Put on your blinders to succeed on the USMLE Step 1

The rumors and details you will overhear about your classmates’ studying will shock you. They can stun even the most conscientious student with pangs of worry and feelings of inadequacy.

“Did you hear about Caroline?” they’ll say. “She already made 3 passes through First Aid and is already starting her 4th, and she also did UWorld twice.”

“Yup, I just finished my second pass through cardio, neuro, and renal. Since we have 7 weeks to go I figure I’ll finish Kaplan’s q-bank and do UWorld again, then see how I do on my 5th NBME practice test.”

The examples above are merely generalities about studying “achievements.” If you start talking about the details of—say—renal pathology, antiarrhythmics, or glycogen storage disorders, your buddies might be spouting off answers from memory while you wonder how you got so far behind (and how to spell “antiarrhythmics”).

Hearing these statements from seemingly superhuman classmates who are abusing First Aid can make you feel like your competition is running circles around you, and make you think you’re way behind. That’s why I found it best to “put my blinders on” while preparing for Step 1.

Often, the student who sound like they’ve studied extensively (the “multiple passes after only 3 weeks” folks) are overly focused on First Aid to the exclusion of better resources. They may have developed a destructive First Aid addiction early-on, forgoing their deeper course readings for First Aid‘s superficial outline. If they claim to have gone through UWorld multiple times, they may have sped through it without reviewing questions they got wrong and without reading the explanations carefully.

The advice you receive from this blog (assuming you have similar study habits so it will work for you) will guide you towards a better score. Further, in the long run, if you follow this advice, you will be better prepared for your clerkships with a deeper, more conceptual understanding of the material based on your readings of multiple sources (as compared to some of your “memorization junkie” classmates).

It’s absolutely essential that you have a study plan tailored for what works for you. The anonymous student who received a 260 and gives advice on the Surviving Medicine podcast ([pending] blog post: link; actual podcast: link) reiterates this point several times. Most students heed this advice and tailor a study plan. You classmates are following their own plans. Listening to their patter as they work through their plan is irrelevant. Until test day (and perhaps even on test day!), they will continue to have large gaps in their knowledge. Puffed-up classmates may not show these knowledge gaps as they spout off the material they’ve already conquered; it’s easy to mislead yourself into thinking they have no weaknesses. There’s no need to feel inadequate when they seem to have all the answers. I recommend avoiding the subject of boards prep with friends unless you really think you have some wisdom to gain from them (or you have something to get off your chest). Talk about anything else!

tl;dr—Have your own plan and ignore what your classmates are bragging about as you prep for Step 1.

Books, podcasts, and websites for ophthalmology clerkships

Despite its fearsome reputation among spelling bee contestants, ophthalmology is the crown jewel of medical specialties. Most ophthalmologists cite reasonable hours, good outcomes, generous compensation, quick and satisfying surgeries, and a good mix of clinical practice with operating as key aspects they love about their jobs. Indeed, ophthalmology has one of the lowest burnout rates of any field, and a shocking amount of ophthalmologists “pass on the speciality” to their children.

For many med students, ophthalmology is an unfamiliar, niche subject:

Whether you’re new to ophtho or you’ve already realized that it’s the greatest speciality, you’ll need some good resources on deck to help master the basics. Even if you don’t want to go into ophthalmology, mastering the basic eye exam will help you diagnose neurologic disease, deal with common ocular complaints, and assess the progression of diabetes. Far from being an isolated organ, the eye gives you the only means of viewing the CNS noninvasively, and the retinal vasculature closely parallels that of the kidneys.

