USMLE Step 2 CK experience especially for Pakistani Medical Graduates

Writing this experience as I didn’t come across good, detailed Step 2 CK experiences unlike Step 1. All I heard was to do UWORLD and you’ll be good to go, whereas, I had 2-3 PDFs (of different Step 1 scores) when preparing for step 1 which helped me choose a resource or change my course whenever I felt confused. While describing my experience, I will be contrasting it with my prep for Step 1 too. So here it is:

Final exam score: 255. Exam in June, 2019

Total prep time: Almost 4 months. I bought my UWORLD subscription in the mid of February but my actual preparation started at the end of Feb, around 25^th. 

Background: Graduated in 2018 and gave my Step 1 in October, 2018 and scored 258 in it. I did a part of my internship (housejob) year for 3 months in internal medicine right after my step 1 as I was too drained out after studying for 6 months constantly. I got the CK notes printed in December, but couldn’t get to them during my rotation. But the passive learning during the job did help at times later on for CK, but I think doing CK directly after Step 1 would have  been a better idea as a lot of pathophysiology and pharma from FA is tested, especially in the final exam if not the UWORLD practice exam.

Practice Test Scores:

UWSA 1 ( 4 weeks before the exam): 264. This result was after I had completed my 2^nd block by resuming it which had 3-4 questions omitted due to lack of time. Made me realize how much I needed to work on time management skills.

NBME 8 (3 weeks before the exam): Almost 16 questions wrong which is about 252-254. This is a very straightforward exam with little help in adding to content for your preparation, but for some reason most of the students I ask have their final exam score very near to this. A certain correlation graph after widespread research which is doing rounds on different Facebook forums says that NBME 7 is most predictive but this is all based on the perspective.

UWSA 2 (5 days before the exam): 264. I didn’t resume any block despite rushing through the last 5 questions of every block, but it helped me be ready for the lack of time during the last part of each block in my actual exam.

Free120 (same day as UWSA 2): 88%. They are easier than the real thing but definitely do them and look at the tutorial. I made the mistake of not looking at the tutorial for this as I thought it was the same as step 1. But it introduces you to abstract questions and other new stuff which I came to know by wasting two minutes of break time in the real thing.

Resources:

UWORLD NOTES: I got the original ones printed but found 2019 ones later so had them in front of me on pdf almost all the time. But they are also very deficient to cover all of the new questions. I hope we can find the editable word version of the pdf so that it can be edited and updated with time like FA for Step 1 is. Went through them thrice over the period of my preparation. I didn’t do so but I’d suggest going through the notes before starting UW questions. The reasoning has been given in detail later.

UWORLD STEP2 CK: Did it only once, and then quickly went through almost 40% of the questions that were marked or wrong.

OnlineMedEd: I watched videos for topics that were confusing like arrythmias, antibiotics choice etc etc. The best part of OME videos is the final algorithm at the end of the video which is on the whiteboard. I took screenshots of it, but that were not clear.

Uptodate: Used it a lot in the last month before the exam. Especially to search stuff that people were posting on facebook forums and new things from NBME 8 and little bit of CMS forms I did.

CMS: Only did 2 blocks of surgery as I had a low percentage in UW surgery portion.

FA for Step 1. Important topics: Side effects and uses of drugs in Pharma, all of Biostatistics and ethics including patient safety notes, diseases in Biochemistry like Glycogen and Lipid storage diseases, and a lot of Psychiatry but it is covered in CK in more detail too. One has to know pathophysiology of almost all diseases as the final disease name won’t be there in the options, instead its pathology will be written just to confuse you a bit. So a background knowledge of Step 1 does helps a lot.

Study partner: Someone who shares a similar final exam date to you, and who you judge to have a similar intellectual level. This was more beneficial in Step 1 as there was more conceptual learning in subjects like physiology, compared to the hundreds of algorithms in ck which just need to be remembered. But if you can stomach it, I preferred someone bombarding me with random questions all the time. Sometimes it embarrassed me when I couldn’t recall simple stuff, but then such times make you remember that stuff more clearly when the real deal comes.

