by Ayaz M. Khawaja

Salam to every reader. Let me start in God's name whose blessings have been innumerable. My score is 268/99. This article would be a fantastic review especially for those candidates who wish to maintain their Step 2 study in parallel to their final year curriculum. It is highly advisable that you do this since the content is not too different and the USMLE curriculum gives a much greater stronghold over medicine and related disciplines rather than your own final year curriculum. This holds especially true for Pakistani medical students. I am not too sure about the situation for Indian medical students.

Let me start by reviewing some issues the same way I did for my Step 1 article.

Issue # 1:

Give Step 2 before Step 1?

I have heard this question a lot more than I expected, especially from students who thought about giving Step 1 before or within their final year but changed their minds. The answer to this question is highly relative and circumstancial. There's no easy answer however.

If you are at the beginning of your final year, and are serious about Step 2 preparation, I would strongly recommend attempting Step 2 before 1. The reasons are multiple. You have a full 1 year ahead of you for Step 2 preparation. You have just come off the fourth year with a strong background (hopefully!) in Pathological basis of diseases, Histopathology, Pharmacology and Microbiology. It would not require any extra effort other than a once-a-time revision of your old textbooks and/or notes which should not take much time. If you have studied the Kaplan series, this means it would be even more efficient time- and effort-wise to go through these subjects quickly.

The only problem would be psychiatry/ethics/biostatistics; however this is almost as much a problem as is during your Step 1 preparation so that leaves not much difference. Spend time carefully on these topics given that you have a full year ahead of you. Remember Step 1 content is heavily tested/incorporated in the Step 2 exam so much so it would feel highly uncomfortable during Step 2 exam to not be atleast well versed to some extent in Step 1 syllabus. If you don't know which nerve/vessel is vulnerable to injury due to midshaft fractures of humerus, or which nerve root you are testing while eliciting knee jerk reflex, then the Step 2 exam is not for you (sorry for being blunt). These are very basic things that do not qualify as rocket science to any degree yet. If you give it some thought, this knowledge is extremely important for your clinical setting so you are to be fully expected to know some very basic anatomy. Don't be intimidated because you would not be tested how beautifully (or erratically - whichever term you prefer) the trapezius inserts into the spine of scapula. But you will definitely be tested how to check the functions of cranial nerve 11. A lot of your general surgery questions would be testing very basic anatomy. If you still do not feel comfortable, simply give a quick review of Kaplan's anatomy textbook. It shouldn't take more than 10 days. You can skip on histology if you like. Be very knowledgeable about neuroanatomy. Yes this also means you would need to know atleast something about Meyer's loop en route to visual cortex.

Biochemistry may also be sporadically tested. But sufficient information is already available in your Step 2 syllabus, such as galactosaemia etc. It would be quite rare for you to be tested on something like Electron Transport Chain so don't worry about that.

Physiology may also be sporadically tested but remember most of that is incorporated already in your Step 2 syllabus. You do not need to go through the whole syllabus over again.

Other than that, you're all set. A full year ahead, and a syllabus that matches your final year curriculum; do not let this golden opportunity slip besides you.

If you are during the end of final year, I suggest you drop the Step 2 idea. You must not attempt this exam in a haste. It will hurt you badly. If you are one of those who have done their final year and internships already and thinking about taking Step 2 first, my recommendation again would be to simply go through Step 1 first because there's no guarantee you remember any of that very basic stuff.

Issue # 2:

Can Step 2 score eclipse the low score of my Step 1?

Oh yes, to some extent, definitely. The opposite is also true; your high score in Step 1 can improve the outlook of your low score in Step 2 provided the discrepancy is not too noticeable.

However this raises another question: How important are the Step scores these days anyway? That over the recent years has become an important concern because it appears that the Step scores are no longer indispensable. You might have heard stories of how someone with only double 90 got a residency in a competitive programme and a double 99 only managed a lousy one with the difference being the experience and contribution to research, good letters etc etc (insert whatever you want here - experience in handling rats counts, or even mobile phone repairing, fixing computer hard disks or perhaps plumbing provided they're done in a lab. Having a pet at home doesn't score you anything, however).

