Post by Admin on Apr 29, 2014 22:45:39 GMT -5
Salamo Alykom 
I wrote this guide a while ago, but I hesitated in putting it here. Simply because it consists mainly of personal insights into the USMLE, and its contents represent my opinions. However, I do believe that some might find it useful now, after I added some more meaningful content to it, including how to register for the exams. I'll try to add more content as I find elsewhee in shaa Allah.
I also want to thank MANY of my friends who helped me while writing this up, either via direct assisting, or indirectly by supplying me the information at some point. Jazakom Allah khayran...
Section I talks about paperwork for the exam. Sections II and III are general ideas on the Step 1 exam contents. Sections IV, V, and VI includes tips on how to study for the exam. Section VII is on the "Burnout" we get while studying, and how to overcome it.
Sections VIII, IX and X details what one should be doing around exam week, exam night, and exam day. Section XI is a summary.
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I. Registering for the exam. Paperwork.
I. 1. When to register for the your Step 1 Exam?
a. Best time is AFTER you have spent some time, around 2 months, building up concepts off KAPLAN Videos. This will allow you to realistically gauge your study rate, and estimate appropriate time for you to reach your goal.
b. DO NOT FORCE YOURSELF to a specific exam time, in order to “motivate” yourself. It rarely works, and you might force yourself in the end to enter the exam not well-prepared. This is a nightmarish scenario. So stick to scheduling the exam AFTER you’re sure of the pace of your own study time, and after creating a realistic time table.
I. 2. Important notes for both Students and Graduates.
a. First, you create your ECFMG account here (https://secure2.ecfmg.org/emain.asp?app=iwa). Since your name is the most difficult part of your profile to be changed, MAKE SURE to write it as is in the passport. Better yet, if you don’t have a passport, write your name as easily as possible so as to avoid confusion later on. Thus use 4 names, with “First Name” the first three ones, and “Last Name” as the last one. If you have a name like (Abd El – Rahman), it’s best to write it AS A SINGLE WORD, NO DASHES, and ONLY ONE UPPERCASE letter. (Abdelrahman)
b. Next day, your profile will be created. You can start applying for the exam. First, you’ll fill a 23-step application, then you’ll pay the exam fee ($740) and Prometric fee ($140). No Prometric fee if test is taken in the USA.
c. The application has some difficult parts. In Alexandria University, we finish exams by November to December, our scores of 6th year is out by February next year, and University Committee approves awarding the MBBCh on June to August. By this time, you’re free to receive your diploma WHENEVER you want, regardless of the state of your Internship. This maybe different in other schools, where the Diploma will be issued at the last month of Internship.
d. THUS, to avoid discrepancies, best approach is to receive your Diploma on the end of your internship (March of the next year, or whenever you finished it). And while filling your Step 1 application, at the step asking about these dates, choose that Internship IS required for your Diploma, that your graduation date will be where you received MBBCh in your Diploma, and that the date you received your Diploma will be the end of Internship.
e. The form asking for your medical clerkships can be left blank, as you’ll enter them anyways in your ERAS profile, and they’re not a component of ECFMG certificate. Yet, if you feel like filling them, go ahead.
f. Now, paperwork you’ll be doing from this point till the Match involves two major categories. THE first one is the #1. Certification of Identification form (186 or 183), which serves to insure that you’re actually currently enrolled, or was enrolled, in a Med. School listed in IMED.
g. And the #2. Verification of Medical Education Credentials, or in other words, now that they know you were a student, they want to make sure that you actually RECEIVED YOUR DEGREE off that Med. School, and wasn’t suspended or dismissed from it for example. This is done OBVIOUSLY after passing your 6th year exams, and having your Diploma ready. (It can work with the Temporary one, but you’d still need to send the original before the match). For this verification process, they usually need two photocopies of the Diploma on Letter-sized paper, two Original Official translations of the Diploma on Letter-sized paper, Two full-face 5*5 Passport-like Photographs, One Form 187 (Tells ECFMG that you’re submitting important documents), One Form 344 (a checklist), and Two Forms 345 (a request to your Med School to send ECFMG the verification of the Diploma). All the three forms are filled entirely by you. Also to speed things up, send Two Original Official English Transcripts as well. Further details here, (http://www.ecfmg.org/2012ib/credentials-for-certification.html).
h. Obviously, If you register for the exam while being a student, you only need documents for track #1 (Certification of Identification), and the others will wait till after you graduate. BUT, if you register while being a graduate, they will ask you for the ENTIRE set of documents, for both #1. Certification of Identification, and #2. Verification of Medical Education Credentials.
I. 3. Now, If you are a STUDENT.
a. At the end of your application, and depending on your school participation in ECFMG Medical School Web Portal (EMSWP), which is the “Med School” account at ECFMG, you’ll either be issued Form 186 (If the school has EMSWP account), or Form 183 (Med School doesn’t have EMSWP account).
b. Either forms will be signed by an official representative like Registrar, Vice Dean, or Dean. When filling any of these forms, stress to the Secretary of the Registrar/Vice dean that both the typed name and the Registrar’s official signature should be via the same pen. Also remember that you should write your name, sign and date your signature AFTER the form has been signed and dated by the dean, so that you write the SAME DATE in your signature. This is because proper filling of Form 186 requires you to “APPEAR before an authorized official”, meaning that you both sign together.
c. Afterward, the form will be put in an envelope, with the envelope itself signed and stamped, and sent DIRECTLY from the school outgoing mail.
d. When either forms are received by ECFMG, they either confirm its authenticity online through your school EMSWP account (for 186), or via mail form (for 183). If either process was delayed, you can’t be issued a scheduling permit for the exam.
e. Form 186 will be only sent ONCE, and it remains valid for 5 years. Each time you apply for an exam, your credentials will be reaffirmed via EMSWP. Form 183 will be resent with EACH exam application.
f. Once you graduate, complete #2 documents.
I. 4. And if you are a graduate,
a. All medical school graduates MUST print a Certification of Identification Form (Form 186) after completing the on-line part of the application, if they do not have a valid Form 186 on file with ECFMG, regardless of School’s EMSWP participation. No use for Form 183 here, even if your school does NOT have EMSWP. However, the certification of Form 186 can be via THREE different routes depending on how easy it is to return to your Med School to get your School official to sign Form 186. Thus,
b. Route #A. to certify Form 186 is certification through School Official, which is similar to student’s 186 certification, however, it applies to schools EITHER WITH OR WITHOUT EMSWP access. Again, leave the Form at Registrar/Vice Dean/Dean secretary, and after he signs and dates it, you sign and date. The verification back from ECFMG can be online (If school has EMSWP), or by mail (If no EMSWP). Note that in theory, you need to “APPEAR before an authorized official” for your From 186 to be approved. That is, you both sign it together.
c. Route #B. for the 186 is certification through US-approved Notaries (Consular Official off the embassy for $50, Notary Public for L.E ~50, First Class Magistrate in US, or Commissioner of Oaths in US), WITHOUT the need to go to the Med School and “APPEAR before an authorized official” to certify it. After the Notary certifies it, you can send it to the ECFMG. HOWEVER, to be eligible for this route, it’s either that your school must have an EMSWP account, OR ECFMG has already verified your credentials before.
d. What if you’re away from home, thus can’t “APPEAR before an authorized official”, you haven’t still verified your credentials, and your school doesn’t have the EMSWP account? If you certify via Notary and send to ECFMG, there’s no way for ECFMG to reconfirm your credentials. Thus, after getting them notarized (via Route #B), SEND THE CREDENTIALS by mail to your school to get certified by your Official, WITHOUT ECFMG enforcing the need to “APPEAR before an authorized official” in person. Hence, it’s a mix of Route #B, then Route #A.
e. Don’t forget to verify your credentials via Track #2 documents.
I. 5. In Summary,
a. If you are a student and your school DOES NOT participate in EMSWP then your only option is Form 183 certified through School Official.
b. If you are a student and your school participates in EMSWP then you have only one option, Form 186 certified through School Official.
c. If you are a graduate and your school participates in EMSWP then you can choose one of two types, either Route #A (If at home) or Route #B (If away).
d. If you are a graduate and your school DOES NOT participate in EMSWP then you can choose either Route #A (If at home) or Route#B THEN #A (If away).
e. If you are a graduate and your school already verified your credentials before then you can choose either Route #A (If at home) or Route #B (If away).
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II. Before you start your Study
II. 1. What is STEP 1?
a. Structure of Step 1 is fairly known. Exam is composed of 8 blocks. A skip-able 1st block is computer tutorial, followed by block 2 to 8 (7 blocks) each with 46 questions. You have 8 hours to complete the entire exam, with a maximum of 15 minutes for the 1st block, and 60 minutes for the 2nd through the 8th. Leaving 45 minutes for break, or 60 minutes if skipping the 1st block.
b. Questions in Step 1 test CONCEPTS. Simple pieces of information that can be put on a single long list titled, “THESE ARE WHAT YOU MUST BE FAMILIAR WITH AS A MED STUDENT”. This means that if you understand the basic concept, memorized it, and then practiced the different representations/applications of this basic concept, you’ll correctly answer any question regarding it in the exam. Concepts seen in the exams are the same ones we all hear in KAPLAN Videos, Goljan, Online Q. Banks, and all of the other sources we use that are ‘USMLE-oriented”. So in essence, the exam is for the most part very familiar to any one who studied well off these sources.
c. Thus, proper preparation for Step 1 concepts is a three-step procedure. First is to build up seemingly-unrelated concepts, then to memorize them, then to apply them in different settings/questions.
d. Moreover, Concepts can be subdivided into two very broad YET EXTREMELY IMPORTANT categories: HIGH-YIELD, or likely to be on the exam, and LOW-YIELD, or LESS likely to be on the exam.
e. So far, most of the questions I saw on NBMEs, as well as on the actual exam, prompted me to think of Step 1 questions as of three categories; High-Yield Concept Recall, High-Yield Concept Application, and Low-Yield concept Recall.
