发信人: webmd (webmd), 信区: MedicalCareer
标 题: 本人认为年度最佳贴-to usmle 战友 ZT
发信站: Unknown Space - 未名空间 (Sun Nov 21 16:54:23 2004) WWW-POST
本人认为年度最佳贴-to usmle 战友ZT
挣扎后终于看到这篇文章, it totally convert our general conceptions about the
damned rotes and liberate outrselves from numerous text books, lets win usmle
To summarize all I wrote below in one (long) paragraph: I don't think the goal
of studying for USMLE is to get all the questions right. That's virtually
impossible, and the score is scaled (related more to the relative performance
of your group than to absolute number of correct answers). If you are trying
to get them all correct it would make sense to go over embryology and memorize
all the branches of every artery, just in case one question asks you to name
all the carotid branches in order. But can anyone really know all anatomy and
microbiology in depth, just to pick two topics out of many? Each is a several
year course at the masters level. Well, I sure can't. I'll admit I didn't even
try cause I find them boring, but I couldn't anyways, and I'm not the dumbest
person you'll meet in medicine. I made an effort to memorize class notes and
got the highest or almost highest scores in my class of 220 students on every
midterm and final for two years - but I forgot it all a week later. And never
rememorized it either. This stuff simply never comes up in clinical practice,
and if it does you can look it up. What I did concentrate on is being able to
recognize as many diseases as possible from a typical boards presentation
(i.e. one paragraph with several classic "keywords"), and some labs and
treatments that may be applicable. This I knew cold, and even today I don't
have to reach for a book when writing orders on a patient, I know it. This
contrasts to many of my colleagues that proudly remember some obscure
anatomical fact yet still find DKA or MI in the ER confusing, many months into
their residency. I also understood human physiology, and it's hard for me to
see a question I can't figure out from basic concepts I understood long ago -
I don't have to memorize how the heart reacts in various situations, it makes
sense to me. When you study detailed anatomy you are wasting time and brain
cells that could be used to review pathophysiology. Personally I think it's
enjoyable to get those two embryology questions wrong on your exam when you
know you saved a hundred hours by never bothering to rememorize that topic.
You can be certain you will do very well just with pathophysiology,
pharmacology, behavioral science and some clinical micro, genetics,
immunology, etc - all topics that are enjoyable and useful for your future.
There will be few dozen questions out of 800 on the other topics, and you'll
get a good bunch of those right without any review. But the time and effort
you save by not spending months memorizing every muscle attachment etc is
priceless. Like I said I couldn't remember anything from anatomy midterms when
I was taking the finals (our tests where not cumulative) so how was I going to
know it two years later? Today's exams are overwhelmingly clinical and even
the basic science Step 1 is presented in a very clinical setting. NO QUESTIONS
ON WHICH STEP OF THE KREBS CYCLE HAS WHAT ENZYME, AND NO QUESTIONS ON ANYTHING
THAT LOOKS LIKE THE KREBS CYCLE, i.e. pure basic science with no clinical
application. I think you get what I mean :) All topics are NOT tested equally,
you have a finite period of time to review = therefore you must prioritize and
spend the bulk of you time reviewing the more important topics, perhaps
ignoring others altogether at the cost of a few question that won't affect
Here are some of my thoughts on the USMLE (United States Medical Licensing
Examination). When I think back to my fears and expectations before taking
these exams and what I know now the difference is amazing. Mostly the secret
is in only studying certain topics and completely ignoring the endless
details, unless you have a photographic memory. Actually, even a real
photographic memory will not work, these tests are a classic example of how
idiot savants can memorize all of Shakespeare including the position of words
on every page yet are unable to add 2 and 2 together. I mean the USMLE
questions do not test raw recall, and the classic mnemonic devices (using
imagery, arranging a list of drugs that affect P450 so that their first
letters spell something, etc) are useless - not one question asks you for
these things. They test decision-making ability, but of course that ability
rests on knowing (memorizing) a few points about every disease.
I think that most medical students expect that these exams won’t test the
common things, that they must be very difficult and concentrate on the rare
and obscure. Therefore they feel compelled to buy endless review texts and
worst of all try to cram until the last minute unmemorizable info - all drug
side effects, which enzyme deficiency goes with which genetic defect, all the
steps of the Krebs cycle, etc. The book companies support this image to make
profits by scaring students with their huge point-form review books.