Clarification: In a recent meeting with a programme director, it appears very high Step scores do infact favour you quite highly. In the words of the director: "For a competitive residency programme, high Step scores clear at least one obstacle effectively". But the rest still holds very true. It's just one part of the whole spectrum.

My advice? Stop spending 2 years on USMLEs while sitting home. They're not worth that anymore in today's world. Get them done and dusted during your medical school. There's a whole new world awaiting you after your graduation.

Issue # 3:

Step 2 is much easier than Step 1

It's alright if you want to think that way and would be content with an average but if you're talking 240's, things get quite tough. If you're thinking about delving into 250's, it gets quite more difficult, 260's are another very tough territory and 270's a not so manageable place. This pattern also holds true for Step 1. Provided you are well prepared, these are very easy exams and they're tougher to fail than to pass but if your ambitions are to jump into the high 3 digit territory, all of a sudden the whole outlook of your preparation dramtically changes. I personally found Step 2 more challenging than 1 but this possibly could be because I had only two months after my final exams to prepare for Step 2. They turned out to be sufficient but quite intensive.

It's always worth spending that extra bit of time and effort into every step you take in life on your road to a successful career (2 years preparation timeline does not however qualify as an extra "bit" of effort). Like I said, get done with these exams quick, but not real quick. Just be moderate and modest. Step 1 shouldn't take you more than 7-8 months if you could only skip on watching a 2 hour length movie every day. Video gaming is fine (I am saying this because I like that and would happily spend 2 hours every day for gaming). Choose whatever lifestyle you like. But don't tell me it would take a full one year of preparation for Step 1 even if you are studying for 6-8 hours every day with Sundays off. In this case you are overdoing it. You are spending a lot of time on something that would only be *ONE* factor that would be assessed by the residency programme director. Another factor is your Step 2 score, then your number of attempts at CS, then research, then letters, then personal statement, then even research may have different parts (lab/clinical settings), internships, US clinical experience etc etc.

Again my advice? The same as the one in the previos issue.

Another advice: Stop wasting time on societies in your medical school. They're a major distractor. They're evil. They suck up a lot of your time in exchange for poor learning and poor creativity experience. There are an incredible number of different ways how you can so wonderfully spend this time on other stuff and have a great return. Video games, research?, USMLEs during medical school, internships, other random stuff involving creativity and critical thinking (think of any such thing yourself - even programming competitions would count but I know only very basic level C++ so let's just forget that).

I feel extremely embarrassed when I have to answer a question from a student that asks me if their experience in Kemcolian Arts and Photography society as a public relations officer or Class Representative or simply someone who bore the burden of arranging the multimedia equipment during a seminar gone almost wrong would help them in their selection to a Diagnostic Radiology programme at a reputed American Hospital. Oh, it might if you are a direct descendant of Pablo Picasso or artwork's selling for hundreds of thousands of dollars and being displayed inside Cleveland Clinic. If you're not any of that, it's only better for you that you don't embarrass yourself displaying how you managed a Kemcolian Dramatics Society political or physical fight in a very diplomatic fashion or how you went every day (like an idiot) to practice the work of acting for 4-5 hours for two months, only to be booed and hit by audience' airborne shoes (insert tomatoes, apples, banana skin as you like), in your Resume.

{As I think of other issues, I would insert them here. Stay tuned. Ask questions in the comments and I would incorporate them here}

Resources to consider for your preparation:

1. Kaplan medical textbooks:

This is the single most important resource to use for you for your preparation. It is more than sufficient for all practical purposes, including landing you a 99. The beauty of these books is that they also help cover your final year curriculum (especially true for King Edward).

Stay loyal to these. Study them carefully.

However here's some bonus help to aid BOTH your final year plus Step 2 study smoothly.

