EKG/ECG instruction is a mixed-bag nationwide. Every physician is supposed to know how to read an EKG, though for many students, EKG interpretation is a skill one is supposed to somehow pick up naturally (magically) on the wards. No one seems as confident in their abilities as they’d like. And while EKG machines themselves can and do identify many abnormalities, part of the challenge of real life is to know when to ignore the machine reading.

There is a basic subset of foundational EKG knowledge that (second or) third-year medical students should acquire, and many of the resources below will easily get you there. Also note that a strong background in cardiology informs your knowledge of EKGs and vice versa.

When it comes time to learn, do the following three things:

1. Pick a source and read it thoroughly
2. Pick a system/routine of interpretation (your source should detail) and stick to it. Use it every time until it becomes natural.
3. Do examples. Do more examples. Wait until you’re feeling rusty and do some examples again.

If you’re looking for dead trees to hold, then these are the two entry-level EKG texts I recommend:

The most famous and popular EKG book around is hands down Dale Dubin’s Rapid Interpretation of EKG’s (often just called Dubin’s for short). The early portions utilize the same “programmed” learning as Felson’s, which is both effective and makes you feel like a child. Unfortunately, Dr. Dubin has also spent time in jail for making and owning child pornography, so let that information color your reading accordingly. His quite good 14-page summary (taken from the book) is also available for free online and in many ways is all you need to learn the basics or freshen up, depending on your background and the demands of your coursework. Dubin’s website itself also has some good information, but it’s very poorly designed.

Another one stop shop for basic EKG for medical students and non-cardiology-bound residents is The Only EKG Book You’ll Ever Need, which is more of a traditional text, extremely readable, and surprisingly quick. I personally prefer it to Dubin, though Dubin’s is absolutely the more popular of the two.

Your school library will probably have copies of both, but Dubin was always a bit hard to get a hold of at ours.

If you don’t mind the screen, then you can probably get away with a subset of these free resources:

ECGWaves has a free e-book and online course.

Learntheheart.com has what amounts to a complete standalone EKG online coursebook, which is broken down into the basic, topic review, cases, quizzes, and tons of example EKG tracings. The design could use a refresh, but the content is stellar and could easily replace a purchase. There’s also a lengthy review of cardiology.

The University of Utah runs an ECG Learning Center, which includes an “Outline” which is pretty good and also available as a free 88-page pdf.

The University of Wisconsin also has an online ECG course, though I’d say it’s not quite as good as Learn the Heart’s.

ECG Teacher has nice video tutorials: well-produced content, clear illustrations, good sound quality. Probably better than you’ll receive in the classroom.

ECG Made Simple requires a simple free registration but is quite good once past that hurdle. Lots of tutorials (including videos, for those so inclined)

SkillStat has a what seems like most of their The Six Second ECG Workbook available as free pdf chapters online from their website, which would make a nice addition to your iPad or other electronic reading device. They also have a nifty EKG simulator/generator for review and for testing. Either the software generates a tracing for the rhythm you select, or it generates a tracing and you identify it. Sorta fun. For those with ACLS on the horizon, it also has a nice little ACLS testing tool.

Quick ECG highlights and plenty of samples can be out at Online ECG Interpretation for Emergency Physicians (thanks, Paul).

If you’re still looking for some more sample tracings, then look no further than EKG’s for EM Physicians, which has 100 tracings with answers in addition to a succinct “How to read an EKG” section. ECG Wave Maven is a massive collection of cases. ECG library also has a good collection of tracings, though the picture quality leaves something to be desired.

Whether to help yourself or your classmates practice, produce learning materials for your students, make money, or perhaps to create a large free question bank the likes of which have never been seen, knowing how to write a USMLE-style board may be a skill you’re interested in cultivating.

In fact, even for students who only plan to take—not write—the USMLE, understanding the qualities of a Step question may help one understand how to approach (and hopefully guess/answer correctly) the ones on the actual exams.

