ben white

Because Pathology is a cumulative all-encompassing subject, it makes sense that preparing for the Step 1—reading the First Aid—would be good preparation for Pathology Shelf. And while that would work, I don’t think that’s the best use of your time if you only have a few days to try to cram it all in. Pathology is cumulative, but the types of questions the National Board tends to ask demand a specific subset of knowledge: histology, gene mutations, responsible enzymes—these are the core of the pathology. Furthermore, reading a book  (be it the First Aid, Goljan’s Rapid Review, or Robbins) is also a dangerous plan if you’re pressed for time. A) You probably can’t get through it. B) Knowing facts and applying them toward answering a question are separate steps. Its not uncommon to need to see a question about a concept in order to the “bind” that knowledge appropriately.

A good Qbank (like USMLE World) works, but I think the very best way to review pathology is the Robbins and Cotran Review of Pathology, the question-book-companion of the big Robbins that many/most schools use. Benefits of this book:

• Complete, system-organized review of pathology that covers all the important topics and factoids
• Shelf-style questions and focus
• Contains clear but complete explanations—which is key. You’ll get a lot of questions wrong, but this review teaches you the salient distinctions quickly without being cryptic when you do.
• Because it’s organized by system, you can tease apart related conditions and presentations. If you just do a blanket review, it’s hard to do this. Even if you use a Qbank instead, I would still recommend you do a run-through of the pathology questions by system first.

The link above is to the 3rd edition. I used a copy of the 2nd edition I bought at a local Half Price Books, and it certainly didn’t feel out of date. It’s also cheaper online. I think either one would work fine, though I’m sure there have been improvements made in the intervening five years. It’s a high quality resource; I only found two typos/mis-keyed answers in the entire book.

The point is this: there is so much material on Shelf and Step exams that literally anything you learn could be useful. Time and brain space are the limiting factors, so what you need is an efficient study aid. For the NBME Pathology Shelf, I had four days off to study. The Robbins question book is roughly 400 pages. I was able to do 100 pages a day and then follow it up with a few tables in the First Aid (important cytokines, for example), and that was 100% sufficient for Shelf purposes.

Sometimes when you do questions without having a read a text first, the whole experience is just frustrating. Studying for the shelf is inherently painful, but this book really did right by me.

For around $35 a pop, your medical school can pay the NBME to let you and your classmates take the Mini Step 1, a 200 question multi-subject basic science test. It’s hard. Without doing any Step preparation (outside of attending to the usual coursework), I felt absolutely confident in only a handful of questions.

That said, and perhaps it’s just an extra year of medical school talking, the questions seem more doable and slightly less minutia-dependent than those found on the NBME Shelf subject exams. On this run, for example, the demanded anatomy is fairly basic—reserved for the highest yield topics like major artery and nerve distributions & common injuries and syndromes—especially compared to the anatomy shelf I “took” last year. While I assuredly failed this exam with soaring colors, it seems slightly less intimidating then before. Still frightening, quiver-in-your-boots hard, but potentially doable. For most topics, it’s breadth, not depth. Only for key topics (basic metabolism, common bacterial and viral pathogens, big-name diseases like CF, CAD, MI, DM, Crohn’s, Addison’s, etc) is minute detail demanded.

For the question style itself, I was surprised overall with the frequency of first-order questions and the amount of useless writing. If you read Kaplan style questions too much, you see a lot of long vignettes with this scenario:

Long-winded clinical presentation of  Strep throat (without identification). The question might ask, what should the patient’s physician ask before administering the therapy of choice? As we use Penicillin for Strep, we need to ask about a Penicillin allergy.

The ID of the bug is a first-order question. The drug of choice is a second-order question. The common adverse side effect of the drug of choice is yet a third-order question. On the Mini Step, most questions were actually first-order questions. Third order was much much rarer. Most frequently—and annoyingly—the long vignettes end with a diagnosis or ID, thereby negating the need to read the vignette at all! My advice: if you’re the type to run short on time, read the last sentence or two before reading the whole vignette. My other piece of advice is that you shouldn’t let Kaplan or other sample tests scare the crap out of you. They pick the most ridiculous questions they can find in order to frighten you into buying their product.

While Final Exam, a memoir by transplant surgeon Dr. Pauline Chen, deals primarily with doctors’ troubled relationship with death and dying, I was struck most by an essay that deals directly with medical training’s preoccupation with protocol, algorithm, routine, and ritual. For Chen, rituals during her medical training were the foundation on which she built her persona and expertise as a doctor. Medicine is challenging, and ritual is the mechanism by which students—and later, physicians—break down complicated or otherwise difficult tasks in order to approach situations calmly, competently, and treat patients effectively. The harder the situation, the more essential it is to have a ritual to fall back on, as Chen describes how her routines helped steady her during an emotionally challenging pediatric transplant by allowing her to mindlessly do a procedure she had long since mastered.

