The old adage has been two months for Step 1, two weeks for Step 2, #2 pencil for Step 3. In reality, it’s probably more like two months for Step 1, 1 month for Step 2, and two weeks for Step 3. But if you are worried about getting that competitive cardiology fellowship, it’s hard to nurse the popular opinion that Step 3 is $815 pass/fail two-day pain-fest that you can simply walk in and take. That said, if you comfortably passed Step 1 and Step 2 and it hasn’t been years and years, you will pass Step 3 with nominal preparation outside of familiarizing yourself with the CCS software and the official sample cases. Step 3 is a normalized test, and because all residents put less effort into studying, you simply need to do less work to achieve the same score. I’d recommend taking it during your intern year, because the relatively fresh Step skills and knowledge from Step 2 CK are more important than the clinical acumen you will gain during residency.

Last updated: 12/31/2015

Your resources

A busy intern doesn’t have much time (or desire) to comb through any review book. If you only plan to dedicate 2-4 weeks part-time studying (which is typical), then all you really have time for is USMLEWorld. The question bank itself is around 1567 questions with 51 CCS cases. Forgo the books. Do the UW qbank and definitely do the CCS cases, and you might have time to go through the questions you’ve marked/gotten wrong a second time. Besides, UW now has an iOS app so you can do questions while your attending prattles on rounds. The questions are still hard and the test itself still feels awful, but because everyone studies less for Step 3, you’re likely to perform similarly to Step 1/2CK with only a fraction of the work. (The caveat is that if you struggled to pass Step 1/2CK, then you need to take this test seriously [of course].) If you still need or want more questions, BoardVitals is a common choice, and you can get 10% off if you’re interested by using code BW10.

Don’t forget to download the official USMLE Step 3 practice materials here, which contain the official software, some sample questions, and six CCS cases (which are a must do). If you don’t bother going through lots of example cases, at least do the six free cases to become intimate with the software.

If you have the time and desire to do a slow-burn and read actual books, you can (but probably shouldn’t/won’t). However, know that none of the entries from the classic series are really as good as their previous Step counterparts.

Crush Step 3 is the fastest, but it’s skeletal and fulls of holes as always. It’s definitely the only book that’s fast enough to blaze through. First Aid was recently updated and likely less out of date; it’s still that densely-packed outline format, which is less high yield and more difficult to get through than it used to be. Master the Boards USMLE Step 3 is probably the best “complete” book on a time and mental energy budget, but there’s still no way most interns will bother getting through it. USMLE Step 3 Triage is more targeted/high yield than First Aid, very readable and well-organized, with a nice conversational tone and a nice free companion website with practice questions [link dead] that anyone can use; unfortunately, it was last updated in 2008. You can also find some free questions on the Archer USMLE site.

As always, questions are most important, and UW is indispensable. Never use a book in place of questions. If you’ve spent a few days on a medicine service, an ER, done any general surgery, played with kids, or avoided poisoning a developing fetus, then your clinical experience will serve you well. But you don’t really need it—as always, this is a test. It tests your ability to take a test, not to be a physician.

A few words about the CCS (Computer-based Case Simulations)

Typically getting the diagnosis and the primary treatment are pretty straightforward. The finesse comes from two skills:

1. Get the diagnosis and management done quickly and efficiently. Do only the focused physical in an emergency.  Don’t order and wait for tests that delay proper management. The amount of virtual time that passes prior to certain diagnostic tests or interventions does matter. Don’t just be thorough when “time” doesn’t allow for it.
2. Know the related but fundamental orders. Using CCS is awkward. You have to order “patient counseling” and other things that you would simply do in real life. You also need to remember to follow up labs and the like. If you start methotrexate, you need to order a follow-up CBC and hepatic function panel.  If you diagnose someone with lupus, they need a renal biopsy. If you give someone a stent, they need clopidogrel. If someone is going to surgery, they should be consented. Statins and LFTs. Pregnancy test before giving teratogens to women. Etc. Keep these sorts of things in mind, and you’ll feel much better as you go through the cases.
3. That said, the little things matter much less than the key management (i.e. appendicitis requires surgery). Like Step 2 CS, you can forget to do a lot of things.

Before you start, it might help you to write out on the test-center sheet the common orders that you would otherwise forget to do so that you can be methodical in your approach (the kinds of things that just happen in the hospital), like starting an IV.