General Surgery:

This is one place where Kaplan may be considered insufficient to some extent as a lot of jargon knowledge is expected of you in your final year. You are expected to know types there exist of gastro-duodenostomy when this type of knowledge bears absolutely no clinical common sense, whatsoever. You are even expected to know different types of flaps used in Plastic Surgery (as if you are EVER going to attempt that in your clinical practice unless you're a plastic surgeon). But life goes on. Here are my suggestions: Get hold of Ellis Surgery. It's a British textbook and although I hate British textbooks, some I do make exceptions with and this is one. It gives a very nice overview of General Surgery. The author inadvertently descibes an ideal student in his preface as one who has extensively prepared detailed lecture notes and has his Bailey and Love almost raped (the textbook; not the doctors). I completely and vehemently disagree with this sentiment, calling an ideal student someone who is very clever to prepare a large amount of medical jargon plus critical knowledge in the shortest period of time possible. Remember your role as a medical student. Your purpose is to pass the exams with the best scores possible. Don't fool yourself into thinking how caring and gentle you should be towards your patients. How much patient care would you actually ever do during your medical studies? This is a golden time to get rid of all your examinations. Get them done and dusted. If you have already bought Bailey and Love and are thinking about mastering the art of General Surgery, you are more than welcome to waste your life on it. But this won't ever let you get through your Step 2 exam ever without the realistic possibility of actually failing it!

Other suggestions which I absolutely hate to give: Some Pakistani textbooks. Try to study them briefly only for important topics, as a good time/effort wise confrontation with Ellis Surgery would save a HUGE chunk of your time.

Remember always to keep your Kaplan handy. No other book can ever explain trauma, general aspects of General Surgery and some knowledge about specialist surgeries including Orthopaedic Surgery. Trust me, you can study the whole Bailey and you still cannot tell me the step-wise management of Carpal Tunnel Syndrome, or scaphoid frature. Assured.

I studied a bit of NMS Surgery during my ward and I found it to be a significantly strong textbook interms of explaining surgical concepts. This book also has a lot of images, illustrations etc to aid your understanding. Although the information provided in this textbook is more than what you require for your Step 2 exam, it still offers great help for your final year curriculum as well as your General Surgery ward rotation in your school.

Remember a lot of anatomy knowledge is tested in the General Surgery subsection. The next most commonly tested topic is trauma and orthopaedics. Make sure you have very clear concepts on these topics and your facts will need to be very specific, for instance a Monteggia's fracture will need to be internally fixated and the displacement it causes will undergo external reduction. It's clearly written in the kaplan textbook and you must learn it and you will be tested. Anatomy is quite simple as long as you have good concept. For example, a good understanding of peripheral nerve lesions is required to answer the many questions you may be asked on the exam. The same goes for the many different ligaments of the knee joint and the menisci.

Medicine:

Davidson is one of the worst textbooks I have ever ***tried*** to study and failed terribly. The authors do their maximum best to dilly dally their way in explaining important topics and still won't deliver what you absolutely need to know. They won't mention something as important as the association between dermatomyositis and malignancies, or the urgency there is in management of suspected temporal arteritis but they would tell all the genes ever discovered ever since Watson and Crick found out DNA and would explain how intricate the chemical signalling cascades are everywhere in the body, but won't tell you how to manage a patient with Duchenne Dystrophy. I mean, why the hell would I as a physician be concerned with the race to discover a multitude of genes in different diseases unless I am personally involved with that research? Just tell me the damn step wise management and the drug which is all that would help you in patient management.

I don't know Kumar and Clarke, but given the fact they're also British, you can expect them to be almost as much gibberish as their counterparts. You simply cannot afford to waste your time on unnecessary details.

Still I like the compactness of Oxford Handbook of Clinical Medicine. It helps you in those areas slightly where Kaplan might be deficient in covering your final year syllabus (which is really very scarce). It's really not that great a book given the fact it has a tendency of giving you just about every symptom and sign of Acromegaly that exists in the world, but won't tell you something as simple as the fact that Trans-nasal Trans-sphenoidal Surgery is almost always a first step in cutting out pituitary adenomas secreting Growth Hormone. It won't tell you that Bromocriptine is always first step in managing prolactinomas. But still it has some nicely arranged different sections. I particularly liked the sections about heart sounds, clinical chemistry, radiology etc. Keep that handy for your wards.

And of course your ultimate champion: The Kaplan's internal medicine.