My favorite ritual example in Final Exam, pre-surgical hand-washing, illustrates both its positive and negative effects. At first, the routine of scrubbing helped Chen ensure that she observed proper sterile technique; by following the ritual, she achieved technical competence and kept her patients safe. Furthermore, the mindless routine of the ritual was a form of calming meditation, a quiet break that helped separated her—emotionally and temporally—from both her clinical and surgical duties.

Years later (and after years of physical discomfort from an aggressive, skin-damaging style), Chen discovered that she was behind the times: she could achieve the same results by scrubbing for five minutes instead of ten and using a soft sponge instead of hard irritating bristles. The danger of ritual is that it leads doctors to routines that may reinforce bad habits, make it challenging to adapt to advances in patient care, or shield us from responding emotionally to our patients. Chen writes:

After nine years of clinical training, I found it hard to conceive of doing these clinical tasks any differently. In, I fact, I believed there was no other way, because these rituals were what assured the quality of my practice. They were what made me a good doctor.

This devotion to ritual is what helps training doctors learn the way of doing things correctly, even when the way is perhaps not the best way. While rituals may be a necessary first step in the learning process, the art of medicine lies not just in following the ritual effectively—but rather in when knowing to deviate. As Chen argues, a good surgeon doesn’t just know how to perform the right maneuvers; she knows how to fix the surprises that invariably pop up in the moment. It is when we fail to leave room for change in our devotion to ritual that our development as physicians stagnates, because while “they protect us from doing the wrong thing, their protective logic can shield us from fully shouldering responsibility.” (94) If we do everything correctly, the logic goes, then the negative consequences must be beyond our control.

Hand-washing is a relatively benign example because Chen was only hurting herself, but ritual pervades every aspect of medical training and practice, from memorizing the steps of the physical exam to sharing difficult news with a terminally-ill patient. The negative consequences of these rituals are only complicated by the role of the “informal curriculum” in medical training, the instruction that indoctrinates young doctors with the habits of their superiors. What happens when the rituals themselves are faulty? What happens when the carefully rehearsed patterns are themselves a source of doctor error?

In our first year training we learned physical exam techniques from both fourth year students and faculty preceptors. Both groups stressed the importance of learning the rituals of different exams, the routines on which to build our future competence, and so we robotically went through the motions, verbalizing our steps and performing the exam with techniques that only appeared analogous to the real thing. The emphasis was on “pretend” competency: the ability to look like a doctor on camera. This is not a shortcoming of any one school but rather an unfortunate result of the nation’s century-old curriculum design, one that places inordinate importance on some topics to the exclusion of others (oblivious of clinical importance). Soon, undoubtedly and embarrassingly, our class will have to relearn how to perform exam techniques in order to actually evaluate our patients. Right now, the sham ritual is all we have.

As Chen says, the clinical aphorism is “see one, do one,” which means that as doctors we train to master the mistakes of our mentors. Our early success will depend directly on how well we copy our teachers (because it is our teachers, with their idiosyncrasies, that evaluate us). And while rituals may be a useful crutch in the short term, it’s not hard to imagine the future consequences. When our patient interactions become ritualized—each sentence just another item on a mental checklist—our patients will be reduced to a given number of steps. The more times we use our algorithms, the easier it will be to categorize our patients as cases, people as diseases, and conversation as a technical skill—instead of an intrinsic part of what makes us human. This reduction is the process of dehumanization that comes with the epidemic of physician burn-out, naked cynicism, and is a chief component of patient dissatisfaction. It is a mainstay of a generation of medicine we should hope to overcome.

No matter how much money you spend on books, every medical student needs to do a ton practice questions for the USMLE Step 1. Questions are an excellent way to learn the useful tip-offs and keywords, and—depending on the source—get a better feel for the board format. They’re also a form of active learning, unlike trying to self-induce a coma with the universally-utilized First Aid for the USMLE Step 1.