II. 2. High-Yield Concept Recall questions.
a. These are simple, direct answer questions, based on simple concepts that will be known early during the concept building period of your study due to their importance. Some subjects, like Microbiology, Anatomy, Pharmacology, and Behavioral Sciences have most of their questions in this category.
b. Answering these questions correctly will allow you to “PASS” the exam, because they are designed specifically to test the core most essential information. If you have a defect in these basic High-Yield concepts, score can drop markedly. Those who “FAIL” Step 1 have a big defect in these core concepts.
c. Strategy to master these questions is rather simple. They depend on memorization, with no real understanding of the concepts. Know them through KAPLAN Videos/FA, then memorize them via DIT/USMLERx/Brute Force.
d. In exam, these questions can be either very straight, in the form of one liner, or at the end of a complex case. Either way, they SHOULD NOT TAKE MUCH OF YOUR TIME. Some may actually spend too much time on such easy questions, as they’re trying to find the “tricky” part. There are no tricks.
e. Example: “A 28 y/o pt. with burning in urine, and morning urethral exudate. What is the most probable etiology?”. Many Two-Step reasoning questions are usually simple concept recall. Above example can ask about best antibiotic instead of the organism. Or, it can ask on medium used to grow such organism, or a specific biochemical reaction characterizing it.
II. 3. High-Yield Concept Application questions.
a. These questions usually take a simple concept, and apply it to graphs, tables, lab protocols, hypothetical experiments (antagonism in vitro, gene knockout,..), or even relate it to other concepts across multiple disciplines and fields.
b. These questions vary in difficulty, from a reasonable two step question, to an impossibly complicated experiment involving procedures such as gene over-expression. Hence, they’ll represent the gap between those in the 230s to those in the higher 250s.
c. Most of KAPLAN books, KAPLAN Videos, FA, and Q. Banks pay HUGE attention to the idea of concept application. This is simply because concept recall questions are easy to answer, and will NOT get you higher scores in the end, as they serve you to just pass. Hence, throughout your study, every new concept you’ll encounter in KAPLAN Vids, tutors will invariably apply it in different formats, so that you’re familiar with them if they show up.
d. Strategy to master these questions involve answering as many questions as possible, most notably off UW. Of course, the more you answer questions, the more formats and different applications you’ll encounter. KAPLAN Q. Bank does have many concept application questions, yet many test Low-Yield ones.
e. Another very important advice is that you should expand on these formats by adding your insight as well. Try to explain all the reasoning steps involved to reach such delicate application of a simple concept. Also, try to create your own graphs, charts, and hypothetical experiments involving this same concept. Try to integrate from different fields as well.
f. In exam, you should read the question CAREFULLY, then look at the graph/table/... if present. Try to predict the answer before looking at the choices. A typical question of this category will take 1 to 2 minutes after reading it. Generally, if you know the concept in question, but can’t understand the application, try for 2 minutes with the question. But if you don’t know the concept at all, just PICK A CHOICE and MOVE ON.
g. Another famous subtype of these questions include all of the “equations” found in Step 1. These include Biostatistics, as well as some Renal, Cardiology, and Respiratory equations. In the exam, you can either answer them as soon as you see them, or skip them till the end. Either way, if you don’t know the equation, PICK A CHOICE and MOVE ON.
h. Example: The very famous Cardiac function curve questions. You begin with a simple concept of Preload vs. muscle Tension, and you keep on expanding the idea to arrive at the relatively difficult chapter of Cardiac function curves contrasting LVEDV with CO. Also, relatively famous are the Hormone vs. Effect charts (Plasma Osmolarity vs. ADH levels, or Plasma Ca+2 vs. PTH levels), which expand on concepts of simple feedback regulations.
i. An important point to note is that a Two-Step reasoning question can have the first step from the High-Yield concepts, while the second step from the Low-Yield ones. This question might seem “solvable”, but if you don’t know that Low-Yield concept, don’t try to overwhelm yourself. Just PICK A CHOICE and MOVE ON.
II. 4. Low-Yield Concept Recall questions.
a. These questions are the ones that prevent many from crossing the 260s. The questions are not difficult. But you simply don’t know the answer to them.
b. Low-Yield concepts are the ones that generally NOT encountered in KAPLAN, and NOT seen in UW later on. KAPLAN Q. Bank has many Low-Yield concepts. But the most important of them are found in USMLE-oriented textbooks. These include Lippincott’s Biochemistry, Pharmacology, and Immunology, Costanzo’s Physiology, Goljan’s Rapid Review Pathology, Fischer’s Ethics, Thieme’s Atlas of Anatomy, High-Yield in Neuroanatomy, Embryology, Molecular Biology and Biostatistics, BRS in Behavioral Sciences, and Levinson’s Medical Microbiology.
c. Online sources of immense help, but mostly Low-Yield content include Web Pathology (http://library.med.utah.edu/WebPath/webpath.html#MENU), Harvaed ECG Wave-Maven (http://ecg.bidmc.harvard.edu/maven/mavenmain.asp), Virtual Cell Animations (http://vcell.ndsu.nodak.edu/animations/home.htm), Radiopedia, a Wikia for Radiology (http://radiopaedia.org/), Doctor Fungus (http://www.doctorfungus.org/thefungi/index.php), Indiana Embryology (http://www.indiana.edu/~anat550/embryo_main/), The Whole Brain Atlas (http://www.med.harvard.edu/AANLIB/home.html), XRay 2000 (http://e-radiography.net/ibase8/index.htm), PIER.net (http://peir2.path.uab.edu/pdl/dbra.cgi?uid=default&view_search=1), Inner Body Anatomy (http://www.innerbody.com/htm/body.html), (http://chorus.rad.mcw.edu/), (http://neurolex.org/wiki/Main_Page), (http://image.bloodline.net/category), (http://www9.biostr.washington.edu/da.html), (http://images.rheumatology.org/), (http://antibiotics.toku-e.com/), (http://www.pathguy.com/index1.htm), (http://lifesciencedb.jp/bp3d/)
d. As clearly visible, such material may very well increase your preparation time to span around a year of full committed study for the average person (much less for those with better recall capacity). But again, we’re discussing the +260 realm, which is in itself an extremely high score.
e. The idea here is to be able to cover concepts not present in usual sources (KAPLAN + FA + UW). Questions on these concepts are usually straight forwards, and are particularly easy to spot.
f. Example: Importance of Z-DNA, function of Chaperons, Role of Lefty in Embryogenesis, other examples of counter-current multipliers,.... Again, these questions don’t form a significant portion of Step 1, hence best left to those who want +260 as a goal.
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III. Before doing anything, REMEMBER;
a. ALWAYS KEEP IN MIND THAT PEOPLE ARE COMPLETELY DIFFERENT. What will work for you won’t work for others. If you can understand difficult concept applications easily, you don’t need to even complete UW Q. Bank to reach a comfortable 240. But, if you can’t understand except after multiple times, maybe it’s best to do 2 Q. Banks so that you get the same score. Also, someone with a good recall can pull a +260 in under 6 months, while others need years to do the same. In the end, the more you can recall and the better you can apply, the higher score you’ll get.
b. SET A REALISTIC GOAL that matches your residency of choice. If Psych, aim for +230, but if thinking ENT or Ophtha, aim for +250. (Remember that it’s only 3-digit-score from now on. The 2 digit score has been remarkably different from old scale starting from those taking their exam on and after October 2011, and most importantly WON’T be reported to program directors anymore. See here.)
c. PLAN THE TIME AHEAD CAREFULLY. Different people have different responsibilities and jobs. Again, your timetable must accommodate your daily schedule, but always remember to study DAILY, even if for one hour. Long pauses can seriously harm the materials you worked so hard to understand and memorize.
If you have second thoughts about starting Step 1 vs. Step 2 first, then I think that the answer is invariably Step 1. First, it makes more sense to study Physiology and Biochemistry, then Pathology, then Clinical Medicine. Second, many concepts of basic medicine travel along to Step 2, like those in inborn errors of metabolism, and a hefty amount of pathology as well. These questions WILL be explained in Step 2 videos indeed, but you won't have this deep understanding of them. Lastly, the MYTH that says that it is best to take Step 2 right after your clinical years holds true ONLY if you'll be using your old clinical years' books to study for the USMLE. And as we all know, this is rather ridiculous because our curriculum is VERY DETAILED, NOT ORGANIZED, and most importantly, doesn't allow you to think analytically.
In Short, definitely do Step 1 before 2, unless we're thinking about Hamad Hospital.
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IV. Study Phase One. Building up Concepts (2 to 4 months)(Yellow and Red)
IV. 1. Start from scratch.
a. Since we all are graduates of the prestigious Medical Education system in Egypt, it’s undoubted that the very most important thing is to start from scratch. A fresh start will insure that concepts are updated, meaningful, and that we can expand upon them from our own new understanding.
b. It’s also important to forget the feelings we had in Med school towards a particular subject. For example, we all hated Biochemistry. But in USMLE, you need to know that ALL subjects are covered in an excellent manner, with doctors who KNOW what they’re talking about. Biochemistry becomes as easy as reading a novel, sometimes even more enjoyable. Same applies to our bad experiences with Anatomy, Pharmacology, and Pathology. Do NOT THINK that you’ll be left without understanding a certain point as with our med schools. On the contrary, everything in all subjects will be clear.
