Among young adults with a BMI between 25 and less than 40, the addition of a wearable technology device to a standard behavioral intervention resulted in less weight loss over 24 months. Devices that monitor and provide feedback on physical activity may not offer an advantage over standard behavioral weight loss approaches.

That’s the conclusion of a 2-year 471-participant randomized controlled trial in JAMA of how wearable tracking technology affects weight loss.

Wrinkles: Only 75% completed the study. And both groups did lose weight: 3.5 kg in the “enhanced intervention group” and 5.9 kg in the control.

One wonders if meeting your goals with a wearable might cause some people to skip working out or quit an exercise session earlier than they might otherwise do (at least on occasion). The study also didn’t use one with any of the gamification principles that some people have promoted as making exercise more “fun.”

The public apparently likes the 16-hour shift cap:

After people hear arguments both in favor and against eliminating the 16-hour shift limit, voters’ opposition holds firm at 86%, 79% strongly opposed,” she said. “Eight in 10 would support decreasing the shift limits for second-year residents from 28 hours to 16 hours as well.

These are results from a probably biased Public Citizen survey, a group that vocally opposes the FIRST and iCompare trials that are testing loosening the shift restrictions in surgery and medicine programs across the country.

What I find confusing is that the contemporary discussion always centers on whether or not shift limits are good for residents and/or for patient care. But this focus is always on the impact of shift length on acute fatigue and sleep-deprivation. Nothing about total shift burden, especially when you know that the residents in these studies aren’t magically conforming to the 80-hour rules that are frequently ignored.

I don’t know about most residents, but one imagines a physician to be a lot more likely to do okay on a long shift if (s)he weren’t chronically fatigued working 80+ hours a week. The focus on shift length I think misses the larger and probably more important issue about general overwork, burnout, and chronic fatigue. It’s like being worried about how fresh the oil is in a car without a transmission.

For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.

That is the conclusion of a paper just published in Annals of Internal Medicine.

Outpatient doctors spend at least twice as long proving they provide medical care for billing and compliance purposes as they do actually providing it. “To Err is Human” is more apt than the IOM ever realized.

MEDSKL is a new free medical education site with a much greater than average pedigree. It’s a group of 180+ physicians/professors/faculty from medical schools in the US and Canada who are promoting FOAMed (free and open access education) for medical students.

Its clinical (not basic science) focus is well-suited to third and fourth (and industrious second)-year medical students with brief animated videos, written lectures formatted in a SOAP note format for specific problems (clever), and video lectures. The handful I sampled were polished, high quality, and at a basic unintimidating level.

The educational content is all free. There are a lot of fields represented, but this is clearly a work in progress, and lots of topics have only token coverage. In the future, a paid account will net you self-assessment quizzes, which I imagine is the business model to sustain the project. There are also plans to add official CME this fall.

It’s probably a lot easier to recruit educators for clinical medicine presentations that they’re passionate about than it is to find good basic science educators, who are rare. We now have MEDSKL joining OnlineMedEd in the free clinical medicine lecture series, but no one wants to touch the boring parts of medical school (for free). Still, it’s only a matter of time until these sorts of platforms grow and mature.

I’ve long said that the non-clinical parts of the medical school could be a correspondence course. With the increasingly professional and multimodality online resources available, often for free, this is becoming more and more true. There will be a time not long in the future when the vast majority of schools will have basically nothing to offer students during the basic science years that they can’t get better somewhere else other than friends to commiserate with, a rigid schedule, and an external source of accountability. The current trend of supplanting lectures with TBL/PBL curricula isn’t going to change that one bit.

People often ask me about Step 1 corrections, particularly with regards to the Free 150 120 (for which I’ve posted explanations for several years). The data I’d come across over the years was super old.

Last month, Reddit user Waygzh posted the results of a 208 person survey (with an above average mean score of 245), which includes correlations for UWorld, the Free 150, multiple NBMEs etc.

The spreads are huge and the correlations not particularly good, but it’s the best you’re likely to get. Just don’t get discouraged if the number you see isn’t the number you want. Inspiration is better than deflation.

UPDATE: There’s now a 2017 Reddit survey available here as well.

If you hadn’t heard, there is growing movement to end Step 2 CS (because it’s a stupid, expensive, and ultimately ineffective test). You can read about the background and sign the petition here. There’s also a fun additional JAMA editorial.

• 20,190 MD (ignoring DOs who mostly don’t take it and IMGs, for whom the test was originally designed) students took the test in 2014-15, of which 96% passed. So 807 failed.
• 817 MDs took a repeat and 86% passed (presumably 10 of these were third attempts or re-attempts from the previous year).
• So 114 US MDs were caught by the Step 2 CS hurdle, at the maximum.

So that’s a terrible value proposition: offloading an expensive test offered in a handful of locations to students drowning in debt and short on time in order to catch a relative handful of people in a deficiency that is largely contrived. But what happened to those 114, of which half failed for communication skills and half failed for poor [fake] “clinical” skills? How many students are actually prevented from continuing their careers? And for students that fail and then pass (the vast majority), is there any evidence whatsoever that this process has improved their skills?1This would also apply to the other Steps of course, but CS stands out as being more subjective, less predictable, and thus more frustrating for the students who fail.

I am very curious about the former question. I strongly suspect the latter is completely absent.

The irony is that there are plenty of bad physicians, but none of this testing is well suited to unmasking and dealing with real world deficiencies. The even sadder wrinkle is that there are also clearly physicians in the US who have insufficient English skills to practice medicine properly, so Step 2 CS isn’t even doing what it was originally designed to do well.

If I were an MS1, I’d be praying this momentum snowballs and I could save myself the hassle and additional debt.

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.

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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