Updates 2016-2018 - From internal medicine to subspecialty training

I have not posted in quite a while. Things have been busy, but going really well.

I have completed my internal medicine residency. It was an amazing experience. I will definitely miss my friends that I met during residency.

Even before graduation, I have received a lot of job offers to work as an Internist. The pay was quite good, averaging around USD$180,000 to 220,000 annually.

Below is an example of the emails I received.

The pay around the U.S. for internist is not too bad. As you can see below, it also depends on geographical location.

Anyways, I had actually already decided to pursue a fellowship position in a nephrology. I am currently undergoing an additional 2 years of training in nephrology, to graduate as a nephrologist (this year!). I remember my classmates in medical school in Malaysia mentioning that it is quite rare to see someone finish training to be a subspecialist in nephrology, without any bonds, within just 6 years of graduating from medical school.

I guess if I were to head back to Malaysia to work in private hospitals in the future, I may be one of the younger nephrologist. Anyways, I probably will be working for at least a few years in the U.S. after graduation, just to have enough money to travel the world while I am still young; while at the same time, have fun practicing nephrology!

Jamie

FAQ#17: USMLE Agency

I received an email from a student asking about how to obtain study materials.

Hi, Dr.Jay, good day for you!

I'm *** here. I would like to ask few questions (starter questions) regarding the exam.
First of all, do we need any agency to settle the middle works to go for the USMLE? or we can buy the materials and  just prepare for it on oueselves? 

I did not use an agency when I started my preparation for USMLE. I bought the Kaplan study materials online, just like what my sister is currently offering. I then prepared for the exam myself.

I have met 2 of the agencies that offering help with USMLE, and off course the costly one. I'm not sure what else is counted in except the materials as they charge each step about rm12000-14000.

This is the main reason for me on why I did not go through any agency. It is too expensive for me.

Do you think its worth to work with the agency to get the USMLE done successfully? 

What these agencies offer are probably the official Kaplan USMLE course. You can go with the official course if you can afford the RM 14,000 course fee. I would not recommend any other materials other than Kaplan materials complimented by some other books which I detailed in my other blog post (http://usmle-for-malaysia.blogspot.co.id/2013/02/how-to-study-for-usmle-step-1.html and http://usmle-for-malaysia.blogspot.co.id/2013/02/how-to-study-for-usmle-step-2-ck.html)

Are those videos and books enough for us to prepare for the exam? Do we need any extra tutorials/classes?  

If you go through the videos, it is like going through a live class.


Do we really need to use the latest version of materials or all of them contain the same? 

Medicine does not change a lot from year to year. I would say that as long as your material is within the last 5 years, you will be okay.
The materials I used were 4-5 years old when I studied for my exam. I still did pretty well. Study materials don't really get updated, but how questions are phrased do. You will learn new styles of questions by doing the question banks.


How to register for the exam? Do we need to pay? Manual or online?

You will need to apply online. Please refer to this blog post: http://usmle-for-malaysia.blogspot.co.id/2016/05/applying-for-usmle-exam.html.

Applying for the USMLE Exam

A lot of students/graduates give up on applying for the USMLE because they do not have the patience to learn and understand the application process. It can be complicated, but you will have to spend a few hours researching on the steps to apply.

I have outlined the basic steps below.

Terminology:

ECFMG: This is the official group which takes care of us foreign medical graduate.
IWA: this is a website which allows you to register for the USMLE
Prometric center: test taking center
EMSWP: this is a new program launched recently by ECFMG to improve speed of communication between ECFMG and foreign medical schools. Not all medical schools have EMSWP. If your medical school is enrolled with EMSWP, communication between them and ECFMG will be mostly online (instead of paper mail).
OASIS: website to check your status on USMLE exam registration


1. Check IMED

Check if your medical school is listed under IMED: https://imed.faimer.org/. If your medical school is not listed, you need to contact your medical school and have them register with IMED.

2. Get the USMLE ID
You need to visit this website: https://secure2.ecfmg.org/usmleidrequest/usmleidrequestnavigator.aspx.

Enter your information as directed. They will then send you an email within one week with your “ECFMG ID”, which is an 8-digit ID number. This will be your ID number which you will use in the future to apply for USMLE exams or get your exam results.

If in one week, you do not receive your ID number, check your email thoroughly. If you still do not have it, call ECFMG at +1 (215) 386 5900.

3. IWA application
Ensure that you have a good internet access, and a computer linked to a printer.
Enter the IWA website: https://secure2.ecfmg.org/emain.asp?app=iwa
Enter your USMLE ID and password and log into the website.
If you do not have a password, look at the bottom of the page and follow the link: “If you have a USMLE/ECFMG Identification Number, but you are a first-time user of ECFMG On-line Services, click here to establish an account.”
Fill up the forms on the website as directed.

Following that, you will be required to send ECFMG some paperwork. The most important is : Form 186.

Form 186 are forms that let ECFMG make sure that you (your name and a your photo) are in fact existent and that this is your signature and this is your ECFMG ID. These forms may have to be signed by your medical school official.

4. Certifying that what you said is true
During the IWA process, you will be required to have your medical school send documentations to ECFMG to ensure that you do exist and studied or are studying in the said medical school.


This step can be pretty confusing, and I would recommend that you give ECFMG a call at 1 (215) 386 5900 to clarify anything and everything. You probably need to get a calling card that allows you to call ECFMG at a cheap rate.

If you are already graduated: please read through: http://www.ecfmg.org/2016ib/credentials-for-certification.html. The basic idea is that if you already graduate, ECFMG wants to make sure that you in fact did graduate from whichever medical school you said you graduated from even before they approve you for a USMLE exam. You will need to have your medical school complete FORM 186.

If you are still a medical student: you will need to have your medical school complete Form 186 and Form 183. Also take time and read through Appendix 1. Basically, there is someone in your medical school that has been assigned to be the point person that is authorized to certify Form 186 and Form 183. You need to ask your medical school. If your medical school does not know, you need to get your medical school to contact ECFMG (this will be challenging because of time difference, so you really need to harass/bribe/sweet talk your academic affairs department of student affairs department.

Read Appendix 1 below for more information.

5- Wait for confirmation

ECFMG will contact you by email and by mail. If you do not hear back, do not hesitate to call them at 1 (215) 386 5900. You really need to be proactive in this step.

6. Communication between ECFMG and Medical School
At this stage, ECFMG will be communicating with your medical school. Your role at this stage is to make sure your medical school receives and responds to ECFMG’s communication.