During my review of internal medicine, I had to heavily use Kaplan Pathology. As expected, some topics are omitted which may be tested on exam. This includes Behcets syndrome, Takayasu Arteritis, Thromboangiitis Obliterans, Viral Oligoarthritis, Psoriasis pathophysiology, Acne Vulgaris etc (I would include more topics as I recall). Use other textbooks or Wikipedia to better cover these. Evnetually your Qbanks would also help expand on these.

Gynaecology and Obstetrics:

Ditch your Ten Teachers. Actually I didn't even study it because I could already smell gibberish off of it, or maybe because it was an old rotting textbook in my bookshelf. Who knows.

Your Kaplan's textbook is going to score you highly, both in your step 2 and your final year exam. Assured.

Some topics in your Kaplan may have been omitted. For instance in high volume dysfunctional uterine bleed, you need to administer IV oestrogen. This fact may be frequently tested on exam. For low volume bleeds, NSAIDs or progesterone do help. Ovarian and uterine hyperstimulation have also been omitted. But you may refer to any other textbook such as First Aid (a rare instance in which it has proven useful to some extent), or even while doing your Kaplan Qbank and USMLE World Qbank, you would eventually end up covering it so just make sure you write it somewhere in your notebook for later reference before your exam. Another topic I can recall is hyperemesis gravidarum. For breast diseases, just make sure you also study the concomitant topic given in your General Surgery textbook in order to ensure comprehensive understanding as both books tackle slightly different aspects, even though this group of diseases is actually managed by General Surgeons and not Gynaecologists.

I pity those who study that amazing Pakistani textbook counterpart of Ten Teachers. I mean guys, come on we both passed, right? Alright maybe you scored a distinction and I didn't but we all know how much distinctions and societies like the amazing KAPS go hand in hand when you enter the American medicine circle.

Paediatrics:

You might despise that Kaplan textbook slightly. I did too initially. I thought compared to other books, what's this? Is all that information even relevant? Trust me, it is. This book's role in helping you through your Paediatrics section is more critical than other textbooks. You might feel how much bullshit it has written about obscure diseases but every now and then, they turn up in the exam and then you are unconsciously thanking Dr. Eduardo Pino in the back of your head. Even if you don't like it, study it. There are no two ways around it. Don't go after ready-made platters of Paediatrics review books.

I tried studying the smaller version of Nelson's Essential Paediatrics but failed. It required too much effort and the output was poor. This is RARE for an American textbook (compare Levinson's Microbiology for instance, how much a wonderful textbook that was. Worth EVERY second you spent after it).

And of course, there's another Pakistani counterpart. I got only one thing to say: "Hahahahahahaha nice try biatch". You wanna study it? Go ahead. You are not doing me any favours.

Psychiatry/Ethics/Biostatistics:

These topics are extremely critical. If you underestimate them, they will severely hurt your Step 2 score. It is worthwhile spending mroe time on it than on Gynae/Obs, Paeds. The psychiatry cases are a lot more tougher in Step 2 than in Step 1 and frequently the differential diagnosis is varied and sometimes obscure. You have to have the mastery of psychiatry.

The Kaplan book is good enough. It's good for ethics and Biostats too. The Biostats would be pretty easy if you have already done Step 1. Otherwise I suggest going thorugh High Yield Biostatistics for the new USMLE takers. IT should take about 2 days to master it. Worth that. It explains you everything nicely, including what p value actually is (Kaplan explains it poorly but if you already have the concept, it gives you a beautiful overview of it).

Ethics should be useful. Some suggest doing Conrad Fischer's ethics book. I didn't do it. But I still suggest it since that guy is great anyway so all his material should go along with his awesomess.

Oh and besides, the Psychiatry for final year is really, what they call a halwa. No problem. Just study Kaplan and you'd know much more psychiatry than some self-proclaimed free-thinkers of your class might claim themselves to be, the masters of understanding human mind and philosophy.

Just make sure you go through psychiatry cases again and again. You might consider using some other textbook series (Blueprints perhaps?). The exam would frequently try to confuse you with broad differentials. In a seemingly simple case, it may be very challenging to differentiate anorexia nervosa from bulimia nervosa. As you may recall, both have specific criteria that you must learn. If they do not meet the criteria, the diagnosis is actually "eating disorder not otherwise specified"! The same holds true for mood disorders and examiners would love throwing all sorts of confusing actual life situations at you, with again a very broad differential that may include dysthymia, rapid cycling bipolar, seasonal depression, mood disorder not otherwise specified. In order to tackle these, you must learn the criteria by heart. Same holds true with childhoold mental disorders. You must be able to differentiate between Rett disorder, Childhood disintegrative disorder, Autism, Aspergers and Pervasive Development disorder not otherwise specified.

