uworld Qbank (~2000 questions for Step 1). This helped me build stamina for the real exam.

Don’t ever work yourself too hard. Take constant breaks such as food, music, walking your dog, youtubing a video or checking your email. Once again distractions are the biggest reason people cannot study properly or focus on what they are studying. Avoid long phone conversations, facebook stalking, and wasting time with friends. Everything can be put on hold until you finish this exam. This one score will decide if and where you match, so stay focused. In the end, it all comes down to how much time and concentration you give to studying. If you can motivate yourself and devote your entire time to studying, you will get the score you want. If you have distractions and are not 100% focused while studying, you’ll miss key questions which will lower your score.

One more very important thing, do not rush it. Take this exam only when you feel are ready, and then know you are ready. When I started studying I was soo overwhelmed by all the subjects and material. By the time I was done studying, everything was within reach and nothing looked unfamiliar. I actually felt as if I had passed my peak of knowledge because I scheduled my date a little later then I should have. I was really exhausted, but still kept it going and got the score I wanted. People will say do one week of behavioral, 1 day embryo, etc. Do whatever you think you need more. It’s your knowledge and only you know your strengths and weaknesses. Use the Qbank subject percentages to see what’s missing and focus on that. Timing is very important: to complete it before August, but making sure you completely ready to give it and get a 99. Once again, plan early. Realize you only have these many weeks or months to study, so make use of every single day!

Studying Material

As for studying material, I honestly say use everything and anything available to you. If you don’t, you’re only handicapping yourself. This test covers everything, so study it all. While there are many books and DVDs available, everyone has their own opinion on them. Kaplan has review books which come with the review course if you choose to take it. They also have a DVD set which gives lectures similar to the course. The Kaplan Qbank online has been revised in 2010 with some very difficult questions similar to the USMLE World Qbank. Both Qbanks are great so don’t limit yourself to one. Though a lot of the material is repeated, it only reinforces your knowledge and will make you more fluent to the types of questions and how to solve them quicker. First Aid for Step 1 and Crush Step 2 are great review books. If possible, memorize every word from these books as everything in there can be asked. Goljan Rapid Review is also a great series. Goljan audio lectures are amazing and should be heard by everyone giving this exam. They are quite entertaining and teach you things you will never forget.

Just to show how I studied, let’s use Biochemistry as an example. I used Lippincott to supplement Kaplan Review along with First Aid. For Biochemistry, questions will rarely ask you “what is the rate limiting enzyme of Gluconeogenesis?” They will give you symptoms of a disease caused by an accumulation a substance. You now have to work backwards and remember the signs and symptoms are associated with this disease, which pathway it is from, and what the rate limiting enzyme is. I made sure to memorize and continuously redraw every cycle and pathway until I got it 100% accurate. I then made sure to learn every regulatory enzyme and the diseases associated with them. This can add up to a lot of enzymes and diseases, but that’s what Biochemistry is! I also made a page of notes for every major disease in Biochemistry. Some pages were barely 2 to 3 lines, while others took the entire page. Learn the disorders extremely well as sometimes only one clue may be given, and though you may have wrote it in your notes, if you don’t remember it on the test, you’ll miss that question or waste a lot of time trying to remember it.

From my experience, most of the material I learned was from Uworld Qbank. I did the entire Qbank 3 times, first time scoring under 50%, second time a little under 70%, and third time through over 80%. The first time you go through the answers, take your time and learn them. It’s extremely slow and hard the first time through, but just keep at it. Do 1 or 2 exams a day and build up a good routine. The second time through, you may go faster, focusing on what you you’ve missed. The third time, just skim through, as most of your time is spent on answers, not the questions. Read the explanations of all 5 answer options as that is your studying material and will help you differentiate possible answers. These questions are very hard, and they will actually make the actual Step 1 exam easier; that is how well it prepares you. In your 3rd time through a Qbank, you’ll want to get 90-100%, but you won’t; it’s just that hard! What I did was I wrote down everything I got wrong. I obviously still didn’t understand it after seeing the question 3 times so I made myself learn it so I wouldn’t make that same mistake again.