7. OASIS
The final step is ECFMG receives your medical education credentials/certification directly from your medical school.
When you log into OASIS, you will get to see: "Medical education credentials received and verified".
Congratulations!

8. Apply
Congratulations. Now you will be able to apply for the exam. After paying for the exam, you will receive a scheduling permit. You can use this scheduling permit to schedule your exam in your local prometric center.

APPENDIX 1

Certification Form

Medical School Graduates: To be registered for USMLE, an international medical graduate must provide copies of his/her final medical diploma with the exam application, if the diploma has not been submitted to ECFMG previously. ECFMG also requires that, before an international medical graduate can be registered for USMLE, the applicant's status as a medical graduate must be verified directly by his/her medical school. As a result, the process of applying for examination as a medical school graduate will vary depending on whether your medical education credentials have been verified by ECFMG and whether you are a graduate of a medical school that participates in the ECFMG Medical School Web Portal (EMSWP) Status Verification program.

For complete information on the medical education credentials that may be required at the time of exam application, see Credentials for ECFMG Certification in the ECFMG Information Booklet. You can check the status of your medical education credentials using ECFMG's OASIS. The certification form you will be required to complete as part of your exam application will vary depending on whether or not your medical education credentials have been primary-source verified by ECFMG.

You will be required to complete a Certification of Identification Form (Form 186) if you do not have a valid Certification of Identification Form (Form 186) on file with ECFMG. The Certification of Identification Form (Form 186) must be completed by you and an authorized official of your medical school and/or a Consular Official, First Class Magistrate, Notary Public, or Commissioner of Oaths. Each medical school has been requested to provide ECFMG with a list of medical school officials authorized by the school to certify Form 186. Your form must be certified by an official on this list. Contact your medical school to determine the officials authorized by your medical school for this purpose; ECFMG will not provide this information to applicants.

The on-line part of your application will be transmitted to ECFMG only when you click on one of the links to proceed to the Certification of Identification Form (Form 186).

There are three Certification of Identification Form (Form 186) options for medical school graduates:

• "Certification of Identification Form (Form 186) - Certification by Medical School Official," for all medical school graduates
• "Certification of Identification Form (Form 186) - Certification by Notary Public," for graduates of medical schools that participate in EMSWP Status Verification and for graduates whose medical education credentials have been primary-source verified by ECFMG
• "Certification of Identification Form (Form 186) - Certification by Notary Public and Medical School Official," for graduates of medical schools that do not participate in EMSWP Status Verification and whose medical education credentials have not been primary-source verified by ECFMG

When you have completed the on-line part of the application, you will be able to view the Certification of Identification Form (Form 186) options available to you.

If you complete a "Certification of Identification Form (Form 186) - Certification by Medical School Official" or a "Certification of Identification Form (Form 186) - Certification by Notary Public and Medical School Official," your Form 186 must be sent to ECFMG directly from the office of the medical school official who signed the form. If the form is not sent to ECFMG from the office of the medical school official, it will not be accepted.

If you complete a "Certification of Identification Form (Form 186) - Certification by Notary Public," the form can be sent to ECFMG by you.

In either case, the signature(s) of the official(s) must be current; the official(s) must have signed the Certification of Identification Form (Form 186) within four months of the date that it is received at ECFMG.

Additionally, ECFMG must receive the Certification of Identification Form (Form 186) and any additional documents and photographs as soon as possible but no later than 12 months from the date you submit the on-line part of your application. ECFMG must receive the on-line part of your application, the Certification of Identification Form (Form 186), and all required documents to process your application.

Your application will not be considered complete until the completed Form 186 (if you do not have a valid Form 186 on file with ECFMG) and any other required documents are received at ECFMG.

Once accepted by ECFMG, Form 186 remains valid for five years for exam applications and requests to extend Step 1 and Step 2 CK eligibility periods. Applications and requests submitted during this five-year period can be completed entirely on-line.

If you are a graduate of a medical school that participates in EMSWP Status Verification and your medical education credentials have not been primary-source verified by ECFMG, ECFMG cannot complete the processing of your application until your medical school verifies your status through EMSWP. ECFMG will make your record available to your medical school and request verification typically within three weeks of receipt of a complete application. The time needed to complete the processing of your application is contingent upon your medical school’s response to the EMSWP verification request. You will not be registered for examination until your medical school verifies your status.

Medical School Students: The certification form that you are required to complete will vary depending on whether your medical school participates in the ECFMG Medical School Web Portal (EMSWP) Status Verification program. Medical school students enrolled in medical schools that participate in EMSWP Status Verification will be required to complete a Certification of Identification Form (Form 186), if they do not have a valid Form 186 on file with ECFMG. Students enrolled in medical schools that do not participate in EMSWP Status Verification will be required to complete a Certification Statement (Form 183).

Once accepted by ECFMG, Form 186 remains valid for five years for exam applications and requests to extend Step 1 and Step 2 CK eligibility periods. Applications and requests submitted during this five-year period can be completed entirely on-line. A completed Form 183 must be submitted for each exam application.

Both the Certification of Identification Form (Form 186) and Certification Statement (Form 183) must be completed by you and an authorized official of your medical school. The on-line part of your application will be transmitted to ECFMG only when you click on the link to proceed to the Certification of Identification Form (Form 186) or Certification Statement (Form 183).

Each medical school has been requested to provide ECFMG with a list of medical school officials authorized by the school to certify Form 186 and Form 183. Your form must be certified by an official on this list. Contact you medical school to determine the officials authorized by your medical school for this purpose; ECFMG will not provide this information to applicants. The signature of the medical school official who signs your Certification of Identification Form (Form 186) or Certification Statement (Form 183) must be current; the official must have signed the form within four months of the date that it is received at ECFMG. The form must be sent to ECFMG directly from the office of this official. If the form is not sent to ECFMG from the office of the medical school official, it will not be accepted.

If you are required to complete a Certification of Identification Form (Form 186), ECFMG must receive the Certification of Identification Form (Form 186) and any additional documents as soon as possible but no later than 12 months from the date you submit the on-line part of your application. ECFMG must receive the on-line part of your application, the Certification of Identification Form (Form 186), and all required documents to process your application. To complete the processing of your application, your medical school must verify your status through EMSWP. ECFMG will make your record available to your medical school and request verification typically within three weeks of receipt of a complete application. The time needed to complete the processing of your application is contingent upon your medical school's response to the EMSWP verification request. You will not be registered for examination until your medical school verifies your status.