IV. 2. What I mean with the word “concept”.
a. Concepts mean separate sets of information, seemingly-non related, but with each set of them containing a coherent collection of materials. Think of them as the different bullet points which step 1 administrators think a second-year med-student (MS2) needs to know. In KAPLAN books, they’re called “What the USMLE require you to know”. In UW, they’re called “Educational Objectives”...
b. To fully master a specific concept, one needs to be familiar with the Origin (What..), Mechanism (How..), Normal Functioning (Why..) and Consequences (Thus..) of the concept. For example, with concept of Centrilobular Emphysema in Smoking, you need to understand the origin (What is emphysema), Mechanism (Elastase hyperactivity), Normal functioning (Neutrophils constant circulation), and Consequences (Acquired Alpha1 deficiency).
c. Once you’re familiar with all of these, you can start applying this understanding via different applications of the same concept. Each application will deepen your understanding, and will reinforce your memorization of the specific points regarding these HY concepts.
d. Best approach to build concepts is through KAPLAN Videos, NOT books. In recent videos, the books are the same as the videos, which incorporates slides that have the same text in the books. Exceptions include some additional concepts in Anatomy, Behavioral, and Immunology books which can be read at the end.
e. While watching the videos, you need to follow along. Some do this via writing on a separate sheets of paper. Others follow from KAPLAN Books, and others use MedEssentials. You can either listen to the videos, then read KAPLAN books, or do the reverse.
f. For me however, I ditched KAPLAN books from the very beginning. I used First Aid 2011 from THE FIRST DAY of my study as the main book of the curriculum. So I annotated all the materials in it as I followed along with KAPLAN Videos. Although the two are not progressing simultaneously, once you know where everything in FA is, it becomes easy to follow along.
IV. 3. Why I started from KAPLAN Videos and First Aid?
a. Since USMLE is a BIG exam, with a HUGE amount of information, you need to understand these information in an organized fashion, and have them stored in easily accessible mental “shelves”. This means, they must be memorized, and in a perfect order, in order to be able to draw concepts from different subjects.
b. Hence, I preferred to use one single book, FA 2011, and add to it all of my understanding, and all the concepts I’ll encounter, each is to be put in its natural place within the book. I started with KAPLAN Videos, so as to build a ground base of information. Thus, I was able to finish both KAPLAN and FA in the same time. This also allowed me, when I read KAPLAN Anatomy and Behavioral Science books later on, to simply add the “new concepts” directly in FA. All the important concepts stressed about in the Vids, I highlighted them in FA in Yellow.
c. But more importantly, I was able to add all the “reasoning” of many concepts and their different applications in the same setting as I understood it from KAPLAN, so that when I finished the videos, ALL of FA was very clear and understandable. Thus, even if I forgot the method of explaining such phenomenon, such as Vascular function curves, I had the explanation from KAPLAN right next to it. It also helped me to add some more insight of my own to FA, perfectly integrated with what I understood off KAPLAN Vids. I highlighted these “reasoning” additions in Red.
d. KAPLAN Videos + FA was a good combination in ALL of subjects, including Pathology. I started with Biochemistry and Physiology, followed by Pharmacology, and finally Pathology. This took 2 months of 6 hours/day. AFTER I finished KAPLAN Videos, I did the same with Goljan Audio Lectures, listening to them while annotating directly into FA. Took 2 weeks. I also did the same with Acland’s Human Anatomy videos. I left the cram-able subjects (Microbiology, Anatomy, and Behavioral Science) till the end.
e. You can cut the spine off FA book, punch 3 holes in it (o5’romo), and put it in a 2” 3-holed binder. Thus, whenever there’s a page/image/article you need to add it to the book, you can add it easily, and wherever you want it.
IV. 4. Now that I knew the High-Yield Concepts, how about the Low-Yield ones? (another 2 to 6 months)(Violet)
a. As I mentioned before, KAPLAN Q. Bank covers many Low-Yield concepts not covered already in KAPLAN Vids/Books. I used after finishing the High-Yield part, around after 3 months from the beginning of my study. I annotated directly in FA. I used a different highlighter (violet) to highlight the Low-Yield I added to the book. Although I couldn’t finish the Q. Bank, I think that 2 months are fairly good to finish it properly. Since you’ll be annotating, you only need to do it once. Better yet, use the offline version.
b. If aiming for a very high score, start your reading of the texts ALONG with KAPLAN Q. Bank. You’ll be only READING off the texts. You won’t memorize anything, but rather skimming over the chapters. As with other sources, any important concept MUST be annotated into FA directly, and in its appropriate location. Highlight those as well, or even cut the pages and insert them in FA directly.
c. Priority of the texts should be as those of the Videos. Lippincott’s Biochemistry and Costanzo’s Physiology first, followed by Lippincott’s Pharmacology, and finally Goljan’s Rapid Review Pathology. The sequence should take about 3 to 6 months of 6 hours/day. ALWAYS remember to add interesting new concepts to FA.
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V. Study Phase Two. Memorizing Concepts (1 month)
a. This is where all of the concepts, both High and Low-Yield, have been added to FA. Now I needed to put all these disorganized mess of information into proper “shelves” in my brain. This is the MOST important phase of the study. This phase should be as short as possible, so as to cram everything in. If it were to be longer, you would forget some earlier topics.
b. The best and simplest approach, and the one I was best comfortable with, is to memorize the book as I did in Med. School, a method I call “Brute Force”. Whatever you did to cram those +10,000 pages of our seven years curricula into your brain cells, do it to cram these +600 pages now. Main difference is that you actually understand all of this that you’re memorizing. This should take around 1 week of 10 hours/day, but it may be the MOST IMPORTANT WEEK IN ALL OF YOUR STUDY. Make absolute commitment in it, and minimize all distractions. By the end of the week, you should have seen every information in FA twice by now. Once along KAPLAN Vids, and the other during its memorization.
c. As for the Low-Yield “violet” additions, and other “red” concept applications I added while listening to Kap Videos, I just skimmed over them but didn’t spend too much time memorizing them.
d. Afterwards, you can use Doctors In Training for Step 1. I didn’t use them till the end as I felt them not particularly valuable if I’ve used KAPLAN Vids to understand FA, as I had already seen everything in FA, and even added my own understanding to them. But if you want to add some more Low-Yield concepts, and revise everything you wrote in FA along with some guy talking, this is a good option. Take note though that his “star rating” is relatively wrong. Takes 2 weeks of 4 hours/day to finish.
e. Another way to memorize FA smoothly is to use USMLERx Q. Bank, which is developed by FA team itself. It offers “Snippet” view in the answer of each question, bringing up a scan of the FA page in which the concept is mentioned. Hence, it effectively generates Photo Memory of each concept, that you’ll easily recall them later on. Effective for memorizing, but lacks meaningful USMLE-oriented questions and also only tests High-Yield concepts present in FA, which again was reason enough form,e not to purchase it. Should take 1 month of 5 hours/day, as it’s +3000 questions.
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VI. Study Phase Three. Applying Concepts (2 to 3 months)(Green)
a. After memorizing FA as best as I managed, it was time to test my understanding of the core High-Yield concepts via USMLE World Q. Bank. The Q. Bank is famous because it emphasizes cross-subject integration, Multiple-Step reasoning, and most importantly, different applications of the same concept.
b. Thus, do not think of UW as an assessment tool. Indeed, the bank does have some simple recall questions, particularly in Anatomy and Ethics, but usually the questions need deep thinking, and in many of them there are new ideas and formats for the relatively most tested High-Yield concepts.
c. For example, CGD can be asked from a biochemical (NADPH Oxidase Deficiency), Immunological (Phagocyte Dysfunction), microbiological (Infection with Catalase positive pathogens), and pathological ( points of views. Other examples include Rate of Clearance plotted against Plasma concentration of Substance X, OBC under different CADET conditions, Pressure-Volume loops, Cardiac and Vascular function curves in different hemodynamic disorders, Acid-Base Nomograms in different metabolic disorders, Darrow-Yannet and Wigger’s Diagrams correlations, and last but not least Flow-Volume loops.
d. All above examples share a common feature. They need understanding of some basic concept, and then ability to apply this concept in different situations. The most important point here is that USMLE can generate an entirely new application that you have never encountered before, although based on a VERY famous concept. They can simply change the x- and y- axes of a famous chart, as with Biostatistics 2 by 2 tables, and Dose Response curves. Hence, the emphasis on generating such new applications and different question formats on the same concept at the KAPLAN Videos stage is of paramount importance.
e. Although annotating FA can be very helpful, it can also take time. Hence, if you plan on doing so thoroughly, 3 months are a reasonable time to finish FA twice, with FA annotation. Otherwise, 2 months are enough. I highlighted UW additions in Green.
f. Best way to approach UW is to do it twice. 1st time as Unused Mixed questions, with any correct answer marked. In the 2nd time, answer all the Incorrect, and unmark the marked questions.
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VII. Burnout Syndrome.
