Thoughts on Step 1

I took (survived?) Step 1 about two weeks ago. Hence the reason I haven’t posted for a while. The test was a beast, there’s no way around it. Here are a few random thoughts about Step 1.

– I took about five weeks of full time studying to prepare. I did a little bit of studying as we finished up our last course of the year but ultimately it wasn’t very helpful. It was difficult for me to focus on two things at once. Five weeks felt just about right as I was definitely getting burnt out towards the end.

– The freedom of studying without pressing obligations is both a blessing and a curse.

– Some people I talked to from the previous year enjoyed studying for Step 1. They liked integrating all of the material from two years of school. Things that did not make sense started “clicking” for them. There is no way I could say I “enjoyed” studying for Step 1. Ultimately the constant stress wore me down and took away any pleasure I would have gotten from mastering the material.

– The stress and pressure was like white-noise machine running constantly in the background. You could ignore it and possibly even forget about it during breaks, but it was always there muting all other experiences and interactions.

– I regret not owning a copy of First Aid earlier. I wish I had used it throughout the first two years. It may not help with classes much, but I think it would have been worth it to be more familiar with the book. It’s easy to get through and would not have added much of a burden to study time for my courses.

– Test day was brutal but a relief. I took pretty much the whole eight hours and needed every bit of break time to re-focus my brain.

– Throughout med school (and even before) people were always telling me the worst was over. “Oh the MCAT, that was the worst test I ever had to take, nothing in med school compared. Oh first year of medical school was the most difficult. Oh, once you get past cardio, second year is a breeze.” I call BS. Step 1 was far more difficult than the MCAT, second year was harder than first year, and the classes never seemed to get easier second year. Of course, that was just my experience. But if someone ever says something similar to you, take it with a grain of salt.

– Where would I be without my wife? She had to put up with me stressing out over this test for what probably felt like eternity. She says I am just now starting to get back to normal. She’s amazing. Being in a relationship with a med student is no cake-walk, enter at your own risk. When I walk at graduation in a couple years I think they should give my a wife a medal or something. : )

Congratulations to all of you who have taken Step 1! I hope you get some well-deserved rest.

Clinic Tales

I watched as Dr. P broke the news. Lung cancer. While the diagnosis was not a surprise to the patient (she had brought her sister and son to the appointment, I’m assuming for support), it was still a somber moment. I was impressed with Dr. P’s calm but empathetic demeanor during the conversation. In no way did I feel the encounter was rushed. Dr. P answered every question to the best of her ability in a straightforward manner.

That was a rough way to start out the afternoon.

Later, I was able to see two patients on my own, both with COPD. I learned very quickly that patients with COPD have breath sounds that are very minimal or often absent. I had a conversation with Dr. P that went something like this:

“So what do you hear?”

Me, listening intently for something but not hearing anything, “Umm… not much actually.”

“Good. Yeah, there is very little air movement.”

I was relieved and glad I didn’t try to make an uneducated guess.

Something else I have noticed as I spend more time in clinic is that Dr. P knows her patients very well. For whatever reason I had in my mind the idea that specialists spend less time with patients and don’t really get to know them outside of their disease. I realize now what a ridiculous assumption this is, especially because even in a specialty social and family factors are always going to play a role and a good physician should be generally aware of what is going on.

Creighton Joins Alegent Health: What Does it Mean for Medical Students?

There was big news this week as Creighton University and Alegent health creighton_universityentered into a “long term strategic affiliation”. What exactly does this mean? Here’s how I understand it:

– Alegent Health will take over operations of Creighton University Medical Center as well as their physician group, Creighton Medical Associates.

– Creighton students will eventually have more opportunities to getalegent health experience at Alegent sites around Omaha. Bergan-Mercy was specifically mentioned as a possible site for exposure to maternity care.

– There will be an addition of about 130 attending physicians from the Alegent group to potentially teach students.

– The academic/educational process will be overseen only by Creighton University. How this will be affected by the hospital being owned by another entity is not entirely clear.

– We’ll most likely be switching EMRs to EPIC. I really don’t like our current EMR so this is good news to me.

– We have been told there will be very little changes to rotations for this upcoming academic year.

Overall this seems to be a very positive development for Creighton University and specifically the medical school. Our dean seemed legitimately excited about the opportunity. It should expand clinical learning opportunities as well as make sure we have enough space for all our professional health schools (medicine, dental, nursing, PT, OT, pharmacy).