All forms and documents required to complete your application must be sent to ECFMG in one envelope. If you are required to complete a Form 186 or a Form 183, this envelope must be sent to ECFMG from the office of the medical school official who certifies your form. If you are not required to complete a Form 186 or a Form 183, this envelope can be sent to ECFMG by you.

If you are required to complete a Certification Statement (Form 183), ECFMG must receive the Certification Statement (Form 183) and any additional documents as soon as possible but no later than four months from the date you submit the on-line part of your application. ECFMG must receive the on-line part of your application, the Certification Statement (Form 183), and all required documents to process your application.

FAQ#16: Question from a JPA scholar

I received an email from a second year Malaysian medical student who is a JPA scholar. 

Hi Dr Jay,
I am a 2nd year Medical Student in Malaysia and am very interested in pursuing a residency in USA. I am currently preparing for my STEP 1.
 
1. Is residency equivalent to Masters?
Yes. In Malaysia, after housemanship and 1-2 years of MO-ship, you may apply and enter into a Masters training program, which is basically a specialization program such as internal medicine, surgery, orthopedics or pediatrics. In the U.S., after the USMLE, you immediately enter into a residency program such as "internal medicine, surgery, orthopedics or pediatrics".

2. I am a Jpa scholar and thus bonded by the government. Is there any way to pursue a residency in USA by a Malaysia government scholarship like MYBRAIN15?

 

I am not familiar with scholarships. However, if you question is if you need a scholarship to pursue residency, the answer is no. You get PAID to train in the U.S. In Malaysia, you will have to be sponsored by KKM to undergo Masters training. The result of KKM sponsorship is that you will have to be bonded by KKM after graduating from Masters training.

3. I would like to come back to Malaysia after pursuing a residency. What status would I be in? A specialist, fellow or a master student?

Specialist or Consultant. Essentially you will have COMPLETED your training.

4. Is there any expiry for USMLE step 1 score?

 

When applying for residency, most States will have a law that you will be expected to complete Step 1, 2 CK, and 2 CS within 7 years. Means the date which you take your first paper to your last paper must be within 7 years. You will then be "ECFMG certified". The ECFMG certification does not have an expiry date.

5. I am intersted in Neurology/Neurosurgery. I realise that an IMG prospects to get a match in the field is impossible. But still are they are img in neurology/neurosurgery?

 

Neurosurgery would be impossible unless you are willing to spend a few years doing research in the U.S. Neurology is easy to get into in the U.S. About 30% of neurology residents in the U.S. are foreign medical graduates based on my rough estimation.

6. What are the advantages of me doing a residency in neurology/neurosurgery compared to a master programme in Malaysia?

 

I think your question is about pros/cons of each pathway. Right now you are thinking: should I just stay in Malaysia for Masters, or should I head to the U.S. for residency?

 

Malaysian Masters

Pros: 

- get to stay back in Malaysia, be with your family

- familiar with the local hospital system

- familiar with lecturers/educators from same background

- comfortable

Cons: 

- will be bonded with KKM after completion of training

- will be posted to underserved areas after completion. It will be unlikely for you to be able to stay ina big city. KKM will definitely need to post you to small towns to serve as a specialist

- will only start many years after graduating from Medical school as you will have to do housemanship and even some years of MO-ship first

- not recognized in any other country except Malaysia 

- there will be a time gap between completion of Masters training and the start of subspecialty training

U.S. Residency

Pros: 

- recognized globally

- structured training program. Has been in existence since the 1900s. The first residency program was started by Sir William Osler himself

- no bond after graduation

- earn USD while training with estimated take home salary of USD$3500 every month

- you will get to apply for fellowship (subspecialty) training even before completing residency. No time gap between residency and fellowship. Fellowship for example will be: general surgery going into vascular surgery, general surgery going into plastic surgery, internal medicine going into gastroenterology, pediatrics going into pediatric cardiology, anesthesiology going into pain medicine, radiology going into interventional radiology. There also won't be any time gap if you decide to continue on to be a sub-sub specialist: eg: internal medicine into cardiology followed by electrophysiology, or internal medicine into nephrology followed by transplant nephrology.

 

Cons:

- requires completion of the USMLE

- stepping out of one's comfort bubble

- some specialties will be very difficult for a foreign medical graduate to get into. You will need to look at the statistics to find out the % of foreign medical graduates in each specialty to estimate your chance.

 

FAQ#15: Exam dates, recent graduate from medical school

I received this email from a medical student who just graduated and is currently waiting for housemanship posting, He is thinking about the USMLE given that he has some time at hand.

Before i start i would like to intro myself here... I just graduated from Medical school and currently waiting for my housemanship posting. I have always been interested in taking the Usmle
Here i would like to ask 3 simple questions which i hope ul can guide me thru it.

1. When are the examination dates? Is it only once a year?

The exams for USMLE Step 1 and Step 2 CK will be taken in a test center. There is one in Kuala Lumpur. It is a computerized test. Just think of it as taking an 8-hour driving license. Like driving license test, you can take it any day of the year. You will have many people in the center taking other tests as well, such as TOEFL. There may also be those who will happen to be taking USMLE on the same day as you. Just like driving license computer test, the questions will be entirely different even if you take them on the same day.

2. Can i know how and where i could get myself registered for this exam?

You can apply for the exam via USMLE.org.

3. Do u think it is possible to study for Usmle during housemanship because i might be getting my posting in XXX and i think it my distrupt the entire studying process. Do u think it is worth to delay my housemanship a year later just to focus on this exam? I really hope you can give me a good advice on this.

I think it really depends on what are your goals. Most fresh medical graduates who express interest in the USMLE belong to one of the following groups:

The “All-in” group : I am sure that I really want to go to the U.S. My family is supportive of me putting away housemanship and focusing in the USMLE exams. I don’t care if my friends start posting their housemanship photos on Facebook. I won’t be envious because I have a much bigger goal now.

The “50-50” group: I really want to go to the U.S. However, I am not sure if I can really make it. Can I really do well in the USMLE? I don’t think my family will approve of me taking time off to study. All my friends are already working, how can I just keep studying and spending parent’s money? Okay, perhaps I will not delay my housemanship. In the meantime, I will spend my current free time studying for the USMLE. I will also try to work hard and take some hours out to study for USMLE when my housemanship starts. Perhaps I will do well in the Step 2 CK that I will be taking, which gives me the sign that I should continue to study and ace the Step 1, and then pass the Step 2 CS. Once I have those papers done, perhaps I will apply to the U.S. before I start MO-ship and have a chance to train in the U.S. Anyways, studying for the USMLE now will keep my clinical knowledge active, rather than lazing around before housemanship.