We all experience “mental fatigue”, boredom, and feeling of inadequacy while studying for this mammoth exam. It's actually a well-documented phenomenon (http://en.wikipedia.org/wiki/Burnout_(psychology)#Phases). Some tips that helped me, and some of my friends, while studying were;
a. ALWAYS start your study time with 5 minutes mental preparation. Recite some Quran, give yourself some pep talk and remind yourself of your goal.
b. Start with 1 hour study time/day for a week, then 2 hours/day for a week, and keep on slightly increasing your study time per day. Moreover, give yourself a 5 to 10 minute break every 2 hours. Prepare a cup of coffee, pray, do some exercises, then back to study. And whenever possible, even if you had the worst day ever, try to pull off AT LEAST one hour daily.
c. Always use a Stopwatch to correctly estimate your study and break time. Try to be strict with yourself.
d. Dedicate a new place to study in your home, and NEVER DO ANYTHING ELSE while at this place. For example, move your old disk to a new location, and name it the “Study Zone”. Just sit on it ONLY when you’ll start to study, and whenever you do something else, leave it automatically. This will create the “Studying mood” whenever you’re in this place, and will certainly help you focus. If you want to surf the Internet, or check on your emails, also do it in a separate location.
If possible, study in a GROUP. The value of group study is that different people shed different lights on the same idea, and maybe each person came up with his own scenario or application on this idea or concept. Hence, Exchange of ideas strengthen the overall understanding. Discussion also alleviates the boredom associated with non-stop solo study.
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VIII. Two weeks prior to exam.
a. Start to sleep by 10 pm, and wake up by 6 am. daily.
b. I did a THOROUGH First Aid review, this time, which was my third and last time, I emphasized all the HY concepts highlighted from before (in Yellow), UW additions (in Green), and any other explanation seemed important (in Red). This roughly took 1 week of NON-STOP work. Goal here was to keep the HY concepts and the method by which I understood them fresh in my mind
c. Do the NBME self assessment Forms (#7 is the one most predictive. #11 and #12 are rather new, and more difficult than actual exam)
d. Do the UW Self Assessment forms.( UWSA #1 is more predictive than #2)
e. FOCUS on subject areas that are weak among all of your evaluations. If any subject is week, quickly read the parts you know are bad off KAPLAN Books, and listen to Goljan Audio, or read Goljan Rapid Review if applicable.
f. Make a one-night hotel reservation. My advice is for Rose Hotel at Iran St., Dokki. A 5-minute-distance away from test center by Taxi, with the night costing L.E. ~180.
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IX. Exam Night
a. Travel to Cairo the night prior, and stay at the reserved hotel. NEVER travel on the morning of the exam.
b. PAPERS. Prepare your SIGNED Passport (or any ID with your signature on it, like a credit card), National ID, ECFMG IWA Scheduling Permit and PROMETRIC appointment confirmation to take to the test center.
c. FOOD. Get some beverage (Red Bull is a good placebo), as well as any quality refrigerator-safe sandwich, like Turkey Sandwich from “On the Run” at many Gas station. Some light chocolate can also be a nice add-on.
d. Try to minimize new study. If you have some Q. Bank questions left to REVIEW, do it. But do NOT read new materials. Focus on the “Easily forgettable Concepts mentioned here; (http://www.usmle-forums.com/usmle-step-1-recommended-threads/1401-list-forgettables.html). VERY Recommended.
e. Relax. Watch a movie. Read Quran. Sleep by 10 p.m. You MUST make yourself ready for such early sleep by waking up very early this same day.
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X. Exam Day
a. WEAR slightly heavy clothes even if it’s summer, as the testing center has a central conditioning of about 20 deg. which, along with nervousness of the exam day, can make you rather chilly.
b. Take a small bag with your PAPERS and FOOD. Arrive around 8:30 am. Put the food on the counter outside the testing region, so that it’s easily accessible.
c. Inside the testing room, you’ll deposit your bag in a safe. You’ll be photographed, and given two markers, two erasable laminated papers, and your CIN. You’ll also use your passport (or National ID + Signed Credit Card) to enter and exit the exam room.
d. Once you sign in the sheet, you’ll only have in your hand the passport, your Bag safe’s key, the 2 markers and the 2 papers with your CIN written on one of them. Take all, sit on your assigned PC, and manually enter your CIN, the 8 hours start to count down. Rapidly skip the Tutorial, and start your 2nd block.
e. The questions will be hard, dry, weird, crazy, and all of these nice descriptions. But you’ll find yourself gradually getting used to them, understand them better, and your answer to them will be faster.
f. As general rules, for HY Concept Recall, just answer the question as soon as you finish reading. They’re direct easy questions, and no tricks are hidden. Don’t be fooled by the “Red Herring” choice in the presented answers. For both LY Recall, and HY Recall questions; If you don’t know the concept in question, just PICK A CHOICE and MOVE ON.
g. For HY Concept Application questions, if you know the concept and how it’s applied, you’ll eventually find an answer to it within 1 to 2 minutes after reading it. If you still didn’t come up with an answer, MARK, MAKE AN EDUCATED GUESS, and MOVE ON. Remember to go to the same question at the end of the block if time permits.
h. However, if the question tests a specific concept application you’re entirely unfamiliar with, then it’s either a very difficult question, or it can be a trial (not for credit) one. Here, you don’t need to mark the question, as there is a low probability that you’ll be able to answer it later. Just MAKE AN EDUCATED GUESS, and MOVE ON.
i. AFTER finishing each block, you’ll be given a question: Do you want to continue to the next block, or do you want to take a break? You must make a selection within 30 seconds.
j. The 60-minute break can be divided as: 1st Block Skip -> 2nd Block -> 5 minutes at bathroom -> 3rd -> 5 minutes at bathroom -> 4th -> 10 minutes at bathroom. Maybe some chocolate and a Red Bull -> 5th -> 20 minutes to eat your sandwich, more Red Bull, and pray Dhuhr -> 6th -> 10 minutes at bathroom, some food off counter -> 7th -> 10 minutes at bathroom, some food off counter -> 8th.
k. Every time you take a break, grab your passport and safe’s key, sign out at the entrance of the testing room, go OUT OF THE ROOM, grab something off your food placed on the counter right outside the room, go to the bathroom, wash face, and exercise yourself. When you go back in again, sign in again at the entrance of the room, empty your pockets, show him your passport, and again take your passport and safe key back to the PC. RE-ENTER your CIN, and continue.
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XI. In Summary.
XI. 1. Resources.
a. KAPLAN Videos. A must to those who lack core HY concepts, and want to start from scratch.
b. Goljan Audio Lectures are a MUST as well. They integrate many ideas from different branches. If you did KAPLAN videos thoroughly, no new huge content will be in Goljan’s. However, the integration is worth your time. Annotate new info in FA as well.
c. Acland’s Human Anatomy. A set of 6 lectures, each ~2hour long, explaining very detailed and extremely well done anatomical relations. Watch it once, and annotate content you feel important in FA. Do it AFTER finishing Anatomy videos.
d. KAPLAN Q. Bank. Questions focus on recall, with many involve simple Two-Step reasoning, and not enough concept application questions. However, it covers many Low-Yield concepts not mentioned in its books.
e. USMLERx Q. Bank. Has over +3000 questions, yet all are direct concept recall. There are some difficult questions, because FA does have difficult concepts at points. However, if you mastered FA along KAPLAN Vids, the bank won’t add anything new. Use only to easily memorize core concepts in FA.
f. USMLE World Q. Bank. A must. Many new ideas that expand on your understanding of core High0Yield. It also prepares you to be able to handle completely new applications on exam day. Best used after MASTERING the HY content, and memorizing it.
g.KAPLAN Books. Recent videos incorporate most of the books, except in Anatomy (and Neuroanatomy), Behavioral Science and Immunology. Rapid skimming after listening to the videos is a good idea. Annotate new information not mentioned in the videos to FA as well.
h. KAPLAN medEssentials is a very useful tool to the visual learners. The book is packed with diagrams, tables and illustrations, with virtually no free text at all. I used it mainly in certain complex ideas, by cutting the important diagrams, such as that of Vascular function curve examples and Peripheral Nervous System, and inserting them in FA.
i. USMLE Textbooks are recommended to those who want to master Low-Yield concepts as well. Best ones are Lippincott’s Biochemistry, Costanzo’s Physiology, Lippincott’s Pharmacology, and finally Goljan’s Rapid Review Pathology. Simple reading, highlighting, and FA annotation is enough.
j. Online sources for Low-Yield contents are mentioned above. Particularly important are WebPath (http://library.med.utah.edu/WebPath/webpath.html#MENU), Harvard ECG Wave-Maven (http://ecg.bidmc.harvard.edu/maven/mavenmain.asp), Virtual Cell (http://vcell.ndsu.nodak.edu/animations/home.htm) and Radiopedia (http://radiopaedia.org).
k. Avoid resources like PreTest, as they are full of mistakes, and contain material that are NOT USMLE-oriented. Also, avoid texts that are not directed to the USMLE, as Harpers’ Biochemistry, Ganong’s Physiology, and Kutzung’s Pharmacology. Also, no need for the FA: General Principles, and FA: Organ Systems. Old edition was full of mistakes. No feedback on the new 2011 editions yet.
XI. 2. Schemes.
a. If aiming to PASS, just master HY Concept Recall questions, by memorizing essential concepts present in FA. Understanding of concepts in not necessary.
b. If aiming for 99 (230s to 250s), invest much time in building concepts, and applying them in different formats. Build your concepts from KAPLAN Videos, annotating FA while listening to them. Supplement the videos with Goljan Pathology Audio Lectures, and Acland’s Human Anatomy, both are also annotated in FA. Intense memorization phase, followed by applying these concepts via answering UW twice. The difference between 230 vs. 250 is the depth of understanding of these core HY concepts.
c. If aiming for +260s, incorporate Low-Yield concepts as well. Use KAPLAN Vids + FA. Then KAPLAN Q. Bank, along with USMLE-oriented textbooks. Intense memorization phase, followed by applying these concepts via answering UW twice.