  • Practicing the retina exam
    • If you can get access to an indirect and a condensing lens (20 D), the little eye cube that comes with Welch-Allyn direct ophthalmoscopes is a good model for practicing. Unlike (non-comatose) patients, models don’t care if you shine bright lights at them for an hour!
  • Suggested books
    • If new, start with OphthoBook (https://timroot.com/ophthobook/). You can read PDFs of each chapter for free online, but I prefer the print copy. I highly recommend reading it before starting any ophtho clerkship.
    • Start OphthoBook Questions towards the end of OphthoBook.
    • Helpful books I found in my library:
      • Slit Lamp: Examination and Photography B5 .M37 2007 (oversized). You can skim the historical and photographic discussions, but the beautiful images will help you start recognizing patterns. This book does a great job of breaking down how experienced ophthalmic healthcare workers control lighting with the slit lamp for viewing various ocular structures and pathology.
      • Practical Ophthalmology: A Manual for Beginning Residents RE75 .M36 2005 is good for starting to appreciate the techniques.
      • Wills Eye Manual is a good reference for tagging along with residents; you’ll find concise information for dealing with nearly anything that comes into the ER.
      • Ophthalmology Made Ridiculously Simple RE56 G56 1987 is worth a skim if you need to brush up on the basics. It’s concise and a decent example of an MRS book; you’ll find the other titles in this series useful for micro and for the boards.
      • Vitreoretinal Surgery RE501 .W55 2008 is a good way to get oriented if you are spending a morning in the OR with a vitreoretinal (VR) surgeon.
    • Basic Ophthalmology is good; an old edition is fine.

In the words of my attending, “Basic Ophthamology is too basic; Practical Ophthalmology would be practical.

  • Websites
  • Podcasts
    • Tim Root has two podcasts covering the basics (the eye exam and anatomy): https://timroot.com/extras/.
    • Dr. J. Lawton Smith recorded some really good neuro-ophtho lectures in the 1970’s. They’re really funny since he uses wacky South Carolina idioms (“happier than a dead hog in the sun,” “Marcus-Gunn pupil wide enough to drive a Mack truck through it,” “enough Mydriacyl to float the Queen Mary,” “MMM-mmmmm!” “rare as hen’s teeth,” “more hypermetropia than you can shake a stick at,” etc.). Find them at https://novel.utah.edu/Smith/outline.php They are a bit dated, however. The first ten or so are more boring, but then Dr. Smith starts drinking more coffee and using weirder idioms, so they get much more “high energy” and exciting. He has some really “knock-out” patient interviews on some of the tapes.
    • Straight from the Cutter’s Mouth: A Retina Podcast (http://www.retinapodcast.com/)—Lots of episodes; very hit-or-miss and way too much sports talk on some of them! I recommend the ones where they interview Dr. Matthew Weed about inherited retinopathies (Ep. 76, 62, 56, 23). The matched MS4 panels (Ep. 89 and 21) are also quite good.
    • Eyetube.net podcasts
      • New Retina Radio—Great content but the most annoying transitions possible. Definitely check out the anti-VEGF biographies!
      • Ophthalmology off the Grid—Excellent content! I wish it came out more often. Often focused on cataract surgery and innovations. Ep. 29, “From Engineering to Vitrectomy” is pretty inspiring; the interviewee is a machine and a standout in the field.

The 7 best books you’re missing for USMLE Step 1 prep

The USMLE Step 1 is no joke, so you’ll want to go in having studied from the best resources. No one resource contains everything you need to know (yes, this includes First Aid); consequently, I recommend having a wealth of resources and drawing from the best of them for each subject you need to review for the boards.