That's how psychiatry is. Tough luck buddy. Get down to cramming all the criteria. Kaplan has it all so that's why I repeatedly stress and request that you should ditch your weighty textbooks in favour of one that lays out this pattern beautifully infront of you.

Ethics is almost the same as Step 1. Usually it may be a hit and miss. Biostatistics is also almost the same as Step 1 and provided you have clear concepts, there's really no biostats question you should get wrong in your exam. It's really not that tough.

Kaplan's Qbank:

You might hear some not so great reviews about it and they are true to some extent. But I suggest using this early in your coursework. Important. A bit expensive but they help you a lot consolidating your Kaplan study since most of the questions are based off of the correlating textbooks. Regular fact reviewing helps fix them in your long term memory. Recall is also very important in Step 2 as it is in Step 1.

- Use early in your coursework. Use during your regular final year study.

USMLE World:

Oh this really is what the whole Step 2 exam is about. I purchased this subscription in the last three weeks and my suggestion is about last month actually! Why? Because it's just so important! Don't purchase it earlier and end up wasting it. Keep that for that one last month that counts so much to improving your Step 2 eventual score.

For 110$, you get not only a month's subscription but also the U world Self Assessment Exam (save 20$). I found that to be veyr nice. My scores in UWSA and Step 2 were both the exact 268.

First Aid:

This books feels like a bunch of nerdy head-scratching dandruff-inflicted chronically insomnic (some with athlete's foot too) and overworked medical students compiling their personal medical notes derived from those big textbooks (remember Nelson's?) into a regular textbook. It's not as bad as I describe it to be, but it's not worth your time if you are as pressed on a race against time as I was. Even though the authors, as a formality, advise against using it as a primary coursework, I still won't recommend it. It's much better to study Kaplan in a detailed fashion and complement it in every way possible in that one last month with U world, and Kaplan Qbank during regular studying.

Probably the faculty reviewers were more interested in drinking their morning coffee than reviewing the book. The same holds true for the regular first two authors who though tthat perhaps the success of their first aid series exempts them from quality control.

Several times you would notice First Aid has ripped tables from big weighty textbooks (with permission of course) but have done extremely poorly in explaining these making it an extra burden rather than truly being "first aid". It's better it simply ignore those tables if you want to review this book.

Your kaplan books are written by expert faculty doctors. Learn what they have to say.

You can use it if you wish but just make sure you do that in the initial stages of your study to complement Kaplan. Don't spend extra time on it in the last month.

USMLE Step 2 Secrets:

Written by an author who also ended up writing Crush Step 2 (for some weird reason), this book comprises a series of questions that precede some facts presented in the form of an answer. It was actually a very nice book as it explained facts in a concise, yet almost-comprehensive manner which you can easily cover in less than 2 days. Maybe you might want to study it in the last three days or early, and add that knowledge to your Kaplan books. Whatever your choice be.

Definitely recommended ,especially over First Aid.

My personal experience:

Because I had attempted the Step 1 exam in June last year, that left little time to give the 2nd part before my exams. Also that I went for electives, this took out even more. So the plan shifted till after the exams, by taking 2 months of dedicated study. During my routine studies, as I already stated in the resources information given above, I would frequently use the Kaplan textbooks and add some supplementary material (the textbooks have already been stated above). This continued into the exams, with some study of the Kaplan Qbank as well but only sporadically.

As soon as the exam ended I picked up the Kaplan Qbank and went through all of it. I don't exactly remember my percentage. Perhaps around 82% but not entirely sure. It helped me consolidate my facts and add some extra knowledge, for instance neutropaenic fever which is also relatively frequently tested in Uworld.

