USMLE & Residency in the USA

- prepared in June 2015

Dr. Prajwal Dhakal

Dr. Ashmita Siwakoti
Dr. Prabhat Adhikari
What is the USMLE?
 Three steps:
 Step 1
 Step 2 CK and CS
 Step 3
 USMLE Step 1 score is a measure of a student’s understanding of
important basic science concepts and the ability to apply that
knowledge to the practice of medicine.
 USMLE Step 2 score is a measure of an applicant's ability to apply
the medical knowledge, skills, and understanding of clinical
science essential for providing patient care.
 http://www.usmle.org/
 http://www.nrmp.org/
 Step 1 and 2 CK- MCQs
 Step 2 CS
 “Hands on” experience
 Patient encounter
 Patient notes
 Step 3
WHY USMLE?
 Higher education
 Research career
 Financial reason
 International exposure & travel , etc
Requirements
 ECFMG CERTIFICATION
 USMLE Step 1
 USMLE Step 2 CK
 USMLE Step 2 CS
 USMLE Step 3(needed for certain visa issues)
 Deans Letter
 Most important letter from the dean is MSPE
 Evaluations from each department
 ERAS Application
 Personal Statement
 Letter of Recommendations
 US clinical experience (added advantage, not a requirement!)
Step 1
 Includes
 Physiology (study in this order)
 Biochemistry
 Anatomy/Histology
 Pathology
 Microbiology
 Pharmacology
 Also
 Behavioral science/ Psychiatry
 Biostatics
 Genetics
 Medical Ethics
Materials for Step 1
 Kaplan books
 Kaplan videos
 Goljan pathology book
 Goljan audio (pathology)
 First aid for Step 1
 Questions
 Uworld
 NBME
 Kaplan
Tips
 Total 6 months of study (on average)
 Take an online exam 1 months prior to exam date to check
your preparation
 NBME can also be used as a guide to check your prep
 Last 1-2 weeks- only first aid/ notes
 Sleep routine (Good sleep is very important)
 Last 1-2 days- Don’t “question” yourself
 Mock test/ Practice materials (e.g. Few blocks of questions
to check time management)
http://www.usmle.org/practice-materials/
Step 1 Exam
 7 sets
 44 questions per section
 Total of 308 questions
 One hour is the time provided for each section
 Personal Breaks:
 Cumulative 45 minutes (during the test day)
 (There is a 15 minute tutorial at the beginning of the exam, which the
test-taker can choose to skip and have that time added to break time.)
 Finishes any section before allotted time limit, unused time added to
break time total
 http://www.usmle.org/step-1/
Exam Day
 SLEEP WELL!
 ID- Passport
 Food
 Water, ORS, glucose
 Chocolates, cakes, juice
 Something “salty” as well
 Eat and drink in almost every break!
 Medicine-
 PCM/ Flexon (Headache)
 PPIs (Stress, Gastritis)
 Propanolol (anxiety), Zolpidem (sleep/ anxiety)
Exam Day
 How to answer questions?
 Usually what you think at first is the right answer.
 Don’t linger too much on ‘hard’ questions, you might not have
time for easier ones
 Long questions- Read 1st sentence, then the last sentence and then
the options. Might help you answer straightaway. Read the full
question to confirm/ answer.
 If you are not sure, chose an option (make the best possible guess)
and then MARK the question.
 Finish each block 5 minutes early and go back to marked
questions.
 Time management is the key!
Personal Breaks
 Not more than 3 blocks (2 on average) continuously
 Take a break immediately after the “hard” block
 Finish as many blocks as you can in the morning time. Things
get slow and blur in the afternoon (after about 4 blocks).
 Block division:
 2/3 (blocks)- 2- 1- 1- 1(- 1)
 Eat and drink regularly, even if you don’t feel hungry.