In my school half the students were always sitting in the lecture hall and
study rooms, 1 am on a Saturday night, while I was out having some beers and
playing pool. They sat there with a giant pile of books, like three different
anatomy texts at the same time, plus their recordings of lectures and the
typed lecture notes they bought, and they were writing their own longhand
notes. They did this for two years. It’s really a mystery because most of
them still did average on exams and when I later met them on the wards they
couldn’t say anything too intelligent about simple patient management issues.
When I took the USMLE I remembered very few details of anything, I NEVER knew
any anatomy, biochem etc, (except for the mid-term and finals at school - I
literally forgot everything one day later). Even though I got A-grades
throughout, which is at my school was just about impossible, I would have
gotten zero if I had to retake a midterm anatomy exam a month later, however I
could think clearly and just had a good feeling of what makes medical sense in
any situation. I was very afraid going in that I made a terrible mistake by
not memorizing the details - but YES the exams test reasoning and not
memorization of the bones of the hand in order.
The truth is the exam is very fair. You are asked to give back some memorized
fact only a few times per 100 questions. The exam tests logic and common
A LOT of questions are soft - what to say to a patient, easy psychiatry, easy
Every single patient presentation is simple and easy - it tells you many
classic keywords and labs to recognize the exact diagnosis
That does not mean you’ll be able to answer the actual question however. Here
are the problems:
The presentations are very long, and give a lot of useless normal signs and
symptoms and other info. You have to be very quick, only 60 seconds per
Most questions on step 1 and 2 have more than 5 answers - they go to h, k or
even all the way to z. Guessing is not going to work.
Even when you read a case and recognize the Dx immediately don’t get excited,
you’re only halfway there. The question is almost never “what does this
patient have”. They always go a few steps beyond to ask something about the
disease, e.g. treatment, labs to be ordered, etc, without ever naming the
actual disease. All the wrong answers (distracters) make sense and are the
appropriate steps if the patient actually had a different disease in the
differential of the presentation. If you don’t KNOW the Dx before reading any
of the answers you won’t be able to guess. The questions are “tricky” and
extremely well designed to eliminate rote recall of facts. They really do test
your ability to make common sense medical decisions in a real setting. They
only give a few bits of information for every patient, while in a hospital you
would actually get a lot more in the first minutes to narrow the Dx.
The vast majority of questions deal with very common everyday diseases, there
very few questions on obscure genetic problems, porphyria, etc. All the cases
have a simple Dx as may be found in the Schneider’s Red BRS Pathology book -
Addison’s, Graves, MS, etc. There are no complicated multiple problems that
would take days to figure out in real life hospital. The distribution is very
equal - pulmonary, heart, endo, GI, it’s all there. Even in Step 3 you do NOT
need to know the sort of stuff found in Internal Medicine boards - all SLE
criteria, exact heart failure categories, etc. It’s still the same diseases
you learned in pathology. Do not learn ICU management, ventilator settings,
details of surgeries, etc. Completely useless.
The best way to prepare for these exams is to IGNORE all the stuff that you
could barely remember in first year and forgot immediately after the finals.
Do not study any anatomy, neuroanatomy, biochemical pathways, histology,
embryology, etc. You will only lose a few points even if you don’t know what
the thigh bone is called.
What is vital is to have on instant recall all the classic diseases found in
the BRS Pathology book. First of all you must be able to immediately recognize
the diagnosis from a classic patient presentation, i.e. buffalo hump + stria =
Cushing's, petechia + hematuria & belly pain = HSP, etc. All the cases make it
obvious what the Dx is, there are no tricks. If you can’t do this before even
looking at the answers you’ll get nowhere. Do this for several hundred
diseases. When I say the Dx is obvious I mean it was obvious to me, I'm sure
it was super confusing to many others. Even then answering the question was a
fair challenge. CONCENTRATE ON PATIENT PRESENTATIONS.
Then just learn one thing you would do to test for this disease and a couple
of first line treatments. Anyone can do this, but you must know this as you do
your own name, clearly and instantaneously. The problem is when you try to
memorize each disease in detail - pathology, genetics, epidemiology,
everything - it becomes impossible. There is no limit to the depth of detail
you can go to (why not just memorize the entire Harrison’s), and when you end
up at the exam you’ll still be unsure what drug and test go for Graves while
you remember a lot of crap about enzyme synthesis, thyroid anatomy, etc.