The “maybe” group : I just graduated,and have some time. What should I do? Maybe try to study for the USMLE? I am not too sure if I want to do that. This is my last vacation before slaving off with KKM. Wouldn’t it be good if my medical school degree is recognized all over the world? Anyways, will see. Perhaps I will try searching around about this USMLE thing, and see how hard the exam really is.

Therefore, I think in the end, it really depends on the amount of "pain" you are willing to go through. You probably just completed your major final medical school exam. You may decide that you want to take the time off to enjoy. Or you may decide to continue the momentum you had from studying for your finals, and pour your energy into studying for the USMLE.

FAQ#14: Being an average medical student with financial difficulties

This was an email I received from M a while back. One of the first challenge to overcome when deciding to take the USMLE is self-doubt. The second challenge to overcome is the concern that their dreams are more than what their finances can handle. The third challenge to overcome is to forget all the anecdotal evidence of those who have failed while remembering those who succeeded.

Dear Dr. Jamie,

Hello. I've researched on USMLE and came across your blog. You are truly aspiring! I am a Malaysian medical student, studying in XXX.

I am wondering if you think I should apply for USMLE, given that my syllabus back in XXX is more of a problem-based learning system (and not lecture based)? I am always worried that my medical knowledge is not on par with the rest of my fellow classmates. Furthermore, I am not exactly the top scorer of my class. I dedicated a lot of my time studying, but will only score fairly (sometimes just passing, sometimes above average). Even so, do you think I should take USMLE? 

I know you mentioned that with time & motivation, one could compensate for the lack in memory & intelligence, but I'll be starting clinical rotations at the start of January, and I am quite worried I would be burnt out after my rotations and wouldn't dedicate as much time as I should. 

I wasn’t a top student as well when I started out with my USMLE journey. During my first two years of medical school, looking back at the percentile, I was actually below average. In my second year, I decided that I really wanted to go to the U.S. I started focusing 60-70% of my time in medical school studying for the USMLE. I realized that having good scores would get me a ticket to the U.S. I also realized that scoring well in medical school doesn’t mean much. In the end, anyone who passes, top scorer or not, gets to work as a doctor in Malaysia. However, doing well in the USMLE will allow me to get immediately into a specialization training program in the U.S. Fast forward many years later, I was thankful for the decision I made back then. While the top scorers in my medical school are still waiting for the government to offer them Masters position (which has more to do with connections, duration of service and racial quotas than merit), me, the below average student, is going to start subspecialization training.

Like you've mentioned in your blog, financial issue is a big factor and would deter us from taking the exam..it is indeed true. As an international medical student, I am paying alot more than the locals and other government sponsored students. I am worried that if I take the exams, my results would not be as good (below average/fail) & would make me feel that I've wasted my money. Or even if I did well in USMLE, I might not secure a spot in residency as well. My lecturer emphasised that it is getting tougher and tougher each year and not everyone could successfully matched in their residency program. I knew of a Singaporean senior who achieved 270 in USMLE Step 1 and still did not match. 

Not everyone would match. In terms of foreign applicants, there are around 12,000 each year, and you have to be better than 50% of them in order to match. In addition of USMLE scores, getting a position also depends on interview skills as well as specialties, which you choose. In the U.S., everything is almost transparent. Every year, the match statistics are released, and it reveals valuable information such as the number of applicants, probability of matching based on score and so on.

Looking at the chart below, you can see that for Foreign-trained physicians, the number of applicants has been around 12,000 per year. The probability of matching remains the same at around 50%, meaning that if you are in a class of 10, you will have to beat the other 5 to match.

This is another chart, which shows the probability of matching based on USMLE scores for a NON-US medical student in light green. I scored 240++, and I stood an 80% chance of matching. After receiving my Step 1 results, I immediately started my Step 2 CK preparation and also made more detailed plans to get into the U.S.

The reason I'm interested in USMLE is because there are more and more medical students all over the world, with very limited training slots/internships/residency places. Like everyone else, medical school is expensive and I am paying a large sum for tuition fees & cost of living. Inevitably, I would like to have a good job prospect to repay my student loan, etc. but I'm really worried about my future and the direction I'll be heading. Please kindly advice and I am sorry to bore you with such a long email.

Around 6-7 years ago when I made the decision to head to the U.S. I took the gamble and studied hard for the exam to improve my odds of matching. I knew that nothing was a 100% and no one can guarantee my entry into a training position. I justified paying for the exams by thinking that the cost of the USMLE process is peanuts compared to the cost of my medical school. However, the difference between being able to enter the U.S. specialization system and entering the Kementerian Kesihatan Malaysia workforce is huge.

If one of your main hesitation to take the USMLE is due to financial reasons, I would suggest that you consider taking one of the steps first. If you do really well in that step, take it as a sign that you should proceed with other steps. If you do poorly in that step, then stop your pursuit of the USMLE but be satisfied to know that at least you have tried.

FAQ#13: Questions from a Paediatric Medical Officer with MRCPCH

I apologize for the long hiatus, being caught up in residency training program. I will be completing my residency program in a few months, and have also been accepted into a subspecialty fellowship program. Life has been great here in the States to the point that I am second guessing my decision to move back to Malaysia at the end of my training. Perhaps I may decide to just stay on and work here in an academic institution, and only go back to Malaysia once a while to help conduct training courses for my fellow Malaysians.

I have received tons of questions via email, but was not able to respond to all of them. I will try to respond to some from now onwards. I received this email from a medical officer who is really dedicated towards his/her own training.

Hi. I m medical officer working in XXX.  I had previously email you as a houseman at the final year. I chose to stay in Malaysia and came to sarawak after completion of my housemanship.  I sat for mrcpch and passed the first 2 parts within 1 year. During that time, I was not ready to leave Malaysia. However, only after I started as a medical officer, I does not seem to be satisfied with the training here. It does not make me to be confident to work as a paediatrician in the future. And, there are a lot of issues of medical officer overloaded, followed by the previous issue of houseman overload.
It made me to rethink whether decision of staying back is correct.

I had few questions. 
1) After I completed my housemanship, I will be exempted from licensing exam in Ireland. I realised that work overload issues at Ireland are obvious and economic state in Ireland are unstable. 
My aim is to be trained better. Going Ireland is within my choices. Mrcpch Is not recognised in Ireland. I need to take mrcp paed Ireland beginning from part 1.

