PLAB vs USMLE

Now that I can write about my personal experiences without fear of having to take the exam again, I shall dispense my advice freely.

For the USMLE, I used a old edition of First Aid for CS and found it to be sufficient for my purpose. I also looked at NMS review for Step 2 which is quite a good book as well. I fear that I have become a First Aid convert and am proselytizing the world (or at least those that I come in contact with).

I think you need to read all the clinical scenarios and have some idea of the differential diagnosis and investigations you are going to order for each clinical scenario. After that, I suppose you should have a practiced and orderly examination protocol. This is what I did not have, in fact the reason for my first couple of scenarios being terrible was because in my head I did not have any idea of what I was doing. It took me some time to get questions I must not forget and some order to the general physical examination.

In hindsight, primitive medical training more than 5 years old came to my rescue. After a point I was on automatic mode. I was not conscious of what I was doing, it became automatic. I had to keep reminding myself of only the things that I should not forget to do which I had not done routinely as a medical intern, things like allergy history,sexual history and social history. My thought process started happening at the spinal level, never really reaching my cortex. It reminds me of how it was when we were immunising 60 odd subjects in the FGF. After a point, you have no clue as to what you are doing or why - your hands move automatically.

I suppose that was why I was really scared about the exam, because I had not prepared for it well enough and everything I did was reflex. It might have been correct or it might have not. Unlike for my PLAB exam, for which I did a course, spent almost one month practising physical examination scenarios, memorising procedural steps and learning by rote things to say and do in certain scenarios, I did NOTHING for the USMLE exam. I spent less than a total of 10 days studying for about a couple of hours a day reading through the clinical scenarios.

The big difference between the two exams is the marking system. PLAB has consultants sitting at each station who grade you on your physical examination technique, patient interaction and generally pass or fail you. However, the scary bit with the USMLE is that you have these Standardised Patients (actors who have been taught to act or say certain things) who mark you on everything. They have a sheet with questions you should have asked in history,whether the physcial examination was complete and on patient interaction and english speaking ability. This is much more difficult because you need to be able to second guess what exists on that marking sheet of theirs. From what I understand, they have a checklist and tick boxes. Unlike PLAB, where a medical consultant who knows what is important to ask or examine the SP has no medical knowledge. Therefore, you could have asked a very relevant question which does not exist on his checklist and therefore you do not get marks for it. On the other hand, if you don't ask something trivial that does exist on his marking list, you get marked down. The same principle holds true for physical examination. So, I would argue that the PLAB exam is in a way fairer, more valid and more likely to weed out poor physicians as judged by their own superiors.

The other difference exists in the time alloted per station. PLAB has five minutes per station, while USMLE has 10 minute of examination and another 10 minutes to write a patient note. PLAB does not require you to write anything. So the examiner who is a consultant sits in your station and marks you. Its as simple as that. Of course, because of the shorter time limit, you really must be proficient in your examination. Also, the tasks assigned to you in PLAB are far more specific. examples include - perform an examination of the Left knee for this 68 year old woman, counsel the lady about meningococcal vaccination, speak to your consultant on the telephone about a case of abdominal pain that has presented to you in the ER.

USMLE have clinic based scenarios, things you are supposed to handle when you become a first year resident. The idea behind this exam is that you weed out sociopathic or pyschopathic doctors who cannot interact with a patient in a normal way. US physicians and medical schools believe this is the most important exam for any medical student during their entire career.

Most important difference between the two exams - PLAB is only for Foreign medical students, whereas the USMLE is given by every single medic who wishes to practice in the US. Therefore the emphasis as you can understand is very different for the two exams.

Anyway, my last piece of advice for step 2CS - trust yourself as a doctor and you will be fine. As long as you are a normal human being and can hold a conversation in English with another human being you will pass this exam. At least, that seems to be my experience.

I passed - Whew!

So, I passed my Step 2 CS exam. This is the exam I gave within a couple of days of landing in the US. Recap - arrive SF 25th June, move to Stern Hall 26th June, leave for LA 27th June, exam on 28th June, return to SF 28th June, set up basic necessities of life 29th June (friday), spend weekend with G,trek up Mission Point(photos for proof), 2nd August - am attending classes!