Once you go through the Qbank once, you will be a lot more accustomed to these types of questions and answer them quicker. You really have to train yourself to read what they’re asking and react to an answer, making sure they’re not asking for something else or a different answer may be a better answer. Just missing one line in a question may change the entire objective of the question, so concentrate hard when reading questions. After you’ve seen it all, everything becomes much easier and time isn’t really an issue. Mark anything difficult and come back to it. If you can do 1q/min you’ll be fine. Here is example of a classic 3-step vignette question. They will give you symptoms of a Myasthenia Gravis, and will want you to diagnose the disease, know that it’s a type 2 HS, and ask you to name another example of a type 2 HS.

Tip: make sure to learn your ECGs, heart sounds, CTs, MRIs, breath sounds; all of these are free points and you don’t just need to know these for the test, but for everyday practice.

Tip: If something looks unfamiliar to you, learn it. Make your weaknesses your strength; this is the most important thing I can advise.

Regarding Kaplan courses, I choose not to take them as I prefer studying on my own schedule rather than going to class from 8-5. I think they would be a great review for people who like to learn in class, but they are pricey (though there should be no limit to cost in preparing for this exam!)

Practice Exams

There are 7 NBME exams for the Step 1 which are very similar to USMLE questions. Some are actually repeated (or worded differently) so you MUST do all 7. The scores you get on your NBMEs are extremely accurate as to how you will score on your real test. I have attached a chart which can convert your NBME score to a USMLE score and percentage. You’ll want to see progression on these exams, one after the other. I personally took all my tests in my last month of studying because I was never ready early and didn’t want a low score. As long as you’re seeing improvement on each one after a few days of studying, you’re doing fine. Space them out evenly, and please do ALL of them. Go over each and every answer and make sure you understand why you got something wrong. There are also 2 practice exams from Uworld (both are very difficult, but great practice). There are 4 NBMEs for Step 2 CK, and 1 Uworld practice exam.

If you’d like to give your NBMEs offline, they are available quite easily on the internet. Just make sure to not follow the answer sheets attached to them! They are many mistakes and you do not want to be making the same mistakes as the person who wrote the answer sheet. Your best bet is to lookup every answer for yourself. It may take a lot of time, but you are reinforcing the knowledge while looking up every question.

Step 1

This exam is 7 blocks of 48 questions each = 336 questions. You have one hour to complete each block, so one minute and 15 seconds per question. You can mark questions and always come back to them, which is actually recommended as you do not want to waste precious time stuck on one question and end up not finishing the block. Missing one very hard question while completing 5 easy ones is worth it! There are also “experimental” questions in each block. Which ones are experimental, no one really knows, but you may have an idea while giving the exam. It’ll be a strange question which you either have no idea what they are talking about, or just something which is completely irrelevant and out of the norm of the rest of the questions. These are there for the USMLE board as an experiment to see what percentage of examinees can get it right and if to add it to an exam in the future. It will not count towards your test score so do not worry about it too much, but once again you do not know which are experimental or not, so answer every question the best you can. The Step 1 covers a lot of subjects so I will weight them out, in my opinion of course, and give common examples of things to study in each. Remember, EVERYTHING and ANYTHING can be asked; this is just what I thought of each subject weightage in my experience.

Scale 1-10, 10 being THE most important subject, 1 being least important

Behavioral Science  7
(can use same notes for Psychology for Step 2, focus on psych disorders, drug abuse, statistics)

Biochemistry  5
(pathways, enzymes, diseases, cycles)

CVS  9
(almost every vignette gives vitals and EKG/Echo findings)

GI  8
(all GI disorders)

General Principles of Health and Disease  3
(don’t remember)

Genetics  8
(trimsomies 21 18 13, other common disorders, good in first aid and Uworld Qbank)

Gross Anatomy, Neuroanatomy and Embryo  6
(Atlas helps, hernias, limb nerves, all Neuro cross sections with cranial nerves)

Hem + Lymporeticular  8
(anemias, platelet disorders, lymphomas, etc)

Histology + Cell Biology  4
(RER and transport of proteins and DNA)

Micro + Immuno  8
(micro is HUGE, learn all the bugs one by one. Immunology is as important, spend extra time on it if its weak)

Musculoskeletal, Skin, Connective Tissue  8
(all are KEY, do not skip them. If you mix up disorders, you will lose points)

