This post is adapted from a response to a reader email. There’s a special kind of question I get a lot of every spring. The format is always the same: there is an unmet goal or stagnated improvement on a qbank during dedicated board review with a subsequent ton of anxiety about succeeding on the test. This is a common, frustrating, and scary situation for lots of students. The fact is that not everyone will meet their goals, but that doesn’t mean that you shouldn’t optimize your attitude and approach. It deserves as much if not more attention than picking your resources or schedule (things that people have no problem agonizing over ad nauseum).

You need to start by not beating yourself up. Your specific goal—whatever it is—is awesome, and I hope you get it, but you need to know that goals are only helpful as a means of motivation—not something to tie your entire self-worth into. A misconstrued or stringent goal can be demoralizing and thus does not serve you well. A friend’s stated performance, posts on SDN—absolutely none of that matters to your personal needs.

Don’t let demoralization prevent you from utilizing practice questions as a primary component of your preparation. The reason UWorld and other qbanks are good tools is twofold. 1) Your knowledge is only helpful if it helps you answer a question. The best way to see how to apply your knowledge to a question is with a question. 2) The explanation teaches you both the correct facts, the ancillary facts (incorrect choices), and the context/test-taking/pearls/trends/etc.

Stop and consider why you feel sad when you review your performance after finishing a qbank section. Because being optimistic and believing in your strategy are important components of getting through this tough period and gaining/maintaining your momentum.

A lot of people shortchange themselves on point #2. They get upset when they get a question wrong and don’t use it as a learning opportunity. You should almost want to get questions wrong, because then it means you have an opportunity to improve, a potential blind spot to weed out. There are lots of reasons to get questions wrong and you need to approach the explanations as a chance to learn, not a chance to be disappointed. When you get questions wrong, flag them and do them again.

The other thing students do is use that negative emotional valence to overread the explanation. They take an exception and turn into a new rule. They try to generalize too much. They take something specific to one question and apply it to other questions where it doesn’t apply (“but last time I guessed X and it was Y; this time it’s X, wtf!”). All of this comes from stress and self-doubt.

The way to not burn out is to try to actively switch your attitude from fear to excitement. You’re doing this so you can learn, and, in a few weeks, you’ll be done. That is astoundingly exciting. It’s a huge milestone. When you start feeling amped up and nervous, you need to say “I am excited.” Excitement and panic are both states of heightened arousal, and they’re more similar than you’d think. Whenever you feel the panic rising, whether after a section on the qbank or the real thing, don’t “forget” that you’re actually excited.

If you don’t have much trouble with time management, I’d continue using tutor mode for the vast majority of your dedicated studying. Remember, the qbank is primarily about learning first and emulating the test day experience second. Stop paying attention to how you’re doing as you go through a section. Whether you do bad or good or your score changes doesn’t matter. This is how you’re going to study and you’re going to embrace it. Use books to supplement as needed when an explanation isn’t enough, need another perspective, or you hit something that requires re-memorizing a table (cytokines, glycogen storage diseases, things of that nature). You can switch to timed blocks to simulate the exam the last week and get into a groove. Find the confidence to go with your gut, not agonize, not get stressed by a long question stem, etc. If one particular thing seems like you’ll never learn it, then don’t. Your score doesn’t hinge on a single topic. For most people, there’s plenty of other material to learn instead.

Don’t forget that Step 1 should be a happy time. It’s the culmination of another chapter of your life and marks the transition from seemingly endless book learning to finally starting your journey in clinical medicine.

You need to study, do your best, and be proud of yourself.

I stumbled across this in my Google Docs. My school used to put together a book of letters every year from third years at the end of their year to give to students about to start clinical clerkships. This was written in 2011 (I still largely agree with myself).

Long before the end of third year, people will start talking about boring or interesting patients or about scut work or about the grind of clinic. Most of us probably wondered at some point during second year how long it would take us to be comfortable enough to feel bored. The beauty (or the bane) of third year is that each time you are comfortable enough to feel bored, your residents switch, or you change clinic or team or hospital or clerkship. You have just enough time to say, “hey, I’ve got this,” and then you’re on to the next adventure. It’s at least mildly frustrating, but then at some point you’ll come to this realization: If I’m bored today, that means I’m comfortable today. And that means I can do this.