Anyway, my exam was a disaster. Its a miracle I passed. In fact I had to check my results at three times before I was absolutely sure I passed. There were lots of reasons why I did badly. I did not study enough, I was totally jetlagged and had not been able to sleep at night for the previous couple of days. The day before the exam I arrived in LA at the hotel around 3pm and promptly went off to sleep. I don't know how long I slept,missed dinner and woke up around 10pm frantic,nervous and scared. I tried to study courtesy of four cups of coffee but my heart was not in it. I just could not get myself to concentrate hard enough or motivate myself to work. So, I spent about two hours getting ready and packing my stuff up and around 6am decided to head out to get some breakfast. The closest open place other than the rather expensive hotel breakfast was McDonald's! Hmm..early morning Big Mac did not sound good preparation for an 8 hour exam, so hung around till the building coffee shop opened around 7.30.

In the meantime, I had a long conversation with the security guard. Obviously, he was used to people like me coming in every morning to write exams and asked me the usual where, why,when questions.
Recgonising that my accent was not American and was not very Indian as well, we came around to the fact that the man has spent some time working in Liverpool. He asked what I did and I replied that I worked on malaria. What ensued was truly amazing. The man was a parasitologist from Nigeria as it turned out. His mother was a physician in Nigeria and he had worked on malaria and herbal remedies for some time after his bachelor's degree in parasitology! So, we discussed plasmodium falciparum in the hour leading upto my exam. I am grateful to him for distracting me and minimising my adrenaline surge. Of course, after a 16oz cup of English Breakfast ( this takes about half hour to drink) my adrenal glands were back to full speed.

The exam itself started only about 9.30 after induction blah blah. At this point I was ready for a quick nap but my first station was a lady who had been assaulted. After taking a detailed history and making sure that I got all the places she got hurt, I panicked during my examination and forgot to examine her jaw and face where she told me she felt the most pain! I got out and while writing up my medical notes, realised I had screwed up.
Forget it, next one I told myself. The next lady was an easy case of cough or something. Now, I was told and the books had this written. Must ask sexual history - partners, active/inactive, sexuality, contraception, H/o STI. Ok, so I went ahead and ascertained that she was sexually active with a single partner. So, I now began advising this young lady (22 yo) about safe sexual practices when in a surprised voice she mentioned that her partner was a female!! I spluttered and stammered pathetically and rapidly ended the interview.
I reckoned I was 0/2 there and had only 10 left to go. The general advice is you need to pass at least on 10 of your 12 stations to pass. So, it was all or nothing now. I calmed down and obviously was fine after that.

I suppose it was my fault for being so badly prepared. I remember studying so much harder for my PLAB 2 exam, which is a similar format except you have to do CPR on a dummy and you have procedures to complete on dummies as well. I really worked hard for the PLAB exam even attending a course in London (costing me 300GBP) over Xmas. Its pretty useless now, although I never know. I might just land up in the UK again.

USMLE - My learning resources.

I depended a lot on forums for people's views and comments on preparation and this is my two bits. Its going to be a bit all over the place, so bear with me. Also, dont read any further if you are not interested in taking the MLE because its basically really boring.

Preparation time: My opinion is you could do one of two things - spend six months preparing or spend one month. I think anything in between is a bit useless and low value. I made the mistake of working in fits and starts - in the end I spent about 4 weeks studying at about 4 hours a day average which is not enough.

Pre-study preparation: I advise spending about 2 days reading all the forums available to get an idea about what is available and come up with a plan of what you want to achieve and how to go about it.

Text Resources: I would use First Aid (FA) for study outline. Most of the areas they touch on is covered by the exam, but their content is nowhere close to sufficient. Here is my list for the subjects:

Microbiology - Kaplan notes are quite extensive. I found FA very good for a quick revision. Correlate it with every system you read. Correlate it clinically as well - causes of UTI,Pneumonia,Wound infections etc. Also, know everything about HIV/AIDS, especially opportunistic infections.