Nervous System  9
(stroke, Parkinson’s, Alzheimer’s, headaches, tumors)

Nutrition  5
(kcal/g)

Pathology 10
(the most important subject of Step 1, probably 50% of the test or more, if you learn this well now, it will make your Step 2 medicine studying a joke since you’ll know every disease)

Pharmacology  9
(all common drugs, drug interactions, side effects of important drugs – warfarin, digoxin, SLE / Steve Johnson’s causing, neurotoxic, nephrotoxic, hepatotoxic, etc. just list them out and memorize, don’t forget pharmacokinetics and dynamics)

Physiology  7
(physio Kaplan vids are decent + first aid formulas)

Renal/Uninary 7
(stones, RCC, TCC, pyelo, prostate CA, BPH)

Reproductive + Endo  9
(diabetes, PCOS, thyroid, differentiating primary secondary pseudo diseases with labs)

Respiratory  8
(PE, pulm hypertension, pneumonias, etc)

Step 2 CK

It is very similar to Step 1 actually, just more clinical oriented and less basic science subjects. Whichever exam you give first (Step 1 or Step 2 CK), it’ll make the second one easier. They overlap a LOT, so try to do the second as quickly as possible after the first! This exam has 8 blocks of 44 questions each = 352 questions. While longer than the Step 1, I found this test a lot easier. I may get more into details of this exam in the future, but as of now, its very similar to Step 1 studying and subjects (Medicine=pathology, Psych=Behavioral). Crush for Step 2 is great, along with Kaplan and Uworld Qbanks. They pretty much cover everything for this exam.

Exam Day

As for the exam day, if you could handle 4-5 blocks of a Qbank a day, then the 7 or 8 block Step 1 or Step 2 won’t be too bad. If you want to do back to back NBME’s in one day (8 blocks), go for it. If you can handle that, you are more than ready for the exam. I personally took a break after each block. Taking a 5 minute walk or drink, or just washing your face helps you be ready for the next set of questions. Doing 2 in a row I found to be very exhausting. If you finish a block early, you’ll have tons of time left over for a 20 minute lunch.

Step 2 CS

Imagine a day working at the clinic. You meet a new patient every 15-30 minutes, gather a history, do a physical exam, order investigations, make a differential diagnosis and treatment plan, and write out a patient note. That is your Step 2 CS. If you have ever worked in clinic for a few weeks, have rotated in a medicine ward, or done a clinical elective at any hospital, you’re almost ready for the CS.

This exam lasts 8 hours, in which you see a total of 12 patients. Each patient encounter begins with a sheet on the door stating the name, age, vitals, and presenting complaint. Begin writing notes on the pad provided (after time starts), then knock on the door and enter. Smile and introduce yourself to the patient. Begin obtaining a history, while keeping focus on their primary complaint and any associated symptoms. Do not forget to obtain a social history (alcohol, smoking, drug use) as this is key to the counseling portion of your encounter. Once you feel you have adequately covered all pertinent questions to the case (PC, HOPC, ROS, PMH, PSH, FH, SH, Rx, allergies) in around 5 minutes, move on to physical exam. Wash your hands and let the patient know what you are about to do before touching them! Begin only relevant examinations (CVS for chest pain, Abd exam for abd pain) for each patient. Neuro exam is the longest, so do a quick MMSE, hearing tests, or cranial nerves if appropriate. Try to complete examinations in 5-7 minutes. A 5 minute warning is announced, which is where you want to be near completion of your examination. Then wash your hands, sit down near the patient and clearly discuss the investigations you would like to do. Make sure to counsel them regarding any findings from social history and ask if they have any questions. You do not have to announce a differential diagnosis to them! You simply say “I would like to run some tests before coming to a definitive diagnosis. Once the results are in, we will decide a treatment plan appropriate for you.” Smile, say your goodbye, and leave the room.

Remember, these patients are actually trained actors, so use that to your advantage! If you ever dreamed of being an actor/actress, now is your time to shine. Out-act these actors! You are the doctor, not them. Though they know a little bit about what each physical examination is like, you know it better than them (hopefully). You do not have to sit there and waste 2 minutes trying to find a crackles on auscultation. You simply place your stethoscope on their chest, assess for 5 seconds, then move on. If you have no findings, write that on your patient note examination portion. Remember these are actors not real patients. If you hear the patient make a noise or try to ‘act’ something out, most likely something is there which you should be noticing. Ask about their cough if they are continuously coughing during the encounter.