Remember you’ll only have seconds to put down your answer, if your knowledge
is at a level that you have to stop and strain to recall something about
treatment that you vaguely remember - you are lost. It is much better to have
rock solid knowledge of just a few facts on most diseases and also being able
to instantly recognize the disease from a classic presentation than to have
knowledge that is even slightly vague but covers dozens of facts per disease.
Such a goal is achievable while it is impossible to know where to stop with
the details (every disease has a hundred+ page text devoted just to it). But I
think students are convinced that on the boards the questions will concentrate
on the most obscure detail of a disease - NOT TRUE.
Overall if you did well in med school you can walk in without studying and
pass - 94% of American students do and some of them are as dumb as they get.
This is because you only need to answer 60% or so correctly to pass and at
least 30% of the questions are INCREDIBLY EASY. Another 30% can be answered
with some very basic knowledge. The problem is, for IMGs, just passing is
worthless. You MUST get a high score, and now you come up against the rest of
the questions, which are difficult. You can get some of them again simply by
having the ability to recognize classic presentations and knowing with
CERTAINTY the common diagnostic workup and treatment. Unfortunately the rest
of the questions are classic boards material - not found in real life, not
found in review texts, worded confusingly, and you just go “how the hell did
they come up with that?”. Some of them no-one can answer, but you still must
answer some to do well, and I think some of the stuff I’ve used is very
What’s the solution? First and very important is not to waste time on topics
that are rarely tested and concentrate on things that are.
NOT TESTED: Anatomy, histology, detailed neuroanatomy and pathways,
embryology, hard-core basic science microbiology & virology (clinical micro is
tested), parasitology, ALL BIOCHEMISTRY, nutrition. There is very little
hard-core pathology, but plenty of pathophysiology. If you know absolutely
nothing about any of these subject you will lose only a few points.
IS TESTED: All 3 exams are very politically correct and contain an absolutely
incredible amount of talking to patients, ethics, & behavioral science. Step 3
only has a very large amount of statistics & epidemiology - Chi Square,
positive predictive value, relative risk, everything.
Steps 1 & 2 have a lot of immunology, molecular biology and genetics.
Steps 2 and 3 have a very equal distribution of the 5 clinical disciplines,
but MOSTLY it’s inpatient adult medicine, followed by Peds and Ob/Gyn, LOTS
of psychiatry (easy basic questions) and very little surgery.
Finally all steps are OVERWHELMINGLY clinical in nature. I mean virtually
every single last question gives a full patient presentation of some sort.
Here pharmacology comes in with a bunch of pathophysiology basic science
There are very few photos of any sort.
I remember before starting the clinical years I knew a bunch of pathology but
had a great problems putting down the diagnosis from a patient presentation.
When I heard a patient described no disease names popped up in my head, even
though if somebody named one of the possible diseases I could give a nice
lecture about it. If this is true for you too, you’re in for a world of hurt,
you’ll never pass. Get the Underground Clinical Vignettes and similar books
until you can do it. It’s a learned skill, and if you just read the NMS texts
or whatever you’ll have problems. I remember once I concentrated on it I
could shout out the Dx after the first few words of a typical “Patient, sex,
race, age presents with…” read to me. I guarantee you this skill is the
basis for my success.
THERE ARE NO QUESTIONS THAT GO “All of the following statements about
nephrotic syndrome are true except…”. That you could easily answer from your
pathology days, however in the exam you will only see a patient with edema and
some history of cancer, medications or whatever, the words "nephrotic" or even
kidney never appear anywhere, and the question will ask something about maybe
getting lipid levels or giving steroids, worded in a tricky manner. Most
people will think of anything BUT nephrotic, even if they know a whole bunch
of facts about it, and laugh off these (actually correct) answers and fall for
some attractive distracter answer. Believe me - under pressure, in a few
seconds, it is impossible to mentally come up with a differential for edema
(what is it, a hundred things?) and go down the list eliminating each.
Somewhere in the question will be a clue or two, age, sex, previous medical
history or whatever lost in three giant paragraphs of normal useless data.
