Step 2 Study Experience

[Scottish Chap]

This will be considerably shorter than my post for Step 1. Consistent with my post for Step 1, I am careful not to discuss any specific questions or reconstruct the examination from memory. This is forbidden by the National Board of Medical Examiners, and unfair to other test-taker. I can, however, give you my two cents worth on preparing for the exam--based on my own experience and that of my classmates.

My background: British, undergraduate degree from the U.K., medical degree from the U.S. Because of where I trained, some things may seem intuitive to me, but I'll try to emphasize the main points that our system in the U.S. expects for these exams.

USMLE Step 2CK: USMLE® : Test Content & Practice Materials
This test is divided into eight blocks - each with 46 questions. The questions can range from A-->E (most common) to A-->N (least common). There are also ‘multi-step’ questions, where the question will ‘lock’ your answer (you can’t change it), and the next question will ask you another question based on more information available for the same patient. Usually the first question is looking for you to give a diagnosis or suggest a test, and the second part is asking for medical management. The nice thing about this (I had three of these questions) is that the second part of the question will give you the answer to the first part. Thus, I knew that I got at least three questions right when I completed the exam! Step 2CK also has videos and interactive cartoons (you can auscultate for murmurs, view child development and assess milestones etc.). Be very careful! They are sneaky, and often turn up as the last question on each test block. They are very time-consuming (it might take 2-3 minutes) and, when you are inevitably pushed for time on the last question, you will be forced to guess. A good strategy is to go to the last question as soon as you start the test block. If you see a video there, do it first.

You will have access to lab values and a calculator. I had several statistical questions. My calculator and lab panel would not open for almost an entire test block, so I had to guess (who remembers what a mid follicular LH level should be in women!). The exam proctor wrote to the NBME, but they didn’t care (they actually sent me a curt e-mail twenty minutes before midnight the day before the exam results were to be posted electronically….interpret that any way you wish). One strategy that served me well was to read the last line of the question stem first. Are they looking for a diagnosis, a mechanism, disease management? The question stems are LONG, often interjected with lab values, x-rays, MRIs, exam findings etc., and you have to read and think QUICKLY. This strategy can save you time, so you can gloss over the superfluous information.

Step 2CK covers diagnosis, understanding of disease mechanisms, and clinical management of the core subjects: internal medicine, surgery, paediatrics, psychiatry, obstetrics and gynaecology. There are some emergency medicine and preventive medicine questions etc., but they’re hard to spot. A passing score was 184 this year, with a mean of around 224 on the three-digit scale. On the two-digit scale, a passing score is 75 (this is NOT a percentile or % correct; some states require that the score be reported this way, and so the USMLE still reports it this way). The entire 'experience' lasts around nine hours. You have 60 minutes per block, and you have about 45 minutes of break time that you can divide after each block as you see fit throughout the day. I took around 5-8 minutes of break time each two hours (after two blocks). The experience sucks overall, and I was definitely ragged by block six. You also receive a breakdown of your performance. Embarrassingly, I performed a little better on the surgery section than in internal medicine (I’m starting as an intern in internal medicine in June this year)

Preparation - books:
There are a lot of them out there, but I didn't really use any. A friend loaned me Crush Step 2, and I read a few chapters of it. I can't say that it helped. Because my medical school forces us to subscribe to Kaplan, I do have the review books. I read most of them during my clinical attachments. The two books that I found to be highest yield for Step 2CK were the surgery and the pediatrics Kaplan review books. I would stay away from the medicine and psychiatry Kaplan review books unless you are enrolled in their prep. course. They are far too dense.

Preparation - question banks:
Again, because my medical school forces us to subscribe to Kaplan, I had access to both their old and their new CK question banks for a year. I activated it to allow me to use it with each rotation I was on (paeds, surgery, internal medicine, neurology ob/gyn, psychiatry etc.) and it expired before I started studying for Step 2. The new Kaplan Q bank is actually quite good and, in my opinion, gives USMLEWORLD some real competition. The QC is better with Kaplan because they are a professional agency. USMLEWORLD is just a bunch of doctors that got together, and they are raking in the dough. Keep that in mind. I only had around 2.5 weeks to prepare for Step 2CK, so I purchased USMLEWORLD. Using any question bank is probably more than enough preparation. I found the USMLEWORLD questions to be pretty representative of CK—more so than their Step 1 show, which grossly under-estimates the length of the questions stems in the real exam. I will tell you that I had just one question from USMLEWORLD that was almost word-for-word the same on Step 2CK. Don't purchase it for this reason.

I changed strategies from Step 1, and I did the CK question bank in tutor more or in untimed mode. This lead to a better understanding. Anything that surprised me ("I know I'll need to know that as a junior doctor!"), I wrote down on a small note card. I did this discipline-by-discipline. In the end, I had great notes that I can keep. USMLEWORLD has a device in their software that presents you from cutting and pasting, so don't try. Focus on understanding, and do not pay attention you your score. I used the medfriends score estimator (MedFriends.org Home Page), and found it to be highly predictive of my actual Step 2 score (based on USMLEWORD). It massively over-estimated my Step 1 score, though.

The result:
I found Step 2CK harder than my Step 1 exam. Many of the questions appear to have two correct answers, but one of them is 'more correct'. As with clinical practice, you must use your judgment and move on. Perhaps this is because I felt less prepared.

Now, my medical school makes us take "shelf exams" at the end of each rotation (those are written by the NBME--the same people that write the USMLE) and they are pretty tough. Because of this, I had already taken what I felt would be the same questions in: family medicine, neurology, psychiatry, internal medicine, surgery, ob/gyn, and paediatrics. A psychological advantage? I'm not sure. In addition, because I am graduating from a North American medical school, residency directors only really care about our Step 1 exam score; that is what they use to invite us to interview and rank us in the match. If you attend a medical school outside of the U.S. or Canada, you are required to have both Step 1 and Step 2 results in hand before they will think about interviewing you.

I did not bother to purchase any of the retired NBME exams like I did for Step 1. I will tell you that those are usually HIGHLY predictive of your final score, but I knew I was going to pass and, after giving the National Board of Medical Examiners (the people that write the USMLE) thousands of dollars between Step 1, Step 2CK, and Step 2CS, I absolutely refused to give them any more of my money. I never did the free online questions released by the NBME. The style tends to be so different from the current exam, so I felt it was pointless. In the end, I was happy with my score, which was eight points higher than my Step 1 score. Most people do a little better on Step 2 than Step 1, though a person in my class went from a 240 (99) on Step 1 to a 210 on Step 2, so give the exam the respect that it deserves.

Overall, this is a very reasonable examination. As with Step 1, you WILL leave the test feeling like you guessed more than you are comfortable with, but get used to trusting your instincts. Practice is key. More often than not, your instincts will be correct. Remember, all these exams do is assess your ability to pass an exam. Get your union card, and move on. I feel I am a pretty average standardized test-taker. If I can do well, you can, too.