Most patients will be very open ended cases. Remember, if a patient starts with one complaint, that does not mean that is his or her only complaint. Be inquisitive and organized on which questions you ask, not jumping around or repeating already asked questions. Always go in with an open mind. Let’s say for example a patient complains of a headache, along with vague symptoms of nausea and fatigue. That’s it. This leaves the differential diagnosis very open, and that is how the CS is supposed to be! You can easily make your DDx for this case: migraine, tension headache, cluster headache, anemia, tumor, trauma, drug SE, etc. This is how your CS cases will be. They want to leave it open ended so that making a DDx is very easy. It’s OK if you only have 2 DDx on your list. Remember they are not assessing your clinical knowledge in this exam; they want to test your clinical skills and how well you can take a history and examination, create a list of investigations and DDx. You must type your notes now, which is great as it is cleaner, more organized, and you can always go back and edit things. You have 10 minutes to complete the note, so be organized, list positive findings, appropriate negative findings, any medications, allergies, etc. For investigations, start with the simple ones first (CBC, UA, electrolytes), then move to more specific (EKG, CXR, Abd U/S, CT, MRI). There is no wrong investigation really, but tailor it to your patient’s history and examination (do not order a CT for a patient with a common cold). DDx is the same thing, start with most likely first, then move to the rarer ones. Do not make up things in case you have forgotten something. You are human and it’s ok to forget, just make sure to remember the important things from the history and examination. The vitals given on the door can be used to write in the patient note.

Examples of Patients:

  1. The angry patient. Remember, do not lose your cool! They are actors and their job is to assess how you react to them. Let’s say a patient is yelling at you because he has been waiting 30 minutes for you to arrive; it is now your job to calm him down. Respond by saying, “I understand Mr. Anderson that you are very upset, and I am truly sorry for the delay. I can assure you that I will give you as much time as needed regarding your concern. Let’s begin by telling me what brought you in today?” You have to act apologetic, yet controlled and disciplined. If you are weak, they will be stubborn and not buy what you are saying. Remember the timer is ticking.
  2. The crying patient. This is a little easier. A good portion of your time will be spent counseling this patient, and that is OK. It is a priority to make the patient feel comfortable and calm. Simply introduce yourself by saying, “Hi. My name is Dr. No. I understand there is something troubling you. Would you like to talk about it?” If you do not get a response, give them a few seconds. Most likely they need a few moments to recollect themselves and then they will speak. If you still get nothing, say “Mrs. Anderson, I really would like to help you and you do not have to feel as if you have to hide anything from me. Our conversation is strictly confidential. If you need a few moments, that is completely fine; I will be right here and ready to speak when you are.” Once they begin to talk, reassure them that you are there to help and get through this.
  3. The “no” patient. This one is a pain. You ask them 20 questions and they respond with “no.” I got one like this and it was probably my worst patient of the 12. Regardless, I did my best, did a PE, counseled him, then let him know I will run some tests and get back with him. Remember, this type of patient basically has no other complaints other than his presenting complaint. Work with that and make your DD. No positive findings on history of physical examination is simply no findings.
  4. The phone call patient. This is very easy. Take the history by the phone. Take your time as you do not have an examination to do. Counsel as much as you can, and if there is even a little doubt as to whether they should come in to see you, ask them to come in. Offer transportation arrangements if they cannot make it on their own. These usually end early so you will have extra time to write your notes.
  5. The female patient for a male. This gets a lot of guys nervous, and you really shouldn’t be! They are actors and they know if you need to do a CVS or respiratory exam, you will ask them to remove their shirt so that you can complete your examination appropriately. The main thing is to always let them know what you are about to do, ask them to politely do remove their shirt, and use the drape to cover any portion of the body which does not need to be exposed. Once completed, let them redress and continue. Do not place your hand in any inappropriate places. Be professional and respectful.

