USMLE preparation is about getting ready for a test – not necessarily understanding everything about medicine. Here are the techniques I think are most effective for studying for the USMLE.
1. Sample questions. Having been through the process, it is clear that the most effective way to study for the USMLE is by using professionally developed question banks (KAPLAN, USMLWORLD and many others). These question banks focus on the important, tested topics, and are pretty good at identifying distracters.
But one should be cautious not to start preparing from outset by doing questions. Get a good grasp of the subjects by reading KAPLAN books and then start attempting questions. Consult KAPLAN books again for topics where you feel yourself weak .
2. Focus on your weaknesses. The USMLE is broken down by topics. That means you have to perform in all the areas to do well on the test as a whole. You can get an objective assessment of your strengths and weaknesses by using diagnostic tests i.e. by answering the sample questions and getting your scores.
3. Aim to score high. In today’s very competitive market, just passing USMLE is not enough to get into a good residency programme. One should aim for a score above 90’s, which means you should be scoring at least 65-70% in practice MCQ’s sessions. Top internal medicine programs are looking for step 1 scores of 230 or higher.
USMLE Step 1 :

• Needs good knowledge of basic medical sciences i.e. biochemistry and molecular biology, cell biology, genetics and development, pathology, psychiatry, physiology, pharmacology, microbiology, immunology, and statistics
• To score high one should specially concentrate on subjects like biochemistry, genetics, immunology, microbiology, statistics and ethics etc.
• Preparation will take about 6-12 months.
• Read all the KAPLAN books including Q book, Q bank.
• Subscribe and do online KAPLAN questions as well.
• Step 1 is a one-day examination and consists of multiple-choice questions divided into 60-minute blocks. The Step 1 testing session lasts approximately eight hours. Minimal passing score is 185.

Sample Question 1:

A 25-year-old female is in hospital with a cranial lesion caused by a fall from her horse. The following clinical signs are found: 1) speech troubles and hoarseness, 2) swallowing problems and paresis of the soft palate, 3) rapid heart rate, and 4) dilatation of the stomach with vomiting.
Which cranial nerve injury can explain all symptoms and signs.

a) bilateral vagus nerve

b) bilateral hypoglossal nerve injury

c) bilateral facial nerve

d) unilateral glossopharyngeal nerve

e) bilateral spinal accessory nerve

Sample question 2

A cytokine that has a role in modulating HLA class 2 expression

a) Interleukin 1

b) Interleukin 2

c) Interleukin 6

d) Interleukin 8

e) Interleukin 10

Sample Question 3  

Protein synthesis is the process whereby DNA encodes for the production of amino acids and proteins.
In this process what is a unit of three nucleotides on the mRNA called?

a) ribozyme

b) tripltelase

c) base-pair

d) codon

e) anticodon

 USMLE Step 2 :
The USMLE Step 2 is broken into two distinct sections.
1- Step 2 CK (Clinical Knowledge)

• The first section is designed to test your knowledge of the clinical fundamentals needed for the practice of medicine.
• Will take up to 6 months, any previous experience of hospital medicine in UK will be advantageous.
• Step 2 is a one-day examination and again consists of multiple-choice questions divided into 60-minute blocks. The Step 2 testing session lasts approximately nine hours. Minimal passing score is 184.
• Again go through Step2 KAPLAN books and Q book, Q bank as well.
• For USMLE 2, I subscribed to USMLEWORLD MCQ’s and found them useful.

Sample Question 1

A 38 year old female has been investigated at length because of infertility problems. She now presents at her gynecologist because of low back pain. She has noted that the pain is closely associated with her menstrual period. Her gynecologist strongly suspects endometriosis.
Which of the following is most likely to confirm the diagnosis of endometriosis in this patient

a) Ultrasound

b) laparoscopy

c) CT scan

d) MRI scan

e) cervical smear test

Sample Question 2

A 52 year old woman with a long history of headaches and depression is on long term treatment with analgesics. She develops chronic renal failure and her physician is worried that this may be a complication of her therapy. Analgesic nephropathy is likely to result in

a) polycystic disease of the kidneys

b) Berger’s nephritis

c) chronic interstitial nephritis

d) renal vein thrombosis

e) renal tubular acidosis

Sample Question 3

A mother brings her 6 month old baby to her pediatrician complaining that her son has been continuously bringing up food ever since she started weaning him onto solid foods 2 weeks previously. She also noticed he occasionally becomes ‘blue’ during a bottle feed. Which of the following is the most likely congenital arch anomaly to be associated with these signs

a) Right aortic arch with aberrant left subclavian artery

b) Right aortic arch with mirror-image branching

c) double aortic arch

d) Left aortic arch with aberrant right subclavian artery

e) Right aortic arch with isolated left subclavian artery

2- Step 2 CS (Clinical Skills)

• This is a live whole day exam and consists of 12 simulated patient cases, each lasting for 15 minutes.
• The goal of this part of the exam is to determine if you have the basic skills in history taking, physical examination, making a differential diagnosis based upon the information given, knowing basic initial diagnostic tests and treatment of the disorder and testing your communication skills.
• Takes at least one month preparation.
• Like final year exams, PLAB2 and PACES, practice of the sample cases in groups is paramount.
• Subscribe to USMLEWORLD website from the beginning and read whole stuff. It will cover 90% of the cases asked in the examination.

Sample cases are like

• Chronic cough
• Chronic diarrhea
• Swelling and redness of leg
• Knee joint pain
• Alcoholism
• Telephone encounter with a mum, worried about his child who has developed rash
• Psychiatric case history taking  

Useful Websites
 www.usmleworld.com – t he MCQs site
www.kaplan.com – t he MCQ’s site
www.ecfmg.org – the official ECFMG web site
www.usmle.org -t he official USMLE web site
www.nbme.org – National Board of Medical Examiners
www.usmle.net – this is a good site for discussion
www.prep4usmle.com – very good site for discussion and resource links
www.usmleforum.com – very good public discussion forums for USMLE
www.conntutorials.com – very good video clippings covering all organ systems, initial patient encounter through complete step-by-step clinical diagnostic techniques.
Author – Dr Muhammad Tufail, Specialist Registrar in Acute Medicine, Northern Deanery
December 2008