Immunology - I think you need to have a very fundamental understanding of the subject. I did not really study it at all - hoped that teaching and doing a PhD might help. It did not!!

General Pathology - Robbin's Pathology is what I skimmed through, but would recommend as standard book. Emphasis on oncogenesis seems extraordinarily high. If you ask me its slightly absurd testing me on the transcription factor responsible for aniridia, but thats what the Board wants. Understand how oncogenes,tumor-suppressor genes work. Also, I looked at all the pictures in Robbins. Cancer in every system is frequently asked so you have to know everything about everything.

Pharmacology - crucial you understand basis of neurotransmission, G protein etc. Kaplan notes in Pharmac and Biochem cover this ground well. Also, I did not read Kaplan for system pharmac but used Lippincott's review of Pharmacology + kaplan + FA for new drugs.
I usually studied Pharmac with Physiology although I found that I spent too much time on Physiology and not enough on Pharmac. I think you should study them separately.

Physiology - you have to read a good text book. Kaplan is very good for Endocrine,reproductive sciences but for the other systems I referred to bits of Ganong and some other textbooks.
It is absolutely vital that you understand the physiology of every system as most questions on pathophysiology cannot be prepared. Usually the question will ask you about parameters you have not really thought about. For example, in a question about secondary parathyroidism I was asked about Vit.D functions which was difficult as I had not thought about it.

Anatomy - mainly clinically relevant anatomy is asked. I spent a day on Anatomy and used Snell to study. Neuroanatomy is good in Kaplan Anatomy.

Embryology - again there are a few must know facts. Use FA for that. Clinically relevant embryology and defects I used USMLE Review Embryology.

Statistics,Behavioural sciences,Psychiatry - I think FA is more than enough but you must know everything in FA. For Stats do a lot of questions to understand the concepts.

Biochemistry & molecular biology - This is the hardest part of the part 1 exam. They really ask you some difficult questions. There were a few questions I could answer based on working in a lab for four years but there is no doubt that I would not know any of the answers otherwise.
I enjoyed reading the Kaplan notes which I think are detailed enough for a first read and then back it up with lots of questions.

Question Banks: As with most such exams, the best preparation is questions galore. The way to start is to do about 200 questions like an exam. Then spend a day analysing your results. Break it down into questions you guessed,did not know and were absolutely sure about. Then sub stratify them subjectwise. Now that you know what you think you are good at or poor at, make a study plan. Its critical to study smartly. For example, there is really no point studying a pyschiatry text book when only about five questions are asked and you can answer them anyway. I spent an inordinate amount of time on Microbiology but thats because I realised a large number of questions are asked in various forms.

Which qbank is the best?
After spending some time reading about other people's experiences and also my own experience of three qbanks, my answer to this question is - "It depends". ( I am a good scientist and as all scientists will tell you, the answer to every question is "it depends")

On what? I think two things:
1. How much time you have - If you are spending six months or more to prepare, an unlimited budget then do every question bank you can lay your hands on. If not,then I would argue for a more circumspect strategy.
2. How much money you are willing to spend -
I did questions from - Kaplan QBank, USMLE Rx (this is the web version of First Aid),Kaplan Q Book, First Aid q book and Appleton Lange Question book.
Of these -
USMLE Rx is very good for factual learning and reasonably cheap $59 for 1 month. It is not remotely similar to the actual exam. I used it to memorise facts and do questions topic wise and make sure I cover most topics. They do not have a very big collection of epidemiology,biostats and behavioural sciences questions but otherwise they are ok. I mainly used it as a guide to topics in every system I must not forget to study.
The Kaplan Q book is ok and again use it after you finish studying a particular topic. The First Aid Q book is terrible because all the questions are based on facts given in the First Aid text book and therefore not very detailed or extensive.
I used the Appleton Lange book once to do a seven hour exam. The questions are ok and again a rough guide to the actual exam and also because it has about 13 blocks is useful in terms of quantity of questions.