I wrote this guide a while ago, but I hesitated in putting it here. Simply because it consists mainly of personal insights into the USMLE, and its contents represent my opinions. However, I do believe that some might find it useful now, after I added some more meaningful content to it, including how to register for the exams. I'll try to add more content as I find elsewhee in shaa Allah.
I also want to thank MANY of my friends who helped me while writing this up, either via direct assisting, or indirectly by supplying me the information at some point. Jazakom Allah khayran...
Section I talks about paperwork for the exam. Sections II and III are general ideas on the Step 1 exam contents. Sections IV, V, and VI includes tips on how to study for the exam. Section VII is on the "Burnout" we get while studying, and how to overcome it.
Sections VIII, IX and X details what one should be doing around exam week, exam night, and exam day. Section XI is a summary.
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I. Registering for the exam. Paperwork.
I. 1. When to register for the your Step 1 Exam?
a. Best time is AFTER you have spent some time, around 2 months, building up concepts off KAPLAN Videos. This will allow you to realistically gauge your study rate, and estimate appropriate time for you to reach your goal.
b. DO NOT FORCE YOURSELF to a specific exam time, in order to “motivate” yourself. It rarely works, and you might force yourself in the end to enter the exam not well-prepared. This is a nightmarish scenario. So stick to scheduling the exam AFTER you’re sure of the pace of your own study time, and after creating a realistic time table.
I. 2. Important notes for both Students and Graduates.
a. First, you create your ECFMG account here (https://secure2.ecfmg.org/emain.asp?app=iwa). Since your name is the most difficult part of your profile to be changed, MAKE SURE to write it as is in the passport. Better yet, if you don’t have a passport, write your name as easily as possible so as to avoid confusion later on. Thus use 4 names, with “First Name” the first three ones, and “Last Name” as the last one. If you have a name like (Abd El – Rahman), it’s best to write it AS A SINGLE WORD, NO DASHES, and ONLY ONE UPPERCASE letter. (Abdelrahman)
b. Next day, your profile will be created. You can start applying for the exam. First, you’ll fill a 23-step application, then you’ll pay the exam fee ($740) and Prometric fee ($140). No Prometric fee if test is taken in the USA.
c. The application has some difficult parts. In Alexandria University, we finish exams by November to December, our scores of 6th year is out by February next year, and University Committee approves awarding the MBBCh on June to August. By this time, you’re free to receive your diploma WHENEVER you want, regardless of the state of your Internship. This maybe different in other schools, where the Diploma will be issued at the last month of Internship.
d. THUS, to avoid discrepancies, best approach is to receive your Diploma on the end of your internship (March of the next year, or whenever you finished it). And while filling your Step 1 application, at the step asking about these dates, choose that Internship IS required for your Diploma, that your graduation date will be where you received MBBCh in your Diploma, and that the date you received your Diploma will be the end of Internship.
e. The form asking for your medical clerkships can be left blank, as you’ll enter them anyways in your ERAS profile, and they’re not a component of ECFMG certificate. Yet, if you feel like filling them, go ahead.
f. Now, paperwork you’ll be doing from this point till the Match involves two major categories. THE first one is the #1. Certification of Identification form (186 or 183), which serves to insure that you’re actually currently enrolled, or was enrolled, in a Med. School listed in IMED.
g. And the #2. Verification of Medical Education Credentials, or in other words, now that they know you were a student, they want to make sure that you actually RECEIVED YOUR DEGREE off that Med. School, and wasn’t suspended or dismissed from it for example. This is done OBVIOUSLY after passing your 6th year exams, and having your Diploma ready. (It can work with the Temporary one, but you’d still need to send the original before the match). For this verification process, they usually need two photocopies of the Diploma on Letter-sized paper, two Original Official translations of the Diploma on Letter-sized paper, Two full-face 5*5 Passport-like Photographs, One Form 187 (Tells ECFMG that you’re submitting important documents), One Form 344 (a checklist), and Two Forms 345 (a request to your Med School to send ECFMG the verification of the Diploma). All the three forms are filled entirely by you. Also to speed things up, send Two Original Official English Transcripts as well. Further details here, (http://www.ecfmg.org/2012ib/credentials-for-certification.html).
h. Obviously, If you register for the exam while being a student, you only need documents for track #1 (Certification of Identification), and the others will wait till after you graduate. BUT, if you register while being a graduate, they will ask you for the ENTIRE set of documents, for both #1. Certification of Identification, and #2. Verification of Medical Education Credentials.
I. 3. Now, If you are a STUDENT.
a. At the end of your application, and depending on your school participation in ECFMG Medical School Web Portal (EMSWP), which is the “Med School” account at ECFMG, you’ll either be issued Form 186 (If the school has EMSWP account), or Form 183 (Med School doesn’t have EMSWP account).
b. Either forms will be signed by an official representative like Registrar, Vice Dean, or Dean. When filling any of these forms, stress to the Secretary of the Registrar/Vice dean that both the typed name and the Registrar’s official signature should be via the same pen. Also remember that you should write your name, sign and date your signature AFTER the form has been signed and dated by the dean, so that you write the SAME DATE in your signature. This is because proper filling of Form 186 requires you to “APPEAR before an authorized official”, meaning that you both sign together.
c. Afterward, the form will be put in an envelope, with the envelope itself signed and stamped, and sent DIRECTLY from the school outgoing mail.
d. When either forms are received by ECFMG, they either confirm its authenticity online through your school EMSWP account (for 186), or via mail form (for 183). If either process was delayed, you can’t be issued a scheduling permit for the exam.
e. Form 186 will be only sent ONCE, and it remains valid for 5 years. Each time you apply for an exam, your credentials will be reaffirmed via EMSWP. Form 183 will be resent with EACH exam application.
f. Once you graduate, complete #2 documents.
I. 4. And if you are a graduate,
a. All medical school graduates MUST print a Certification of Identification Form (Form 186) after completing the on-line part of the application, if they do not have a valid Form 186 on file with ECFMG, regardless of School’s EMSWP participation. No use for Form 183 here, even if your school does NOT have EMSWP. However, the certification of Form 186 can be via THREE different routes depending on how easy it is to return to your Med School to get your School official to sign Form 186. Thus,
b. Route #A. to certify Form 186 is certification through School Official, which is similar to student’s 186 certification, however, it applies to schools EITHER WITH OR WITHOUT EMSWP access. Again, leave the Form at Registrar/Vice Dean/Dean secretary, and after he signs and dates it, you sign and date. The verification back from ECFMG can be online (If school has EMSWP), or by mail (If no EMSWP). Note that in theory, you need to “APPEAR before an authorized official” for your From 186 to be approved. That is, you both sign it together.
c. Route #B. for the 186 is certification through US-approved Notaries (Consular Official off the embassy for $50, Notary Public for L.E ~50, First Class Magistrate in US, or Commissioner of Oaths in US), WITHOUT the need to go to the Med School and “APPEAR before an authorized official” to certify it. After the Notary certifies it, you can send it to the ECFMG. HOWEVER, to be eligible for this route, it’s either that your school must have an EMSWP account, OR ECFMG has already verified your credentials before.
d. What if you’re away from home, thus can’t “APPEAR before an authorized official”, you haven’t still verified your credentials, and your school doesn’t have the EMSWP account? If you certify via Notary and send to ECFMG, there’s no way for ECFMG to reconfirm your credentials. Thus, after getting them notarized (via Route #B), SEND THE CREDENTIALS by mail to your school to get certified by your Official, WITHOUT ECFMG enforcing the need to “APPEAR before an authorized official” in person. Hence, it’s a mix of Route #B, then Route #A.
e. Don’t forget to verify your credentials via Track #2 documents.
I. 5. In Summary,
a. If you are a student and your school DOES NOT participate in EMSWP then your only option is Form 183 certified through School Official.
b. If you are a student and your school participates in EMSWP then you have only one option, Form 186 certified through School Official.
c. If you are a graduate and your school participates in EMSWP then you can choose one of two types, either Route #A (If at home) or Route #B (If away).
d. If you are a graduate and your school DOES NOT participate in EMSWP then you can choose either Route #A (If at home) or Route#B THEN #A (If away).
e. If you are a graduate and your school already verified your credentials before then you can choose either Route #A (If at home) or Route #B (If away).
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II. Before you start your Study
II. 1. What is STEP 1?
a. Structure of Step 1 is fairly known. Exam is composed of 8 blocks. A skip-able 1st block is computer tutorial, followed by block 2 to 8 (7 blocks) each with 46 questions. You have 8 hours to complete the entire exam, with a maximum of 15 minutes for the 1st block, and 60 minutes for the 2nd through the 8th. Leaving 45 minutes for break, or 60 minutes if skipping the 1st block.
b. Questions in Step 1 test CONCEPTS. Simple pieces of information that can be put on a single long list titled, “THESE ARE WHAT YOU MUST BE FAMILIAR WITH AS A MED STUDENT”. This means that if you understand the basic concept, memorized it, and then practiced the different representations/applications of this basic concept, you’ll correctly answer any question regarding it in the exam. Concepts seen in the exams are the same ones we all hear in KAPLAN Videos, Goljan, Online Q. Banks, and all of the other sources we use that are ‘USMLE-oriented”. So in essence, the exam is for the most part very familiar to any one who studied well off these sources.
c. Thus, proper preparation for Step 1 concepts is a three-step procedure. First is to build up seemingly-unrelated concepts, then to memorize them, then to apply them in different settings/questions.
d. Moreover, Concepts can be subdivided into two very broad YET EXTREMELY IMPORTANT categories: HIGH-YIELD, or likely to be on the exam, and LOW-YIELD, or LESS likely to be on the exam.
e. So far, most of the questions I saw on NBMEs, as well as on the actual exam, prompted me to think of Step 1 questions as of three categories; High-Yield Concept Recall, High-Yield Concept Application, and Low-Yield concept Recall.