The NBME actually has an extremely detailed Item Writing Manual (181 pages!). It’s quite long (but full of lots of examples), so I’ve compiled some highlights below. Read More →

If I could go back to the first two years of medical school, I would buy USMLE World and make it an integral part of my longitudinal studying. The more I look back, the more I believe that doing questions as a primary learning activity formed the basis of the vast majority of my medical knowledge (Wikipedia probably filled in the rest).

Studying for Step 1 isn’t something you do for a month or two at the end of your second year; it’s actually a great way to learn the basic sciences for the first time as well. But for those looking online for additional sources to get you through your first two years (and sometimes you just need to read), the following is a compilation of free online resources for studying the basic sciences in medical school, including lectures and question banks.

Anatomy & physiology

SUNY downstate has a virtual anatomy practical, which is an excellent accompaniment to hours in the cadaver lab and Rohen’s. It also has a virtual dissection section, but the software/organization is a bit tedious. The University of Utah has a great neuroanatomy online anatomy section (as well as anatomy, pathology, and more).

Michael Anson has a Creative Commons-licensed question book that is freely downloadable online and contains more than 3600 questions in anatomy and physiology. The book is written in a fill in the blank style much to aid in fast memorization, much like Felson’s and Dubin’s.

Wikibooks has a free textbook, Human Physiology, which is actually pretty good. It’s nice to have a second easily-accessible resource online sometimes.

Biochemistry

The Medical Biochemistry Page is a nice little (but still dense) online text-book of clinical biochemistry. If your lecture slides are poor or your instructor doesn’t speak English (or both), you might supplement with these quick articles.

Histology

Histology World – an exhaustive and multi-sensory histology learning site, including pictures, audio, games, and quizzes. If you can ignore the mid-1990s’ site design, there’s a lot to learn.

Blue Histology also has images and great quizzes.

BU’s Histology Learning System is also beloved and has images that you can click to label/unlabel to learn your stuff.

The University of Michigan has what amounts to an entire histology course available online. The quality is excellent.

Temple has a nice collection of labelled histology and imaging slides to help learn neuroanatomy. UCSD medpics has even more.

Microbiology

Todar’s Online Textbook of Bacteriology is excellent. It just is. No fungi, parasites, or viruses though.

The University of South Carolina School of Medicine has an online microbio textbook that includes immunology, bacteriology, parasitology, virology, and mycology. You can use the site (it even has a stripped formatting version for mobile devices) or download pdf/ppt files.

Baron’s Medical Microbiology (4th ed) is also available online for free from the NCBI. It’s a real, thick textbook and best used as a resource PRN.

Medfools has high-yield microbiology charts for bacterial, fungal, and parasitic pathology. The series is only missing viruses. Many of your classmates will spend oodles of time making their own, but these are probably better (if you’re the kind of person who can stomach endless rows of microbiology crammed as tight as possible).

The Merck Manual of Infectious Disease is well-organized and concise.

Pathology

UPMC has a nice collection of pathology cases—these are extremely academic in nature and very dense, not for the feint of heart. (The Robbins casebook is a far easier way to learn high-yield pathology for board purposes).

Genetics

Some free online questions from Utah here are a nice self-assessment.

Pharmacology

Tulane has some nice interactive/instructional pharmacology quizzes organized by body system/use.

Multidisciplinary

MedMaster has learning tools for USMLE Step 1 and Step 2, a nice Atlas of Microbiology, and several other free downloads.

The University of Utah has a massive online resource that includes cross-sectional anatomy, neuroanatomy, pathology, and histology images, in addition to a large pathology question bank (in board-style format).

For the second-year clinical sciences (and beyond), The Merck Manual has great, well-organized and concise content on nearly all high-yield topics. MEDSKL is a growing site filled with polished & painless basic clinical medicine lectures.

You can find my recommendations for basic science textbooks and the preclinical NBME shelf exams here. My list of free online Step 1 questions is here.

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.