When ordering consults or inputting the primary diagnosis on the final screen, you may ask yourself, “I wonder how this is graded?” Do they have human beings read through more than 25,000 tests to determine if the words deserve credit? Is there an algorithm that checks the text for the presence of the correct words? The answer is neither. This text is not saved as part of the examination, is lost forever in the sands of time, and is in no way used for scoring. Interesting isn’t it? So it makes more sense to use the last two minutes on the final screen of each case to make sure your final orders are as complete as possible rather than making sure you have time to type up the diagnosis.

Recent changes in 2014-15

1. Being able to take the test on two nonconsecutive days is a good thing, both for scheduling flexibility and for test fatigue.
2. I see no reason to be overly concerned about the much-maligned “return of basic sciences.” Content changes for the Step exams have remained minimal for quite some time. It’s not as though the addition of “drug ad” style questions has meaningfully changed the prior Step exams or required a significant shift in study patterns. The basic sciences that will be invoked on this test are unlikely to be of sufficient quantity to matter to most takers and are also likely to be the most relevant or highest-yield bits from the old days—the stuff you are most likely to remember anyway. I personally wouldn’t worry too much.

How do you interpret a shelf exam score? The NBME shelf exams were originally scaled to a mean of 70 and a standard deviation of 8. Keep in mind, this is not recalculated every year. The actual average in a given year has tended to creep up and is usually somewhere in the low-to-mid 70s. Similarly, at its creation, the USMLE average was 200 with a std of 20. Now the average is >220.

It’s tempting to assume that this two-digit score is a “raw” score (i.e. that it represents a percentage of correct answers); it does not. The relationship between raw percentage and the NBME two-digit score is not publicized nor is it released. You will not see it. Your school may be able to ask for this information in order to use it for grading purposes (see this interesting post), but as a student you will never know the calculus.

It’s also sometimes thought to reflect a percentile—it does not. Your score report does indeed have a percentile breakdown for a given score if you read through it (sample). If you want to have a general idea in advance (or for estimating your USMLE percentiles, which are not released), you can always use this handy percentile calculator to see. When your NBME score is >92-93, your percentile is generally greater than 99% (with the exception of the psychiatry shelf, which seems to have a significantly larger number of 90s raw scores). So those individuals who manage to get a 99 on their shelf exams have no way of knowing exactly how much they outperformed their peers, nor is it publicized how much better you have to do in terms of percentage correct in order to get these scores.

It’s also worth noting again that the two-digit NBME score has nothing to do with the two-digit USMLE score, which also has nothing to do with percentiles. In fact, later this year the two-digit USMLE score is going the way of the dodo (good riddance).

The score of 70 +/- 8 is already scaled to approximate a normal distribution (although at the lower margin it’s probably skewed with a left tail).

As always, keep in mind this point that I’ve made previously: not all schools use shelf exams the same way. Though the shelf averages were determined by using first-time test-takers using the NBME exam as a final exam, schools often use the shelf as extra-credit, a pass-fail test, a true graded final exam, or as a yay/nay determinant of honors. Your performance can also hinge a bit depending on what part of the year you take the exam, as scores tend to go up a small amount over the course of the year, presumably due to the accumulation of generally useful clinical knowledge (aka the “there was a lot of medicine on that exam” phenomenon). For this reason, your NBME shelf exam percentile is not as reflective of your performance compared to your peers as it would be for the USMLE exams, when all takers have the same amount of skin in the game.

If you’re a North American allopathic medical student, with difficulty. And yet several hundred students fail their first attempt at this “English” test every year. SDN and the like are full of stories about students with massive Step 1 scores who fail Step 2 CS, which makes anyone reading think that no one is safe (or that people who do extremely well on MCQ tests are robots [or both]).Read More →

“What equipment do I need for medical school?” was a question I had as a nascent first year. At the time, I just listened to whatever my school demanded and bought most my stuff from the bookstore. Bad idea on both counts. I’ve written about some of my favorite purchases and some of the less good ones on this site, but the following is a treatment of everything your school says you should buy and what I think about it:

Stethoscope

Your one absolute essential, a possibly career-long piece of equipment. I recommend not skimping. I’ve treated this topic at length elsewhere, but my overall pick is the Littmann Cardiology III.