Anki Cards: I initially downloaded Tzanki and WiWa and did CVS from them, but I decided instead to make my own cards. This allowed me to have no other notebook when doing notes for the second time. I didn’t highlight anything in my notes, instead I made a flashcard of anything that I couldn’t remember or I thought it was new to me. So the last two days before my exam, I just went through these flash cards. Excellent way to build memory. Also did the flash cards of a few difficult topics before UWSAs.

Patient Safety Notes: Go through them once before the exam. Helps a lot in making sense to what you initially think can be answered just by common sense. Last few pages of Public Health chapter of FA covering swiss cheese model etc. helps with this too.

Step Up to Medicine: I studied this book for my medicine clerkship and final medicine professional exam in final year of med school. I loved this book. Even though it had been more than a year since I studied it, I still remembered some major algorithms from it. It has a lot of extra knowledge that’s not needed but it had made a base for me to build upon. If you have more time, I’d suggest starting with this book.

MTB 2&3 and FA for CK: Have no idea about them. Never saw the book or pdf of them.

UW for Step 3: Didn’t use it myself but can be helpful for those who didn’t do random, timed uworld for ck. Will help dealing with unknown questions. Don’t go through the explanations just use it as a question practice tool.

UWORLD FOR STEP 2CK

UW covers almost 80% of the actual test items. But then again the questions are an amalgam of common sense, step 1 knowledge and clinical knowledge. There are 3 types of questions: Diagnosis & risk factors, Best investigation/treatment, Best next step. One can do diagnosis by Step 1 knowledge usually. It’s for the latter two that you have to prepare for. A colleague said to me: if you think you are guessing the answer in CK, then you are doing it wrong. There is always a right answer according to some latest guideline.

HOW TO DO UWORLD?

A question that confused me a lot during both my Step 1 and CK was how to do my UWORLD? I did UW for Step 1 random, and timed from the beginning and completed it in 2 months and so was able to give my exam more quickly compared to other exam takers. Now an advice I would like to give to everyone, preparing for either Step 1 or CK is that even though UWORLD is a huge knowledge source, it is also a very good testing source. Yes, the percentage of correct questions doesn’t matter a lot, but it helps you measure every single day of your preparation. Most importantly though, the questions are perfectly written. They are exactly what you need for practicing the confusing scenarios of the final exam. I did it slightly differently in Step 2 CK and not completely random as I have described later.

The reason why I advocate doing random, timed UW is because: Firstly, it teaches you time management from the get go. Secondly, it recreates an exam-like environment which trains you for the final exam which at the end will be random and will have unknown questions that you’ll have to solve by ruling out the wrong options. And the only way to practice for that is to start with random stuff. So you save prep time and train your mind to think openly. And I will stress on one final point, everyone looks at the answer once done with the question, but remember to look at the QUESTION STEM again when reviewing the answers as now you’ll be able to find the specific clue related to the answer. Also look at the age, risk factor etc. within the stem as these are very important in CK.

Finally, everyone has their own way to go about this question bank, some even do it tutored which was also useful to me in my marked questions as I will describe later. But again, once a question is used it almost becomes useless the second time. Doing random, timed UWORLD the second time takes away the time management required and also the surprise factor which is necessary to prepare you for the out of the world questions of the final exam.

Preparation timeline

First Month – until end of March – Did 60% of the UW in timed, alternative blocks of each volume way

I always studied in my bedroom throughout med school, but I decided to go to a library nearby for both step 1 and ck as it is necessary to maintain sanity with people around for such a long study schedule.

So now coming to how I went about my prep. Sorry to disappoint you, my main resource was also UWORLD. I had the notes printed and made them my main book as I have this bad need to write stuff down and I write so much that it becomes confusing even to my own self, hence I devised a method to avoid any confusion and also used this with FA when doing step 1 that I’d write question IDs of most of the difficult questions, almost one-third of all, on my notes write next to the topic heading that the question pertains to. I did the same with FA previously in step 1. Now it’s very arduous work to open the notes to the page of the same topic of the notes when you are doing it randomly, so I’d have the pdf open on my laptop. I’d just search the word in notes pertaining to my question and it would appear, if not I’d know this question is not in the notes. So I’ll have to write down its information myself. I did this with FA too in step 1. I started UW without giving a read to the notes to ensure I maintain the surprise factor of the UW and read the notes along with UW. There is one thing I did differently in the UWORLD for CK to help me jotting down new points more easily:

