Ben White

Free USMLE Step 1 Questions

08.30.09 // Medicine

No matter how much money you spend on books, every medical student needs to do a ton of practice questions for the USMLE Step 1. Questions are an excellent way to learn the useful tip-offs and keywords, and—depending on the source—get a better feel for the board format. They’re also a form of active learning, unlike trying to self-induce a coma with the universally-utilized First Aid for the USMLE Step 1. I believe USMLEWorld is the best question bank out there—despite its draconian efforts to prevent IP theft—and there is no free source out there that matches it (especially for the final marathon push before the big day). That said, there are other ways to study, especially during the basic science years.

For question books, post-Step MS3s and your local used book store are always good resources to buy study materials on the cheap. But free is better, and the internet is undeniably convenient and portable. I scoured the web to find free question banks online (updated June 2019):

  • The NBME offers its own small set of free practice materials for the Steps 1, 2, and 3. You see the most recent set here, which includes a browser-based software version that mirrors the actual program Step uses (Fred V2), a tutorial, and 100+ question practice test. A must do. A pdf file is also available from the above link, which contains the same questions for your offline viewing pleasure. I’ve written answers/explanations to the past several sets, which are linked here.
  • Lecturio has made their 2200 question USMLE question bank completely free after registering for a free account. If you’re interested in buying their full-featured video lecture/qbank product, you can get a 25% discount with code hpG6C.
  • Pastest is a 2300-question commercial qbank that has a 48-hour free trial.
  • WikiDoc has a 696 question board-style USMLE Step 1 qbank. Robust, very nice. Qbank appearance approximates the USMLE Fred software. Totally free but requires a login.
  • MedBullets has a 1000+ question Step 1 qbank in clinical vignette style. Registration required, pretty robust software (tutor mode, tracks prior questions, etc).
  • USMLE Sapphire is a free online qbank (registration required), currently with 520 questions. Style is more concise/abbreviated/clinical-flashcardy than the real clinical vignettes and the software handles the explanations in an annoying way, but the site keeps your test history, lets you review prior answers (no tutor mode), and pick questions based on subject and body system. Some of the bits I saw were a bit obscure, particularly given its size.
  • Osmosis is a completely free big (>5000 question) qbank and video product. Many questions are more on the Step 2 side of things, but an impressive collection nonetheless.
  • USMLEQuickPrep is a large (~4500 questions) and entirely free qbank. It’s the largest and most exhaustive free source out there. The questions are a mixed bag, and not all are in Step-style, but most have explanations, the site isn’t too clunky, and it certainly stands out for its sheer volume. [site is down again]
  • Lippincott’s 350-Question Practice Test for USMLE Step 1 is solid, but you must register (for free) before using it. [now defunct]
  • MedMaster (makers of the “made ridiculously simple” series) has a USMLE Step 1 qbank (among others). The questions are not step-style but rather content review. It’s a good foundational accompaniment to book learning, as it clearly highlights key facts and distinctions that are crucial for Step 1, but it does not prepare you for the exam proper. There are also no puns or goofy diagrams like the book series.
  • Test Prep Review has a USMLE practice self-assessment section. There are 20 modules of 20 questions for 400 questions. They’re mainly fact-recall and not vignette-based, but it’s easy to use and accessible.
  • Wiki Test Prep [now defunct, but with questions available as a pdf for download] is was a student-written qbank with over 900 questions with explanations. The site is great, and you can browse questions by keyword, flag questions, and create your own tests. It also lets you know what percentage of students answer the question correctly, which is interesting. The questions are in clinical-vignette board format.
  • MDLexicon has a bunch of vignette questions organized by category, it’s hard to tell exactly how many. The site design is bit odd, but it works.
  • 4tests.com hosts an old 60-question Kaplan diagnostic exam. Answers can be exposed during the test if desired and do contain explanations. (Mom MD also has the identical sampler, only organized in six 10-question pages with answers directly below questions)
  • ValueMD has a large question bank divided up by subject. The site also requires a free registration. The questions are straightforward fact-recall type and the site itself is clunky and hideous, but it’s still decent review.
  • Kaplan lets you try one 48-question section for free after signing up.
  • Learntheheart.com has 50 cardiology USMLE Step 1 questions, with plans to add more.

Enjoy. I can’t vouch for the quality of these resources, but WikiDoc, Lecturio, MedBullets, Sapphire, and Wiki Test Prep together are about 3500 questions, bigger than UW (though assuredly with lots of overlap between sources). Osmosis, a new free player, adds in a lot as well. Add in the past few years of official practice questions (the “Free 150”) and you’ve got even more.

There are also several free questions sources for the MRCP (The UK’s version of the Step), for which there is considerable overlap:

(For more information on how I personally would recommend studying, feel free to peruse my post: How to Approach the USMLE Step 1. You can also find my compilation of free study resources for the basic sciences here.)