II. 2. High-Yield Concept Recall questions.
a. These are simple, direct answer questions, based on simple concepts that will be known early during the concept building period of your study due to their importance. Some subjects, like Microbiology, Anatomy, Pharmacology, and Behavioral Sciences have most of their questions in this category.
b. Answering these questions correctly will allow you to “PASS” the exam, because they are designed specifically to test the core most essential information. If you have a defect in these basic High-Yield concepts, score can drop markedly. Those who “FAIL” Step 1 have a big defect in these core concepts.
c. Strategy to master these questions is rather simple. They depend on memorization, with no real understanding of the concepts. Know them through KAPLAN Videos/FA, then memorize them via DIT/USMLERx/Brute Force.
d. In exam, these questions can be either very straight, in the form of one liner, or at the end of a complex case. Either way, they SHOULD NOT TAKE MUCH OF YOUR TIME. Some may actually spend too much time on such easy questions, as they’re trying to find the “tricky” part. There are no tricks.
e. Example: “A 28 y/o pt. with burning in urine, and morning urethral exudate. What is the most probable etiology?”. Many Two-Step reasoning questions are usually simple concept recall. Above example can ask about best antibiotic instead of the organism. Or, it can ask on medium used to grow such organism, or a specific biochemical reaction characterizing it.
II. 3. High-Yield Concept Application questions.
a. These questions usually take a simple concept, and apply it to graphs, tables, lab protocols, hypothetical experiments (antagonism in vitro, gene knockout,..), or even relate it to other concepts across multiple disciplines and fields.
b. These questions vary in difficulty, from a reasonable two step question, to an impossibly complicated experiment involving procedures such as gene over-expression. Hence, they’ll represent the gap between those in the 230s to those in the higher 250s.
c. Most of KAPLAN books, KAPLAN Videos, FA, and Q. Banks pay HUGE attention to the idea of concept application. This is simply because concept recall questions are easy to answer, and will NOT get you higher scores in the end, as they serve you to just pass. Hence, throughout your study, every new concept you’ll encounter in KAPLAN Vids, tutors will invariably apply it in different formats, so that you’re familiar with them if they show up.
d. Strategy to master these questions involve answering as many questions as possible, most notably off UW. Of course, the more you answer questions, the more formats and different applications you’ll encounter. KAPLAN Q. Bank does have many concept application questions, yet many test Low-Yield ones.
e. Another very important advice is that you should expand on these formats by adding your insight as well. Try to explain all the reasoning steps involved to reach such delicate application of a simple concept. Also, try to create your own graphs, charts, and hypothetical experiments involving this same concept. Try to integrate from different fields as well.
f. In exam, you should read the question CAREFULLY, then look at the graph/table/... if present. Try to predict the answer before looking at the choices. A typical question of this category will take 1 to 2 minutes after reading it. Generally, if you know the concept in question, but can’t understand the application, try for 2 minutes with the question. But if you don’t know the concept at all, just PICK A CHOICE and MOVE ON.
g. Another famous subtype of these questions include all of the “equations” found in Step 1. These include Biostatistics, as well as some Renal, Cardiology, and Respiratory equations. In the exam, you can either answer them as soon as you see them, or skip them till the end. Either way, if you don’t know the equation, PICK A CHOICE and MOVE ON.
h. Example: The very famous Cardiac function curve questions. You begin with a simple concept of Preload vs. muscle Tension, and you keep on expanding the idea to arrive at the relatively difficult chapter of Cardiac function curves contrasting LVEDV with CO. Also, relatively famous are the Hormone vs. Effect charts (Plasma Osmolarity vs. ADH levels, or Plasma Ca+2 vs. PTH levels), which expand on concepts of simple feedback regulations.
i. An important point to note is that a Two-Step reasoning question can have the first step from the High-Yield concepts, while the second step from the Low-Yield ones. This question might seem “solvable”, but if you don’t know that Low-Yield concept, don’t try to overwhelm yourself. Just PICK A CHOICE and MOVE ON.
II. 4. Low-Yield Concept Recall questions.
a. These questions are the ones that prevent many from crossing the 260s. The questions are not difficult. But you simply don’t know the answer to them.
b. Low-Yield concepts are the ones that generally NOT encountered in KAPLAN, and NOT seen in UW later on. KAPLAN Q. Bank has many Low-Yield concepts. But the most important of them are found in USMLE-oriented textbooks. These include Lippincott’s Biochemistry, Pharmacology, and Immunology, Costanzo’s Physiology, Goljan’s Rapid Review Pathology, Fischer’s Ethics, Thieme’s Atlas of Anatomy, High-Yield in Neuroanatomy, Embryology, Molecular Biology and Biostatistics, BRS in Behavioral Sciences, and Levinson’s Medical Microbiology.
c. Online sources of immense help, but mostly Low-Yield content include Web Pathology (http://library.med.utah.edu/WebPath/webpath.html#MENU), Harvaed ECG Wave-Maven (http://ecg.bidmc.harvard.edu/maven/mavenmain.asp), Virtual Cell Animations (http://vcell.ndsu.nodak.edu/animations/home.htm), Radiopedia, a Wikia for Radiology (http://radiopaedia.org/), Doctor Fungus (http://www.doctorfungus.org/thefungi/index.php), Indiana Embryology (http://www.indiana.edu/~anat550/embryo_main/), The Whole Brain Atlas (http://www.med.harvard.edu/AANLIB/home.html), XRay 2000 (http://e-radiography.net/ibase8/index.htm), PIER.net (http://peir2.path.uab.edu/pdl/dbra.cgi?uid=default&view_search=1), Inner Body Anatomy (http://www.innerbody.com/htm/body.html), (http://chorus.rad.mcw.edu/), (http://neurolex.org/wiki/Main_Page), (http://image.bloodline.net/category), (http://www9.biostr.washington.edu/da.html), (http://images.rheumatology.org/), (http://antibiotics.toku-e.com/), (http://www.pathguy.com/index1.htm), (http://lifesciencedb.jp/bp3d/)
d. As clearly visible, such material may very well increase your preparation time to span around a year of full committed study for the average person (much less for those with better recall capacity). But again, we’re discussing the +260 realm, which is in itself an extremely high score.
e. The idea here is to be able to cover concepts not present in usual sources (KAPLAN + FA + UW). Questions on these concepts are usually straight forwards, and are particularly easy to spot.
f. Example: Importance of Z-DNA, function of Chaperons, Role of Lefty in Embryogenesis, other examples of counter-current multipliers,.... Again, these questions don’t form a significant portion of Step 1, hence best left to those who want +260 as a goal.
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III. Before doing anything, REMEMBER;
a. ALWAYS KEEP IN MIND THAT PEOPLE ARE COMPLETELY DIFFERENT. What will work for you won’t work for others. If you can understand difficult concept applications easily, you don’t need to even complete UW Q. Bank to reach a comfortable 240. But, if you can’t understand except after multiple times, maybe it’s best to do 2 Q. Banks so that you get the same score. Also, someone with a good recall can pull a +260 in under 6 months, while others need years to do the same. In the end, the more you can recall and the better you can apply, the higher score you’ll get.
b. SET A REALISTIC GOAL that matches your residency of choice. If Psych, aim for +230, but if thinking ENT or Ophtha, aim for +250. (Remember that it’s only 3-digit-score from now on. The 2 digit score has been remarkably different from old scale starting from those taking their exam on and after October 2011, and most importantly WON’T be reported to program directors anymore. See here.)
c. PLAN THE TIME AHEAD CAREFULLY. Different people have different responsibilities and jobs. Again, your timetable must accommodate your daily schedule, but always remember to study DAILY, even if for one hour. Long pauses can seriously harm the materials you worked so hard to understand and memorize.
If you have second thoughts about starting Step 1 vs. Step 2 first, then I think that the answer is invariably Step 1. First, it makes more sense to study Physiology and Biochemistry, then Pathology, then Clinical Medicine. Second, many concepts of basic medicine travel along to Step 2, like those in inborn errors of metabolism, and a hefty amount of pathology as well. These questions WILL be explained in Step 2 videos indeed, but you won't have this deep understanding of them. Lastly, the MYTH that says that it is best to take Step 2 right after your clinical years holds true ONLY if you'll be using your old clinical years' books to study for the USMLE. And as we all know, this is rather ridiculous because our curriculum is VERY DETAILED, NOT ORGANIZED, and most importantly, doesn't allow you to think analytically.
In Short, definitely do Step 1 before 2, unless we're thinking about Hamad Hospital.
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IV. Study Phase One. Building up Concepts (2 to 4 months)(Yellow and Red)
IV. 1. Start from scratch.
a. Since we all are graduates of the prestigious Medical Education system in Egypt, it’s undoubted that the very most important thing is to start from scratch. A fresh start will insure that concepts are updated, meaningful, and that we can expand upon them from our own new understanding.
b. It’s also important to forget the feelings we had in Med school towards a particular subject. For example, we all hated Biochemistry. But in USMLE, you need to know that ALL subjects are covered in an excellent manner, with doctors who KNOW what they’re talking about. Biochemistry becomes as easy as reading a novel, sometimes even more enjoyable. Same applies to our bad experiences with Anatomy, Pharmacology, and Pathology. Do NOT THINK that you’ll be left without understanding a certain point as with our med schools. On the contrary, everything in all subjects will be clear.
