USMLE - my journey so far
Wow, mentioned that I was doing USMLEs at the moment on doctors.net and got quite a response with people asking for advice! Not sure how qualified I am to answer all the questions, but I will do my best... for those unaware, my background is a UK trained doctor who is fortunate enough to have dual nationality. I graduated under the "old system" of medical training with 2 years pre-clinical and three years clinical; that was back in 1999. Since then, I've specialised in paediatrics, travelled around the world, and basically seen the postgraduate training system in the UK fall apart... As such, I figured that now was a good time to bail: the new PMETB Article 14 regulations mean that it is not necessary to gain a CCST (certificate of completion of specialist training) in the UK to be admitted onto the specialist register, but instead it is possible to use experience from the preceding 5 years that has been gained anywhere in the world, provided it is considered equivalent to what the UK training would have been.
So, I'll try to describe what I've done and know, and to answer questions that were posed to me along the way...
OK, so the first advice I got was to just answer questions. Actually, that's not entirely true: it was suggested that I do the Step 2 CK first - but let me go back a stage even further, and explain the basics.
To work in the States as a doctor, it is necessary to do a few things (this is the same for anyone, no matter where you come from). They are:
- go to a recognised medical school - as per some (appropriate*) directory listing
- complete USMLE Step 1 exam
- complete USMLE Step 2 Clinical Knowledge (CK) exam
- complete USMLE Step 2 Clinical Skills (CS) exam
- complete USMLE Step 3 exam
I think that there are probably some other requirements, depending on what specialty you want to work in; I haven't figured all those out yet. However, these listed ones are the basic one common for everyone, no matter where they train (USA or overseas) or what area of medicine they want to practise. One key thing to note (I think) is that there is no specified order to do the exams in - but you must complete them all within 7 years.
Ok, so seeing as it had been quite a while since I a) graduated from medical school, and b) passed my membership - in summary, meaning that it has been a while since I have done any exams - it was suggested that I do the Step 2 CK to et back in the hang of studying again. I liked this idea, particularly as I had no overwhelming desire to study biochemistry, anatomy, etc all over again. And that is exactly what I did, although I still found it hard. I got a load of books out of the BMA library (but there's others too, for example the Royal Society of Medicine has a fantastic library, and most people should have access to books through local hospitals I would guess) and sat down to study.
Revision technique
I think this is important. First is to draw up some kind of schedule - and stick to it. Second is to make sure you actually do something active, and not just sit and read books. I did both, although I failed to stick to my schedule, finding distractions very easily, particularly at home. I guess my advice there is to go out somewhere (a library or study centre or wherever) and just hide away from whatever you are interested in. Doing active stuff wasn't so hard: I would do an hours worth of questions, then mark it, and for questions that I had got wrong (or that were right merely because I guessed) I would do a 4x6 index card. That way, I could go over it when I was travelling on the train, or sitting around waiting for my dinner to cook, or whenever.
Problem was, I still wasn't getting stuff done. I was getting there, and I think I almost got to a stage where I would have passed, but then I started to introduce the Step 1 exams as well, and I realised that there was no way that I could do the basic science stuff anymore: too much had changed since I'd first learnt it and new stuff discovered - it wasn't just the fact that I didn't remember anymore.
Kaplan - and what I did
I attended a USMLE seminar at the Kaplan institute in London. I'm lucky, I live in London so that was relatively easy, plus I'd been advised by someone I knew in the States to go there months before, but thought I was able to do it on my own and so hadn't. The seminar gave lots of information about the process of applying (most of which I knew from reading the USMLE and ECFMG websites already) plus stats on applications by IMGs and various info on the whole Residency process. It was thirty quid, but if you then went onto book a course (which, by that time, I had pretty much decided I was going to do) you got a 10% discount.
From this point, I was much more able to focus on stuff. I still did Step 2 CK first, even though that was against the advice of the Kaplan people - and I think that was better for me. It might not be so for everyone, though, especially if you're within a year or so of graduating from medical school. However, the stuff that I have learnt in my clinical experience, working: my pre-reg year as a house officer and my subsequent time in paediatrics; it has all helped make the clinical knowledge much more comprehensible. Things like COPD and CO2 retention in acute exacerbations (never give them oxygen!), various wierd syndromes like amyotrophic lateral sclerosis, also known as Lou Gehrig's disease (which actually is what I had previously learnt as motor neuron disease - but was always confused by the different names!) and so on: these all made sense to me, as opposed to be some wierd condition in a text book that I'd never seen but was tested on as a student. So I was able to study for it pretty easily, and the lectures were quite enjoyable.