And at first it might take six weeks, but then it’ll be three weeks, and then a week, and then maybe just a few days. You’ll be a little less impressed (or scared) of attendings and residents and maybe even disease, because when you show up to work and see your patients and write your notes you’ll realize that at this stage of the game you don’t need to be scared anymore. That looking back that some of those fresh interns on July 1st didn’t know much more than you did and were probably twice as scared. That you’ll always have backup. That the majority of patients you see will have the same common problems and that common problems can be diagnosed and treated once you’ve done it a few times. Then there are the “interesting” cases, the tough ones, the demanding attendings, and the fascinatingly rare zebras–and all of that is great, especially when you can help–because they keep things fresh. Hopefully at that point, the individual wrinkles that each patient has can stand out, and that’s what makes practicing medicine worthwhile. The people.

But when you first start and you’re scared and you know full well that you can’t do a history or a physical (let alone both at the same time), don’t worry. You’ll be fine. We all were.

Here are the explanations for the updated 2016-17 official “USMLE Step 2 CK Sample Test Questions” PDF, which can be found here.

Overall, the June 2016 update removes 21 questions as a result of the decrease in block size taking effect this year. There are exactly two new questions in this year’s set (#19 and #117), but the question order has been completely scrambled. The explanations for last year’s set can still be found here (I’ve expanded a few of the repeat explanations, just for fun).

Helpful reader Jarrett has made a list converting the question order from the online FRED version to the pdf numbers.

Read More →

This is technically a list of my book recommendations for the basic sciences, classically the MS1/MS2 years (my books recommendations for the clinical clerkships are here).

In practice, there are no true “best” books, but there often multiple good ones. I’ve made an editorial selection here to provide a few good and reasonable options depending on your needs that you can read without remorse and should work well in most circumstances.

Please note and be assured that–depending on your course materials, preferences, and comfort with online resources—you don’t necessarily need to buy any books. Most people would at least get an anatomy atlas and a review book or two for Step 1, but outside of that pretty much all roads lead to Rome (I’ve compiled a nice list of free online resources here). So don’t be afraid to not buy books, and don’t be afraid to switch study styles or plans if things aren’t working out for you the way they used to in college. Iteration is the key to personal growth. You can figure this out.

The most important thing about your study lineup is that you are comfortable with it. One of the most pervasive medical student fears is the fear of missing out. The mantra of medical school should actually be: more isn’t always better. Trust me, the only thing you’re really missing out on is the life of a twenty-something with disposable income.

Medical students love to compete with each other when it comes to resources. Some students gleefully tell their peers how many resources they are using or will disdainfully remark that the book you’re reading isn’t that great, doesn’t contain enough detail, etc. Anyone who tells you what you must and must not do is almost invariably wrong. In real life, you don’t necessarily need any particular book or even a book at all for every course. And no book has a monopoly on relevant “high-yield” medical knowledge just as how no hospital has a monopoly on sick people. You may have detailed lecture powerpoints or good course syllabi, not to mention Al Gore invented the Internet for a reason.

Anatomy

• Moore for the textbook (if you need one, your school syllabus may be enough). Note that most students will supplement an anatomy textbook with an atlas of some type.
• If cadaver-based gross anatomy is anything other than pass/fail, I’d recommend using Rohen to study for practicals. The real photos go a long way toward helping you identify structures in real life compared to stylized Netter-type drawings. However, the combination is synergistic; Netter shows you the ideal relationships; Rohen shows you how to actually identify structures in the lab. Not wanting to buy two big atlases, some students go for the Rohen atlas and buy the Netter flashcards. At least when it comes to gross lab, I guarantee someone nearby will have the big Netter.
• If you want a combination of Netter-style illustrations mixed with a bit more explanatory text, better organization, and some really nice tables, consider Thieme’s Atlas of Anatomy (it’s excellent; the downside is that your school probably isn’t using it as the official text). Rohen + Thieme (or Netter if you prefer) are a great combination.