Studying for the Basic Sciences and (preclinical) NBME Shelf Exams

05.22.09 // Medicine

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

Anatomy:

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

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

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

Favorite books: Moore for the textbook (though your school syllabus may be enough). Rohen for the atlas, end stop. (I prefer real photos to Netter drawings, though the combination is synergistic; Netter shows you the ideal relationships; Rohen shows you how to actually identify structures on your practicals).

If you want a combination of Netter-style illustrations mixed with a healthier amount of explanatory text and some 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).

Physiology:

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

Almost all physio questions require knowledge of the various trends and formulas; they usually demand that you know why something happened or what happens next. For example, you need to know the body’s compensatory mechanisms to keep fluid volume stable, and how these are used to correct for hemorrhage, dehydration, diabetes insipidus, etc etc etc. If something going up makes something else go up or down, then there will be a question about it.

Also, know your renal.

Favorite book: Costanzo, easily. She also wrote the BRS Physiology Review, which I’ve heard good things about.

Biochemistry:

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

Favorite book:  I used the course syllabi supplemented with the wordy but quite good Lange flashcards. Lippincott is the common favorite. Goljan’s Rapid Review covers the topic nicely as well and many people end up buying it anyway. I’ve also heard pretty good things about First Aid for the Basic Sciences.

Microbiology:

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

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

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

Favorite book: Clinical Microbiology Made Ridiculously Simple, hands down. For rapid bug review, try the BRS flash cards. Fast and painless and better than making your own.

And that’s it. You’ll be fine.

(Keep in mind: Questions are good. Do questions. If you have cash to burn, USMLE World has plenty of them. You can also find my compilation of free study resources for the basic sciences here. You can find my views on the pathology shelf here.)

NBME Shelf Exam scores, with a grain of salt

04.21.09 // Medicine

The NBME Shelf exams are enjoyable standardized tests that every first year looks forward to with almost unbearable glee. Each tests a single subject (“Anatomy”) and is (for the preclinical years)  made up from the old or junior varsity questions from the USMLE Step 1, a test that makes the MCAT look like the GRE and the SAT look like building with Lincoln logs.

Some schools force their students to take a variety of Shelf exams (spending/wasting $30 a pop) to help measure how well their students have mastered the material (AKA how they are doing compared to their national counterparts). What is a bit amusing and misleading about the whole ordeal is that the national norms are probably a big crock.

Different schools use the “shelves” differently. Some use them as a just-for-fun intellectual exercise, others as extra-credit, and still others as a true final exam. Don’t get me wrong, it’s not a bad thing to get some USMLE Step 1 experience, but it’s highly dependent on the environment: if you take five shelf exams in a single week, you are clearly not going to be prepared or even particularly focused. If it’s your final exam, you are going to do your best to rock it.

So if the national average is computed from all of these groups together, then it’s going to have a huge unseen left tail: if people are taking the exam who don’t care how they perform, they’re going to be dragging the average down from where it would otherwise be. So while the test is technically normalized, it’s not the same normal as a regular standardized test: Unlike the MCAT, not every student has something riding on the exam. I personally knew people who filled out all C’s on an exam that was for extra-credit only.

While your school receives the group’s average and your grade relative to your test group (classmates), the theoretically more interesting numbers a student receives are the grade based on the national average and corresponding percentile. I’m curious as to how far off the scores really are. If all those people who weren’t making a good faith effort actually tried (as they do on the USMLE Steps 1, 2, 3), then I’d wager it’d be a different ball game. It’s essentially an unstandardized standardized test.

Further reading: How NBME Shelf Scores Work

Lip service surveys

03.17.09 // Medicine, Miscellany

The world is full of surveys: surveys for free meals at TGI Friday’s, surveys for news polls, and at school, surveys for curricular reform:

“In order to improve this course for next year, we would appreciate it very much if you would take a few minutes and fill out this evaluation form.”

And the idea behind a survey is a good (nay, excellent) one: to gather feedback and ostensibly make changes and corrections based on it. The issue is in survey construction and follow-through. The usual survey has a variety of broadly worded statements with answer choices 1-5, 1 being “strongly agree” and 5 being “strongly disagree.” There will usually be a text-box for general comments at the end. You take this survey and your answers disappear into the depths of the internet never to be heard from again.

But from the beginning, the idea that you can sum up whether something works effectively or not based on a numerical average is a kludge. Furthermore, even if an average of 4 does approximate satisfaction, that doesn’t mean there aren’t better ways to do things. It’s an understandable shorthand, but anyone hoping that it’s sufficient to understand reception  is fooling themselves. If people’s responses show that weekly quizzes are on the whole useful, that doesn’t mean they wouldn’t prefer or think it better if they were biweekly, on Mondays, on Fridays, longer, shorter, or anything else. If people say dividing the year into 4 chunks is no good, it doesn’t mean 7 would be better. A number is all well and good, but at the end of the day, how someone feels isn’t the crux: it’s why they feel the way they do.

