USMLE Talk Thomas Cotter
Outline • Overview of required Residency portfolio • USMLE Step 1 • USMLE Step 2 CK • USMLE Step 2 CS • US Electives • Research • Residency Programs • Other issues • Other options
Overview – Residency steps (Bigger picture) • ECFMG Certification: USMLE Step 1, USMLE Step 2 CK, USMLE Step 2 CS, Medical Diploma • Class ranking • US Electives/Letters of Recommendation • Research • ERAS application (Scores, Ranking, CV, LOR, Personal Statement, Publications, etc). Apply to Programs. Do interview. Participate in the “Match”
USMLE Step 1 • Why do it? • NEGATIVES: - Time - Cost - Stress - Does not help NUIG grades (Maybe in MCQ and long case in Final Med only) - Lessons from UCC
Do not do it to “keep options open,” or “because X is doing it and I can’t leave X get one up on me” • Do it if genuine interest in training in the States or have interest in broadening your understanding of medicine in the long run.
Word of caution PASS RATE: • High failure rate in the past. Has improved drastically in the last couple of yrs Reasons for failure rate: - Studying wrong material (not focusing on HIGH YIELD topics) (BRS books, etc . . .wrong approach, need to do Qbank very well) - Gulf between Galway syllabus and USMLE (naivety??) - Not giving oneself enough time/lack of motivation (Summer distractions, etc)
Step 1 Overview • MCQ: 7 x 1 hr blocks of 46 q’s (322q’s). Hour break interspersed. • (http://en.wikipedia.org/wiki/USMLE_Step_1, First Aid Book) • Pre-clinical (Questions clinically orientated) • Anatomy, embryology, behavioral sciences, biochemistry, genetics, microbiology, pathology, pharmacology, and physiology • Asks why, not what. Two step thinking. • STUDY TIME: Minimum 8 wks, ideally 10 to 12 weeks • Application process: Start early. www.ecfmg.org (via OASIS). Takes about 4 wks to complete it. 1. Need to pay and register first (about e750), 2. Then go through the school office for verification (I-94), 3. Finally can complete application when ecfmg approve your I-94. You will then receive your scheduling permit. (If going to Academy in 3.2, would be prudent to sort it out this side of Christmas if you are certain you are doing it) • Book seat on www.prometric.com. Available in Dublin (8 seats), London, • Time limit of 7 yrs to pass all 3 parts for ECFMG Certification
Resources • Audio Lectures: Goljan Lectures, Kaplan Audio Lectures (specifically biochemistry, pharmacology, behavioral sciences) (Physiology??) • Textbooks: First Aid, Rapid Review of Pathology • *NB* QUESTION BANKS: USMLE World (Use as a learning tool, “Tutor” “untimed” mode, Do the relevant blocks as you study the subject. Can do “timed” and “random” closer to the date to get into exam mode). Start Qbank straight away in your study. • SELF ASSESSMENT EXAMS: USMLE World have 2 (cheaper if get when buying Qbanks), NBME (www.nbme.org) - Comprehensive Basic Science 5, 6,7,12,13. (Score only, does not provide explanations). Very useful though. • Ancillary texts: Secrets Step 1 • Make out a study timetable and try to stick to it as much as possible.
Other resources • Pass Program (Dr. Francis) – Avoid at all costs • Kaplan Qbank??? – Definitely not in same class as UWorld but may help re-inforce commonly tested concepts. Probably overkill. • Commercial Review courses available like “Doctors in Training” can be useful • BOTTOM LINE:USMLE World Qbank, First Aid are essential and you will pass comfortably if you go through these very well.Goljan and Kaplan videos will increase your score further, as will self assessing yourself a couple of times and improving your evident weak areas. It all depends on how well you want to do.
Exam Day • Bring food (bananas, fluids, etc) • Comfortable clothes • Skip tutorial to get full hr break • Fine tune your tactics: Example = • Block 1 & 2 together - 10min break - Block 3, 10min break - Block 4, 10min break - Block 5, 20mins break - Block 6 10min break - Block 7 • (Probably will finish blocks early which will lengthen your break time)
When to do it? • Summer between 3MB and 4MB – optimal time as will have more optionsfor US elective during summer between 4MB and 5MB. • However, early final year can also be a time to consider (2 students just did it in our year and did excellent). The longer you wait the more knowledge you will have acquired and the better you will do.
What’s a “good” score? • The US national mean score is 225, an increase from last year’s mean 221. IMGs mean is usually around the 212 mark. • Many top residency programs use a "cutoff" score for Step 1, below which applicants are unlikely to be considered. Most other residency programs follow a similar "cutoff," but will allow consideration of applicants with significantly higher Step 2 scores. (Is 230 the golden number for some programs??) • Only 3 digit is now reported to the Programs, 2 digit is now more or less obsolete
USMLE Step 2 CK - Overview • Eight 44-question sets (352 multiple-choice questions in total). (30 more than Step 1) • Internal medicine, obstetrics and gynecology, pediatrics, preventive medicine, psychiatry, surgery. • Usually NUIG students do it a couple of weeks after they graduate. 1 student in our class did it last summer, I plan to do it in January. • Some programs may give Step 2 CK more weight in comparison to Step 1 as it is more relevant (e.g. IM, Paeds, etc) • Need to do well, generally the average score is about 230. Score needs to correlate well with Step 1 score and should be at least 6 or 7 points higher. A high Step 1 score and low Step 2 score will set the alarm bells ringing for the Program Directors.