There is no way to pick up on this unless you’ve developed the skill to say
the classic “boards” Dx (not real life, you don’t have all the data
available as you would in a hospital) after a couple of sentences of a
presentation. Like I keep saying, without this skill, even if you are a
professor of pharmacology you won’t answer a simple drug question because
every damn one begins with a patient presentation.
Finally what about the 35%-40% of questions which are classic boards material?
They haven’t changed these for decades. Every lecture I ever heard the doctor
would say something about a classic boards question. Although the boards HAVE
gotten a lot more fair and you can pass them just with common basic useful
medical knowledge you cannot do very well, since a lot of questions will be
about stuff you never see emphasized in textbooks and never encounter or study
in the wards. The typical PreTest or similar review book you find has a few
pearls but it’s hopelessly lost among hundreds of too detailed questions
which are NEVER found on the boards, they might make you feel good about being
so smart but that’s all. Please read about the stuff I’m selling. I'm not
claiming it's all you need to pass, but I'm sure it is very high-yield for
classic board questions.
All three steps are quite fair: though the questions are long and confusing,
they are asking about simple things that every doctor really must know. The
majority of the exam has nothing to do with obscure details, difficult to
memorize lists, or advanced management that only senior residents and
specialists are involved in. It’s all first line family practice stuff. It’s
possible for the vast majority of American med students, no matter how badly
they did in school, to walk in with no review whatsoever and pass. This is due
to a fair number of joke questions plus another part that’s quite easy.
Getting a high grade however is a different story and obviously not guaranteed
no matter what you do. But for sure taking 6 months off to re-memorize
everything learned in basic sciences or studying advanced subspecialty texts
will raise your grade NOT AT ALL or maybe by 2%. Going over favorite board
topics, if you know what they are, only takes a few weeks and can raise your
score to 260 for all I know. I got 245s and it was EASY. When I came up
against the 1 question in 5 that I did not know, I could smile and just guess,
because I knew I was getting a lot of the others right. These exams have
grammatical mistakes, they repeat the same question three time in one block,
it’s a real mess, but the same topics keep cropping up again and again.
The last point is that every question begins “A patient, age, sex, blah blah
” and goes on for quite a while. It’s the same as the classic “A common
complication of disease X is a, b, c, d, or e”, but here disease X is
described in a patient format and never mentioned by name, and the question
will be “The best advice to give your patient at this point is:” (referring
to the common complication, but again the word “complication” is never
mentioned). If you have to read the presentation twice, make little notes,
strain your brain about the differential you’ll get nowhere, it takes 45
seconds just to scan thru all the writing on the screen. But after really
trying for a few months to think about everything in terms of what it looks
like on a patient as typically presented on the boards YOU WILL know which
disease they are describing and you’ll know the answer before even reading
UPDATE - USMLE Step 3
I got my Step 3 result: 206/83 (177 is pass). I got 245/96 and 245/92 on steps
1 and 2. I DID NOT STUDY FOR THIS TEST. Not even for ten minutes. Just
practiced the CCS software for a few hours. I would advise folks not to worry
about it, and take it ASAP if needed for H-1B. You DO NOT need a year of
residency or outpatient experience or anything else for this test. Just the
usual Step 2 stuff with emphasis on treatment. At least 50% of the questions
cannot be studied for, they are common sense and not found in textbooks, e.g.
what to say to a patient, simple epidemiology, ethics. No need to study
ventilator settings, advanced EKG, photo atlases, and so on, all the questions
are 5 answer multiple-guess format amazingly similar to Step 2, and worded so
strangely that I think that the people who wrote them would have trouble being
100% sure of the answer with an open Harrison's in front of them. The CCS
component - all I can say is, practice a lot with the sample software. The
cases are easy but the software is hard to figure out, plus it tends to crash
every 30 minutes. If you can get 215 on Step 2 you can pass this the next day.
There is no basic science on step 3. Of course it's possible to raise your
grade greatly by knowing in detail the management of common diseases, but why
bother? This is the easiest of all steps, just take it as soon as you get your
ECFMG certificate, at least this is the one Step you just need to pass instead
of worrying how much over 200 you need to get to be competitive.
※ 修改:·webmd 於 Nov 21 16:54:23 修改本文·[FROM: 149.162.]
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