Step 2 CK
 Basic science correlation – step 1 study
 Major Subjects
 Internal Medicine
 Surgery
 Obstetrics
 Gynecology
 Pediatrics
 Behavioral science/ Psychiatry
 Study for 3-4 months (immediately after Step 1)
 Books
 Kaplan, Goljan Pathology, First- Aid
 Questions- Uworld, NBME, Kaplan, usmle.org
Step 2 CK
 9 hour single-day exam
 8 sets of questions
 Maximum 45 questions per set
 355 multiple-choice questions maximum
 Section one hour long
 Personal Break: same as step 1
 http://www.usmle.org/step-2-ck/
Visa
 Important Documents
 Letter from ECFMG
 Sponsor letter from a person in USA
 Preferably living near to your exam center
 USMLE Step 1 and Step 2 CK scores
 Documents showing adequate financial resources to support
you ( Cash and Fixed assets)
 Timeline for residency match/ NRMP match events
Step 2 Clinical Skills Exam
 “Hands on” Exam
 Tests: Clinical & Communication Skills
 Cases tested represent common and important
situations.
 http://www.usmle.org/step-2-cs/
Step 2 CS
 Book- First Aid
 Most important thing- PARTNER (someone with CS date
close to yours) and PRACTICE
 Time is of the essence.
 Observership/ Externships before CS are very helpful
 Plan well ahead before you leave for US
 Talk to people around you in streets, malls, anywhere!
 Practice and understand empathy
 Work on your typing skills.
Exam Format
 Uses standardized patients (SP) who are actors trained to
mimic the chosen illnesses
 Each encounter is 25 minutes long
 Time spent with the SP will be 15 minutes
 Once door closes, you cannot return.You are no longer
permitted any further contact with the SP
 10 minutes to type the patient note
Patient note
 History and Physical Examination
 Differential Diagonses (max. 3)
 Most likely diagnosis first!
 Findings in support of your DD (positive or negative)
 History & Physical examination

 Diagnostic workup
 Include examination that are not allowed in CS
 rectal, pelvic, genitourinary, inguinal hernia, female breast, or corneal
reflex examinations, throat swab
 Diagnostic studies/ tests
 Do not include treatment, consultations, or referrals
Managing Your Time
Examinee, the encounter may now begin:
 Read Doorway information & formulate DD for 1-2 minutes
 Mnemonic for “questions-to-ask”
 Introduction and Focused History: 6-7 minutes
 Relevant Physical Examination: 4-5 minutes
 Closing and Summary: 2 minutes
 Type notes- 10 minutes
Step 2 CS
 Three components:
 Communication and Interpersonal Skills (CIS)
 Spoken English Proficiency (SEP)
 Integrated Clinical Encounter (ICE).
 Think of Step 2 CS as primarily being a test of your
communication skills rather than a test of your medical
knowledge
 You must pass each section.
 Grade for each section is the average of the 12 cases.
Step 2 CS Grade
 Majority of your final grade will be determined by the
standardized patient, no physician
 Standardized patient will grade your ability and skill to
obtain the focused history, do the relevant physical exam and
identify the pertinent positive and negative findings as well as
your communication/interpersonal skills and spoken english.
 Only the patient note will be graded by a physician
How do you apply?
 Electronic Residency Application Service(ERAS)
 ERAS transmits:
 ERAS application
 MSPE
 LORs
 Personal Statement
 Medical school transcripts
 USMLE transcripts
 https://www.aamc.org/students/medstudents/eras/
ERAS application
 Includes
 Work Experience
 Volunteer Experience
 Demonstrates care for fellow man, interests
 Research Experience
 Publications, Presentations
 Hobbies/ Interests
 Might catch somebody’s attention (if similar interests)
 Can be a topic for discussion during Interviews
 Be truthful
 Explain everything in detail.
Personal Statement
 An essay about yourself. Advertise yourself!
 Explain, with examples, :
 Why doctor?
 Why specific specialty (e.g. Internal Medicine)?
 Your strength/ virtues/ interests
 Goals
 Not more than a page (about 600-700 words)
 Start early- July/August
 Multiple corrections, edits
 Write yourself, let somebody correct errors, if any
Letter of Recommendation
 LORs, at least 4:
 1 letter from the Chairman of Department that specializes in
the residency you are interested in
 e.g. Internal Medicine Residency – need Chairman of Medicine Dept.
 2 letters from the specialty you are applying for
 e.g. General Surgery Residency – general surgeon or surgical specialty
 US LORs
US Clinical Experience
 Observership or Externship
 Not an absolute requirement, added advantage
 More competitive residency programs require 3/6/9 months
 WHERE?
 Mostly through contacts
 Places where people have been before
 Look up contact information on internet (email id, phone number)
and get in touch
 Examples- Brown University, Rhode island; Beth Israel, New Jersey;
Sarah Bush Cancer Center, Illinois; SUNY Upstate, New York
 Advantages- LOR, Communication Skills, Medical Knowledge
Apply
 September 15, don’t be late!