My only concern is what will happen when conflicts arise between what our university thinks is best for our education and what Alegent thinks is best for it’s hospitals. This was brought up in our Q&A regarding our simulation center in the hospital. Our dean re-assured us that Alegent knows it needs to stay around. But is there any obligation for Alegent to comply? Does Creighton have any leverage in the matter after giving up ownership in the hospital? I imagine these sorts of issues have been discussed and hopefully worked out but the answers given were not very concrete.

Anyway, check out this PR video highlighting the affiliation. It’s entertaining just for the corporate-speak dropped throughout the video. Our university president actually uses the word “synergy” which I’ve only heard in the context of 30 Rock.

How I Scored a 257 On USMLE Step 1

Note: This is a guest post from Mike Frazier who writes at Medical School Insider.


If you are a second year medical student, there is one thing on your mind at this time of year: Step 1. For me, there was nothing quite as scary as preparing for that test or walking into the testing center that day. But, there are things that you can do to help calm your anxiety and get your best score possible.

Set a Goal
In my opinion, before you start really preparing for the USMLE exam, you should have a couple of things clearly in mind: where you are with your score and where you want to be. To determine where you are, you need to take a USMLE Step 1 practice test. Our school gave us one that we took as a class. Your school might do the same. You might be scared by this score. I know I was (208). But, it’s good to know where you’re starting from.


A passing score on Step 1 is 188. The national average score on USMLE Step 1 is 221. The most competitive specialties have average USMLE Step 1 scores of around 240.

So, before you start studying, set your goal. If you are trying for a less competitive specialty, your USMLE Step 1 score won’t be as important and you might be shooting for average or just above. Nothing wrong with that. If you’re going for orthopedic surgery, you had better hit the books! Probably the best resource for what you need to do to match into particular specialties can be found here, the NMRP’s report on “charting outcomes in the match.” It goes into volunteer, research and other activities as well as Step 1 scores for different specialties. The first pages of First Aid for the USMLE Step 1 have information about average Step 1 scores for different specialties. If you know what specialty you want, you’ll have a good target for your score. You can also find this information on the Careers in Medicine website under specialty information.

If you’re not sure what you want to do, you’ll want to score as high as possible. I wasn’t too sure going into the test, so I set a high goal of 245. That way I wouldn’t be kept out of any specialty based on my score. I needed to spend plenty of time studying, especially since my first practice test said I was at a 208!

Start Studying Early
Looking back, I wish I would have been using the resources I used for my USMLE prep throughout first and second year. That way when it came time to prepare for the test in earnest, I would have been more familiar with the resources. That said, it worked out ok without doing that, so don’t get too stressed out if you’re looking at your prep materials for the first time now.
Our school gave us about two months to really study for Step 1 (meaning we didn’t have any classes scheduled during that time). I would recommend starting relatively serious study starting in January of your second year and really serious study for 2-3 months before you take the test. That should give you enough time to get your best score.

Choose the Right Resources
Choosing the right resources will depend partly on your learning style, but there are a few that are must-haves.

  • A Question Bank

There’s always the debate about whether Kaplan or USMLE World is the better question bank. In my experience, USMLE World was absolutely the best resource that I used for my USMLE prep. USMLE World gives you the opportunity to take tests on the exact same program that you will use on the actual USMLE exam. This was comforting to me since I knew how to mark questions for review, how to look up lab values and do the other tasks that might have been foreign to me had I not used USMLE world. I imagine Kaplan does the same thing, but that was helpful.

The thing that impressed me most about USMLE world was how similar the questions on the USMLE review were to those on the actual USMLE exam. When I came to the USMLE exam, I really felt as though I was just taking another set of questions from USMLE world. In this way, I felt that it was the best USMLE prep that I did.

Also, the explanations of questions on USMLE World were great. They give detailed explanations of why the right answer is right and why the wrong answers are wrong.  I learned five or six important concepts that tested on Step 1 from one question and its explanation. This made USMLE world a very efficient study tool.

I don’t say this for very many things, but First Aid for the USMLE Step 1 is a must-have for your Step 1 prep. You will likely see some of your classmates using this book throughout their first and second years of medical school. I thought that my classmates were nerds for doing this. But, looking back, this was a great way to start USMLE prep.

