USMLE Preparation
Latha Chandran MD, MPH
Associate Dean for Academic
Affairs
SUNY at Stony Brook
Our agenda
 What
is Step I?
 Sample questions
 Strategies to study
 Resources
 Sample schedules
 CBSSA
 Discussion with students
HANDOUTS
 My
ppt presentation
 Sources to use
 Sample study schedules
 Performance check list
 Feedback form
Final goal
 Pass
USMLE Step I, II and III
 Pace yourself like a long distance
runner- practice, practice and
practice to build up endurance
 Guard against procrastination
Lumpers vs splitters

How do you do your best thinking?
• Talk it out (energizers) OR think it thru ( listeners)

What do you pay the most attention to?
• Focus on “specifics” (describers) vs “the big picture” (
wonderers)

How do you make decisions?
• Based on “my logic” (facts, impersonal) or “my values”
(sensitive, personal)

How do you spend your time?
• Joy of “closure” ( accomplishment oriented) OR joy of
“discovery” (process oriented)
Linear vs integrative learning
You cant memorize
understanding!
 It
is not what you know, it is HOW
you think about what you know
Visual metaphors
 Pictures
 Charts
 Tables
 Algorithms
 Bubble
diagrams
 Concept maps
 DISCOVER relationships!
Step I exam
 Designed
“to determine if an
examinee understands and can apply
key concepts of biomedical science,
with an emphasis of principles and
mechanisms of health, disease and
modes of therapy”
USMLE Questions
 Three
dimensions
 Organizational level- molecule, cell,
organ, person
 Processes
 Systems
 Trend to add large clinically related
stems to all steps including
simulations
Questions to ponder
 What
to study?- books, questions
 How to study?- alone, with others,
study calendar
 Where to study- home/ library/
group
 When to study?- small/large blocks/
day/ night,
Useful books for Step I
 Kaplan
USMLE Step I review- Useful
 First Aid- Essential
 NMS Pathology, Appleton and Lange
series
 Micro made simple ( micro and
immunology)
 Lippincott Pharm ( pharm cards)
 NMS Physiology, Underground clinical
Question books for Step I
 Free
diagnostic test Kaplan
 Board Simulator series
 National medical series
 USMLE Practice CD- very useful
 Q bank - Kaplan 1m or 4 m
 60% of exam is Path- Pharm- Micro
 Look at www.usmle.org for details
Useful resources for Step II
 Secrets
Step II
 Boards and Wards
 Kaplan Q bank
 NMS Question Book
 USMLE practice questions- very
useful with answers free from Kaplan
Tools
 Time
AND study focus
 Adequate time for all subjects
 Develop a workable schedule
 Note your progress ( lack of)
 Use your own notes
 Practice scanning large paragraphs
for main ideas- useful skill to read
large question stems
Practice questions
Answer in logical clusters (50)- don’t look
each answer up
 Use wrong answers as your diagnostic guide
to identify gaps in knowledge
 Study alone, with partner, with group
 Study the hardest subject first at your
high energy time
 Train your biological clock to have high
energy 8A- 5PM (exam time)
 performance check list

Questions are powerful study
aids
 Look
for topics in stem and answer
choices
 Understand correct answer
 Understand wrong answers- powerful!
• Make charts/entries for confusing areas
 Rephrase
the question-- more
questions answered
 Info not available in one place
Wrong answers
 Requires
an understanding of cause
and effect relationships
 Make logical connections between
structures and their functions
Initial planning
 Spend
about 20 hrs reviewing all you
need to know
 Attention to labels, underlines
 Do pretest/s pacing yourself
correctly
 Classify subject areas into “ know
well”, “know somewhat” and “no clue”
 Make a realistic schedule
Without a study schedule, you
will run out of time before you
run out of material!
Time allotment
 Two
thirds of time on” not too sure”
topics
 Weak areas need MORE time
 Keep tabs of your progress in a large
wall chart
 Schedule small breaks between 1-2
hours of work
 Make your own questions
Practice tests
 Retake
only AFTER reviewing material
 Last three weeks- do organ system
review
 Study groups twice a week- two hours
 Study partner with unlike learning
style works best
 At least two full length exams
Practice exams
 http://www.usmle.org/step1/2005Ste
p1.pdf
 200 questions in four hours
 Request for accommodations early!
 Familiarize with interface ( disc or
website)
 practice using white board
Tips for optimal learning
 Create
a realistic schedule and
follow it
 It is your best friend
 Have positive thoughts (avoid neg self
talk)
 Say “Dr ---”- pep talk once an hour
 Stop studying the day before the
exam- do fun stuff
Stress reduction techniques
 Breathing
 Yoga
 Stretching/
Exercise
 Sensory imagery
Day of exam
 Good
sleep
 Nourishments
 Picture yourself as a competent
doctor working in a beautiful place
 Answer each question as it appears,
check every 10 questions for time
 No penalty for guessing
Actual test taking
 350
questions in 7 blocks
 MONITOR you time
 Mark on upper left hand side
questions you are unsure of, to review
later if possible
 Keep all your wild guesses the same
letter
 Don’t get stuck in one question- move
on after you answer
Generate your answer
After you read the stem, think about
the right answer
 Then see if it is there
 Read all options before you mark ( Js
beware)
Other tips
 Absolute
terms- never,always, all
 Read the directions- Ns beware
 Read the lead in sentence first
• What kind of a question is this?
• Diagnosis/Management/ Prognosis/
Ethics etc
Other tips
 Look
for word associations
 Longer/ more detailed answer usually
correct
 Frequency of elements
 Middle choice may be correct with
quantitative information
 If pair wise confusion in matching
questions, use same answer for both
Examples- I
 What
will the peripheral smear look
like after one month of iron therapy
for iron deficiency anemia?
•
•
•
•
•
Almost all larger than normal RBCs
Almost all normal RBCs
Almost all small, but not hypochromic
Almost all small, hypochromic RBCs
some small and some normal RBCs
Examples -II