In order for a survey to be effective, it has to take time. Each question needs to have its own comment box. Then, someone needs to go through those comment boxes and compile all of the suggestions and problems. Take the suggestions and complaints, then formulate new courses of action. Then, before implementing them, offer them anew in a survey:  What do you think about these choices? Do they sound good? How good? Better then before? If not, why not? If that takes too much time to do, have students volunteer to do the grunt work. They’ll put in on their CVs, the administrators can continue doing whatever it is that administrators do, and everyone is happy. This is also how you make changes quickly. It doesn’t need to take years.

People tend to make incremental changes to the status quo. It’s hard to make drastic changes, especially if those changes reverse your hard work or go against your own inclinations; it’s even harder to come up with these changes yourself when necessary. This difficulty then breeds the stagnation that allows bad systems to continue even when their obsolescence is practically taken for granted. And yet, this is how you get curricular form with a stethoscope on the heartbeat of a student body.

Sometimes things don’t work—but if a goal is truly to teach a subject effectively, then no one can tell you better what does and does not work than students. This is how you don’t spin your wheels around a problem, making arbitrary changes. You need to ask for feedback, but more importantly, you need to be willing to listen to it.

Anatomy of an NBME Shelf Exam

03.04.09 // Medicine

The NBME offers comprehensive subject exams, ostensibly to torture students and devour whatever scraps of self-worth they have left. The typical question format:

A X-year-old [type of person] reports to the doctor/ER with a X-hour/day/week/month/year history of not-feeling-so-hot. Upon examination, distracting details. Irrelevant information. Single key relationship. More words to make the test take longer. Talkie-talkie. What is the likely cause of this you-should-have-learned-in-your-class-and-probably-did-but-maybe-you-didn’t-who-knows-there-are-so-many-questions-on-this-test-it’s-all-a-blur person’s problem?

Rinse and repeat for three hours. Then do it for it every class you take. The joys of biochemistry could never be fully appreciated until they were compiled in such a form.

In-ear, shmin-ear

02.22.09 // Medicine

Every few months, I see some news report on the revelation that listening to loud music can cause hearing loss.  Yesterday, Time online posted “iPod Safety: Preventing Hearing Loss in Teens,” the latest in this series of mediocre ear-science.  I’ll admit that in this case the facts are accurate, it reminds me of a lot of stories that are less so.

The point, which is true, is that listening to loud noises of any kind tends to be bad for the ears. The louder the noise, the less time it takes to cause damage. Prolonged exposure to loud noise leads to both tinnitus (ear-ringing, which sucks) and sensorineural hearing loss (which sucks and is irreversible). This is actually a serious problem, and it’s caused the kind of hearing loss in teens that used to be reserved for old-time factory workers. My beef is that there is one finding several years ago that has given rise to a huge misconception:

In-ear head phones generate more sound pressure at a given volume setting than over-the-ear counterparts [source].

This is logical, given that in-ear headphones are actually in your ear, literally closer to your tympanic membrane, which transmits the physical pressure waves to your middle ear. Because iPods are generally used with in-ear headphones, some news outlets and people came away with the idea that in-ear headphones are automagically more dangerous—which is hogwash.

This is silly because pressure and volume are essentially the same thing. When the in-ear headphones produce more “volume” at a given setting, the user actually hears the music louder. If I were to switch from over-the-ear to in-ear phones, chances are I’d adjust the volume accordingly. The fact that earbuds can pump out more decibels in and of itself is meaningless. Admittedly, there has been some work that has shown that some earbuds don’t cancel external sound all that well and therefore might lead to higher volumes when used, but this varies wildly between brands. All that means is that the government should subsidize some new Bose headphones for people who work in loud places, because good sound-canceling headphones are the only ones that eliminate this problem effectively. Being closer to the ear is not an inherent problem unless the volume isn’t adjusted accordingly. This is not an unnoticeable danger increase.

What studies have shown is that individuals have a preferred ambient listening volume. Some very angry teenagers who like thrash metal tend to like to blow a hole out of their eardrum, but the rest of us tend to fall somewhere on a decent curve. What matters is what relative volume we prefer, not what method we use to get there. When people taken off the street were tested for average listening volume, the data reflect this reality: the biggest problem is background noise. We tend to like our music somewhere around 60dB. If the ambient noise is 20dB, many people will turn up the volume to 80dB. If you correct for background noise, preferred volume is nearly constant. So when people listen to their iPod somewhere loud (on an airplane or the subway), they’re probably doing a lot more damage than if they’re at home. It really is that simple.

The idea that in-ear headphones are actually worse for you is based on this distortion. They’re not; your preferences and habitat may be.