First Aid is essentially a very condensed version of most of the things you’ll learn in your first and second year of medical school (at least the material that will be covered on the USMLE exam). The more familiar you are with First Aid, the better off you will be when you start using it for your formal USMLE prep. If you use this book during your curriculum, you’ll be able to have a summary of the things you’ve learned, as well as seeing what might not have been covered by your school that is covered on the USMLE exam.

This book is similar to First Aid in that the material is condensed into bullet points. However, it has more information about the “why” of diseases than First Aid. It gives great explanations about pathophysiology and this material is stressed heavily on Step 1.

These are the only resources that I used for my Step 1 prep. As you can probably tell, I study more on my own. Also, I learn best from practice questions. If this is not your style, then this strategy is probably not a good fit for you. If you work better in groups, make sure you find a group that will help you learn the material well. Also choose a group that doesn’t stress you out. You want your time to be spent in the most efficient way for you and stress generally makes learning harder.


How I Used These Resources

  • USMLE World
    • What I bought from USMLE World. I purchased a 6 month subscription to the USMLE World QBank. In retrospect, I would have probably purchased a shorter subscription. I thought that I would have time to start doing questions before my school let out to give us time to study for the Step 1, but I really didn’t. So, I would recommend buying the QBank for the amount of time you have committed solely to your USMLE review (probably 2-3 months). I also purchased two practice tests, but only ended up doing one of them. Our school also gave us a practice test before we were given time off for USMLE study.

I spent a lot of time answering questions and reviewing them near the end of my USMLE review period, but only got through about half of the QBank. In my opinion, if you really study the answer explanations provided by USMLE world, you’ll be able to master the concepts covered by the USMLE exam without having to do all of the questions. That was my experience, anyway. Obviously, however, the more you do, the better prepared you will be for the exam.

As far as how your QBank score correlates with your final score, UWorld questions tend to be a little harder than the actual test. I was scoring in the high 70s on my question blocks before I went into the test and ended up with a 257. My overall was about 60%, but my percentages were getting much higher on each question block the more questions I did.

    • My study strategy with USMLE World. As I said before, at first I thought I would start studying the questions before my protected USMLE review time. As it turned out, I really started studying USMLE world about when I started my official USMLE prep.

I took one of the practice tests at the beginning of my USMLE prep to help find out about where I was. This is a good idea to help you know how close you are to your goal. UWorld gives you a breakdown by topic of how you did so that you can target your studying to areas that need the most work. After this test, I spent my time studying in First Aid USMLE and in Goljan Rapid Review Pathology. After I would finish a section in one of these, I would go through questions about that section in USMLE world. I really started doing the questions more (about 2-3 question blocks per day) during the last month of my studying. This was, for me, the most helpful part of my USMLE prep.

Again, the way that I learn best for tests is by taking practice questions and studying the answers. This is why USMLE world was such a great tool for my USMLE prep. If you study style is different, this may not work as well for you.

  • First Aid
    • There are helpful figures in First Aid USMLE and mnemonics to help you memorize things. I found the organization of the book very helpful in my USMLE prep. First Aid USMLE breaks the huge amount of information you need to know for the big test into categories that make sense for your study. You will learn about immunology, endocrinology, pharmacology, the cardiovascular system, the renal system and all other important information for the USMLE exam. Again, the information is condensed in First Aid USMLE, so you may need to supplement the information with things from the internet or other books if you have bought them. The bottom line is: First Aid USMLE has what you need to know for the test.
    • Don’t sweat the biochemistry. One tip I have is to not spend a ton of time on the biochemistry section of First Aid. Understand the key steps that have to do with certain diseases (e.g. what does lead poisoning or B12 deficiency affect), but don’t try to memorize full pathways that don’t have specific clinical relevance. I spent a lot of time on this and saw very few questions on the test. My classmates had the same experience.
    • My study strategy was as follows: get through the book twice in depth before my test. I tried to finish about 2 weeks before my actual test date. That was combined with my studies with USMLE World and Goljan Rapid Review Pathology.
  • Goljan
    • My study strategy was the same for Goljan’s book as it was with First Aid USMLE. I tried to get through the material in the book twice and know it well about 2 weeks before my actual test date. I would use the material in this book to compliment and supplement the material in First Aid USMLE. For example, if I was reading about endocrinology in First Aid, I would also read about that in Rapid Review Pathology.