Reflex Hammers

A reflex hammer is worth having, both educationally and clinically. If you want to elicit a reflex, throw out (or don’t buy) the tomahawk (called a “Taylor”) sold in your school’s bookstore. It’s junk. To get a reflex, you need skill and a hammer heavy and balanced enough to tap the tendon just so. The tomahawks don’t have the heft. The Babinski hammers (the ones with the circular or “Queen’s Square”-style head) are a good choice. They do the job and barely cost any more than the $2 cheapos. But the “best” white coat-able hammer styles (and the ones you’ll see the neurologists rocking on rounds) are the Trömner (and occasionally the Dejerine), which are also the most expensive (and some are absurdly pricey). If you don’t want to spend $20-40 on a reflex hammer but you want to learn and do a real neuro exam, then the Babinski is the reasonable middle ground.

If you have a relatively substantial stethoscope (e.g. Littman Cardiology III), then the edge of the head is heavy enough to get reflexes in a pinch and will save your pocket the additional junk (not quite as professional though). If you have decent percussion technique, you can also tap out a knee jerk (but likely not the others) with your fingers.

Otoscope/Ophthalmoscope (Diagnostic Set)

A “required” but rarely used pair. To buy or not to buy? And if you’re going to buy, which one? Useless cheap POS, affordable and good (Riester Ri-Mini), or the holy Panoptic? I’ve written about this.

Tuning Forks

Chances are your school will also “require” you to buy two tuning forks, the 512 hz and the 128 hz. They’re cheap. The 512 is for hearing testing; you’ll only use it for standardized patient encounters/OSCEs and the like. In real life, you’ll be rubbing your fingers together instead. The 128 is actually useful, at least insofar as performing a proper neuro exam (vibration sense). On the wards, you might actually carry it in your pocket on some clerkships. If you want to save a few bucks, you could buy the 128 and skip/borrow the 512.

Miscellaneous

Other things many people buy are whitecoat clipboards, BP cuffs, eye charts, trauma shears, and penlights (which I also saw fit to write about). Trauma shears will come in handy in the ER and on the wards, but other than a good penlight, none of these are truly essential.

Two articles this week—one from the Atlantic and the other from the NYT—deal with a couple of rare modern pilot programs to condense medical school into three instead of four years for a small number of students. The Atlantic article in particular is pretty bad and clearly written by someone who has no meaningful familiarity with medical education in this country. The concern is that shortening medical school will hinder the quality of the education. Of course, this presupposes that the length of training equals the quality of training, which is a fallacy based on nothing so far as I can tell. Of note, most countries in the world do not have an eight-year total premedical and medical school system (ours is an exception).

There are also other programs across the country (and the number is increasing) that are condensing the basic sciences (first two years of medical school) from 2 years to 1.5 years to give more time for clinical exposure. Hell, one of the years at Duke medical school is completely unrelated to the traditional medical school curriculum (you can use it to get another degree or do research). Therefore, even though it’s a four-year degree, only three of those years are used for a traditional medical curriculum. Last I checked, that is not news.

But there’s more than one way to make medical education more efficient. Here are several:

1. The AAMC premed requirements are currently: one year of biology, physics, English, and two years of chemistry. Many schools tack on additional biology and math requirements. Physics is low-yield. Two years of chemistry is overkill. What if the pre-med requirements that are broad and largely inapplicable to medicine were trimmed, and instead premedical students took basic science courses, say…physiology and microbiology. In fact, some students take these courses already and actually repeat this coursework for a second time during medical school. The premed requirements have not been changed in eons, and they’re a wasted opportunity. You can make any class hard enough to scare people away, it doesn’t have to be a year of “orgo.”
2. Combine the first and second years of basic science into one cohesive 12-18 month experience as above. A significant portion of second year is spent re-teaching what it taught during first year. Additionally, a lot of school curricula are inefficient and actually teach the same thing across multiple classes because curricula are often insufficiently integrated. In some ways, there is too much material to learn for the Step 1 (the most critical portion of the licensing exam series) and too much information to take in for basic sciences; however, more time just means more time to forget more things. Preparing for the boards is largely a function of a 4-8 week marathon prior to the test.
3. The fourth year is extremely variable. The minimum requirements that a school must offer to suffice are miniscule, and many students spend very little of this time meaningfully. The fourth year exists essentially for students to make final choices about their residency choice, obtain recommendation letters and do audition rotations, and then interview for jobs. While some students may develop meaningfully during fourth year, many many do not, especially during the second semester.

