Tip : Food and accomodation during interviews

- by Jamie

Travelling around in the U.S. for interviews can be a pretty expensive endeavor. Depending on the type and number of hospitals you apply to, you may receive about 5-8 interview offers – and you will have to make your way there to attend the interviews in person.  One of the challenging aspects during the interview season is to save money.

This experience thought me how to use the public transport - which is very efficient in major cities, and hunt for cheap food and accommodation. As for food, you can survive well with a USD$5 Foot-long subway sandwich which can last you two meals (just $2.50 per meal!). Public transportation is typically USD$2.25 for each way. 

As for accomodation, it may cost you up to USD$30-50 per night. If you are staying in an area for a long term, you may consider to rent a room. Renting a room in Queens, New York, may cost about USD$500-700 per month - and you can easily google rooms to rent for students in the U.S. Your housemates will usually be students in nearby hospitals or universities. Occasionally you may want to spoil yourself with a good meal of noodle soup, which may cost you USD$7-8, or if you are in New York, grab yourself a Chatime (just 2 for $2!).

How should I get started on my USMLE journey?

I will divide this section into 3 parts:

a) As a doctor

b) As a clinical student

c) As a pre-clinical student

As a doctor

It is never too late to start preparing for the USMLE. I know of a couple of my seniors who only started preparing for the USMLE only after graduation. The few of my seniors in the U.S. are now doing their subspecialty (fellowship) training in the U.S., while most of their peers are still waiting to get into Masters program, and some just completed MRCP and have years before they can enter a subspecialty training.

It is important to know that in the U.S., subspecialty (fellowship) training is immediately after your specialist (residency) training. There is no such thing as gazettement or bond right after residency. The hardest part is just to get in. Once you are in, it is almost smooth sailing for you up till your subspecialty or superspecialty. Even if you wish to work in a private setting right after residency, it’s up to you.

While I was in the U.S. interviewing, I also met many who have worked in their home country for 3-7 years, before finally deciding to come to the U.S. Some already completed their specialist back home, but decided to head to the U.S. to set up a life in the U.S. - almost like how some of our consultants will migrate to work in Australia/UK. In the U.S., regardless of how senior you are, you still have to undergo residency training again. I remembered one of the applicants which I interviewed with was a 52 year old gastroenterologist from South Korea.

How should you begin your preparation? There are two options. You can either sit for the USMLE Step 2 CK first, or the Step 1 first. If you are fresh out of clinical school, I would suggest that you sit for the Step 2 CK first because your clinical knowledge is still fresh in your mind. If it has already been a while since medical school, I would suggest that you study for the Step 1 first, and immediately follow that up with the Step 2 CK.

Once you complete Step 1 and Step 2 CK, you should head to the U.S. for the Step 2 CS. Upon completion of this 3 exams, you are then ECFMG certified and may apply for the upcoming “residency match” in September.

How fast/slow you should study depends on when do you want to apply. Application opens in September 15^th every year, and you should have all your exams done before that date. The interview season runs from November to January. Results will be out on the middle of March, and you will begin your residency training in June-July.

As a third-fifth (clinical) year medical student

If you are a final year medical student, I would suggest that you study and sit for the Step 2 CK first because your knowledge of the clinical disciplines are still fresh in your mind. I sat for my CK while I was in my pediatrics rotation as a final year student. My final year pediatrics rotation is one of the more “relaxing” rotations in my medical school. However, I did start my preparation for the Step 2 CK for about 4-5 months before that.

Immediately upon completion of your Step 2 CK, you should start preparing for the Step 1, and you can sit for this exam after graduation, when you feel ready.

If you are a third/forth year medical student, I have no recommendations as to whether you should sit for the Step 1 or Step 2 CK first. This really depends on how intense your clinical years is in your medical school, and whether are you willing to give up time learning in the hospital and just studying at home for the USMLE. I know of one who did his Step 1 while he was a forth year medical student, and scored 256 for Step 1. However, I also know of one who did poorly in the Step 1 when she did her Step 1 as a forth year student. If you have a period of a long break during your 3^rd and 4^th year, you may consider to use that break to sit for the Step 1. Of course, you need to start your Step 1 preparation way before that break. The reason I emphasize on using holidays to sit for Step 1 is because you can afford to give in 8 hours of preparation time during holidays as a final push before sitting for the Step 1. Unlike the Step 2 CK, the final phase of preparation for the Step 1 is more intense. Immediately upon completion of your Step 1, you should start preparing for Step 2 CK, with the aim of sitting for it in your final year.