Remember, this exam is not testing your medical knowledge. That is what the Step 1 and Step 2 CK are for. This is simple assessing your communication skills, English proficiency, and basic clinical skills. Any medical student who has completed rotations or electives is capable of passing this exam as long as they are confident, organized, and speak proficient English. This exam is harder for those who struggle with English or cannot properly communicate with a patient. If this is your weakness, work on it. To practice as a physician in the U.S., your communication skills have to be perfect. Do not just practice this for this exam, but for your career ahead. Building rapport with each and every patient you encounter will make it easier for you and your patients. This exam is no exception. Introduce yourself politely, greet the patient, look and act concerned, knowing they are actors, but as if they are patients. Put on your biggest smile, nicest and friendliest personality (if you aren’t at all times), and really keep that peak of energy throughout the day.  8 hours will go by in 10 minutes. Your first patient might be your hardest, but you will get the hang of it after 2 or 3. One after the other, just hit a reset button and jump to your next with your set list of questions and examination. It’s OK if you screw up on one or two patients. Out of your 12 encounters, you will still pass if you do well on majority of them. Just don’t make the same mistake on every patient. They grade you based on a checklist of things you cover on each encounter. If you complete that checklist, you did perfect. If you are missing a lot of things on the list, you did not pass that encounter. You have 12 patients so do well on most of them and you’ll be fine!

You must pass 3 portions of the exam:

  • Integrated Clinical Encounter (ICE) - This component includes the ability of the examinees to collect pertinent clinical information from the SP, and to write an appropriate patient note with differential after the clinical encounter. The former part is graded by the simulated patient, and the latter by a practicing physician.
  • Communication and Interpersonal Skills (CIS) - This component includes evaluating the examinees’ question asking skills (asking open ended questions, avoiding repetition and medical jargon), information sharing skills (acknowledging patient concerns, providing counseling and information about what will happen in the future), and professionalism / rapport (asking about feelings and concerns, showing consideration for patient comfort, proper hygiene during examinations, providing empathy and respect for the simulated patient).
  • Spoken English Proficiency (SEP) - This component includes clarity of spoken English communication in the context of pronunciation, word choice, and minimizing the need to repeat questions or statements.

(Wiki Step 2 CS)

Remember, this is a pass or fail grade. You need to pass all 3 of these components to pass this exam. ICE is the history taking and patient note part. SEP is English proficiency. CIS, the hardest for most IMGs, is the assessment of communication and interpersonal skills. This is what I mean by acting empathetic, concerned, and considerate for the patient. Make them feel as if you are really concerned about them and are there to help. If you can accomplish that, the rest is a breeze.

Studying Material:

I simply used First Aid for Step 2 CS. This is a great book with around 30 common cases seen in your exam. Memorize it front to back and you will pretty much be ready for this test. I also used Kaplan for Step 2 CS as I wanted to review more cases and it had a ton. Most of my exam was still out of First Aid so its not necessary, but if you want to go the extra mile, go for it. Make sure to practice the entire patient encounter with someone. This will not only make you feel more comfortable asking questions and completing a physical exam, but it will also time you to see if you are going over or not. I practiced on 3 people, all of which were very different encounters. Some made me laugh while others were very serious, so was nice to get different experiences. I studied for a total of 10 days, which I found more than enough. Everyone is different though, so if you feel you need to work on your English proficiency or communication skills, do that!

Tip: Bring your ID! No ID, no exam!
Tip: Wear a clean lab coat and bring a unenhanced stethoscope. That’s it. Everything else is provided.
Tip: Do not be overly aggressive on examination. A simple, quick, superficial and deep palpation of the abdomen will suffice. Do not palpate looking for a spleen for 30 seconds and hurting the patient.
Tip: Use the drape to cover the patient in areas which do not need to be exposed on examination.
Tip: Keep that smile going throughout the encounter.
Tip: Make sure you have gathered all necessary information before leaving the room. You cannot re-enter once you have left.
Tip: Go into this exam with the mindset of a normal day in the clinic; you will far exceed their expectations in passing this exam.

In the end, it’s simply hard work. You only take these exams only once in your life so give it your best. You want to look back and say I did the best I could, instead of I could have done better or worked harder. Your USMLE scores are THE first thing residency programs look at for IMGs, so make them shine.

Links:

USMLE World

NBME

Kaplan

Step 2 CS Manual

NBME to USMLE Score Converter

 

Step 3: ECFMG Certification