Ultimately, there are one-to-two wasted years in college that could be used to better effect (and I don’t mean letting people go to medical school after sophomore year of college, which is a separate but reasonable idea; I personally believe a slightly more diverse liberal arts education has value in making well-rounded students). If a portion of the basic sciences were part of college instead of in medical school, the total basic science time could be drastically trimmed. Honestly, most of it could even be a correspondence course. But even keeping the content the same, many schools are moving from a 2-year to 18-month curriculum. If the nation wanted to be extreme, then it would even be possible to begin the residency selection process early, have match day in the fall, graduate in the winter, and start residency after the new year instead of July 1st!

And, let’s say four years is a good length. Fine, fine. But then let’s not fool ourselves and say that the programs shortening the system are likely going to provide worse training. To the contrary, they’re taking advantage of waste inherent in the modern American medical education model: we can simply do more (and less) in four years than we are doing now.

1. Establish a relationship with the program director at your institution (and additional mentors, when possible) for the specialty of your choosing to help you develop your plan for fourth year. He or she will help you determine:

• Your competitiveness for the field
• How many programs (and of what type) to apply to based on your academic and geographic needs
• Other possible goals for fourth year to round out your application, which may include particular letters of recommendation to obtain, research needs, away rotations, etc.
• The earlier you meet with the PD the better
• Take their suggestions very seriously but always seek additional viewpoints when practical

2. Talk to as many people as you can to gather as much match “experience” as you can. Match experiences are highly variable and often passed down from generation to generation. Talk to residents, classmates, recent grads, etc. throughout the process. Take all advice seriously and with a full shaker of salt.

3. Update your CV and write your personal statement early. Write multiple drafts. Sit on them. Give yourself time to get it right.

4. Complete your application in a timely manner. For the NRMP (regular) match, that means your goal should be September 15. This really does matter and can make a huge difference both in the quantity and quality of the interviews you receive, as well as when you receive them during the process (which can make your scheduling much more flexible).

5. Apply to the appropriate number of programs for your specialty and competitiveness. Like college, it’s important to have a mix of reaches, reasonables, and safeties. It is much better to over-apply and cancel unneeded interviews than it is to under-apply, as it is much more difficult to obtain interviews later in the season if you are short.

• Avg # of applications: 20-30 (up to 60ish for dermatology)
• If you are applying to an advanced specialty (which includes most but not all radiology, radiation oncology, dermatology, ophthalmology, physical medicine & rehab, and some anesthesia and neurology), do not forget to apply to preliminary and/or transitional (PGY1/internship) programs.
• Talk to as many people as you can (fellow students, residents, and faculty) to learn about programs. The internet can be helpful (sometimes) but is irritatingly insufficient. Forums, in particular, can also be a very stressful read.

6. Check your email constantly, including your spam folder, as interview invitations are almost always granted via email and often demand instantaneous responses in order to get desired dates. Do not hold onto invitations without responding. It’s an invitation, not a guarantee. If you are unsure, schedule the interview and then cancel in a timely manner (never no-show on the day of) or request to reschedule if necessary (politely).

7. Interview at the appropriate number of programs.

• Avg # of interviews: 10-12 (ranking 12 virtually guarantees a match in most specialties)
• Do not plan to enter the SOAP under any circumstances. There is no benefit to this “strategy.”
• For advanced specialties: preliminary programs vary widely in competitiveness and intensity. Make sure to have a sufficient number of preliminary programs as well. There are often some categorical and “pseudo-categorical” programs that have internships more or less included with the advanced spot. Residents who under-interview for preliminary or transitional year (TY) programs may find themselves forced to scramble into preliminary surgery years (generally undesirable). Take getting an internship seriously.
• If you receive less than 10 interviews by November then you may need a backup plan and should consult your advisor. You should go on at least 7 interviews.

8. Make your rank list. There is no gaming the system, just put your programs down in the order you actually want them. Rank every program you interview at unless you would literally rather not have a job than train there.