Crush Step 1

  1. Crush Step 1: This one’s the grandaddy. The top drawer. The Rolls-Royce. I relied on this book more than any other resource (save for UWorld). Although the chapters vary in quality, most of them give great, concise explanations of what you need to know for each topic. The only chapters to skip are biochem. The general pharm chapter is top-notch (I wish I had it when I took the course). Use it towards the beginning/middle of each organ block.
  2. Clinical Microbiology Made Ridiculously Simple: I covered this book in “How to Crush Microbiology.” It’s worth another mention, however. I read through the whole thing around the middle of my micro review for step 1 and found it a worthwhile way to review this high-yield topic. The silly, visual mnemonics (or should I say “mnemococci”) came in handy and earned me a few points on the exam. They complemented Sketchy Micro quite nicely as well. This book was a good way to get another “pass” through the material.
  3. USMLE Behavioral Science Made Ridiculously Simple: You can read this (while taking notes and highlighting) in 2 or 3 hours and it will fill in all of the “extra” concepts you need and can’t find elsewhere. It also will help you review a lot of high-yield facts for psychiatry. This was a pretty interesting “tasty treat” to read as far as Step 1 prep books are concerned.
  4. Clinical Neuroanatomy Made Ridiculously Simple: Starting to notice a theme here? A lot of the MRS series books are quite good. That said, they all have different authors and vary greatly in quality, with Clinical Microbiology MRS leading the pack. Clinical Neuroanatomy MRS, however, takes a different tack. Unlike Clinical Micro MRSClinical Neuroanatomy is tiny (barely over 50 pages, and small enough to fit in your white coat). It’s an excellent review book. Most notably, it contains one page with five key sections through the brainstem. Each section is drawn as a cutesy mnemonic (e.g., a gingerbread man) that lets you pin the key features down. Your struggles memorizing cranial nerve nuclei have come to an end. I found the beginning of the book much higher-yield than the end, which gets a bit off-the-rails describing each pathway. Read through it and copy down the key diagrams towards the beginning of your neuro review.
  5. Clinical Pathophysiology Made Ridiculously Simple: This is the second-best book in the MRS series. It’s relatively short (187 pages), and it contains short chapters on each organ block that will get you oriented as you begin reviewing each one. It does a great job of walking the fine line between oversimplifying the material and dragging on too long. It was—along with PathomaCrush Step 1 and First Aid—one of the few books I had spiral-bound to make it easier to read and to write in it.
  6. Clot or Bleed: A Painless Guide for People Who Hate Coag: This is a short eBook by pathologist and master educator Kristine Krafts, MD. It only takes a few hours to read, and it breaks down coagulation into a simple, memorable framework that will help you speed through boards questions. It’s worth every penny. Her other resources (e.g., the free Path Bites email list) are worth checking out as well, but I particularly liked Clot or Bleed.
  7. First Aid Cases for the USMLE Step 1: Obviously everyone gets First Aid. Surprisingly few of my classmates, however, realized that there’s more to the series than First Aid alone. Though I didn’t find First Aid for the Basic Sciences: General Principles or [same]: Organ Systems to be that helpful, Cases is a real gem. It’s short, and features dozens of one-page cases in Q&A format that go through the common presentations you need to know, sorted into chapters by organ block. The interactive, case-based format is more engaging than reading, and I found doing cases in it to be a good way to “take a break” from hardcore studying while still learning. It’s best used towards the end of reviewing each organ block so you will get the most out of each case (and have a reasonable success rate in answering the questions).

These seven books may raise a few eyebrows since they’re not as well-known. I found them extremely helpful, however, and I trust you will too. I’m surprised that the word about them hasn’t gotten around yet. Fortunately, you’re in a select crowd that knows what’s up.

How to study for your medical microbiology course

Microbiology is typically one of the hardest courses in medical school. There are dozens of drugs to learn and hundreds of bugs, along with lots of molecular details, lab tests, and host-pathogen interactions. At least at my medical school, it was on par with—if not harder than—anatomy. That said, it’s a rewarding course that pays dividends for the boards (it’s high-yield), and—more importantly—lays down foundational knowledge for all fields of medicine.

The human mind is a pisspoor tool for memorizing lists of facts. On the other hand, it is unbelievably good at taking in visual details laid out in a scene, and is excellent at remembering engaging stories. While older microbiology texts lay out the information in lists of facts, newer resources take advantage of the powers of human memory to grok information from visuals and stories. I’m going to cover three microbiology resources that reflect this approach, and I highly recommend that you use them.