Kaplan Qbank which is really expensive(costs $199 for one month) for only 2000 odd questions is supposed to be the closest in content and difficulty to the real exam. I found the exam much more difficult however the Qbank did cover about 90% of the topics asked in the exam. My advise with the Qbank is not to rely on it entirely and remember that you will almost never have a question repeated from Qbank in the exam. I had someone tell me that no question was repeated and so the Qbank was not great - well dont expect questions to be exactly the same.

I found the Qbank useful even if I was unable to complete all the questions so would recommend it to everyone, but use it sensibly. I only took complete 50 question blocks similar to the exam with all topics included and found it was useful.

NBME - The 4 block 200 question Forms(as they are called) are closest to the real exam in terms of difficulty. I recommend doing all of them if you have enough money. It costs $45/form.
The other big problem is that you cannot reveiw your exam and dont know what the correct answers are or where you went wrong. So, use it to scare yourself into working harder. I only did Form 4 two days before the exam and it terrified me into studying Biochemistry for the next six hours.

Lastly, USMLE ECFMG CD - the one that they send to you. Kaplan has the explanations for the CD questions. I found that the CD is pretty close to the real exam and although I never went through the explanations, I would recommend doing the CD at least one week before your exam.

Doing a complete exam - 7 blocks in a timed way is absolutely vital. It allows you to get used to sitting down and concentrating for 7 hours, learn about timing your breaks and also about your score over 350 questions rather than 50 questions. It gives you a much better idea about your strengths and weaknesses. I did the 7 block exam twice and did pretty badly both times. However, it allowed me to test my endurance limits and whether taking three blocks at a time is feasible and also sort out my food,coffee and toilet breaks.

Internet resources: I did not use that much of the internet resources that are quoted in First Aid but I did use a few. here are my USMLE bookmarks!
The Biology project - useful for quick basic mol bio concepts.
http://library.med.utah.edu/WebPath/webpath.html - Internet Pathology slide website. I did not find this as useful as it is made out to be but its good to have a quick look at it , perhaps one day or maybe when you are having dinner or something.
The really useful part on this website are the review exams. I found the neuroanatomy ones very useful for revision.
Lippincott USMLE test - I dont know about this. I did not take the exam so cannot comment.
Parasitology quiz - ok. dont waste time if you dont have it.
The Princeton review - Again similar to Kaplan but I didn't have the money to do both.
USMLE Web - I found some of the free questions, forums etc. useful. Again, you cannot spend too much time on this stuff if like me you only study for four weeks.
NBME - Good. Must do the tests on this website. Scares you into studying harder.

At the end of all this, my gut feeling is that your basics will get you through. I feel as if all I actually studied in my first and second year in college and all the hard work I put in paid off because there were lots of topics I did not study this time and just hoped that whatever I had learnt over 10 years ago will help me out. It sometimes did, so I expect if you slogged instead of pissing around this exam might help show that up.

I dont know if D reads this, but I know GI does. Just wanted to thank her for detailed,useful and unstinting advice. I doubt whether I would have taken the exam today if it wasn't for a morale boosting email. D needs to be repaid for getting me all these Kaplan books, but somehow I suspect Napa Valley and some Talisker in the evening might cancel the debt!
I met AS on Monday and thermos purchase is thanks to him. He also gets credit for me suddenly realising that Neuroanat and biochem are important areas to be studied.
Now its off to bed and then to Boston where the Little One seems to have stuff half-planned,except for forgetting to book Spiderman 3 tickets!!

IT IS OVER

Its over. At precisely 14:49 today, I left the examination room after having accomplished the arduous task of attempting to sit in a chair for more than two hours continuously.