9. Inform programs of your intentions:

• You may tell your number one (and only your number one) program that they are your very first choice.
• Tell other programs of your interest. Do not lie. Statements like “very high on my list” are fine so long as they are true. These general statements are generally viewed as meaningless (because they generally are!).
• Do not believe programs when they tell you nice things. Rank only as your dreams dictate, not based on any verbal or informal agreements.

10. Enjoy the matching process. Try not to stress.

• You will be informed on the Monday of Match Week if you’ve matched (or not). This will include both prelim and advanced positions when applicable.
• If you do not match, you will have the chance to enter the SOAP (formerly the ‘scramble’) match of unfilled positions. There are jobs out there, but the quantity and quality are highly variable, and one should never plan to enter the SOAP.

That’s a quick recap of fourth year, ERAS, the residency interview process, and the NRMP match.

Why would I/we enter the couples match?

Generally, because you are married or close enough. Any two people can enter the NRMP match as a couple, which will tie your residencies together by whatever rubric you choose. This is usually done in order to end up in the same geographic location, which can be defined as tightly (Manhattan) or as loosely (the Midwest) as suits your needs and circumstances:

On the whole, couples do relatively well in the match (91.6% of partners match together and at least one partner matched in 94.6% in 2012 according to the NRMP), barely different from that of singletons (95%). That said, your advisor will recommend that you increase the number of programs you apply and interview at accordingly. The more difficult the field you enter, the harder it is to couples match (per conventional wisdom). Double pediatrics is easier than pediatrics/radiology, which in turn is easier than radiology/dermatology.

The overall process itself is simple: you check an extra box on ERAS to inform programs and check another box (and pay an extra $15) for the NRMP to register, then submit your ROL (rank order list) together. The lists will link up, and you both must specify every single combination you’d like in order (up to 300 combinations). You enter it exactly as you want it. If you want prestige over closeness for your dream program, you can do that (though your relationship might not survive it!).

“No match” is also an option for the couples ROL, a potentially useful backup so that one partner’s success isn’t jeopardized if the second partner simply cannot match. The second person would then hopefully be able to SOAP somewhere nearby, but this may prove difficult as the location of the successful partner’s match would still be unknown. Regardless, this may be especially helpful when one applicant is reaching and the couple would rather try to SOAP for one spot in desperation instead of two.

Special Cases

There is no couples match for the early match specialties, although, if applicable, all preliminary years are part of the NRMP and eligible for the couples match. That means that if one or more partners is entering ophthalmology or urology, there is no way to guarantee being together during residency, end stop. There can be informal agreements and all sorts of hand-shaking, but no formal system will help you or preserve your sanity. Historically, ENT, neurosurgery, and pediatric neurology were also early match, but that is no longer the case.

All residencies requiring a preliminary year can also be tough. These include radiology, ophthalmology, radiation oncology, dermatology, as well as some neurology, rehab, and anesthesia. There are some programs in these fields that are categorical (meaning that they include the internship year), in which case you will match normally. But anyone entering an advanced field will couples match that advanced field with their partner’s program. The prelim year is not and cannot be part of the couples match itself (except for early match advanced fields). This means you cannot guarantee being in the same location for internship (but you can maximize your chances by attempting to go to locales or programs with large or multiple preliminary programs or be willing to enter a preliminary surgery year). If you want to ensure being together during intern year, then prepare for a large number of preliminary and transitional interviews and increased application/interview costs.

How to approach the process as a couple

It is advisable to let programs know you are couples matching.  This can be done on ERAS directly. You can also touch on this in your personal statement if it flows. This encourages PDs in different specialties at the same institution to talk and can result in interviews for one applicant that they may not have otherwise received.

You will bring it up briefly during every interview (you’d be surprised how often programs can forget).

It is generally easier to focus on areas that have a sufficient number of options to make matching likely. This in part varies on which fields you will pursue, but larger cities like NYC, Chicago, Boston, etc. tend to work well for increasing the number of permutations. It’s also generally easy to get a larger number of interviews in your geographical region.

For couples with one partner in the Early Match, it is worth it to keep in contact with programs once the spouse knows where they have matched in order to stress that you are specifically vying for a particular area/program.

It is okay to politely inquire as to application status when one partner has received interviews from an institution but the other has not heard back, especially in areas with only one institution. Some fields send invitations significantly earlier than others. Most programs understand that one spouse will have little interest in attending an interview only to find out their significant other has been rejected. It’s a wasted interview from both sides of the table.