Neuroanatomy

• First year neuroanatomy can be a complicated beatdown but often doesn’t require a book.
• Clinical Neuroanatomy Made Ridiculously Simple can help with the highlights (hits a good portion of testable points) in a relatively painless way but won’t replace your course materials.
• High Yield Neuroanatomy is a more thorough but dryer version.

Embryology

• Your needs will vary a lot depending on your school’s course, so ask up. Commonly, embryology is deemphasized and you’ll be safe with nothing. The handful of parts they care about may be folded into your anatomy course and require nothing else.
• For focused reading, you might benefit from High Yield Embryology vs BRS for the relevant material (same author, same material, a bit more explanation + length + practice questions in BRS).
• But if the anatomy & embryology folks truly have a stranglehold on your education, you may just want to pluck down for whatever they want. Langman’s is probably the most thorough and has lots of clinical correlation (which is a plus [if you can tolerate lots of graphic photos]) but generates strong dichotomous love/visceral hate from students. Moore’s Before We are Born is the most concise textbook, but her The Developing Human is ultimately stronger, more clearly written, and more popular. Larsen’s rounds out the list. If you’re really picking your own, then it’s worth taking a look in person and seeing which one speaks to you: embryology is visually complex and often meaninglessly detailed; you want something that jives with your preferences.

Histology

• Histology is another course that students often need not buy a specific book for depending on class materials and requirements. The salient portions for Step 1 are reinforced adequately by most pathology courses, so it’s often really a first-year endeavor. The main question to answer as you plan your studies is how slide/image heavy your course is so you know how deep to go down the histo rabbit hole. Outside of that, as they say in design, form follows function. Always think about relating structure to function as you learn, and you’ll be fine.
• I’d pick The Color Atlas and Text of Histology (great pictures, pretty friendly text) or Wheater’s, but Ross’ Histology or Junquiera’s Basic Histology are also fine if that’s what your school recommends/derives exam material from.
• Please see this page of links to a variety of online histo resources that probably obviate the need for an atlas for most students.

Physiology

• Costanzo’s Physiology, easily. It’s a real textbook, but it’s well written and actually relatively concise. Physiology actually matters in medicine, so it’s something worth learning well. A strong physiology background will take you far on Step 1 as well. People are often scared of renal and acid/base. Don’t be scared. Be hungry.
• Costanzo also wrote the BRS Physiology Review, which is somewhat shorter, more concise review. Conceivably, you could read her main book as an MS1 and then use BRS during MS2 to review for Step 1 (as some students advocate), but I think this is overkill. You can use the main book as a reference for as much as you need.

Biochemistry

• Lippincott is the strong choice, if you want to actually learn biochemistry at all. Biochemistry lends itself well to brute force rote memorization over deep understanding, but you’re gonna have to work for it no matter what you use. It comes with questions baked in and an additional 500+ online question bank as well.
• The Lange flashcards are quite good. They’re essentially a concise high-yield review book divided into flashcards with lots of clinical vignettes. This could be enough for you; it honestly was for me.
• For something in between a dedicated text and flash cards, consider First Aid for the Basic Sciences, which fleshes out the FA bones for your initial exposures.

Microbiology

• Clinical Microbiology Made Ridiculously Simple is a classic highlight. It doesn’t cover everything, and it’s not detailed enough to stand completely alone, but what it does it does really well. It’s also pretty cheap.
• Since my days, SketchyMicro has taken on and expanded the visual learning mantle (and now includes topics that require such methods less).
• Deja Review Microbiology is essentially a book of clearly explained notecards in a side-by-side column Q&A format. It’s a great format change of pace (and particularly nice for quizzing yourself and friends, gauging your progress, etc). Don’t get the kindle version, which loses the crucial two-column format. Or, for rapid bug review, consider the Lippincott flash cards if that’s more your sort of thing. Fast and painless and probably better than making your own.
• If desperate for a more traditional textbook, try Levinson. For unnecessary additional depth in immunology, go for Abbas. You probably won’t need either one.