Once that was done in about 3 weeks, I picked up the Kaplan books for one last detailed reading along with some extensive study sessions of the Psychiatry section (which as I already stated demands more attention than the content quantity given in it). This took about a little less than 2 weeks. With 3 weeks left till exam, I had attempted the sample Step 2 exam from usmle.org but I don't remember my percentage unfortunately. Then I made the decision to purchase U world subscription plus self assessment form. I did both U world with sporadic study of Kaplan books. I did it all first time, all blocks timed without any tutor mode (what's that by the way? I never tried it). Initially the percentage hovered around 72-73% but then significantly improved to 79% as I started taking it more seriously. I always took notes from explanations in my notebook and always went through all explanations, whether incorrect or correct.

With 5 days, I took the exam of UWSA. There's only one form. I scored 268 on it. I also did nbme forms 3 and 4 offline (illegal - don't be so bold about it) and didn't mark them. They were only to get an idea of what goes on it the mind of an American examiner. As per the suggestions of other candidates, nbme form 4 is the best to give. Form 3 is a bit of a hit and miss and the questions seemed not too clever to me, rather more like too factual and obscure. Let's have your inputs on the different nbme forms in the comments so that I could add that to my article.

Last 2 days: My notes in notebook, Step 2 secrets, some Kaplan, heart sounds and that's all.

Last night: Full of fun. Went to sleep at 7pm, or rather attempted to go to sleep. Eventually fell to sleep at 12am and woke at 6am. Once again sleep deprived. For some reason the insomnia always hits at the worst times even though I was not the least bit afraid or anxious of the exam. Just like Step 1, it was more of a fight to stay awake during exam rather than fight the exam itself. Fun stuff. Panadol extra and Red Bull did help to some extent. Panadol extra has extra caffeine in it (no amphetamines; don't worry) so it does help. Recommended.

This reminds me of CTs, MRIs, histopathology, ECGs etc. Uworld helps you a lot especially the ECGs. I suggest that if you don't feel comfortable with ECGs, pick up some book like ECG made easy and study them. You are given a whole ECG strip with all leads in the exam and you need to make a very quick assessment of the ECG tracings. For images, just search through google and also use Webpath. Refer to my Step 1 article for more details.

Exam: It started relatively fine but until blocks 4, 5 and onwards, the exam progressively got increasingly difficult and frustrating. They always find a way to capture your imagination and cause frustration. They're very clever. But don't fret. Provided you have followed a well balanced study plan, you will get a 99. It's not at all difficult to get a score in 230's, but as you want to go higher, it becomes increasingly troublesome and challenging.

My study timeline: About 4-4.5 months effectively. There were many breaks as you can imagine with any major exam getting fit into it. Maybe if I could have added 1-2 months, my scores could have improved? Possibly but not worth it as I had my electives pending my attention.

What you should do during your study?

Step 2 requires you to be very specific during management. You cannot beat around the bush. You need to be aware of following issues:

- What's the next best step in diagnosis? (Means what's the best initial step. (PSA Levels for suspected prostate cancer, based on the finding of a hard prostate nodule on DRE)

- What's the overall best step in diagnosis? (Possibly refers to gold standard). (Trans-urethral ultrasound guided prostate biopsy, for the above case)

- What's the next best step in management or treatment? (what's the best initial step -> Evaluate for metastasis and do clinical staging depending upon local extension, involvement of capsule etc).

- What's the best overall step in management or treatment? (TURP for local cancer; any of GnRH agonists/orchiectomy etc for metastatic cancer; none if age greater than 75 as these cancers are slow growing and surgery itself may cause more morbidity and mortality [Consider radiation perhaps? Definitely irradiate if there are blastic metastasis to spine])

So basically that's the way to arrange your study. Be very very specific. For prolactinoma, you cannot answer: "Surgery, radiation, chemotherapy, bromocriptine". This is beating around the bush. Your first step is always dopamine agonists.

Important note: If you wish to use this article elsewhere on a different forum, please acquire my explicit permission at dr.ayazmk@yahoo.com. I would definitely not deny it, but I would really appreciate it if you would get this formality done. Please also note that while commenting, give a brief introduction about yourself as it gives a good impression. Thank you for taking your time out to read this article. Anything you want added to it, please write so in the comments section and I would incorporate it into the main body.

{This article would be continued at a later time}.