Optional : If you have yet to schedule your electives, I would suggest that you consider going to the U.S. for one-two months of electives. This way, you can obtain letters of recommendation from doctors in the U.S., which will really help you get a training position at one of the top hospitals in the U.S. Furthermore, you can make use of this trip to sit for the Step 2 CS. Don’t worry if you have not taken Step 1 or 2 CK, because the Step 2 CS is really easy. You only need about 2 weeks of preparation for it.

As a first/second year (pre-clinical or basic sciences) medical student

You should start preparing for the Step 1 as early as you can, and aim to sit for the Step 1 during a major break - right after you complete your basic sciences, or during a major holiday in an early phase of your clinical years.

The best time is to sit for it is right after your final exam for your basic sciences, and before transitioning into your clinical years. This is because you don’t want your clinical rotations to distract you from studying biochemistry or pathology. However, you should also make sure that you have a period of at least 3-4 weeks right before the exam date where you can give 80%-100% of your time and energy to focus on the question banks. Otherwise, it is also a good idea to sit for it during a major break while in the early phase of your clinical years.

During your clinical years, you should consider going to the U.S. for an elective. You can utilize this period to sit for the Step 2 Clinical Skills (CS), and also get letters of recommendation from U.S. doctors. If you choose not to go to the U.S. for electives, you can sit for your Step 2 CS later, perhaps right after your graduation.

As for the Step 2 CK, you can sit for it either during your final year as a clinical student, or right after your graduation. Be sure to prepare for this throughout your clinical years, alongside your clinical rotations. 

- Jamie -
  

How to study for the USMLE Step 2 CK

The preparation strategy for the Clinical Knowledge (CK) exam is more straightforward compared to the Step 1 exam.

Materials you need:

1.  Kaplan Video DVDs
2. Kaplan Lecture Notes
3. Kaplan QBook

Best study timeline

Phase 1 : Books + Videos (1-3 months)

In this phase, you should use the videos to pace your study, understand how the CK exam questions are posed, and receive tips on how to tackle exam questions. I will break down the study strategy for each discipline below:

• Internal Medicine
• You should start the CK preparation with internal medicine first, before moving to other disciplines. Reason is because Conrad Fischer (internal medicine Kaplan lecturer) is really good in giving you strategies to answer exams in CK. You can then apply the same strategy to all the other disciplines.
• It is important to know that the CK exam composes of a huge proportion of internal medicine questions, as compared to other specialties. Therefore, you should aim to go through this section well.

• Obstetrics and Gynaecology and Surgery
• For OBGYN and surgery, it is adequate to go through at a moderate speed. Use the videos and the lecture notes simultaneously. OBGYN video lectures are really good.

• Psychiatry
• If you are doing Step 2 CK as your first exam, you need to go through the video lectures along with the lecture notes. The videos cover epidemiology as well.

•  Pediatric
• The pediatric video lectures are not as good as the videos for the other disciplines. For pediatrics, I would advice that you just go through the lecture notes without the video lectures.

Phase 2 – Kaplan QBook (2-3 weeks)

Complete the Kaplan QBook for CK. This will help prepare you before you go for the USMLE World. While you are going through the questions in the Qbook, you should also take the time to review your Kaplan lecture notes, especially in disciplines which you are weak at.

Phase 3 – USMLE World (1 month)

The USMLE World is the best question bank for CK. Completing this question bank will help you train for the actual exam.

Phase 4 – Final weeks before exam

As you are done with about 50% of the USMLE World question bank, start doing NBMEs. There are 4 forms in total. Complete forms 1-3 offline, and do form 4 online. NBME Form 4 will predict your Step 2 CK score, and will give you confidence/assurance when you sit for your exam.

Optional: you can opt to add a Phase 1.5, where you consolidate your facts into a quick review book. In the Step 2 CK, the First Aid is a terrible book to use. If you were to choose a book to consolidate your facts into, you should you Master the Boards for the Step 2 CK. This phase is really optional only. I bought Master the Boards but did not use it, and did pretty well. So you can definitely opt to ignore this consolidation phase. However, you need to highlight the important facts in your Kaplan lecture notes well, preferably with a yellow color pencil instead of a bright highlighter. This will make important facts stand out and make your final review faster, but will not overshadow the other texts in the lecture notes.

How to study for the USMLE Step 1

The most important part of undertaking a task - is planning it. Prior to preparing for my Step 1, I did extensive research to find the best study plan. I also made modifications to my original plan as I proceeded along my Step 1 preparation, and finally completed the Step 1. I feel that I should share my experience with my fellow Malaysians on how to prepare and ace the USMLE.