Second choices that I has is stay back at Malaysia and finish my last part.
The mrcpch will be clinical.


Thirdly,
I start to wonder whether I shall consider US residency as one of my other options. Can you interpretate the pros and cons of choosing this option? I start to consider migrate to oversea as I really disappointed with Malaysia health system.

I am not familiar with the training program in Ireland, and how does the Irish training program work. In general, the questions you would have to ask are (1) Will they accept you immediately into a pediatric training program and guaranteed to complete it as a consultant pediatrician? (2) Will they accept you into a pediatric subspecialty training program? (3) Will they discriminate against your nationality when it comes to competing against locals?

I think you should not thinking of going to the U.S. for training having to be a permanent endeavor. You can always return to Malaysia as a subspecialist, or head to Singapore. I also feel that you should think beyond general pediatrics. You would want to be able to contribute more, beyond general pediatrics to the community. Think about this: (1) if you were to stay in Malaysia, will you pursue pediatric subspecialty training? (2) will you be satisfied with the pediatric subspecialty training and become a confident subspecialist? (3) will you be okay with staying in the KKM system for an additional 8+ years? This is because you have to complete your MRCPCH, undergo gazettement, apply for Masters for subspecialty training, undergo Masters training, get bonded.

The best part about training in the U.S. is that you get trained as a pediatric subspecialist really quickly with no bonds. I am now a third year medical resident, and will start as a subspecialty fellow in a fellowship training program soon. When I complete my fellowship program, I will be a subspecialist and am free to choose to either work in an academic institution in the U.S., work in a private hospital in the U.S., return to Malaysia, head to Singapore, head to Australia, and many other choices.

Another thing about the application is that U.S. is not like some other countries where perhaps those with citizenship will be accepted first, with foreigners taking the leftover spots. I have been accepted into a pretty competitive fellowship program. Four, including myself, in my class, applied for this specific fellowship. Based on merit, myself and another classmate got the fellowship. The other two did were not as good, did not get the fellowship, although they were Americans. Here in the U.S., as long as you work hard, you will be judged almost equally.

2) second question, am I too old to start as a resident at us? Going to  be 28 this year

When I started my residency (1st year), the average age of the class is around 29-30. The oldest in my residency class was 35. This is because the American medical school is a graduate entry program. Furthermore, many Americans usually do some other work before deciding that medicine is for them.

3) do Ielts a must to proof my English proficiency? I sat once. But writing component was too poor despite of overall mark of 7.5

IELTS is not required. Passing the USMLE Step 2 clinical skills exam gives the programs the assurance that you can communicate well with patients.

4) let say, If I decide to go for usmle, which part you would suggest me to start first? Any link on application process that you could share with me?

I would suggest you go with USMLE Step 1 first. It has been awhile since you were exposed to surgery, psychiatric etc. Therefore, just take it step by step. Furthermore, completing part 1 MRCPCH would probably give you some good basic science knowledge to tackle Step 1. Looking into USMLE Forums would be a good start.

FAQ#12: After housemanship

I received an email from a house officer who is about to complete his housemanship:

"I am a houseman now who is about to finish  housemanship in 4 months time, so I m thinking all this while about my future, where and who I want to be.

Mrcpch and usmle are my choice of option now.

In your opinion, how many years do I need before I pass all the exam and start my residency in the US?

And which pathway could be faster to become a specialist?

Do I need to complete all 3steps before I start applying for residency?"


1) How many years do I need before I pass my exams?
I would estimate about 1 year of part time studying.

2) Do I need to complete all 3 steps before I start applying for residency?
You will need to complete Step 1, Step 2 CK, and Step 2 CS.

3) Which is the fastest pathway to become a specialist?
I am assuming you would like to be a pediatrician, given your interest in MRCPCH.  Following the Malaysian path, I assume that you may take about 2 years to complete your MRCPCH.  You will then proceed to gazette for 1.5 years, and you will be a General Pediatrician.  So as a final year HO, you are looking into about 4 years before becoming a General Pediatrician. 

If you were to take the U.S. path, you will take about 1 year plus to complete USMLE, and about 6 months in the whole application process.  That would be about 1.5 years before starting Pediatric Residency.  You will then enter into a 3 year Pediatric Residency program, where you will rotate through all the core specialties in Pediatric from neonatology to pediatric outpatient clinic.  After that, you will become a General Pediatrician.  This means about 4.5 years if you take the U.S. path.

Now, the question you need to ask yourself is, do I want to go beyond General Pediatrics?  In Malaysia, how fast do you think you can be a Pediatric Gastroenterologist?  These are questions you may want to ponder.  Perhaps two to three years after working as a General Pediatrician, you apply for a subspecialty training program in University Malaya? You can self sponsor for your MRCPCH, but you cannot do that for a subspecialty training program, which means you most likely need to receive scholarship from the Ministry of Education or the Ministry of Health, for which you will be bonded for another 2-3 years after your subspecialty training.

If you choose the U.S. path, in your second year of residency, which is about 3-4 years from now (for you), you will be given the option to apply for a subspecialty training program, otherwise known as a Fellowship.  Fellowships generally ranges from 2-3 years.  The first day of fellowship training (July 1st) starts on the day after your last day in residency (June 30th), and there is no time gap between residency and fellowship training.  Immediately after fellowship training, there is no bond or contract, and you can choose to work in whichever academic or private facility as you would like.

I would recommend that you think of what is your end goal.  Do not limit yourself to your surroundings and know that, everything is possible if you have the determination.

FAQ#11: Plans for a final year European medical student

Question for a medical student from overseas:

"I am a final year medical student from Malaysia studying in Europe, and I would like to take the USMLE exam, therefore, I would like to seek your opinion, should I take the Step2 CK first since you mentioned in your blogs that the clinical knowledge are still fresh in mind? If so, when and where can I sit for the exam? I have read most of the FAQs written on your blog, that I can take the exam in Kuala Lumpur. As I am still in Europe, is it better for me to take the exam somewhere in Europe, for e.g Germany? 

I am JPA sponsored student, therefore, my initial plan was to go back to Malaysia, work as a houseman and then only seek to specialise after getting experiences from housemanship years, however, like yourself, I am interested in living in the US, and due to the issue of overflow of housemen in our country, do you think that I should just sit for the exam, which I have not planned and studied for it, yet. Therefore, I do not know if my plan to take the USMLE is good for me, Or, I should start my work as a houseman in Malaysia, and study for the USMLE as a part time job?