IV. 2. What I mean with the word “concept”.
a. Concepts mean separate sets of information, seemingly-non related, but with each set of them containing a coherent collection of materials. Think of them as the different bullet points which step 1 administrators think a second-year med-student (MS2) needs to know. In KAPLAN books, they’re called “What the USMLE require you to know”. In UW, they’re called “Educational Objectives”...
b. To fully master a specific concept, one needs to be familiar with the Origin (What..), Mechanism (How..), Normal Functioning (Why..) and Consequences (Thus..) of the concept. For example, with concept of Centrilobular Emphysema in Smoking, you need to understand the origin (What is emphysema), Mechanism (Elastase hyperactivity), Normal functioning (Neutrophils constant circulation), and Consequences (Acquired Alpha1 deficiency).
c. Once you’re familiar with all of these, you can start applying this understanding via different applications of the same concept. Each application will deepen your understanding, and will reinforce your memorization of the specific points regarding these HY concepts.
d. Best approach to build concepts is through KAPLAN Videos, NOT books. In recent videos, the books are the same as the videos, which incorporates slides that have the same text in the books. Exceptions include some additional concepts in Anatomy, Behavioral, and Immunology books which can be read at the end.
e. While watching the videos, you need to follow along. Some do this via writing on a separate sheets of paper. Others follow from KAPLAN Books, and others use MedEssentials. You can either listen to the videos, then read KAPLAN books, or do the reverse.
f. For me however, I ditched KAPLAN books from the very beginning. I used First Aid 2011 from THE FIRST DAY of my study as the main book of the curriculum. So I annotated all the materials in it as I followed along with KAPLAN Videos. Although the two are not progressing simultaneously, once you know where everything in FA is, it becomes easy to follow along.
IV. 3. Why I started from KAPLAN Videos and First Aid?
a. Since USMLE is a BIG exam, with a HUGE amount of information, you need to understand these information in an organized fashion, and have them stored in easily accessible mental “shelves”. This means, they must be memorized, and in a perfect order, in order to be able to draw concepts from different subjects.
b. Hence, I preferred to use one single book, FA 2011, and add to it all of my understanding, and all the concepts I’ll encounter, each is to be put in its natural place within the book. I started with KAPLAN Videos, so as to build a ground base of information. Thus, I was able to finish both KAPLAN and FA in the same time. This also allowed me, when I read KAPLAN Anatomy and Behavioral Science books later on, to simply add the “new concepts” directly in FA. All the important concepts stressed about in the Vids, I highlighted them in FA in Yellow.
c. But more importantly, I was able to add all the “reasoning” of many concepts and their different applications in the same setting as I understood it from KAPLAN, so that when I finished the videos, ALL of FA was very clear and understandable. Thus, even if I forgot the method of explaining such phenomenon, such as Vascular function curves, I had the explanation from KAPLAN right next to it. It also helped me to add some more insight of my own to FA, perfectly integrated with what I understood off KAPLAN Vids. I highlighted these “reasoning” additions in Red.
d. KAPLAN Videos + FA was a good combination in ALL of subjects, including Pathology. I started with Biochemistry and Physiology, followed by Pharmacology, and finally Pathology. This took 2 months of 6 hours/day. AFTER I finished KAPLAN Videos, I did the same with Goljan Audio Lectures, listening to them while annotating directly into FA. Took 2 weeks. I also did the same with Acland’s Human Anatomy videos. I left the cram-able subjects (Microbiology, Anatomy, and Behavioral Science) till the end.
e. You can cut the spine off FA book, punch 3 holes in it (o5’romo), and put it in a 2” 3-holed binder. Thus, whenever there’s a page/image/article you need to add it to the book, you can add it easily, and wherever you want it.
IV. 4. Now that I knew the High-Yield Concepts, how about the Low-Yield ones? (another 2 to 6 months)(Violet)
a. As I mentioned before, KAPLAN Q. Bank covers many Low-Yield concepts not covered already in KAPLAN Vids/Books. I used after finishing the High-Yield part, around after 3 months from the beginning of my study. I annotated directly in FA. I used a different highlighter (violet) to highlight the Low-Yield I added to the book. Although I couldn’t finish the Q. Bank, I think that 2 months are fairly good to finish it properly. Since you’ll be annotating, you only need to do it once. Better yet, use the offline version.
b. If aiming for a very high score, start your reading of the texts ALONG with KAPLAN Q. Bank. You’ll be only READING off the texts. You won’t memorize anything, but rather skimming over the chapters. As with other sources, any important concept MUST be annotated into FA directly, and in its appropriate location. Highlight those as well, or even cut the pages and insert them in FA directly.
c. Priority of the texts should be as those of the Videos. Lippincott’s Biochemistry and Costanzo’s Physiology first, followed by Lippincott’s Pharmacology, and finally Goljan’s Rapid Review Pathology. The sequence should take about 3 to 6 months of 6 hours/day. ALWAYS remember to add interesting new concepts to FA.
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V. Study Phase Two. Memorizing Concepts (1 month)
a. This is where all of the concepts, both High and Low-Yield, have been added to FA. Now I needed to put all these disorganized mess of information into proper “shelves” in my brain. This is the MOST important phase of the study. This phase should be as short as possible, so as to cram everything in. If it were to be longer, you would forget some earlier topics.
b. The best and simplest approach, and the one I was best comfortable with, is to memorize the book as I did in Med. School, a method I call “Brute Force”. Whatever you did to cram those +10,000 pages of our seven years curricula into your brain cells, do it to cram these +600 pages now. Main difference is that you actually understand all of this that you’re memorizing. This should take around 1 week of 10 hours/day, but it may be the MOST IMPORTANT WEEK IN ALL OF YOUR STUDY. Make absolute commitment in it, and minimize all distractions. By the end of the week, you should have seen every information in FA twice by now. Once along KAPLAN Vids, and the other during its memorization.
c. As for the Low-Yield “violet” additions, and other “red” concept applications I added while listening to Kap Videos, I just skimmed over them but didn’t spend too much time memorizing them.
d. Afterwards, you can use Doctors In Training for Step 1. I didn’t use them till the end as I felt them not particularly valuable if I’ve used KAPLAN Vids to understand FA, as I had already seen everything in FA, and even added my own understanding to them. But if you want to add some more Low-Yield concepts, and revise everything you wrote in FA along with some guy talking, this is a good option. Take note though that his “star rating” is relatively wrong. Takes 2 weeks of 4 hours/day to finish.
e. Another way to memorize FA smoothly is to use USMLERx Q. Bank, which is developed by FA team itself. It offers “Snippet” view in the answer of each question, bringing up a scan of the FA page in which the concept is mentioned. Hence, it effectively generates Photo Memory of each concept, that you’ll easily recall them later on. Effective for memorizing, but lacks meaningful USMLE-oriented questions and also only tests High-Yield concepts present in FA, which again was reason enough form,e not to purchase it. Should take 1 month of 5 hours/day, as it’s +3000 questions.
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VI. Study Phase Three. Applying Concepts (2 to 3 months)(Green)
a. After memorizing FA as best as I managed, it was time to test my understanding of the core High-Yield concepts via USMLE World Q. Bank. The Q. Bank is famous because it emphasizes cross-subject integration, Multiple-Step reasoning, and most importantly, different applications of the same concept.
b. Thus, do not think of UW as an assessment tool. Indeed, the bank does have some simple recall questions, particularly in Anatomy and Ethics, but usually the questions need deep thinking, and in many of them there are new ideas and formats for the relatively most tested High-Yield concepts.
c. For example, CGD can be asked from a biochemical (NADPH Oxidase Deficiency), Immunological (Phagocyte Dysfunction), microbiological (Infection with Catalase positive pathogens), and pathological ( points of views. Other examples include Rate of Clearance plotted against Plasma concentration of Substance X, OBC under different CADET conditions, Pressure-Volume loops, Cardiac and Vascular function curves in different hemodynamic disorders, Acid-Base Nomograms in different metabolic disorders, Darrow-Yannet and Wigger’s Diagrams correlations, and last but not least Flow-Volume loops.
d. All above examples share a common feature. They need understanding of some basic concept, and then ability to apply this concept in different situations. The most important point here is that USMLE can generate an entirely new application that you have never encountered before, although based on a VERY famous concept. They can simply change the x- and y- axes of a famous chart, as with Biostatistics 2 by 2 tables, and Dose Response curves. Hence, the emphasis on generating such new applications and different question formats on the same concept at the KAPLAN Videos stage is of paramount importance.
e. Although annotating FA can be very helpful, it can also take time. Hence, if you plan on doing so thoroughly, 3 months are a reasonable time to finish FA twice, with FA annotation. Otherwise, 2 months are enough. I highlighted UW additions in Green.
f. Best way to approach UW is to do it twice. 1st time as Unused Mixed questions, with any correct answer marked. In the 2nd time, answer all the Incorrect, and unmark the marked questions.
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VII. Burnout Syndrome.