USMLE Step 2 CK • Resources: - Videos: Kaplan Videos - Internal Medicine (Conrad Fischer - excellent), Surgery (very good), Paediatrics (good), Obs & Gyn(excellent). Psych not great. - Books: Master the Boards (Fischer) (For IM and Surgery consolidates the Kaplan videos), Step up to Medicine (Excellent book), First Aid Step 2 CK (Paeds, Obs, Psych all useful) - USMLE World Step 2 CK Qbank - ESSENTIAL - Ancillary Text: Secrets USMLE Step 2 (helps re-inforce commonly tested concepts, Bed time reading)
BOTTOM LINE FOR STEP 2: Unlike Step 1 there is no perfect book (like First Aid Step 1). USMLE World Qbank, MTB (for IM & Surgery), First Aid Step 2 CK (Paeds, Obs&Gyn, Psych) are the essentials and you should do well if you cover these thoroughly.
USMLE Step 2 CS • Can only do it in US (Philly, Chicago, Houston, LA, Atlanta) • 11 or 12 patient (Standardised patients) encounters: examinees take a history, do a physical examination, determine differential diagnoses, and then write a patient note based on their determinations • 15 minutes to complete each encounter and 10 minutes for the patient note for a single patient encounter. • Easy exam to pass: 96% US student pass rate, 75% International pass rate (lack of English fluency main issue) • NB: It’s only PASS/FAIL therefore doing well in it not important as only the “PASS” grade is reported to your program not your performance. BUT WOULD LOOK TERRIBLE IF YOU FAIL IT. • Advice: First Aid only resource required. Practise doing focused clinical exam (Focus on the involved system plus always do a quick Cardio, Resp and GI exam), practise typing up note in 10 mins. If you do a US elective make sure you do it to get it out of the way while over in the States.
US Elective • Consider during Summer before Final Med • US electives are intense. Personally, I would advise you to do them only if you are genuinely interested in working in the US. I did two electives: Mayo (Mn) and San Antonio (Tx). Great experience but really long hrs. 6 days a wk, 6am-6pm mostly. • AIM: Secure a Residency interview and LORs • Firstly, decide what type of elective you want to do/preferred location/amount you're willing to spend, etc.
Start elective portfolio early and get all your documents in order, both as hard copies (have plenty of photocopies) and as electronic copies (preferably pdf files). Most hospitals look for a standard set of documents. Your portfolio should include: CV, immunisation details, USMLE score transcript, School transcripts, personal statement, Personal Health Insurance, Letters of reference, photo). A lot of effort and stress involed. • The whole point of a US elective is to try to secure interviews for US residency so I would urge to choose places that you genuinely can see yourself living in the States. It is important to impress to secure vital letters of recommendation, etc. Each place will have different deadlines/elective fees/application fees/visas/ malpractice insurance policy, etc so email/phone the school early to clarify all these. A lot of hospitals do not take students in July. The vast majority require USMLE Step 1 passed. • Letters of recommendation • NB: ARRANGE TO MEET THE PROGRAM DIRECTOR • Email me before you go on elective (Advice on approaching the attending, SOAP format, etc)
Useful sites: • https://services.aamc.org/eec/students/(This is the best site. Some of the data is not current though but a simple email/phone call can clarify things) • http://www.usmleweb.com/sample_personal_statements.html (A lot of hospitals will require you to do a personal statement) • http://electives.us/unilistims.html (handy info)
Research • Publications essential for the really top-tier programs
Residency Programs • Top-tier, Middle-tier, Lower-tier. • Aim: To secure a top tier Fellowship • Decide on area of interest: Internal Medicine (getting more competitive) (3 yrs), Paediatrics (not as competitive), Surgery (Very competitive). Other specialties a lot more competitive and will require top scores. • Best locations usually unattainable (Cali – Remember Cali License, Boston, New York, Chicago, etc) • Research Programs online, see the requirements, Check current number of foreign qualified Residents (?IMG-Friendly Programs) • FREIDA Online – great resource (location, “university program” is NB)
Apply through ERAS. • When to go?? - Before intern yr? very risky in case Residency does not go well (not fully registered with Irish system), won’t be eligible for H1B visa, lack of clinical experience, worst possible position if you want to come back to Ireland - After intern yr? (good to have a practical yr behind you and NB to be fully registered before you go. Not in as strong a position if decide to return to Ireland, variable success coming back). - After SHO yrs with membership exams done (ideal time, majority of Irish doctors still only 25/26 at this time, US starting Residency are generally around 26/27, stronger position if you want to return to Ireland)
BOTTOM LINE FOR RESIDENCY: - STEP SCORES ARE NB, AS IS YOUR CLASS RANKING, HOWEVER, A MEDICAL ELECTIVE AT THE INSTITUTION IS THE SINGLE MOST NB THING IF YOU WISH TO WORK THERE AS LONG AS YOU HAVE REASONABLE STEP SCORES
Other issues • Costly undertaking for students (Can the college subsidise the Qbanks??) • ?Forge links with other universities (not only in the States but Canada, Oz, etc) • For elective: Malpractice insurance issue (MPS?, NUIG?, Hosting institution?) • For residency: Visa issue is a potential stumbling block (J1 versus H1-B (requires Step 3 done)). Basic differences between them important to know as you may end up regretting it further down the line. • Contact thesecurrent Final Meds about USMLE material: firstname.lastname@example.org, Cormac O’Brien (email@example.com), Conor Moran (firstname.lastname@example.org)
Other options • US (have other options other than US residency with the excellent Galway medicine scheme, opportunities for fellowship without Residency??) • Ireland (Good training system) • UK • Canada? (nearly impossible for international students to secure Residency, Fellowship options though) • Australia/New Zealand (Very good training and hours much better, no extra exams required as an Irish graduate) • Mainland Europe (France)
US: Excellent training and the vast majority of institutions are very teaching-focussed which is what I like. However, it’s competitive-central (can be cut-throat), intense hours, mediocre salary until consultant level, expensive process to get there and a lot of hard work.