My Schedule


Month 1-2: Monday to Friday I would read a new section in First Aid USMLE and the corresponding section in Goljan’s book. I would read new material in the morning (around 6-8am), new material in the afternoon (1-3pm) and review the material from the day at night (7-9pm). Those hours might go a little longer on some days. The night review would sometimes include USMLE World questions on the related topics. On Saturday I would review the things that I had studied in the previous days. This would include USMLE world questions about the topics.

In the middle of this I also took the USMLE world practice test and found that I was around 220. This was encouraging since it was about what I needed for psychiatry, but lower than my goal of 245. So, I had to keep working on my USMLE prep!

Now, this was the ideal schedule for me and didn’t always happen just like this. I would sometimes get tired of reviewing material or wouldn’t have enough time to do USMLE World questions at night or whatever. This was my ideal. You can set your own dates for reviewing your material. I wanted to finish by 2 weeks before my test date. I would also take breaks at times during my studies to go play basketball, run, or take other breaks. I study a lot better when I take breaks between. You might be different.


Month 3: This is where I started transitioning to doing more USMLE world questions. I had finished most of First Aid USMLE and Goljan by this point, so it was more just doing questions. Usually I did 2 sets per day and started studying at the same hours with the same breaks. It was what worked for me. With having a family, it worked well to do studying before the kids woke up, during their naps, and after they went to sleep.


Test Day: I scheduled my test day for the middle of June, a couple of weeks before rotations started on July 1st. Looking back I wish I would have done it a week earlier. That last week probably made very little difference on my score but took a week away from vacation that I would have loved to have before starting rotations my third year of medical school. So, my advice to you would be to take it at the beginning of June.

On test day, make sure you bring snacks and food. It’s a very, very long test. I would also recommend taking all of your breaks. I would run around the building, do push-ups or do other things to keep my body and mind refreshed. That might just be my thing, but if I sit for too long I start going crazy!

So, with all of this, I was able to surpass my target score of 245, with a 257 which I was very happy with. Again, this is what worked for me and may not work as well for you. But, USMLE World, First Aid USMLE and Goljan Pathology are top notch resources no matter your study preferences. You may also want to work with groups to help each other learn the material. At any rate, best of luck! And remember, although important, Step 1 isn’t everything. Programs look at a lot more than just this score, particularly your transcript and letters of recommendation. Good luck!

How Working as an ER Scribe Prepared Me for Medical School

Note: this is the draft I submitted to KevinMD, you can see that post here.

After undergrad and before starting medical school I worked for two years as an ER Scribe. I followed emergency room physicians and completed theirThis looks familiar... charts as they saw patients. I would also remind the physicians of various tasks to complete, alert them of abnormal lab values and pull up x-rays to be interpreted.

One of the reasons I wanted the job was to gain experience in medicine, first as a litmus test to determine if medicine was right for me and then as sort of an early training grounds to help me succeed in medical school and beyond.

Now, as a second year medical student I see my experience as an ER Scribe as invaluable. Working as a scribe gave me a jump start into the world of medicine.

Here are a few specific areas where I have noticed an advantage:

Terminology

Medicine is a whole new language. The most difficult part of starting out as a scribe was learning how to spell and recognize the variety of foreign terms. Not to mentioning having a vague idea of their meaning. After a steep learning curve, I started to become comfortable with the language of the hospital. Now that language is used in my education and I don’t have to expend any more energy looking up definitions.

Taking a History

While taking a history in an ER is often a rushed affair, the basic structure still holds. I observed and recorded countless patient interviews, learning not just the structure of a history but how to alter and refine questions based on previous answers. When I work in clinic now taking a history usually flows quite naturally.

Clinical Knowledge

Working as a scribe I looked at hundreds of x-rays and recorded each interpretation by the physician into the chart. I am grateful for this little head start I have in interpreting x-rays.

I have even found benefits during exams and quizzes. On several occasions during exams I have come across a question I was not sure about but was able to think back to experiences as an ER Scribe and remember the treatment or disease.

While working as a Scribe was a great experience nothing can completely prepare you for the rigors of medical school. But any little edge helps!

Pre med students, if you are interested in becoming a scribe, search for jobs in your area. A pre med advisor at your college should be aware of any scribe programs nearby.

ER Physicians, please remember that your ER Scribe may be a future colleague. They may model how they practice medicine after you and if you take the time to teach them something, that knowledge will stay with them.