I did the UW not completely random. A colleague who, herself, got a very good score in CK advised me that doing UW completely randomly is not advantageous in CK as you can easily know the system of the question by looking at the stem, and making notes is so tough with it. So initially, I followed her way. My notes were divided into 5 volumes:

1. CVS, Resp, Endocrinology  2. Rheumatology, Hemonc, ID&Immuno  3. Neuro and GI  4. Gyne/Obs, Renal, Male RS  5. Derma, Eye, ENT, Multisystems, BS, Biostats, Psychiatry and all other small topics

So I used to take only one volume to my library each day and I would just make a block of the specific 3 or so systems in that volume. So first day I’d do a block of CVS, Resp and Edo of all Med, Surgery, Paeds etc. And then next day I’ll do 1 block of next volume until I came back to the first volume on the 6^th day. So this allowed me to maintain a certain amount of randomization, and I would come back to each topic every week. This allows reinforcement of the specific system every now and then which is very important in long term studying. As the more you study something over time, the easier it becomes to retain over a long period of time. This is a better way than doing one system complete first, and then second and so on as then you forget the initial systems by the time you reach the last one. After the initial start I’d try to review more than 40 questions/day so I’d do two blocks of one volume in one go to build some stamina and review at least 60 questions/day.

Remember, I had timed blocks from the get go. Initially, I used to go over time by 10 minutes. The overtime was calculated based on the time it took to resume and complete the omitted questions. But by the end I was able to devise ways to read questions that allowed me to complete the block in time. But remember, the time issue is a big one in CK vs Step 1 in which you are left with more than 5 minutes in every block no matter how difficult. But CK is different with longer stems and confusing scenarios. While reviewing, I’d add anything missing from the notes and carefully read the explanations. It took 6-8 hours to do one block initially and only 4 hours later on when I had acquired some knowledge. I was scoring barely 70% which had me worried throughout. By the end of the month I was done with 60% of the UW which was adding questions at the speed of light.

2^nd month – Until end of April, 2019 – Revised notes

I had done 60% of UW with equal amount of blocks from each volume. And since I had only improved to about 72% in my correct questions I decided to do the notes completely once before I continued doing questions. So I spent almost all of April except last 2-3 days doing the notes. I reviewed them extensively and would open the Question IDs I wrote, wherever I felt that the information in the notes was lacking despite my own annotations. Of course, I was yet to annotate 40% of the notes as I hadn’t complete UW.  I would make flash cards on ANKIDroid of anything peculiar or new or something that needed to be remembered and took pictures/screenshots of all the algorithms from the notes. After every system I revised from notes, I’d do the important onlinemeded videos. So every volume, as I have described above, took me almost 5-6 days to review. For biostats here, I revised the FA and also revised Biostats review Qs which I had already done for Step 1, so took me almost 2 hours to do again. I’d supplement anything confusing with FA during this preparation and ensured I understood everything before moving back to solving questions.

One thing that I was worried about during this revision was that I’d be compromising on the questions of the rest of 40% of UW that I was yet to do by already reading the information pertaining to the question in the notes. But what I realized later is, that unless you have read the question before, you are still tackling it for the first time. If you read only the information in the form of notes, you just gain the knowledge like you do with FA before random UW in step 1. So going through notes is basically familiarizing yourself with the extra knowledge that Step 2CK brings. Basically, these notes were exactly like FA to me. So they don’t compromise on what the question tries to confuse you with. You just have extra knowledge that the question bank tests.

3^rd month- Until May 25^th, completed the remaining 40% UW and did some practice tests

So starting from May 1^st, I started doing UW again from where I left it, this time completely random, timed and not according to volumes like before. I did 60-80 questions per day and completed my remaining 40% questions in almost 18-20 days. My overall percentage improved from 72% to 76%. I could see the effect of reviewing notes once and going through OME. I was scoring in 80s and sometimes even 90% in the blocks and overall I was feeling more confident. But obviously these scores were still less than my random, timed Step 1 average. Once I completed UW, I spent the next day reviewing ANKICards I had made of important topics.