For question books, post-Step MS3s and your local Half-Price Books are always good resources to buy study materials on the cheap. But free is better, and the internet is undeniably convenient and portable. I scoured the web to find free question banks online (updated August 2011):

• Test Prep Review has a USMLE practice self-assessment section. There are 20 modules of 20 questions for 400 questions. They’re mainly fact-recall and not vignette-based, but it’s easy to use and accessible.
• Wiki Test Prep [now defunct] is was a student-written qbank with over 900 questions with explanations. The site is great, and you can browse questions by keyword, flag questions, and create your own tests. It also lets you know what percentage of students answer the question correctly, which is interesting. The questions are in clinical-vignette board format.
• 4tests.com hosts the 60 question Kaplan diagnostic exam. Answers can be exposed during the test if desired and do contain explanations. (Mom MD also has the identical sampler, only organized in six 10-question pages with answers directly below questions)
• Lippincott’s 350-Question Practice Test for USMLE Step 1 is a solid Qbank, but you must register (for free) before using it.
• ValueMD has a large question bank divided up by subject. The site also requires a free registration. The questions are straightforward fact-recall type and the site itself is clunky and hideous, but it’s still good review.
• The NBME offers its own small set of free practice materials for the Steps 1, 2, and 3. You have to download the 2012 program here (50mb), Windows only. It contains the software that the actual Step uses (Fred V2), a tutorial, and 100+ question practice test. A must do.
• USMLERx has a free 20 question qbank test using the NBME’s Fred V2 software. Their qbank is also one of the cheaper ones, in that you can buy it for just a month at a time (making it a great second option for the last push).

Enjoy.

Some thoughts for intrepid and probably antsy first-years as they stumble upon this page on their search for the truth. Here are some tidbits about the Anatomy, Physiology, Biochemistry, and Microbiology shelves.

Anatomy:

Anatomy, if learned well over the year, is doable. It is crammable if (and only if) you’ve actually paid attention and learned everything once. This is not the time to learn anything for the first time. Even with a good background, it tests a ton of material. Pay special attention to high yield parts—things that are often injured or easily framed in a clinical vignette. While everything is there, it’s not there equally often.

For example, collateral circulation is a big favorite for several systems. You’ll see questions that involve artery transection from stab wounds as well as a occluded arteries from cholesterol plaques. You need to know what other arteries can supply these areas–they’ll be there in spades. Focus not just on knowing body parts but also on 3d relationships between body parts, because they’ll often ask for one part in relation to another (the structure immediately lateral to the X is….).

Lastly, pay attention to common injuries and conditions. If someone falls on an outstretched hand, what bone is probably broken? Scaphoid. What bone is most likely dislocated? Lunate. So on and so forth.

Physiology:

Memorize lab values, especially if you’re the type who doesn’t finish tests quickly (this is also a time-saver on the Step 1). More so than other shelves, Physiology clinical vignettes often include lab values that are actually key to understanding what’s wrong (not the case for Microbiology, for example, where lab values are almost always superfluous). Because the test demands more problem solving/reasoning over rote memorization, the physio test is also one of the more tiring, in my humble opinion.

Almost all physio questions require knowledge of the various trends and formulas; they usually demand that you know why something happened or what happens next. For example, you need to know the body’s compensatory mechanisms to keep fluid volume stable, and how these are used to correct for hemorrhage, dehydration, diabetes insipidus, etc etc etc.

Also, know your renal.

Biochemistry:

Buy a set of notecards and memorize them. Know all of the incredibly rare diseases and what enzyme is deficient in the pathway. Not much to say here: it’s a hard test. The things that are most often covered in detail in your biochemistry class are the things you must know in greater detail. So, you have to know metabolism incredibly well. Intimate knowledge of pathways like glycolysis, glycogenolysis, and gluconeogenesis is very high yield. For less important topics, like microtubules, basic gist-level knowledge is sufficient.

Microbiology:

The most crammable exam. First, know basic virology and bacteriology. How they work, change, evolve etc. You definitely must learn about the multiple ways bacteria become virulent and gain new genetic material. A lot of the test comes directly from the sort of stuff everyone overlooks when they start memorizing pathogens.

Second, for clinical vignettes, a good notecard set is always helpful. For most pathogens, there are a handful of key words that will set you off to the question—they usually ask for either an identification or a secondary fact about it. Everything else in the question is just time-wasting fluff. Memorize the key relationship, and you will be fine on the majority of the vignettes. Will you really understand what’s going on? Probably not, but these questions are often designed to test your knowledge of these stereotypical cases, not whether or not you’ll actually be a competent physician.

For example, H. pylori, which causes gastric ulcers produces urease. If you see a patient with an ulcer, the answer is probably either the ID or the enzyme. Aspergillus makes a “fungus ball.” Coccioides is a spherule in the body. People who get a non-healing lesion after being pricked by a rose thorn have an infection from Sporothrix. If a bacteria is coagulase positive, it’s Staph aureus. It really is that superficial. Key word > answer. The difficulty comes from information overload. The more rare the disease, the more likely the question will be an easy form of memory recall (e.g. fever that goes up and down (undulates) is Brucellosis). For more common bugs like Staph and Strep and the very well known diseases (Malaria, TB, etc)—do a better job nailing down greater details.

And that’s it. You’ll be fine.

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