If you research online in forums where many Foreign Medical Graduates discuss and share their experience, there is one thing in common between all those who scored well. They all used a combination of Kaplan materials, USMLE World question bank, First Aid and Goljan. I used the same strategy as well, and scored 99 for my USMLE Step 1.

Here is the best strategy for the USMLE step 1.

Materials you need :

1. Kaplan Lecture Notes (any edition within the past 5 years)
2. Kaplan Video DVDs (any edition within the past 6 years)
3. Goljan Audio
4. First Aid (any edition within the past 2 years)

Best study timeline
Phase 1 - Books + Videos (2-4 months)
This phase is the most important phase. In the exam, it is not so much about what you managed to memorize, but rather how much you understand. The questions tests your understanding of the concepts in basic science, not how much you can regurgitate like many exams in our Malaysian medical schools. This is why we would need someone to explain it to us in a way that we can understand, which is why using the Kaplan lecture videos and the accompanying lecture notes is the best. It is as if you were attending a course for USMLE at your own pace. The lecture notes are designed to be complemented with the video lectures, and using them together will greatly enhance your learning experience. Here is the outline of the steps you should take to approach this first phase.

• Physiology, Biochemistry and Pharmacology - study well using Kaplan video lectures and lecture notes
• these topics are important for Step 1. It is very important that you grasp the concepts well - and make it unshakable. They may twist the questions to various forms, but your understanding of the concept will carry you through.
• the video lectures are really important here because they really help you understand the concepts well
• Anatomy, Microbiology and Immunology, Behavioural Science - quickly go through it using Kaplan video lectures and lecture notes
• these topics are less important for Step 1, but also necessary for you to score well 
• The Behavioural Science Video Lectures is very important. Dr. Daughtery will also teach you statistics very well inside the behavioral science videos.
•  Pathology - study using Kaplan, but listen to Goljan audio as well
• Listen to Goljan audio in your car or on your iPhone, whenever you are travelling, eating, resting. You listen to it over and over again, and this should be your music for the duration of your step 1 preparation

In phase 1, you should note down all the important points highlighted in the Kaplan videos. Another reason that the Kaplan videos are golden, is because they give a lot of exam tips, exam patterns, and how to understand the question to answer it well.

Phase 2 - Consolidation (2-3 weeks)

Once you completed phase 1, now you need to read the First Aid and the corresponding Kaplan chapters at the same time. As you go through First Aid, you should note down the page number for which the Kaplan lecture notes. The reason is because - you will now be transitioning, from Kaplan lecture notes as your main material to First Aid as your main material. Now, every time you look up the answer to a question (when you are doing the question banks) or want to revise a topic, the first thing you should use is the First Aid. If you feel that you want to read more about that topic, like pharmacology of medications for Parkinsons, then you will open up the corresponding Kaplan lecture note section. Writing the corresponding page number in your First Aid will speed up this process.

You can see from my First Aid, how did I write the number of the corresponding page number of Kaplan lecture notes.

Optional tips: You can also see that my book is very colourful. I find that is the way I can learn the fastest. I color-coded various information based on its category. Eg: Risk Factors, Aetiology, Symptoms, Blood investigation findings, Pathology Findings, Treatment, and Complications. This way, I can interpret the paragraph much easier. If I want to compare complications various diseases, I can look at all the purple underlines of paragraphs of various diseases.

Tip : Ability to link between diseases is very important for the USMLE. A sample of one of the difficult MCQ question is : "The disease the patient above has, is treated with a medication which shares a similar complication to which other medication?" That is why you first need to know the diagnosis of the patient, know with which medication is that disease treated with, and then know what are the complications of that particular medication, and which other medications share the same complication.

Phase 3 - Question banks (1-2 months)

This phase is equally as important as phase 1. It is through the question banks which you are able to get a hang of the questions, and integrate all the concepts you have learned. The question bank which is a must for you to use is USMLE World. It is more challenging than the actual USMLE exam, which is why by doing this question bank, you will be much more confident in facing the actual exam.

Optional phase - Kaplan Qbank or USMLE Rx (1 month)
If you have extra time, you can also do one additional Qbank. There is not much difference in choosing between Kaplan Qbank or USMLE Rx. If money is not an issue for you, pick Kaplan Qbank, which is more expensive and slightly better than USMLE Rx.

Phase 4 - Final weeks before exam

This phase overlaps with phase 3. While you are about 70% done with your USMLE World, you should start doing NBMEs. These are "mock exams", and they cost about USD 45 for each set of exam. These exams give you a good predicted score for your actual USMLE exam. If you find that your score in the NBME is low, you should postpone your USMLE exam.

