Journey Through the USMLE’s

I hope I didn’t make that sound like fun, because ‘fun’ is definitely not the word I would use to describe this process. This is a journey that requires persistence, mental toughness, and continued motivation through the series of burnouts you will most certainly have. So sit back, relax for a minute while you can, grab a cup of coffee or as I call it ‘anxiety juice’ to help keep you awake for the ride.

Wether you’re preparing for this venture or if you’re already well on your way I just wanted to share my experience regardless of who is reading it. This is all based off of my collective experience and to be honest I’m writing this from a perspective I rarely have, and thats one of pure, hard earned, joyous success.

Step 1

Study Materials and Stress

Oh boy, this exam is so hyped up and intimidating that you don’t know where to start first. The most important thing is to honestly just start. Delaying studying, or not studying consistently will be to your own detriment. You will be eating, breathing, sleeping and dreaming about First Aid for USMLE Step 1 until you know it better than the back of your hand. This was and still is the king of review books for this exam, but remember, it is a REVIEW book, not a teaching book. If you’re weak in any if your fundamental 3 P’s (Physiology, Pathology, Pharmacology), this book will do nothing to help you. Reinforce it with a back up source, watch your kaplan and pathoma videos, but always, tie it back to your First Aid. No source is a bad source if it helps you, and remember no two people study the same. What worked for some of my friends did zero for me, and vice versa.

Practice questions are your best friend. Although everyone says Uworld is the gold standard you can 100% do other qbanks to help you prepare in addition to it. Uworld is the closest to the actual format of the exam in terms of phrasing/difficulty of the questions. BUT that doesn’t mean using other question banks don’t help, they all help reinforce the endless amounts of pages you’re reading to make sure you’re actually retaining it. Make sure you’re not just memorizing the answers, that will hurt you more than help you. The goal is to understand the major concept of the questions so that when it’s asked again but phrased differently, or asked in a different format, you still get it.

NBME self assessments are scary, I remember my first one and I kid you not, my three digit score was two digits (yes, I was that ill prepared at the time), but I went from fearing these practice tests to wanting to do them. The exact that moment in which that happened was when I did not know what to study anymore. Do I review biochem or go over Heme/Onc again? One of the best ways to efficiently study is to figure out what you suck at, and guess which practice tests tell you that? NBME’s. Start with the older ones, work your way up to the newer ones, save the 2 most recent ones for the end of your studying as they tend to be the best predictors (as well as the UWorld Self Assessments). Using any form a self assessment is the key to studying efficiently, find the holes in your knowledge so you can fill them up before the exam pokes through them.

Your mental health is something you may not feel is important at the time because you’re all consumed by this exam, BUT remember to breath. Go for walks, get some oxygen, leave your room or the library for a few minutes and try not to overwhelm yourself. Try and do some sort of social activity in between studying stretches. I used to take a breather after practice tests and just spend a day with a friend or literally just mentally rest and binge watch Netflix. During my time prepping for this is exam I experienced my first and only panic attack where I convinced myself I was going to die for a solid hour until I cried for another two hours. After that I had to stop and re evaluate how I approached this as it was useless to be successful on paper but be unable to enjoy it in real life.

Also just another piece of advice – don’t compare yourself to other people prepping for this exam. Who cares if Brenda got a 240 after studying for 3 weeks, good for him, but you do you. Focus on yourself, take your time, and just get it done on your own terms. Extend the time if you need to, re-apply if you can afford to, but don’t ever decide things for other people or in spite of them.

Exam Day

You. Can. Do. This.

Remember the hours you spent studying, the number of nights you stayed up reading and reviewing, the knowledge you’ve been packing away in your brain, its time to cash out on the investment and believe you’re gonna succeed. Try not to second guess your life away (I do this way too much to really even be allowed to tell someone not to do it), and just remain calm. I told myself to trust the process, and prayed to the exam gods to take it easy on me. It’s not terrible, it’s just … a lot. By the end of it, my eyes felt like they were going to fall out of my head and my brain was probably leaking out of my ears. I forgot that there was a world outside of this exam and literally had to take a minute to re-integrate back into society after walking out of the testing centre.

Did I feel as though I ruined my entire life in the matter of hours? Yes. But apparently thats normal? for me at least, I am one of those people who does not like to miss a single question, because it makes me doubt any other answer I gave. To distract myself for three weeks, I learned how to knit to keep my mind occupied and because I like scarfs. I watched all of Dexter on Netflix because I could, caught up with friends who hadn’t seen me for weeks as I had gone into my study cave, ate all the food and drank all the drinks I said I would be able to after the exam was over.

By any means, I did not ace this exam, BUT I didn’t scrape by either, I was in the weird no mans land around the national average and that was good enough for me because its something I could work with to get into Residency, which honestly is the main reason why this exam matters. It’s your key to opening some doors by making it through filters. I highly suggest looking up the average score cut off requirements for the specialty you want to pursue. If you miss your mark, it’s not the end of the world, you just have to work harder than those with comfortable scores to get exactly what you want. If you fail, again, the world is not ending. A lot of programs allow at least 1 attempt across the board so you’re still in the clear, but focus on what you think you may have done wrong, and try your best to improve and kick the exams butt.