We all experience “mental fatigue”, boredom, and feeling of inadequacy while studying for this mammoth exam. It's actually a well-documented phenomenon (http://en.wikipedia.org/wiki/Burnout_(psychology)#Phases). Some tips that helped me, and some of my friends, while studying were;
a. ALWAYS start your study time with 5 minutes mental preparation. Recite some Quran, give yourself some pep talk and remind yourself of your goal.
b. Start with 1 hour study time/day for a week, then 2 hours/day for a week, and keep on slightly increasing your study time per day. Moreover, give yourself a 5 to 10 minute break every 2 hours. Prepare a cup of coffee, pray, do some exercises, then back to study. And whenever possible, even if you had the worst day ever, try to pull off AT LEAST one hour daily.
c. Always use a Stopwatch to correctly estimate your study and break time. Try to be strict with yourself.
d. Dedicate a new place to study in your home, and NEVER DO ANYTHING ELSE while at this place. For example, move your old disk to a new location, and name it the “Study Zone”. Just sit on it ONLY when you’ll start to study, and whenever you do something else, leave it automatically. This will create the “Studying mood” whenever you’re in this place, and will certainly help you focus. If you want to surf the Internet, or check on your emails, also do it in a separate location.
If possible, study in a GROUP. The value of group study is that different people shed different lights on the same idea, and maybe each person came up with his own scenario or application on this idea or concept. Hence, Exchange of ideas strengthen the overall understanding. Discussion also alleviates the boredom associated with non-stop solo study.
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VIII. Two weeks prior to exam.
a. Start to sleep by 10 pm, and wake up by 6 am. daily.
b. I did a THOROUGH First Aid review, this time, which was my third and last time, I emphasized all the HY concepts highlighted from before (in Yellow), UW additions (in Green), and any other explanation seemed important (in Red). This roughly took 1 week of NON-STOP work. Goal here was to keep the HY concepts and the method by which I understood them fresh in my mind
c. Do the NBME self assessment Forms (#7 is the one most predictive. #11 and #12 are rather new, and more difficult than actual exam)
d. Do the UW Self Assessment forms.( UWSA #1 is more predictive than #2)
e. FOCUS on subject areas that are weak among all of your evaluations. If any subject is week, quickly read the parts you know are bad off KAPLAN Books, and listen to Goljan Audio, or read Goljan Rapid Review if applicable.
f. Make a one-night hotel reservation. My advice is for Rose Hotel at Iran St., Dokki. A 5-minute-distance away from test center by Taxi, with the night costing L.E. ~180.
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IX. Exam Night
a. Travel to Cairo the night prior, and stay at the reserved hotel. NEVER travel on the morning of the exam.
b. PAPERS. Prepare your SIGNED Passport (or any ID with your signature on it, like a credit card), National ID, ECFMG IWA Scheduling Permit and PROMETRIC appointment confirmation to take to the test center.
c. FOOD. Get some beverage (Red Bull is a good placebo), as well as any quality refrigerator-safe sandwich, like Turkey Sandwich from “On the Run” at many Gas station. Some light chocolate can also be a nice add-on.
d. Try to minimize new study. If you have some Q. Bank questions left to REVIEW, do it. But do NOT read new materials. Focus on the “Easily forgettable Concepts mentioned here; (http://www.usmle-forums.com/usmle-step-1-recommended-threads/1401-list-forgettables.html). VERY Recommended.
e. Relax. Watch a movie. Read Quran. Sleep by 10 p.m. You MUST make yourself ready for such early sleep by waking up very early this same day.
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X. Exam Day
a. WEAR slightly heavy clothes even if it’s summer, as the testing center has a central conditioning of about 20 deg. which, along with nervousness of the exam day, can make you rather chilly.
b. Take a small bag with your PAPERS and FOOD. Arrive around 8:30 am. Put the food on the counter outside the testing region, so that it’s easily accessible.
c. Inside the testing room, you’ll deposit your bag in a safe. You’ll be photographed, and given two markers, two erasable laminated papers, and your CIN. You’ll also use your passport (or National ID + Signed Credit Card) to enter and exit the exam room.
d. Once you sign in the sheet, you’ll only have in your hand the passport, your Bag safe’s key, the 2 markers and the 2 papers with your CIN written on one of them. Take all, sit on your assigned PC, and manually enter your CIN, the 8 hours start to count down. Rapidly skip the Tutorial, and start your 2nd block.
e. The questions will be hard, dry, weird, crazy, and all of these nice descriptions. But you’ll find yourself gradually getting used to them, understand them better, and your answer to them will be faster.
f. As general rules, for HY Concept Recall, just answer the question as soon as you finish reading. They’re direct easy questions, and no tricks are hidden. Don’t be fooled by the “Red Herring” choice in the presented answers. For both LY Recall, and HY Recall questions; If you don’t know the concept in question, just PICK A CHOICE and MOVE ON.
g. For HY Concept Application questions, if you know the concept and how it’s applied, you’ll eventually find an answer to it within 1 to 2 minutes after reading it. If you still didn’t come up with an answer, MARK, MAKE AN EDUCATED GUESS, and MOVE ON. Remember to go to the same question at the end of the block if time permits.
h. However, if the question tests a specific concept application you’re entirely unfamiliar with, then it’s either a very difficult question, or it can be a trial (not for credit) one. Here, you don’t need to mark the question, as there is a low probability that you’ll be able to answer it later. Just MAKE AN EDUCATED GUESS, and MOVE ON.
i. AFTER finishing each block, you’ll be given a question: Do you want to continue to the next block, or do you want to take a break? You must make a selection within 30 seconds.
j. The 60-minute break can be divided as: 1st Block Skip -> 2nd Block -> 5 minutes at bathroom -> 3rd -> 5 minutes at bathroom -> 4th -> 10 minutes at bathroom. Maybe some chocolate and a Red Bull -> 5th -> 20 minutes to eat your sandwich, more Red Bull, and pray Dhuhr -> 6th -> 10 minutes at bathroom, some food off counter -> 7th -> 10 minutes at bathroom, some food off counter -> 8th.
k. Every time you take a break, grab your passport and safe’s key, sign out at the entrance of the testing room, go OUT OF THE ROOM, grab something off your food placed on the counter right outside the room, go to the bathroom, wash face, and exercise yourself. When you go back in again, sign in again at the entrance of the room, empty your pockets, show him your passport, and again take your passport and safe key back to the PC. RE-ENTER your CIN, and continue.
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XI. In Summary.
XI. 1. Resources.
a. KAPLAN Videos. A must to those who lack core HY concepts, and want to start from scratch.
b. Goljan Audio Lectures are a MUST as well. They integrate many ideas from different branches. If you did KAPLAN videos thoroughly, no new huge content will be in Goljan’s. However, the integration is worth your time. Annotate new info in FA as well.
c. Acland’s Human Anatomy. A set of 6 lectures, each ~2hour long, explaining very detailed and extremely well done anatomical relations. Watch it once, and annotate content you feel important in FA. Do it AFTER finishing Anatomy videos.
d. KAPLAN Q. Bank. Questions focus on recall, with many involve simple Two-Step reasoning, and not enough concept application questions. However, it covers many Low-Yield concepts not mentioned in its books.
e. USMLERx Q. Bank. Has over +3000 questions, yet all are direct concept recall. There are some difficult questions, because FA does have difficult concepts at points. However, if you mastered FA along KAPLAN Vids, the bank won’t add anything new. Use only to easily memorize core concepts in FA.
f. USMLE World Q. Bank. A must. Many new ideas that expand on your understanding of core High0Yield. It also prepares you to be able to handle completely new applications on exam day. Best used after MASTERING the HY content, and memorizing it.
g.KAPLAN Books. Recent videos incorporate most of the books, except in Anatomy (and Neuroanatomy), Behavioral Science and Immunology. Rapid skimming after listening to the videos is a good idea. Annotate new information not mentioned in the videos to FA as well.
h. KAPLAN medEssentials is a very useful tool to the visual learners. The book is packed with diagrams, tables and illustrations, with virtually no free text at all. I used it mainly in certain complex ideas, by cutting the important diagrams, such as that of Vascular function curve examples and Peripheral Nervous System, and inserting them in FA.
i. USMLE Textbooks are recommended to those who want to master Low-Yield concepts as well. Best ones are Lippincott’s Biochemistry, Costanzo’s Physiology, Lippincott’s Pharmacology, and finally Goljan’s Rapid Review Pathology. Simple reading, highlighting, and FA annotation is enough.
j. Online sources for Low-Yield contents are mentioned above. Particularly important are WebPath (http://library.med.utah.edu/WebPath/webpath.html#MENU), Harvard ECG Wave-Maven (http://ecg.bidmc.harvard.edu/maven/mavenmain.asp), Virtual Cell (http://vcell.ndsu.nodak.edu/animations/home.htm) and Radiopedia (http://radiopaedia.org).
k. Avoid resources like PreTest, as they are full of mistakes, and contain material that are NOT USMLE-oriented. Also, avoid texts that are not directed to the USMLE, as Harpers’ Biochemistry, Ganong’s Physiology, and Kutzung’s Pharmacology. Also, no need for the FA: General Principles, and FA: Organ Systems. Old edition was full of mistakes. No feedback on the new 2011 editions yet.
XI. 2. Schemes.
a. If aiming to PASS, just master HY Concept Recall questions, by memorizing essential concepts present in FA. Understanding of concepts in not necessary.
b. If aiming for 99 (230s to 250s), invest much time in building concepts, and applying them in different formats. Build your concepts from KAPLAN Videos, annotating FA while listening to them. Supplement the videos with Goljan Pathology Audio Lectures, and Acland’s Human Anatomy, both are also annotated in FA. Intense memorization phase, followed by applying these concepts via answering UW twice. The difference between 230 vs. 250 is the depth of understanding of these core HY concepts.
c. If aiming for +260s, incorporate Low-Yield concepts as well. Use KAPLAN Vids + FA. Then KAPLAN Q. Bank, along with USMLE-oriented textbooks. Intense memorization phase, followed by applying these concepts via answering UW twice.