The final week before your USMLE exam is when you should start calming down. You have worked hard for the past few months, and at this last phase, its only about just going through First Aid over and over again. You should also start training your stamina for the exam by trying to do at least 4 blocks of UWorld or 1 set of UWorld Self Assessment at one go.

On the day before your exam, stop studying. Just relax and calm your mind. You have prepared well, and now its all about optimizing the state of your mind to be able to think during the exam day. I watched Glee and went jalan-jalan at Sunway Pyramid on the day before my exam.

If you follow this study strategy and worked hard, you will be able to handle the exam and score well, and you will be one step closer to your dreams.

 

The day I felt like I won the Oscar.

- Jamie -
Tags : USMLE Step 1, Study strategy, tips, first aid, USMLE, Kuala Lumpur, Malaysia, how to study USMLE, Step 1

What are my chances to successfully get a position in USA?

Is it possible? What are my chances of getting in? Is all this money and effort going to be worth it? Can I finally be a doctor in the US?

These were the questions I used to ask myself everyday when I was thinking of taking the USMLE, and even while I was studying for the USMLE steps.

It is a difficult question. I can only try to answer you using some statistics.

The above data shows the number of positions offered by each specialty, and how many of it is taken up by U.S. medical graduates. Lets discuss a few common specialties which most of us Malaysians are interested in.

Internal Medicine
If you look at internal medicine, there are about 5,000 positions offered, and the U.S. graduates only take up 55.7% percent of these positions. This means that about 2,000 (40%) foreign medical graduates managed to get a position in Internal Medicine in 2012.

General Surgery
There are a total of 1,100 positions being offered for categorical (5-year program) and 1,200 for preliminary (1-year program where you need to re-apply the following year). Out of these, foreign medical graduates take up about 200 (20%) categorical spots and 700 (60%) preliminary spots.

So it seems that there are quite a number of positions taken up by foreign medical graduates in the U.S. Now lets take a look at what does statistics tell us about "chances".

Looking at the data, we can see that the chances of matching is about 40%. To simply put it, about half of those who applied will be successful, and half won't.

Now the big question is : What are the factors which determines who gets a position and who doesn't?

After I completed my USMLE steps, I started preparing for the "Match" - which is the process whereby one gets "matched" into a residency position. This involves submitting my scores, my CV and other various documents, flying to the U.S. for interviews, and finally ranking the programs which I liked (and having the programs rank me as well).

I also bought a couple of books about this "Match" process. Based on my research, the top 2 reasons which are important for the program directors (people who will hire you) when they look at a foreign grad are :

No. 1) USMLE Scores
No. 2) English proficiency during interview

No doubt there are other smaller factors as well, but the above are the top 2. I am not surprised by the 1st factor. USMLE scores is the only way these program directors can objectively judge your knowledge level. However, I was initially quite taken aback by "English proficiency". My reasoning was : if one can pass the USMLE steps, shouldn't they already possess adequate "English"?

Only during my trip to the U.S. for interviews did I understand why. In some of the programs which I interviewed at, there were a lot of other foreign graduates as well. They come from India, Middle East, China and various other countries, and they can be really hard to be understood. Their writing is excellent, but when it comes to speaking, we Malaysians have a huge advantage. We are lucky that we communicate to each other a lot in English. We should also be thankful that our ward rounds and patient notes are all in English. The most frequent comment I received while I was interviewing was "Wow, you can speak really good English!" - and that was even while I was speaking in our normal Malaysian accent.

So actually, the biggest hurdle is one's USMLE scores. If you score poorly, it is going to be really difficult to get a position. I spent a lot of time to come up with a solid study plan and study materials for myself. I am also thankful that I studied hard for the USMLEs. All my sacrifices paid off in the end.

There is no short cut to get to the U.S. for residency training. You need to put in your time and effort, and make sacrifices in terms of your leisure time. One thing about the U.S. as long as you are willing to work hard, nothing will stop you from getting what you want. Not even race or nationality. In fact, let me show you one last data.

5% of US medical graduates and 50% of Americans who trained outside of USA don't get matched (means they don't get a spot).

You may be thinking, "What? But they are American citizens! Why didn't they get a spot?"
The answer is because, program directors want the best, regardless of ones citizenship. Their spot were taken by stronger applicants, who are foreign medical graduates. It is not about your citizenship, whether you are a "European Union citizen" like in the UK, or whether you have a "Permanent Resident status" like in Australia. This is America, the land of immigrants and opportunities. Program directors hire the strongest applicants, regardless of their citizenship status.

The final question is : Can you be the one that they are looking for?

- Jamie -
Tags : what are my chances, working as doctor in USA, residency, specialization in USA, doctor, USMLE, Kuala Lumpur, Malaysia