A minute by minute account of my day (for posterty and my pre-senile amnesia):
3:30 am - Appa's calls from HK - inadvertently waking me up half an hour earlier than planned.
3:45 - 4:25 - milky coffee assisted revision of the water excretory system.
4:25 - off to make Indian type chai(refer to earlier post for protocol) + sandwiches
4:40 - in attempt to pour chai into newly purchased 1L thermos flask, spill it over the sink.
4:42- chai leaks out of flask,spills over floor. This occurs when I tried proving that gravity exists by turning the flask upside down!! (Note to self - physics and sleep deprivation is BAD!)
5:30 - catch Oxford tube after the Bong Thing etc. is done.
Bus driver is being harassed by inebriated man asking for Liam ....
5:30 - 6:30 - bugs and other such undesirables are being memorised
6:30 - sleep hits me at Hillingdon. With thermos ready to slide off table ave to sleep hugging dear thermos.
7:45 - reach Pellipilar House to find that I am early as usual. Anyway, things are quickly soreted out - I am provided a locker to dump my bag, jacket and thermos and we are off.
8:13 - Exam begins..I am nervous,sweaty,hungry and sleepy. fortunately, catecholamines(adrenaline - just finished reading physiology,give me a chance to show off) come to the rescue.
9:50 - take my first break. A Cadbury's roll, quick swig of tea(which I now realised did not have enough sugar and was too dark),cold water splashed on face and back into the room.
The room is like an internet cafe. Multiple computer terminals separated by a hard high screen. This means that while you cannot actually see what the other person is doing, you can hear everyhting thats oing on in the room. Thankfully, they had the big earphones with big rubber pads which muffled the incessant typing of the guy sitting next to me. Of course, I must have been equally annoying to everyone else around me, swiveling my chair, stretching backwards and generally making tiny movements to stretch myself without actually getting up from the seat.
10:00 - Block 3 starts. This and block 2 were my worst blocks..probably got 50% of the questions wrong. Block 4 ok..not great and then pushed on for Block 5 which in hindsight was a poor decision. Very similar to Jayawardene delaying his powerplay - it backfired bigtime. Block 5 was a disaster. 2 hours sitting is ok..3 hours was about 59 minutes too much. By the tenth question, I could not wait to get out. My back hurt,my mind wandered to boston in the summer, SF in july, Napa valley..everything except the fungus causing erythema nodosum.
12: 50 - break no.2. half a sandwich(sundried tomatos and olives on houmous), two cups of yucky tea and a chocolate roll later, I felt half human again.
13:10 - Block 6 starts. I had to start the block by erasing all my previous doodlings from the erasable note paper using my finger. Of course, being a hyper secure testing center, we could not take any pens in and were supplied with these laminated sheets called erasable note paper and a couple of markers. I thought of using my hanky to wipe out my doodlings but decided against it considering clean handkerchiefs are always in short supply.
13:54- break before the last one. Focussing the mind..
13:58 - Block 7 - the last hurdle. I dont know the answers to first ten questions. So much for the final hurrah and a strong finish. Deflated, I potter on and complete the last block and question no.350!
14:49 - Emptiness engulfs me. What am I to do now? decide to call people up - everyone's phone is busy. Embankment and London, here I come. Shuffle on,Cat in my head and a glorious summer day...I walk all the way from Bank to Victoria doing a circle around St.Paul's while talking to Amma.
16:15 - On the Oxford tube and wowing Little One by using the bus' wireless. Plans for the evening. 10 year oldWarre's,tofu and rice(Cafe Orient). and PGW...escape to Blandings!

USMLE - Ten Things it has taught me

1. Preparation for exams lasting 7 hours should be for a minimum of 7 weeks, not 7 days.
2. Reading short study guides instills false confidence, it does not really help answer questions in the exam.
3. I hate Biochemistry, Endocrinology and Reproductive Sciences.
4. A PhD does not help when it comes to mugging the Kreb’s cycle and lysosomal storage disorders.
5. Sundried tomatoes can make anything taste good.
6. Never schedule an exam during the Crucible or a World Cup.
7. Making caffeinated beverages for sustaining cerebral metabolism requires practice!
8. No exam in easy, don’t believe people who tell you otherwise unless they have failed it.
9. You retain as much in 7 days of reading as in 48 hours - so spend the extra time watching sport!
   
10. Sleeping during an exam seems to make time go quicker (unless it is IIT-JEE..but that’s another story)