A farmer develops acute attacks of fever,
dyspnea, cough and leukocytosis when he
works around wet harvested hay. Lung
biopsy is likely to show
• alveoli filled with dense, amorphous proteinaceous
material
• ferruginous bodies
• Interstitial pneumonitis with eosinophils and
interstitial fibrosis
• Intersititial pneumonitis with lymphocytes, plasma
cells and macrophages
• Linear immune deposition along alveolar bast
membrane
Examples -III

33 year old woman develops a reducible
mass of the groin, inferolateral to the
pubic tubercle and medial to the femoral
vein. The most likely diagnosis is
•
•
•
•
•
direct inguinal hernia
femoral hernia
incisional hernia
indirect inguinal hernia
umbilical hernia
Examples IV

55 yr old female stopped menstruating
three months ago. Her pregnancy test is
negative. Which of the foll tests indicate
that she is post menopausal?
•
•
•
•
•
Low LH, low FSH, high estrogen
Low LH, high FSH, low estrogen
High LH, low FSH, low estrogen
High LH, high FSH, low estrogen
High LH, high FSH, high estrogen
Types of questions
 Factoids
 Factoids
as vignettes
 Single jump ( what causes this
problem?)
 Double jump ( what is the problem
and what happens because of this)
 Triple jump- evaluate a situation
based on knowledge
Triple jump question

A previously healthy 34 year old presents
with fever and headache for one week. She
has no history of exposure to illnesses and
is on no medications. Her temperature is
39.3 (102.8 F) BP 135/88 HR 104/mt,
RR24/mt. On exam, she is confused,
oriented only to person. There is jaundice
of the skin and conjunctivae and scattered
petechiae over trunk and back. There is no
lymphadenopathy. Stool is positive for
occult blood
Triple jump question










Hct 32% with fragmented, nucleated RBCs
Leukocyte count: 12,500/mm3
Platelets 20,000/mm3
PT 10, PTT 30 sec
Fibrin split product Negative
BUN 35mg/dl, Creatinine 3 mg/dl
Total bilirubin 3/ 0.5 direct bili
LDH 1000 units/L
Blood and urine culture neg
CT head negative
Triple jump question
 What
is the most likely etiology of
the patient’s symptoms?
•
•
•
•
•
•
Disseminated Intravasc Coagulation
Idiopathic Thrombocytopenic Purpura
Meningococcal Meningitis
Sarcoidosis
Systemic Lupus Erythematosus
Thrombotic thrombocytopenic purpura
Physiology question

An anesthetised patient is undergoing an
operation under mechanical ventilation. His
initial PCO2 was 40 mm Hg and Ph7.42.
What would happen if his ventilation was
decreased?
•
•
•
•
•
•
Decreased PCO2, increased pH
Decreased PCO2, decreased pH
Decreased PCO2, no change pH
Increased PCO2, increased pH
Increased PCO2, decreased pH
Increased PCO2, no change in pH
Another example

Lab tests from an edematous 35 y/o man
shows normal serum complement, and
increased serum cholesterol. Urinalysis
shows 4+ protein, 0-5 WBCs/hpf and
several hyaline casts. Examination of tissue
after renal biopsy would most likely show
•
•
•
•
•
Post streptococcal glomerulonephritis
Membranoproliferative GN
Membranous glomerulonephritis
Minimal change disease
Rapidly progressive GN
Educated guesses
 First
choice is usually correct
 Unless you read the question wrongdon’t change it!
Tennis game: Skill development
 You
want to improve your game for a
match in six weeks
•
•
•
•
•
wait till the tournament, you know you are good
watch videos on tennis skills
watch all televised matches, with beer
take lessons and practice daily for two weeks
take lessons several times a wk, play with lots
of partners, work on your weakest area the
most
The message
 Pace
your study
 Start ASAP
 Study actively
 Practice questions regularly
 Get and use feedback
Some other resources
 CBSSA
exam- $45 each- correlation
 Step I review courses- 1m-5m
courses
• Kaplan, Falcon Reviews, UMKC IPP, PASS
 Student
recommended website
http://www.prep4usmle.com/step1/
 www. testprepreview.com
Final comments
 No
substitute for knowledge and its
application
 Follow your schedule strictly
 Have positive thoughts
 Take breaks and RELAX in between
 Lots of good luck!