Step 2’s – CS/CK

Do not underestimate these exams. Everyone say’s they’re not as difficult as Step 1, but I disagree, I think you’re just used to the stress and pressure that it comes more naturally to prepare and complete them.

Clinical Skills – Show me you know how to interact with patients

I would suggest getting First Aid cases for the USMLE Step 2CS and practicing the cases with a partner. I had a few study partners during rotations and we would write doorway information on post-its, have one of us be the simulated patient while the other did the history/exam, then would verbally go over the differentials together. We probably each went through all the cases at least twice and made sure we had all our differentials down. I also would prep each case before entering with the handy “blue sheet mnemonic’s” they were life savers and acted as a mental checklist to make sure I didn’t miss a component of the history. For IMG’s who do not have a lot of experience in America, I recommend watching videos on physical examinations to understand proper protocol (i.e HandWashing, draping, patient comfort etc.)

This is exam is a lot about how you interact with the patient and although it feels weird knowing they’re just acting, you in turn have to play your role well to get through this exam. Practice will make perfect, if you ever have any doubts it may help to run through cases with someone who has already taken the exam. Typing Speed is also something that might be overlooked, there is a set amount of time to get that progress note, differentials with support, and tests to order, so if you’re one finger searching letters on a keyboard, working on that will help you be more efficient.

Clinical Knowledge – Show me you know the order of how to approach your patients

A lot of people recommend Master The Boards for this, and it’s a great book, but I sticked to my guns and used First Aid for Step 2 CK as well, old habits die hard. The penultimate study source for me was actually Online MedEd. They have countless videos that are free to view, the study organizers they make are lifesaving and genuinely save so much time. I could always go back to topics or questions that were troubling me on UWorld and just review those videos and they would help me get key things down. From what I remember the UWSA’s were the best predictors, and Drug Ad’s are still the worst part of it all (seriously I hate those questions).

The hardest part about CK and CS was timing as I was actively rotating during my third and fourth year of medical school. This became extremely overwhelming and I felt like I was being spun in circles. I was studying to prepare for block exams at the end of each rotation, and also trying to not look stupid in front of my preceptors and attendings. It was a time period where 24 hours in a day simply weren’t enough, I was not sleeping properly, eating properly, was constantly on edge and felt very pressured all the time to perform well in all aspects while trying to maintain a healthy lifestyle. Realistically I was far from healthy, mentally and physically, and it took a toll on me. Know you’re not alone, and that we’re all in the same boat struggling together.

The Match

If you thought taking those exams was the hard part, you’re not wrong, but also not totally right. The process of timing your exams correctly and having the scores you need for your specialty are only a part of the game, there are still personal statements, letters of recommendations, CV’s and interviews to go. BUT you made it this far and it should pay off right? as an IMG, statistically it pays off like half the time (I believe our match rate is just above 50%). So what can you do to increase your chances? Well that depends on your specialty and how you approach your goals.

My specialty of choice was family medicine, I arranged my electives to make myself a more well rounded applicant for this position, I attended the AAFP National Conference in Kansas City and networked with residency programs. I got the right LoR’s from the right doctors but somehow yet, during my first attempt at applying for match, I got absolutely nothing. Not even a single interview in the states. Oddly enough, I had taken my MCCEE and NAC OSCE and managed to get 3 interviews in Canada, BUT I still didn’t match. Talk about flying way too close to the sun, because that burned like hell.

Picking myself up while having zero motivation to keep going after getting kicked in the gut so hard was not easy, and I owe a lot of it to my friends and family (Not to mention I also went to Cuba for a week to reset myself and just breath again). I stayed clinically active, my old volunteer position let me directly interact and see patients one on one, thankfully it eventually turned into a paying job and most importantly it helped me stay interested in medicine. Every time we had a patient that would mention how their day was infinitely better after seeing us it made me remember why I started down this path to begin with. I tried again this past cycle, revamped my entire application, attended that conference on more time and connected with the right people, somehow managed to score an interview with an amazing program that I eventually ended up matching with. Up until about a month ago I would have thought I was dreaming, that there was no way it was going to happen, but somehow all the chips fell in to the right places and it worked out.

I can’t sit here and tell you that this process is easy, that it will all work out and life will be great, oh you just wait for it! What I can say is that you have to go out there and work your butt off to get it, nothing will ever be handed to you. However much effort you put in, is what you will get out, and sometimes even that doesn’t follow through but you have to find a way to keep your head up and keep moving forward. I genuinely back up planned my life and was looking at possibly entering MPH, MBA or clinical research programs if I did not match this year, and I had to learn to be content with that. There is more to life than this, I had to go through a lot of experiences to really get me in that mental mindset but once I was there matching into residency just felt like a bonus on top of everything.

If you’re wondering why I haven’t mentioned anything about Step 3, its because I haven’t crossed that bridge yet, but I’ll be there soon. Hopefully this helped shed some perspective on the USMLE experience and again, any advice I droned on about is from my own experience.

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