Behavioral Science

• I’ve never met anyone who needed a behavioral science text. But if you did, you’d buy BRS Behavioral Science. If you do, get the newest edition (Fadem wrote all three of the most common behavioral science books, but only BRS has been updated for DSM5). First Aid does address most of the salient material.

Genetics

• Also not usually necessary. The school choice if there one is probably Medical Genetics (it’s clearly written and not crazy detailed).
• If your school wants you to read more (almost twice more), then it might be Thompson and Thompson. For whatever reason, the 7th (2007) edition of T&T is available just sitting here as a pdf.

Epidemiology & Biostatistics

• Can be safely skipped. First Aid, Crush Step 1, and a number of other resources cover the ground fine.

Pharmacology

• If your lectures aren’t doing the trick, I’d pick the Lippincott Illustrated Reviews: Pharmacology over Katzung and Trevor’s to be your foundation. LIR has a friendlier and more digestible organization, style, and pictures (though K & T has nice USMLE-style questions baked in working in its favor). Either would work fine, though many people won’t end up buying a dedicated pharm text.
• Pharmacology is another great subject for flashcards. Deja Review Pharmacology (format discussed above) is a great option for a notecard-like resource to hammer the details. Making your own could actually be worth your time, but your friends and the internet also have decks of varying quality. If none of that suits you,  the PharmCards are also pretty good overall.

Pathology

• I owe a lot to the Robbins & Cotran Review of Pathology (aka the Robbins question book). You can learn most of the testable information in pathology just by going through the (difficult) questions in each chapter one by one, reading the explanations, and soldiering on. You’ll even start getting questions toward the end of a chapter right because you’ll have learned the testable facts as incorrect choices on earlier questions. Explanations are concise (but awesome), so you’ll occasionally need to supplement, but this is easily my favorite book from the basic science years. I don’t really believe in “must-haves,” but if I did, this was mine. Do the whole thing cover to cover right before your pathology shelf and you’ll have given yourself the best possible chance of destroying it.
• Since my time, Pathoma became a thing. This often replaces everything else “pathology” for a lot of people, though it’s more on the “clear & high-yield” side and less on the thorough. Videos are generally beloved, probably better than your school lectures, and—assuming you attend those—excellent to watch beforehand. The level of detail may or may not be enough for your school’s tests, so ask your more senior peers. They offer a pretty extensive free trial to see if the lectures and book are your style.
• Goljan’s Rapid Review of Pathology has lost some ground to Pathoma but is still very popular, well-received, and is often well-utilized longitudinally throughout a second-year path course (and sometimes just for dedicated Step review). It’s more detailed. RR covers a lot of important material, but personally, I think it’s death by bullet point (the best stuff is the blue boxes/tables/pictures). If you look at your lineup and you just don’t see a good way to fit it in, that’s entirely fine. You don’t need to Goljan to succeed.
• Big Robbins is an excellent textbook if you still like the idea of “really learning the basic sciences” by the time second year rolls around or need a non-pharmacological sleep aid (it’s over 1400 pages). I’d argue that the parts that will show up on tests make their way into the Q&A book just fine, and big Robbins is most efficiently used a reference (if at all). The completionists will, of course, learn pathology “better” by pouring over the whole thing page by page (#yolo/#fomo).

General

• It’s now common practice for students to go through and annotate First Aid for the USMLE Step 1 as they progress through the basic sciences. FA is generally too terse to learn from at first but a universally utilized high-yield review when a foundation is in place. If this method sounds good to you, then by all means do it. If it doesn’t, then don’t—I certainly didn’t. I want my textbooks to be textbooks, my review books to be review books, and I don’t want to take notes in general, let alone in the margins.
• I actually found First Aid to be overrated, tedious to get through, and difficult to retain. Crush Step 1 wasn’t around when I was a medical student, but if it had been, I’d definitely have used it (I was a big Crush Step 2 fan back in the day, though the new Crush takes a more detailed approach). I’d probably still have rushed through FA during dedicated Step 1 review (everyone does), but Crush would have been more helpful at actually teaching/hitting the high points as a longitudinal two-year resource.
• Keep in mind: Questions are good. Do lots of questions. If you have cash to burn, UWorld has great ones, and they’re the most critical component of Step review. Here are some free question resources if you don’t.