I took 4 weeks approximately to go through most of the lectures. I didn't do them all (for example, skipped paediatrics, and there were a couple where I just didn't like the lecturer) but did most of them. I did about 4-5 hours of lectures a day, but that always took 6-7 hours of time, at least, to watch them, take notes, have some breaks and so on. I did not do work in the evenings, but made sure that I had some fun - the biggest thing for me was doing some sport three nights a week, and also cooking/eating good meals! Then, it was Christmas/New Years, and I had less than a month to go. I started doing questions from the Kaplan Qbank aiming to do at least 100 per day, go over the answers and do some more revision cards for ones I was getting wrong. I also made sure that I did a few, full day "exams" where I just sat and did 400 questions in a day, then went over the answers the next day. I also did questions from books that I'd borrowed from the library too.
And that exam: I slowed down the last few days, made sure that I had good sleeping habits of going to bed at a decent time and waking up early; did not eat "heavy" foods in the middle of the day so that I was not falling asleep after lunch, etc. I hoped to pass - and was pretty confident I had done so after I'd finished the exam, although didn't know what my grade would be. I was definitely pleased when I got it!!
Ok, onto step 1 then. I had only 2 1/2 months, plus I was going to the States to present a poster at a conference and visit family for a 10 day period in the middle. So I made sure that I watched as many lectures as I could before I went and bascially tried to ensure that I'd finished the syllabus. This was definitely tougher, but there were some good lecturers, and wierd biochemical stuff was a lot more relevant now that I had clinical context from a few years practise to use it with. Pharmacology even more so. Results came in the middle of me being away (my mum opened them and emailed me) so I ended up having a great holiday and getting trashed lots!! Then, when I got back, my computer broke and that took another week off my studies.
Since then, I've been doing lots of questions - again, the Kaplan Qbank. I'm doing reasonably well, and reckon I should get a good score again, although I'm a bit more erratic, perhaps, then I was with the clinical stuff. However, I'm encouraged by the fact that my mentors in the States (I have a couple) have suggested that people are likely to put more emphasis on my clinical results given that I am a few years out from med school and likely forgotten the basic science. I still plan to try and score as well as I can though.
The future - and the exams
I have my Step 2 CS booked for the end of May. There's only limited places in the States that you can do it - oh, just realised I didn't actually talk about the Step 1 and Step 2 CK exams themselves. Well, they are computer based, multiple choice. Generally of a format which involves 2 or 3 steps: for example, you have to make a diagnosis, from the stem, then the actual question would be along the lines of "which of the following is the most appropriate drug to use for this condition?" If you didn't get the condition right, you're unlikely to pick the right drug. Anyway, the Step 2 CS you have to do over there, but from what I've heard and read, it's pretty easy, with the emphasis very much on communication and being competent history taker, rather than actually getting the medicine 100% correct. Actually, for those who have graduated more recently than I, it is probably even less daunting as I think it is a bit like OSCEs - but I've never done an OSCE so couldn't say for sure.
Having done all this, I will then be in a position to apply for residency. Why residency? Well, everyone has to do residency to be able to practise independently in the States, although if you just want higher training, it's possible to get straight onto a Fellowship - much as one can work here in the UK in a well respected department as a Clinical Fellow or locum Registrar, but not be approved for training purposes. Anyway, application...
I see it as a bit like A-levels and applying for university, except cos we're foreign (IMGs) we need to have our exams before we can apply, to prove that we are good enough. So, the advice is, get your grades. Then, the application process starts in August/September, and is open to November/December. The hospitals start interviewing for their residency programs from about October, I think, and continue up until end of February or so (my dates are all a bit vague cos I'm not sure of the precise details, but it's more or less correct). You are allowed to apply for as many programs as you like - or, as you can afford, cos it all costs money, but you are advised to apply for a reasonable number: they won't all interview you. If you don't get interviewed, then that hospital is ruled out of "the match" for you. Likewise, after the interview, you may decide that you didn't like a certain program and so won't rank it for the match. What is the match, I hear you say? Well, this is the computer program that takes the rankings that you have made of your choices, along with all the other candidates, and matches them against the ranks the hospital programs have made of all the candidates that they interviewed. If you get matched, you must accept that program. You cannot pull out after the match otherwise you get struck off (or whatever the equivalent is) and are not allowed to participate again. For this reason, it's very important that you do not rank programs you would not like to participate in.