 Programs
 Internal Medicine (most common)
 Pediatrics
 Family Medicine
 Neurology
 Psychiatry
 80-100 programs
 lists from the people matched last year
 Programs mostly in NY, NJ, PA, IL, OH, MD, MA.
Interviews
 September- February
 Ask seniors about how interviews are carried out
 Figure answers/ write notes about how you will answer the
typical questions, e.g.
 Tell me about yourself
 Experiences in Nepal/ USA
 Health system in Nepal vs. USA
 Specific things on your application
 Practice with friends, yourself
 Book- (I forgot the name)
Interviews
 Plan while you schedule interviews
 Know everything mentioned on your application. Be ready to
explain anything, if asked
 Be prepared and confident.
 Make notes about how interviews went, try to improve every
time.
 Note what you thought about the program after interview (will
help you while preparing rank order list)
 Look for opportunities, even while waiting for interviews.
 Observerships/ Externships
 Research opportunities
 Publications/ Presentations
Match
 Rank order list
 Prepare the list in your order of preference
 (Forget your interviews)
 Match Results – March
 SOAP
 Residency Begins – July 1
 Step 3
USMLE
 Why is this exam so important?
 One facet of applicant qualifications considered by program
directors
 Only one that is comparable across applicants, and available
during the interview season and prior to the NRMP’s ranking
deadline.
 Scores generally are higher for the more competitive specialties,
but there is substantial overlap when specialties are compared.
Evidence
 How We Select Our Residents—A Survey of
Selection Criteria in General Surgery Residents
 George Makdisi, MD,*† Tetsuya Takeuchi, MD,* Jennifer Rodriguez, MD,‡
James Rucinski, MD,* and LeslieWise, MD* *Department of Surgery, Weill
Medical College of Cornell University, New York Methodist Hospital,
Brooklyn, New York, †Department of Surgery, Albert Einstein
University, Beth Israel Medical Center, New York, New York, and
‡Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, Pennsylvania
Methods
 36-question survey regarding resident selection and
the interview process
 Surgical program directors
 Department chairs
 Associate program directors
 USA & CANADA
RESULTS
 Population:
 262 valid replies were received (65%),
 83% were program directors
 University hospital programs (49%)
 Total of 96% of all programs have female residents,
 66% have non-Liaison Committee on Medical Education graduates(
THIS IS US!)
 38% have Doctor of Osteopathy (DO) residents
 Mean yearly applicant number/ program 571
 82% Indicated that they strictly adhere to their selection Criteria
 62% of the time screening selection is made by the program director
 Only 31% of programs show their selection criteria on their web page
Results
 United States Medical Licensing Examination
(USMLE) Step 1 is the single most important factor
in screening criteria (37%)
 followed by USLME Step 2 (24%)
Results
 Final selection is made by the program director in 49%.
 Although research experience is considered in selection
criteria (80%)
 Only 46% of programs offer research opportunities to their
residents and only 13% require 1-year of research.
 On a Likert 5-point scale, interview is by far the
most important factor (4.69), followed by Step 1
score (4.21), and letters of recommendation (4.02).
Conclusions
 Even though all general surgery programs have a wide
range of screening/selection criteria, USMLE Step 1 is the
single most important factor for preliminary screening, and
the interview is the most important factor in determining the
final selection. The final selection is relatively subjective and
based on a combination of interview, USLME scores,
research experience, and personal judgment.
How to Study for the USMLE?
 Commit to your decision to train abroad
 Get your mind right! Be motivated!
 Learn everything you can about the USMLE
 Forums: http://www.usmleforum.com/
 Other students
 Mental Stamina
 DO WHAT WORKS FOR YOU
 Adapt
Motivation
 Whatever it is… find it
 Money
 Success
 Personal
 IT DOES NOT MATTER
 This will get you through months of studying for the USMLE
PLAN
 GOALS?
 Specialty? Competitiveness?
 While you study,
 Learn It well the first time!
 Understand the material & memorize the terms
 Understand Clinical Correlation
 Set aside time each day for one question block
 Doesn’t have to be 46 questions set
 10 – 15 questions per day
 Group study (or1-2 friends at least)
Recommendations
 Group study (or1-2 friends at least)
 Make routine and adhere!
 Positive Attitude
 Laugh Frequently
 Frequent breaks
 Always remain diligent
 Teach other people
 Do no give BAD advice; every one’s on the same team!
GOOD LUCK!