On 21^st May, I gave my UWSA1. As I have said before, I was short of time in one of the blocks. I did resume the block and completed the test in more time to get 264 at the end. But I was disappointed by the time management problems I had encountered. So I decided to approach questions by looking at the last two lines of the stem and options before looking at the labs and the rest of the stem. This helped me a lot in reducing the time spent per question but then again the issue wasn’t completely resolved even on my test day. There are some new concepts in UWSAs that are very important so make sure you review them.

I did NBME 8 offline after UWSA 1. Also did CMS forms 3 and 4 of Surgery. I think CMS forms are good preparation for new and unknown concepts not discussed in UW but the questions themselves are of poor quality. They are direct questions that don’t require the multiple levels of thinking like in UW and most of the final exam questions. But I have to admit, the final exam does have some direct scenarios like in CMS or NBME which actually were a pleasant surprise. I didn’t have time to do more CMS forms.

Last month – Until exam in mid of June – Revised notes, simulated exam and flash cards

So beginning May, 25^th I started my final revision of notes. This time I completed each volume of book within 3-4 days which amounted to almost 17 days in total. I used to add to my AnkiFlashCards any new information. Before each system, I’d review the previously made flashcards so that I could know what needs to be added while revising the chapter. I would spend an hour every day to do my marked UW questions.

I was left with 5-6 days before my exam date when I gave my UWSA 2, Free120 and a question block of UW of newly added questions on the same day. This was a recreation of the exam environment as I used a timer to ensure that I don’t take more than an hour break. I had similar eating items that I would subsequently use in my exam and I changed the library so that no one I know disturbed me during it. I scheduled my breaks like I would do on the final exam. I did similarly in Step 1 many times, but here I could do it only once as there is a small pool of practice exams. I reviewed all these questions the following day. And then spent two days completing my marked questions. I did 10 blocks a day, each of which only took 35 min to complete as you already know the answers to most of the questions. I got more 90% in most of the blocks, but there were some that surprised me with relatively low percentage. In the last 15 blocks or so I used tutor mode to save time so that I didn’t have to review the block again once I have solved it. Like this I was able to do and also review a block in an hour. In the last two days, I mainly did flashcards, looked at a few algorithms and also radiographs from UW flashcards that I had made while reviewing UW.

TEST DAY

I am kind of a night owl, and get very insomniac during exam nights. But a 9 hour exam like this requires utmost alertness. To tackle this, I started changing my routine 15 days before the exam. I used melatonin initially to correct my cycle. I took a sleeping pill (a benzo) before the exam night and slept around 12 am to wake up at 5 30 which was good enough for me. I did a trial of the sleeping pill before my UWSA2 and Free120 exam simulation too.

Three days before the test, I developed the flu and had 102F fever. I kept studying during it but I also got apprehensive and called prometric to delay my exam, but they were asking for around $300. I waited till the last day but I still had a lot of congestion but no fever. I used a nasal spray that helped me clear my congestion by a huge margin. I took a jacket with me to the center even in summers to tackle any extreme air conditioning in the room. Btw, according to them even asking for a tissue paper will lead to a report being sent to USMLE people. WTH. So I arrived at the prometric center, there were a lot of CK test takers due to the upcoming change in pool and delay of result reporting. We were placed before step 1 takers and the exam started. Thankfully the nasal spray had done it’s magic and I didn’t even need a napkin during the exam.

I did the first two block in the same sitting. From the beginning, I had a problem with timing, I had 2 minutes for the last 2 questions but was able to do them. Took a break after 2^nd block for about 12 minutes in which I had some tea, a bite or two of the Subway sandwich I had brought along, and a little bit of chocolate. Then I did 3^rd and 4^th block together too. It was a mistake as I got really slow in the 4^th block and I actually missed out on two questions. But I made sure to mark a random response on those two questions in the last 10 seconds despite not reading the complete stem. Make sure you do that. Subsequently, I took a break after every block. After the fourth block, I was a bit down, and also started feeling a bit bloated as I was constantly sipping tea, and so really wasn’t hungry enough to eat the sandwich. I remember I felt 6 inch sandwich wasn’t enough in Step 1, so I had brought a footlong this time. But my appetite was completely opposite now. Anyways, I missed out on a question in another block so make sure you practice time management skills. Oddly enough, my best block was my last block.