In your articles, you used US dollar $ in answering questions regarding the exam fees, do you mean RM or it really was in US dollar? I'm asking because for me the fees are expensive. :( 

When should I register myself to sit for the USMLE exam? If I register in May, I can take the exam in September in Kuala Lumpur for example? My graduation day will be in June, I will be staying in Europe in July, and most probably head home in early August, and then I can sit for the exam in September in Kuala Lumpur? where can I get the details of the location? 

I know you mentioned the website ECFMG for registration, get a USMLE ID, and then what's next? I have to make the payment online?

I apologise for all these questions, or rather my expression of confusions in taking the USMLE exams. I hope you can help me to make them clear and guide my visions in taking the USMLE examinations."

Dear Europe Med Student,

I will try to answer your questions one by one.

1) Should I take the Step 2 CK first?

Since you are a final year medical student, I see that it would be more advantageous for you to go for the Step 2 CK first.

2) Is it better for me to take the exam in Europe?

The location for where you take the exam doesn't really matter.  Just choose the exam location based on your convenience.

3) Cost of exam fees?

The exam fees change from time to time, but would cost around USD$800 to 900.  Yes, it is expensive if you convert it to Malaysian ringgit.  When I paid for my Step 1, I used the cost of it to motivate me to study harder and put in longer number of hours.  I am glad that I took it, as now that I am an internal medicine resident here in the U.S., earning salary in USD, and getting awesome training here, I was glad that I didn't let the cost of the exam deter me from taking it.  What you are worried about is that if you did poorly in the exam, you would have wasted all your money.  Let me tell you this, regardless of how well you do in the exam, you will have gained precious medical knowledge and have cultivated in yourself the hardworking spirit as you brace through the preparation process for this exam.

4) When should I register for my exam?

Ideally, you should register about 3-4 months prior to the date you plan to take it.

5) Should I start housemanship and study for the USMLE as a part time job?

That is definitely possible, but you will have to allocated more months in the preparation process.  Instead of 3-4 months full time, you may want to study it for 6-7 months part time.  This means the preparation process starts today.

6) Where is the location of the test center?

It is in K.L.

7) What's the step after getting the USMLE I.D.?

You will have to make the payment for the exam.  Once the payment goes through, your medical school will be sent a letter for them to prove that you are their medical student.  Once all is done, you will be allowed to schedule your exam.

FAQ#10: Housemanship, salary, payment

"I'm a third year medical student ( going to be in this coming August). I am interested in doing USMLE. But I have several questions which I hope to get some idea from you. 

1. I have yet complete USMLE 1. Is it too late to take during my clinical years and continue with USMLE Step 2?

2. I know that it is compulsory to finish the 2 years housmanship and 2 years compulsory service after we finish our medical course. By the way, I am from UNIMAS and not taking any scholarship. Is it possible for us not to complete the housemanship and directly continue the postgraduate training if we are accepted by the USA hospital?

3. Are we get paid if we are accepted by the hospital to do the postgraduate training in USA?"

1. Again, it is never too late or too early to take the USMLE exams.  I have a residency classmate who is an orthopedic surgeon from India, who decided to take the USMLE exams and come to the U.S. for training in Internal Medicine.

2.  I went straight into residency without doing any housemanship or compulsory service.  After I finish residency, I can head back home and work as a specialist in UMMC or UKM etc, without doing any housemanship or compulsory service.  I can even head to Singapore to work as a specialist if I want to.

3.  I get paid about USD$3,000+ per month here while I undergo my residency training.  When I complete Internal Medicine training (in 2 years time) and choose to stay to work in the U.S., the pay for an Internal Medicine specialist here is about USD$200,000 per year.

I would suggest you ask a Masters trainee whether UM or UKM pays for him or her to undergo training in their institution.  You can also ask them if they need to obtain scholarship/sponsorship from government or universities, and ask them if there are any bonds when they complete their training.

I get paid here in the U.S., and there are no bonds attached after my training.  After I complete my training, if I want to leave the U.S. and head back to Malaysia/Singapore, I can do so.

FAQ#9: Australia vs Europe vs U.S.A.

"I am intrested in working across europe and i wanna ask u if USMLE can qualify for applying as medical residency in europe? And what about NZ ? Is USMLE internationally accepted as entrace exam for medical residency worldwide? and which do u think better , USMLE vs PLAB vs AMC ?"

1) The USMLE is a medical student level exam.  PLAB and AMC are meant for graduates.  The level of difficulty is entirely different.

2)  Unlike the U.S., entering Europe or Australia to work as a doctor does not mean you are entering a training position.  In the U.S., you enter directly into a residency (aka specialization position). 3 years after working in U.S., you will be awarded a specialist title.  Eg: American Board of Pediatrics.  With this title, you can either practice in the U.S. as a pediatrician (for example), or work in Malaysia as a pediatrician (yes it is recognized), or if you can also work in Singapore as a pediatrician (yes it is also recognised).

FAQ#8: Questions regarding: Housemanship, registration

Received an email asking about various topics, ranging from timeframe to healthcare system

Question 1: Housemanship

"I would like to know if it is possible for one not to do housemanship in malaysia, and instead prepare for USMLE straight after graduating. Instead of 2 years housemanship can one take USMLE and apply for residency?"

Yes. You can opt to go straight to U.S. without going through housemanship.  When you enter the U.S., you will enter into a residency training spot immediately.  A surgical intern will focus on surgery, and never deliver babies, an O&G intern will focus on O&G, and never manage myocardial infarction.  It is immediate specialization.

Question 2: Registration

"Another thing is how and where should i register in malaysia in order for me to take my Step 1 and the remaining steps."

Try to google usmle ecfmg. They will direct you step by step to apply for the exam.  The process is very simple actually.

Question from another student:

"I am just an average student who managed to squeeze into medical school passing with an average marks. I am currently in my fourth year and I am quite frustrated with the fact that when I graduate the overflow of HO will be quite bad. So, I am opting for USMLE but I am not sure if I can do it as many previous candidates has mentioned that it is extremely difficult. What is your opinion on this matter?

I am also from a below-average family so i'm really concern of the amount of money that is involved. Can i know roughly, how much did you spend for the books, online question banks, applications and etc.?"

The USMLE exams is not impossible.  There are many more exams with greater failure rates, such as the PLAB  or AMC.  The hardest part with the USMLE is to obtain great scores.  And this is definitely doable with hard work.  What one lacks in memory power, one shall have to compensate with time.  In the end, it boils down to motivation.  So the question is, how motivated are you, and how badly do you want to obtain a residency in the U.S.? 