Always be polite, but don’t be too hesitant to contact when it will change your plans. If a program isn’t responsive or accommodating at this stage in a game, that’s something to keep in mind. I was surprised at how accommodating programs were when contacted, even very early in the season.

Most couples prefer to travel together when possible in order to explore new cities, save on travel costs, etc. The success for this is highly variable and depends largely on both programs’ schedules and the pushiness of applicants in attempting to ascertain interviews and reschedule when possible. Programs generally are sympathetic to the plight of the couple.

Finally, the NRMP provides some excellent information and sample couples match rank-order lists (ROL).

The Littmann Cardiology III.

Oh, you actually want to read a treatise on stethoscopes? Well then don’t let me stop you!

A reasonably good stethoscope is the one (and I mean one) and only piece of medical equipment that every medical student should purchase. You will use it during the preclinical years for training and OSCEs, and starting third year you’ll use it almost every day (possibly for your entire career). Stethoscopes aren’t like ophthalmoscopes; you really need to have your own, and it is absolutely worth it to have one that works well. But there are an overwhelming number of models at a huge variety of price points.

You say the word stethoscope, and the response you’re most likely to hear is Littmann. But even then there are a lot of choices. My recommendation for most health care professionals is to buy the Littmann Cardiology III.

From first hand experience, there really is a difference between cheap and expensive stethoscopes, period (even to some extent within the Littmann line of products). I actually used and continue to use an old Littmann Lightweight that was my mother’s. When it went missing briefly, I used a pink cheapo one that my wife had upgraded from. In both cases, I thought I was hearing the right things. I could hear a heartbeat. I could hear breathing. However, there’s a significant difference between hearing the heart and breath sounds and being able to hear diagnostic sounds. I thought residents were lying about hearing faint murmurs or bibasilar crackles. ((Sometimes they were, but that’s beside the point.)) That’s because even with my old Littman, the amplification and frequency response simply wasn’t that good. Everything was muffled. Moreover, the tubes on cheap ‘scopes are so poorly insulated that any slight movement (even chest movement, patient hair, etc) is enough to obfuscate any actual physiologic noise.

My wife has the Cardiology III (a fun present to get from relatives, as it costs around $150), and if I were in the market for a new stethoscope, it is the model I would buy without question (update: my vintage stethoscope broke during intern year; I replaced it with the Cards III). When I first borrowed it my mind was essentially blown. I had no idea what I’d been missing. The Cardiology III strikes the right balance of features and price for essentially any physician. ((If you don’t want/need a pediatric head or a dedicated bell and do need to look awesome, then perhaps the Master Cardiology is for you (see the comments below.) ))

• Tunable heads mean that you can assess both high and low frequency sounds by altering pressure. Once you practice with a tunable diaphragm, it’s actually a great feature as it allows you to rapidly get a full sonic picture of a location in space without having to futz with the stethoscope
• Double (both adult and pediatric) diaphragms (the peds one can be switched to a standalone bell as well, which can be nice if you want to ignore the tunable feature). Some schools require you to have a double-headed model so that you can “switch” modes when taking standardized exams, and this is the model in the cardiology series that is double-headed. This also means that no matter what you do later, this one will get the job done.
• Excellent (I mean excellent) external noise attenuation. You hear what you want to hear.
• The only con is that is a bit on the heavy side. The up-side of this con is that you can easily use the head to test reflexes.

Someone may come to your school to try to sell you a digital/electronic stethoscope (like this Thinklabs one several of my classmates were conned into buying). Outside of increased amplification for the hearing impaired, most digital stethoscopes (while kinda cool) are stupid for a variety of reasons: bulky, most can’t fold properly for a pocket nor easily wear around your neck, need for batteries, etc. I have yet to see a compelling reason to buy one unless you are an educator, as the second-listener feature is great in a classroom setting.

Some people hate Littmann’s “new” tunable stethoscopes. And while essentially everyone I’ve ever worked with carries a Littman, there are some folks (especially old school docs) who swear by a couple of other models, particularly the Harvey Elite, which is even pricier but is universally acclaimed by its users.

In addition to a good stethoscope itself (and certainly the cheaper/lighter Littmann Classic II gets the job done), many of my classmates and fellow residents also swore/swear by their holster, though I myself just bear with the neck strain.