Why did I miss questions in my final exam eventhough I was able to complete my practice blocks in time? I believe for most of the exam I was overthinking a lot. I just couldn’t stop myself from doing it. I never leave questions and move on to the next item. So I would stay stuck between two options which were close enough to confuse you. The stems in the actual exam are balanced. There are some very long questions which I would start reading from the last line before moving up, and a lot of short questions that aren’t so prevalent in UW. So the only reason I couldn’t manage time was because of this added pressure that I couldn’t make the wrong choice between the two options because now this was the real exam and not a practice one. PLEASE AVOID THIS IF YOU CAN. Mark your first choice. I also did some questions correct by overthinking and catching a clue at the last second. So it’s a dilemma. I’d mark around 10-12 questions per block but that mark was for my own conditioning to leave the question and move on, otherwise I didn’t get to review them in any block.

What I did that helped me get a good score?

• ·         Wrote question IDs on my notes and went back to them when revising
• ·         Focused on the question stems as much as the answer explanations
• ·         Used uptodate a lot to clear my confusions
• ·         Timed blocks from the start
• ·         Random blocks from the start.. the method I described above for ck was really helpful in making notes too
• ·         Kept First Aid in the loop
• ·         Simulated the 9 hour exam at least once before the real deal

What I did that prevented from getting a better score, closer to my UWSA 2?

• ·         Get the flu right before the exam. Ofcourse I couldn’t control this factor
• ·         Overthinking during the exam. And poor time management. I think this could have given me an extra 5 score definitely. As CK is more about the exam day than Step 1. You can acquire knowledge as much as you want, but that day is very important. Critical thinking is essential.
• ·         Not doing Step 3 questions, which help developing your mind for the multitude of unknown questions coming up
• ·         Not doing CMS for Obs/Gyne
• ·         Gave 15 minutes to 10 questions during each block. But one should aim for 13 minutes to give yourself some leverage for the final 10 questions as they are more stressful.

Lastly, after my mess ups on the last day, and some friends getting bad score around the same time, I was very worried about my result. Infact the wait for this result was more nerve-wrecking than any exam result ever. I am glad I got a respectable score. So I guess I can say that if you have a 260+ in your UWSA and you can calm your nerves during the exam day, you’re good to go for a 250+ score on the final exam. Best of luck!

Electives in USA via GHLO and otherwise for Pakistani medical students

GHLO (Global Health Learning Opportunities) is a program by AAMC which connects different universities in the world to send and receive medical students for Clinical Electives.  Thanks to the efforts of KEMCAANA, KEMU became a part of this collaboration a few years ago. There are medical schools from all over the world, including Turkey, Saudi Arabia and Malaysia but most importantly for us: there are about 8 to 10 hospitals in USA that offer clinical electives through this system. Given that I had not given my USMLE Step 1 exam, I applied to two programs: Wayne State University and West Virginia University, and got acceptance from both.

How to use this GHLO portal?

First step is to register on the website ghlo.aamc.org. Once you are done filling up the form, a confirmation mail will be sent to the home administrator, who in our case is Mr. Rashid in KEMCAANA computer lab. Visit him and he will approve your account. Now access the portal and select the “search electives” tab. You will get a page with multiple filters, just select the country USA and go through the list of all universities that are offering electives. Select one program from each university and go through its information. This page gives detailed information including:

1. The months a specific elective is being offered in. There are also tentative application deadline dates but remember these are not actually followed. The earlier you apply, the better it is.

2. You can get the program details about what you are going to do once you start the elective.

3. You should look up the tuition fees.

4. Some of the universities are more selective: on this page they have written clearly that they will only accept students from specific schools and not all schools listed in GHLO.

5. Make sure you look at the required document list. This gives you an idea whether the school requires STEP 1/TOEFL and whether you have to pay the tuition fees upfront or after getting accepted.