As for how much it will cost, it's definitely far lesser than a semester of medical school fees, and it buys you a world of opportunities.  It will roughly cost RM 1k+ for books/question banks, RM 3k for applications etc.  Again, you will never study hard for it until you actually pay for the exam. Money can be a deterring factor for one, but can be a motivational factor for another.  Not that I agree with getting well paid as a doctor, but an average internal medicine specialist in the U.S. makes around USD$ 200,000 per year, and this is just after 3 years of residency training.

FAQ#7 : Question from a final year student thinking of the USMLE

I'm in my final year and am only a month away from my finals. I only learnt about the USMLE and it's various perks a couple of months back and am interested in pursuing it. However, housemanship starts a mere 2-3 months after graduation and from what I've read, that would be insufficient time to fully prepare myself for Step 1. Also, preparing during housemanship seems impossible what with the grueling working hours. What would your opinion and advice be in terms of preparing for the USMLE for someone who's in this situation?

There are many who have been in your situation, where they only decide to take the USMLE in their final year.

There are two options right now. And deciding on which option is dependent on how much you are willing to sacrifice to get into the U.S.

If getting into the U.S. is only your backup plan, then I would advice that you try to study for the USMLE as much as you can prior to housemanship, and then aim to treat the USMLE as a part time study as you go through housemanship. With it being the shift system, it is still possible to commit 1-2 hours everyday to prepare for the USMLE.

If getting into the U.S. is your primary plan, and you want to get in as soon as you can and are willing to sacrifice housemanship income, then you should consider postponing housemanship. Complete all the USMLE steps prior to starting housemanship. This should take you about 6-10 months, depending on the speed of which you can study for the USMLE.

FAQ #6 : About electives, CS, and visa

1) Would there be a problem if I apply for the match late? Perhaps one year after my graduation?
It won't make much difference. The difference will be significant if you apply more than 5 years after graduation.

2) If I go for my electives and do my CS at the same time, would it affect my visa application?
No. Just be clear and honest about the reason you are heading to the U.S. during your visa interview.

3) How long before my electives do I need to apply for my visa? Do I really need to wait for the elective approval letters before applying for the Visa?
Generally, you should apply for a U.S. electives at least 6-8 months before your elective period. Complete the application as soon as you can. Visa application and processing may take from one week to one month.

4) What kind of questions do they ask you during the Visa interview? Are Malaysians generally approved for Visas without much difficulties?
It's easy to get a visa as long as you are honest. Just clearly state the reason you are heading to the U.S.

FAQ #5 - about ERAS, Certification, Electies, and Housemanship

I'm now a second year medical student. I'm going to take USMLE Step 1 soon and although it's a little early for me to ask, do we have to complete Step 2 CK & CS in order to participate in ERAS?
There is no absolute rule that you need to have Step 2 CK and CS for ERAS. However, MOST of the international graduates will be ECFMG certified when they apply for the match. Hence, in order to be competitive, you need to get the ECFMG certification. To get ECFMG certification, you need the Step 1, Step 2 CK and Step 2 CS.

How do I plan which hospital to go for my electives?
You need to do extensive research online, and make a list of all the hospitals which provide elective opportunities for international students. List down the pros/cons, including pricing, requirements, location and so on. It should take you a few days to do this, but it will be worth it. I would recommend that you google “Freida”, where you can find a list of all the residency programs in the U.S.

Also, if you do residency without completing internship in Malaysia, will you still be allowed to work in Malaysia? From what I've heard, if we don't complete internship in Malaysia, we will have to start from being a houseman even after we've specialise elsewhere. Is that true?
Not true. When you return to Malaysia, you can choose to apply to universities or to the government. Most foreign trained specialist will apply to work directly into universities, be it local university, or private. Hence, most work in UM medical center, UKM medical center and so on. These are under the Ministry of Higher Education, not the Ministry of Health. There are also those who work directly with government universities without medical centers like UNIMAS, and even local private universities . If you want to “berkhidmat kepada Negara”, you can apply to work with the government. However, the downside is : there is a chance you will be posted to some rural area where there is not enough support staff and equipment for you to fully utilize and contribute your overseas training. There is also a chance that you need to do “housemanship” training in Malaysia. I know of one story a few years ago where an Anesthesiologist trained in the U.K. who returned to serve Malaysia’s Ministry of Health, only to be asked to complete housemanship. He immediately packed his bags and left to work in Singapore. However, there are also many who were not required to do housemanship again. I think it all depends on your luck, and who you know. My suggestion is that if when you return and the government wants you to do housemanship again, just reject their offer and work in UM Medical Center or UKM Medical Center. If you spend more than 10 years overseas, you can also immediately work in private hospitals.

FAQ #4 - About timing, electives, and the match

From KY :

Are the chances of getting a match is higher if I sit for the steps as an undergraduate or after I graduate?
It doesn’t matter whether you sit for your Steps during medical school or after graduation. The end point, the USMLE score, is the most important, regardless of whether you obtained it during medical school or after.

Is it true that the most important thing to do is to get an elective done in the States as an undergraduate while I'm still a medical student?
If you want to get an elective position in the U.S., best is to do it while you are still a medical student. This way, electives are more easily available. After graduation, you can only get observerships or externships as your “U.S. Clinical Experience”.

Are 2 months enough for electives?
Generally, yes. But of course, if you can afford to go for more, I would recommend you to do so.

Can you please tell me something about the match? My friend told me that there is only one match which happens in September every year. Thus, it is important to complete the elective, Step 1, Step 2 CK and the Step 2 CS by August in order to apply for the match in September
Yes, every year, U.S. med students and foreign graduates apply to the match in September.

I am a third year medical student. My plan is to do an elective as a third year medical student in Malaysia, finish my fourth year, do an elective for 2 months in the States in 2014, finish my final year, graduate in May 2015, sit for the Step 1 by the end of 2015, sit for the Step 2 CK by April 2016, complete the Step 2 CS by August 2016, apply for the match in September 2016. What do you think about this?
Your plan is good. However, if I would recommend that you sit for the Step 2 CS when you do your electives in the States in 2014. At the same time, I would also recommend that you start preparing for the Step 2 CK now, and take it BEFORE you graduate – perhaps 6-8 months before graduation. This is definitely doable as ALL U.S. medical students also take the Step 2 CK before they graduate, some even in the third year itself. Don’t worry on not being able to answer its questions because the Step 2 CK focuses more on diagnosis and investigations, as compared to the Step 3 which focuses more on management. You do not need the Step 3 to apply for the match. Then I would recommend that you study for the Step 1 immediately after you sit for Step 2 CK. This way, you can take the Step 1 by July-August 2015, and have your results ready before the Match. You can then apply for the 2015 match. This is the ideal plan, if it don’t work out, you can always postpone the exam and go back to your original plan.