Medical Student Writers

Since I started compiling a list of every med student blog I have become astounded at the quality of writing my fellow med students produce. The talent and passion they have makes me feel all warm and fuzzy about the next generation of physicians.

That being said, I’ve been keeping track of some of the best posts I’ve run across over the past few months and I’d like to share them with you all so that you have the chance to appreciate their writing like I do. Enjoy!

We Work in the Dark is quickly becoming one of my favorite med student blogs. I mean in this epic post Osler’s beast takes themes from Star Trek and relates it to a profound tension in medicine, how can you not love that? I give you this quote from the article as a teaser:

“On one hand, this is an entertaining popular pulp science fiction show (deploying very loose interpretations of Freud). On the other hand, this captures a profound struggle in the aspiring physician-trainee: medicine aspires to be both Vulcan and Human.”

– Shara Yurkiewicz who writes at the PLOS Blog This May Hurt a Bit explores the physical boundaries between patients and physicians. The comments are great on this post as well.

– Rick at Little White Coats (I love that name) writes about The Good Old Days. Basically it’s about “enjoying the ride” which is a welcome reminder during med school.

– This med student writes at Drinking from the Fire Hose. I loved this post called The Art of Raising a Medical Student. A must read for attending physicians? Yes, but who am I to say?

– Proving that I’ve been collecting these posts for a while, I submit this great post exploring the controversy surrounding Plan B by Amanda Wingle at Una Seconda Possibilita. She dissects a complicated issue in a logical and sensitive manner. Kudos!

– This Canadian med student who writes at The Notwithstanding Blog has an excellent couple of posts refuting the idea that the United States is stealing the world’s doctors. Fascinating stuff.

Medaholic (who recently matched in Internal Medicine!) is creating a great list of resources for Medical School and Residency interviews. I especially appreciated the post on The Number One Question I Got Asked at Every Interview.

– Amanda Xi asks if it is possible to be too professional in this post at her blog And thus it begins.

– Allison Greco at MD2B explains her process of deciding a specialty. Reading posts like this make me feel better about not being sure what I want to do.

-For those of you who have USMLE Step 1 coming up I enjoyed this series of posts by Rishi Kumar at RK.MD.

-Speaking of Step 1, check out this Ultimate Guide to USMLE Step 1 and COMLEX at Mind on Medicine. Good stuff.

– Be sure to check out some soon to be medical students as well. Practical Pre Med and Phenomenemily will both be starting medical school this summer, congratulations!

There are many more blogs I will link to in the near future. In the meantime explore the rest on your own!

Gifts for Medical Students- Practical and Fun Gift Ideas for Med Students

Buying a gift for a medical student? Here are a few gift ideas that range from practical to fun.

-Cash

Tough to beat cold, hard cash.

– Art from the Street Anatomy Store

They have some really cool pieces of art related to anatomy and medicine.  You can find a great poster to hang up next to a desk they will be sitting at all the time.

– Nice Pens

Even though I use my laptop to take notes in class, I still write a lot. Having a nice pen actually makes a difference. I love these Pilot G-2 pens I picked up at Costco.

– Stethoscope

This can be a thoughtful gift for a medical student, especially if they are just starting school. I am no expert on stethoscopes but the general consensus is that Littman stethoscopes are the way to go. I have a Littman Classic II S.E. Stethoscope and it works great.

Amazon Gift Card

I love Amazon gift cards because I can use them to buy books for school, and if I want to buy something else (music, movies, games etc.) they have an enormous selection.

– Web Hosting

I love blogging. It gives me the opportunity to hone my writing ability, but more importantly to express myself as I venture through medical school. Owning my own domain and paying for web hosting ensures I have complete control over my website. I use HostMonster for hosting and have no complaints.

– Smartphone or iTouch

A little pricey but a smartphone or iTouch can be really useful for a medical student. The amount of helpful medical apps is astounding.

– A Vacation

This may take some coordination with the medical student but would be well appreciated. Many travel sites have vacation packages and Living Social has a bunch of short getaways.

– Any gift that shows you know them well

Medical students are people too. They have interests outside of medicine and school. If you know them well enough, you should be able to find them a gift that reflects the rest of their identity. They will appreciate a thoughtful gift that demonstrates that you recognize they have a life outside of medical school too.

I hope you find a great gift for the special medical student in your life!

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