Read on: Best Books for the Clinical Clerkships

Additional reading:

• An organized list of my highest yield posts for medical school
• A compilation of free study resources for the basic sciences

When a State severely limits access to safe and legal procedures, women in desperate circumstances may resort to unlicensed rogue practitioners, faute de mieux, at great risk to their health and safety,” she concluded. “So long as this Court adheres to Roe v. Wade and [Casey], Targeted Regulation of Abortion Providers laws like H.B. 2 that ‘do little or nothing for health, but rather strew impediments to abortion’ cannot survive judicial inspection.

That’s Justice Ruth Bader Ginsburg on today’s Supreme Court ruling that overturned a lower court’s upholding of Texas’ newest abortion restrictions. This WaPo infographic demonstrates how the ruling that these laws place an undue burden on women could change other states’ laws.

Regardless of your politics, I think most people can acknowledge that Texas state legislators don’t actually care about women’s health, and the true purpose of these laws was and remains completely unsubtle. A bunch of wholly unscientific white men making unevidenced claims about women’s health as a regulatory pretense is as disingenuous as it is politically expedient.

Not ready yet to extend the rule loosening, the ACGME is expanding and extending its study of the effects of longer shifts for surgeons. The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) has unsurprisingly shown that occasionally longer shifts and a less stringent rest period did not affect the rate of “surgical fatalities or serious complications.”

I say unsurprisingly because despite being tired making all of us drunkenly stupid, residents under supervision (like those in the OR) are unlikely to be able to make a significant number of extra disastrous mistakes when the additional time periods we’re talking about are usually an hour or two. Conveniently, classic fatigue-related personal disasters weren’t even covered: needle-sticks and post-shift car accidents. They also collected duty hours the normal way, meaning that the “control” group was probably lying on their duty hours just like programs do all the time, further eroding any possible real differences. Lying on duty hours is endemic to residencies nationwide, particularly surgeons. So yeah.

What else did FIRST show?

Residents working longer shifts indicated that their educational experience improved, but at the expense of time with friends and family, extracurricular activities, rest, and health. However, these residents generally were no more dissatisfied with their overall well-being than residents whose shifts conformed to the more lifestyle-friendly ACGME rules, the study shows.

This is what I love the most. What FIRST is studying is the effect of different shift length in the context of an 80-hour workweek. While long shifts can be miserable, the underlying issue affecting burnout, misery, and lack of personal well-being isn’t occasionally working 18 or 20 hours instead of 16 (or 32 instead of 30), it’s working 80 hours a week or more for extended periods of time. You can’t have a life working 80 hours a week. If a person wants to have something consistent and grounding outside of medicine, it’s probably not going to happen. And as the young professional demographic that competes against medicine involves more flexibility, better pay, less debt, more travel, etc, this dichotomy hurts young doctors. Every social metric measured was worse, but the study was promising enough to be expanded because overall dissatisfaction was similar. Of course the real bottom line is that residents—and general surgeons in particular—are burnt out.

You take a pie made out of….an unpalatable ingredient, and then tell someone that they have to eat one every week. They have the option to eat it in 5 big pieces or 6 slightly smaller ones. Do you think they’ll care that much? The bigger pieces are harder to eat, sure, but at the end of the day, it’s still a lot of pie. For most people of normal emotional reserve and professional eagerness, it’s probably too much. The FIRST results just tell us that the 80-hour work week trumps shift length—on the whole, both groups were equally miserable.

Duty hours restrictions may have initially started as a patient safety improvement mechanism, but both anecdotally and scientifically, it’s clear that the sacrifices made in the other direction wash away most if not all of those benefits. What duty hours really have the potential to do is make happier doctors who are less likely to suffer from compassion fatigue and other issues of burnout. But to do that, we either need more residents to make the same amount of work doable with less man hours per person, or we need to design systems that are resilient and flexible enough to not be built on the premise and foundation of overworked residents (or both).