Welcome to USMLE Malaysia

2006 - 978 house officers per year.
2009 - 3,150 house officers per year. Number of medical schools increased to 28.

In 2013, it is estimated that more than 6,000 graduate doctors will be joining as house officers. The number of medical schools has increased to 36. This is the biggest problem facing Malaysian healthcare now, the overflow of houseman. It's effects on training is also becoming more evident. There are also limited positions for one to train to become a specialist.
 
Many do not realize the postgraduate training opportunities that one can obtain in the U.S. Common myths include:
1) US postgraduate training is unpaid (false)
2) It is hard to get a spot if you are not a citizen or PR (false)
3) Its impossible for a Malaysian graduate to get to the U.S. for training (false)
4) Specialist training in US is not recognized in Malaysia (false)
5) I need to go to the U.S. to sit for the USMLE (false)

The purpose of this blog is to help you discover that the pathway to residency to the U.S. is 100% possible as long as you put in the hard work, effort and have the right study strategy. The few Malaysians who attempted the USMLEs are already doing their subspecialist training in the U.S., and some have even returned to Malaysia and are currently practicing as consultants in Malaysia.

A good way begin your journey to understand the USMLE is to go through the list of topics available on the right side of this blog.

I wish you all the best in your journey of discovery. If my posts have helped you in any way, I hope that you will click the "like" button available on this blog, and hopefully help more med students and doctors discover this blog.

- Jamie -
 

FAQ #3 - about Step 3, program directors, extra-curricular activities, MoH, and duration

1. Did you complete Step 3 and then proceeded to apply to the US? Is it mandatory to finish Step 3 as an IMG to improve your chances of securing a place?
I did not complete my Step 3. It is good to have Step 3, especially if you have low Step 2 CK scores. It also does improve your chances.

2. Do the directors look at your Step 1 score ONLY or do they also consider your medical school transcript?
Well, this depends on the program directors. Most will only look at your Step score as they would never have heard of your medical school before. Plus, it is hard to standardize a foreign medical school from India vs one from Brazil – for example.

3. Does extracurricular activities play an important role? I do not hold any significant positions at my university. I love volunteering and such I do a lot of volunteering. Will a good Step 1 score help mask this area?
Step 1 score is definitely the main factor. This is because usually when US med students apply, they will only have their Step 1 score, and not Step 2 (they apply at the start of their 4th year). Extra things other than your score will just help you make you “unique” among other applicants. If they want to compare two applicants with equal step 1 score, then they will look in other areas such as volunteer activities.

4. Is a publication important? At my university, we have US graduates coming to talk to us about their experience and they stress the importance of publishing a paper. This is quite tough, as I am not aware of such opportunities to participate in research as undergrads. May I know if you have published anything and could you tell me how I would go about with obtaining a position?
I did not publish any paper before getting a position. Yes, research indeed will help improve your chances of getting in, especially if you have a lower Step score, or if you are aiming for a University based program.

5. Will it be possible for me to come back to Malaysia with a US residency degree and work with the government sector?
Absolutely. There are many US-trained specialist already practicing in University Malaya Medical Center and UKM Medical Center. Do keep in mind that you can even come back to work even if you quit housemanship midway. When you work with UM or UKM, you are hired by the MoHE, not the MOH. If you have not quit housemanship halfway, you can apply to the MOH. You can also apply to the MOH if you quit halfway, but you will rejoin under the contract basis. Most specialist trained overseas will want to work in UM or UKM only though.
Also take note that most Malaysians trained in the U.S. usually head directly to Singapore or Australia. Many will also just continue staying in the U.S. Depends on what are your priorities.

6. Do I have to wait a long period after graduation and before obtaining a place in the States? Could you tell me the duration, is it around 1 and ½ years? How long did you have to wait after you graduated and till you start your residency program?
It depends on whether you have completed your USMLE Steps, and how fast you can prepare for it. Every year, residency application opens in September. If you miss the boat, you will have to apply the following year. It is best you plan your strategy depending on which month you graduate from medical school.

FAQ #2 - about observerships, finance, and Kaplan

Question from SS

1) I have just passed my first week in Year 3, with no prior knowledge or prior experience in USMLE syllabus. Will it be too late for someone like me to just to start preparing?
It is never too late to start preparing. However, you need to be disciplined and commit your time and energy in it. It is no “walk in the park”.

2) May you share your study schedule with me (inclusive of your study time for your University's syllabus)? How many months will it take with intense maximum preparation to finally sit for Step 1?
I studied it part time, alongside my university’s syllabus. It took me about 4-5 months of about 5-6 hours per day to prepare for my Step 1.

When is the USMLE exam held? When should I register for Step 1?
You can register for the Step 1 anytime, and the exam runs all year round. This means that any week of the year, there may be someone taking the exam in KL. Now, the thing is that you need to “book a seat” in the KL test center. You can only book a seat after registering for the exam. I would suggest you register about 3-5 months before the date you want to take the exam.

3) About observership in US, can you get it if you're just a med student?
If you are a medical student, you can get an elective seat. Observership positions are for those who already graduated.

4) I'm currently a self-sponsored medical student and PTPTN is not doing much help either. Still actively hunting for loans and scholarships so finance is an issue for me. How much did you spend for your preparation for:
a) Step 1 alone
b) Step 1, Step 2 CK & CS.
For Step 1 and Step 2 CK, I spent money for (1) Study materials, (2) Online Question Banks, (3) Exam fees. It would be about USD$900-1000 for each step.
For Step 2 CS, you need to spend money to travel to the U.S., stay for a few days, and take the exam. In total, I would say about USD$3000-4000 – from exam fees, to flight, to accommodation and travel.

5) Should I purchase a recent version of Kaplan Lecture Notes? Should I began with Kaplan or FA? Do you still have stock for the Kaplan Lecture Notes series?
Currently, the most recent Kaplan Lecture Videos is the 2009 version which you can get from Rachel. The most recent Kaplan lecture note is the 2012 version, but it is actually no different than the 2009 version as well – other than how they arranged the chapters. You will need to ask about the lecture notes from Rachel.