  1. In microbiology, one of the first books to take the more modern approach was Clinical Microbiology Made Ridiculously Simple. This book is the absolute best of this generally good series. It uses stupid mnemonics, dumb jokes, and unforgettable cartoons to break down what you need to know. Although it’s dated, it’s still one of the best books you can buy to supplement your medical school education. Bread-and-butter microbiology hasn’t exactly changed all that much since it was written, and the authors have done a good job updating it with new editions to reflect the changing state of clinical knowledge.
  2. Did you enjoy playing Pokémon growing up? Microbe Invader is just what the doctor ordered. This online game lets you stock on antibiotics, diagnose infections in patients with funny names, then battle the bacteria, viruses, and fungi! By putting you in charge (and using memorable—though outdated—graphics), Microbe Invader makes microbiology much more memorable and engaging than book learning alone. I played Microbe Invader during study breaks, looking up diagnostic tests and antibiotic susceptibilities as needed and taking a few notes to help me learn the forgettable ones. I found I got more out of the game as the course went on.Screen Shot 2018-02-20 at 11.38.33 PM.png
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  3. The most modern of the three, Sketchy Micro, brings the material to life with vivid images replete with memorable recurring symbols and dumb mnemonics. Like the age-old “memory palace” technique, Sketchy Micro organizes the information into clear symbols that pop up one-at-a time in memorable scenes. Dumb jokes keep it lighthearted and reasonably entertaining. The 5- to 15-minute video length (with the option to play them back at increased speed) packages the information into tasty morsels. Personally, I only used Sketchy Micro when it was time to study for the boards, but many of my classmates used it during the course and found it very helpful.Sketchy Micro is now part of the larger Sketchy Medical collection, which also includes Sketchy Pharm and Sketchy Path. I found Sketchy Micro more helpful than Pharm, though. The Pharm videos often get quite long and the symbolism is necessarily more convoluted, but they often explain organ physiology quite well (e.g., the nephron) and tie in the pharm. I haven’t tried Sketchy Path as I’m an old man and these videos emerged after my time in preclinical med school, though it may be worth checking out. Path is already quite saturated, however, with excellent contributions from Drs. Goljan and Sattar (Pathoma). Though these courses are relatively expensive, they are certainly worth it for the boards and may make a sensible investment during the course as well.IMG_3322.jpeg

Despite the large volume of information, if you start early and study Clinical Micro MRS and Sketchy Micro hard and crush Microbe Invader on the side, you will be in a good position to slay the test. Further, you will set yourself up for a strong performance on the boards and you will serve your future patients well.

Making random rare diseases memorable with the YouTube School of Medicine

The human mind is well-suited to remembering stories, but awful for remembering long lists of facts with no emotional import. In particular, the human mind remembers where items in a place or image are located extremely well, particularly if what’s in the picture has a strong emotional impact.* This fundamental property of the human mind makes a lot of traditional sources used in medical school dreadful for learning the material; case-based learning is much better. Additionally, this is the reason why Sketchy Micro is so useful.

When you’re wading through a long, boring list of conditions in First Aid and you can’t remember one of them, give yourself a story to pin the disease onto. Head over to YouTube and type in the name of the disease. Try to find a ~5 minute video with a patient talking about it, and crank that sucker up to 1.5x or 2x speed. Stay away from any videos that are meant to be USMLE review. Ironically, you’re much better off with a hard-hitting story about a patient and their family as opposed to another boring list of facts about the disease, and a lot of the USMLE reviews out there are very poorly-presented lists of facts. Here are a few examples of good videos to watch:

The only educational video that’s worth watching is this absolutely absurd 1 minute video on Peutz-Jeghers Syndrome and also this clever set of mnemonics for lysosomal storage disorders from a med student studying for the boards.

(H/t to my classmate G for this tip).

* Joshua Fore’s Moonwalking with Einstein offers an entertaining take on how competitive “mental athletes” use techniques like “the memory palace” that leverage this principle; Sketchy Medical and Picmonic basically use this technique.