Specific questions
What sort of time period do I have to consider given that I have not done USMLE or planned for this in any way so far?
I would say that you need at least 2 months of full time work to revise for each of Step 1 and Step 2 CK. Kaplan and most others advise 3 months, so please take me seriously here. If you have some advantage - you just finished studying it at med school or something - you might be able to do it in a shorter period, or in this amount of time and work as well, but I doubt it! My personal opinion about myself is: I ain't stoopid, I'm just lazy! And I sure worked hard for these exams here, like I've never worked in my life before (I didn't do much revision in med school, I must admit - and my grades will testify to that).
That said, do not be put off! If you are serious about doing the exams, people in the States (and here, I think) will recognise that they are serious exams requiring a serious amount of study and will respect you for being dedicated enough to do it. Take 6 months off and treat it as one of the 6 month posts in your SHO rotation - oops, but that's what the problem is, right?! Being serious, though, I was actually amazed that, once I'd made the decision to do the USMLEs and not follow the UK training scheme anymore, I didn't need to apply for the competitive training posts, but could instead choose the Clinical Fellow post (with all the same educational opportunities and study leave budget as the "recognised" posts) in the department and hospital and location that I wanted. Life was so simple!
Is there anything particular for surgery? I hear I have to aim to get high 90th centile - is this true?
Well, yes and no. It depends what your requirements are - but like A-levels, if you want to do the course you want at the hospital you want, the best grades you can get are going to be the most useful. Otherwise, you may end up with the course you want, but be in the middle of Texas (hey, maybe that's what you want?) or have to do something else that's not so popular in the location you want. Oh, and dermatology is a popular specialty: lots of rich people concerned about their skin, and no out of hours work. My personal opinion? I don't want to be a dermatologist!
Interested to know why you think they get more experience - surely even working 80 hours/week can't compensate for only doing 3+ years?
This is one of the catches of the US system. I'm a little familiar with it, having done my elective over there and also spent 6 months looking after my grandmother in the States who had Alzheimer's, thus visited hospitals a lot. Most of the 3 year residency programs are actually training you to be something similar to what we would consider a GP in this country. Granted, they are a bit more specialised, like GPs who only see children (paediatricians) or whatever, but basically that is how it is. However, many people go on to do a Fellowship, which is much more specialised training in an area that they want to focus on. For example, I may do three years as a paediatric resident, then 3 years in a neonatal fellowship... and end up being a neonatologist who works in a hospital somewhere. That's just one of the options I'm currently considering, though... I've still got to figure stuff out a bit more.
Another thing is that the hours aren't that gruelling in all the specialties - I've definitely seen stuff advertised that has 60 hour weeks, which is not so dissimilar to some rotas in this country, and is probably in the region of the optimum amount of time, at least to my mind, for clinical training. Again, it depends on the specialty.
Finally, there was an article on the BBC website that referenced a study in the Occupational and Environmental Medicine journal saying that the number of hours worked was not the most significant thing when looking at errors, etc. However, despite searching the journal website pretty well, I could not find the article: I don't know if it is in the forthcoming edition for April, 2007.
How are UK grads perceived over there? Well respected?
I have no idea as I haven't worked there! Acutally, not quite true: I think that people in the US think highly of doctors who have passed the UK postgraduate exams - i.e. membership. Other than that, well, we've all been to medical school, so better the devil you know than the devil you don't. However, UK trainees are younger or, put another way, more knowledgeable about medicine by the time they get to be the same age as US trainees.
More resources
Well, there's lots! I've written quite a bit about USMLE stuff on this blog, so it's worth reviewing some of my previous posts, although information is definitely jumbled, I have to admit! Below are a few useful links (it's getting late, so it really is just a list - I may come back in the future and tidy up a bit). Google is also your friend.
...and there's lots of others. I'll try to post more links up in the future, but just now I don't have them all to hand. Anyway, get studying!!