Application process

Once you know you want to apply to an elective, just go down this page and select the button to apply. You will have to upload documents within this page either as pdf or image format. Once you submit a document, you can only change it by emailing the GHLO help desk. So save the documents and submit them only at the end. The “Host school” admin only receives your documents once you submit the final application with all documents and our home admin (Mr. Rashid) has approved your application for which again you will have to contact him. It is stated that you need not contact the host admin/elective coordinator before submitting your documents, but I will suggest that look for their email and do contact them and ask any questions regarding the application.

Some documents which may be required (first 4 are within the packet you get from students office):
1. Transcripts
2. Rotations list
3. TOEFL report/English proficiency letter from Dean of school
4. Recommendation letter from Dean
5. CV
6. Personal Statement/Letter of intent. You might have to submit it before or after acceptance depending on the program. You’ve to state why you are interested in the specific field you are applying to.
7. Criminal Background Check (contact nearby police station in your domicile for this)
8. Immunization reports (different colleges have their own document that has to be filled)
9. Health/Malpractice/Travel insurances (these are required only after you are accepted)
10. Copy of passport

You will also have to pay a $45 application fees to GHLO for each elective you apply to. There may be an additional application fees charged by the university for e.g. West Virginia University requires $50 in addition to the GHLO fees. The tuition fee is paid once you have been accepted. If they accept you, ask the coordinator to send you an official acceptance letter for visa purposes. You can upload the post-decision documents like insurance certificates after getting your visa. You may also have to undergo some sort of training like HIPAA/OSHAA in which you read some guidelines and then complete a quiz to get your certificate. Usually, the program coordinator will send you a link to complete this.

Electives that I identified that we can apply to within the GHLO without the Step 1:

1. West Virginia University: I did an elective here along with another classmate. Requires a $50 application fees in addition to $45 registration fees. Also has a $1000 tuition fee that I paid after reaching USA but they may demand it beforehand.  Last year, they didn’t offer any electives in Internal Medicine so my elective was in Neuroradiology. But now I noticed that a sub internship in General IM and some subspecialties are being offered.

2. Wayne State University:  3 of us from KE got accepted for month of June 2017 but there were a few who applied late and got rejected. This elective had no extra fee whatsoever except for the initial $45. Only Internal Medicine is offered and you can select any sub specialty before starting the rotation. Also, they offer the electives only in May and June, with almost 7 spots for international students. Last year, this elective appeared in the search late in September and they accepted students on first come basis.

3. Boston University School of Medicine: Has a $3000 tuition fee and is not offered in summer months of June, July and August. Offer electives in multiple specialties.

4. Baylor Medical School: Has a $1000 application fees which you send without any assurance of getting accepted. Also requires J1 visa so preferable for those who are US citizens. They also offer some sort of observership without GHLO but I am not sure of the process for that.

5. University of Oklahoma: Appeared in search for a while. Offered elective only in Pediatrics.

6. University of Pittsburgh: Offers electives in a few sub-specialties of IM and Surgery. Tuition fee is $2100. Even though it isn’t written on the initial page but a friend called and confirmed that they do require Step 1.

I identified only these schools not requiring the Step 1 but you may find others when searching so keep an eye out for any new additions. Almost all of the programs will waive off the requirement of TOEFL and accept a letter of proof from dean regarding your English proficiency. Make sure you apply as early as possible for greater chances of acceptance.

Programs outside the GHLO portal we can apply to without the Step 1:
1. Cook County Hospital, Chicago
2. Mount Sinai
3. University of Kansas (Requires TOEFL)
4. University of Alabama
5. NIH (Requires TOEFL with a very good score)
6. FIU (Offers
7. Hope Electives by Dr. Sameer Shafi in Joliet, Illinois

Since students from all colleges can apply, one has to apply almost a year in advance for the above universities.
Those who have appeared in their Step 1 exam before final prof have a lot of other options. I only mentioned places that offer clinical electives but there are numerous hospitals and clinics that offer observerships which can be obtained by emailing different doctors or searching up some contacts you may have in the hospitals all over USA. I would personally suggest that do rotations in programs where you will potentially apply for residency later on. Once you are done with your elective and given that you’re able to impress your attending, there is a greater chance of getting an interview call from the same place.