Step 1 is OVER!

Well, I did it!!  I survived Step 1!  I still will not get my scores for a few weeks.  I know I did my best, and hopefully my score will reflect that!


I arrived at the testing centre at 0815, hoping that I would be able to get registered early and get out of there sooner.  The lady did not even show up until 0900, so that plan fell through.  However, registration was quick and easy so I was able to start almost immediately.

::Block 1::
- Time spent: 50 min
- Most questions were way easier than I thought they would be; very little micro or pharm in this block.  There were lots of questions about embryology and hereditary diseases.  My approach to the questions was:

• To read the last sentence first.  That way, I knew whether the question was about diagnosis, treatment, or something I didn't even need the vignette for.
• To read the vignette and highlight relevant information.  This was very helpful went I was reviewing my answers for each block.  Also, just having a purposeful activity during each question helped me to stay focused and not wander off into dream land.
• To try to answer the question in my head without looking at the answers.  This wasn't always possible, but it actually worked for about half of the questions!
• To explain to myself why the other answers were wrong.  Again, not always possible, but it helped me feel very confident about my answer choices, and I was able to find the answer for some harder questions simply by process of elimination.
• Marking questions that I felt merited more time.  I did not mark every question to which I did not know the answer.  Some of the questions were about things I had never even heard of before.  I didn't waste my time on these ones.  I simply made as educated a guess as possible, and moved on.  The questions I did mark were ones that either required some calculations, or needed more "brain time" to sort out.

I was able to finish answering the questions for every block in about 35 minutes using this method.  With the remaining time in each block, I went back over every question and made sure that I was happy with the answer.  Review took 10 - 20 minutes depending on how many marked questions I had in each block.


- I did not take a break after block 1, but went straight into block 2

::Block 2::
- Time spent: 50 min
- Again, a pretty easy block.  I had one question in this block about why HIV rapidly becomes resistant to reverse transcriptase inhibitors.  I really hope I answered correctly, since that question came up in almost identical form three more times during the exam!
- Took a 10 minute break afterward; ate a granola bar, went to the bathroom, had some water

::Block 3::
- Time spent: 55 min
- I felt very fatigued during this block.  I am not sure if it was because I ate during my previous break, or if "midmorning blues" just kicked in.  I almost fell asleep halfway through the block.  There were also some very long vignettes in this block which were exhausting to read through.  History, blah, blah, vitals, blah, blah, patient remembers some relevant fact, blah, blah...  Anyway this was the hardest block for me just because I had to force myself to stay awake.  I made use of my writing boards and drew some cartoons.
-Took a 5 minute break afterward

::Block 4::
- Time spent: 50 min
- I felt better during this block.  I was still so tired, but I knew lunch was coming!  There was a lot of cardio and path in this block and a few weird biostats questions that I wasn't sure about.
- Took a 30 minute lunch break afterward

::Block 5::
- Time spent: 45 min
- I was re-energized and ready to kick the crap out of the last three blocks!  The last three blocks kicked back.  There was a lot of MSK and Neuro anatomy that I was really not prepared for.  I had a couple of questions about paths of cranial nerves, about 5 upper limb msk questions,  and a CT scan of a knee.
- Took a 5 minute break afterward

::Block 6::
- Time spent: 50 min
- At this point I was just really angry about all of the MSK and neuro anat.  Then I got a bunch of stupid pharm questions about adrenoreceptors and crap.  I really wanted to throw a temper tantrum and walk out!  But I didn't. :)  I finished it up and prepared myself for the last block.
- Took a 5 minute break afterward

::Block 7::
- Time spent: 45 min
- This block was actually pretty easy.  There were two or three "WTF" questions, but for the most part it was actually a great block to end with.  I was just really bored and tired at this point.  There are only so many times you can read the word "Zidovudine" before you want to take a nap and explode at the same time.
 - Finished as quickly as possible and got the hell out of there!

Overall, I feel pretty good about the Step 1.  I don't think I did better than on the Qbanks, but I also don't think I did worse.  I found the questions to be a bit easier than Kaplan and UWorld.  They were more straightforward and a lot more clinical (better for me) in emphasis.  The fatigue and boredom just killed me by the end of the day, though.  But I finished in under 7 hours.  And now it's over!!!

Now, the waiting for results begins ...

C'mon... 240!!

I found this nifty USMLE score predictor whilst traversing the internet today.  It's predicting 248 +/- 23.  Which is an enormous range!!  Worst case is a 225, best case is a 271.  While I don't think a 271 is very likely at this point, a 240 would be excellent!!

This is my last official night of studying.  I will do a small bit of review tomorrow, and the day after tomorrow is the real deal! 

I'm so nervous but excited to be finished with this thing!

--KM

70% seems to be my limit :P

Well, 70% is apparently my number. I have completed 50% of UWorld, and my cumulative average is still 70%.  I also did a full-length practice exam from Kaplan today.  (Yes, that is how I spent my Christmas Day.)  Again, 70%.

The breakdown by topic was:
Behavioural science - 71%
Biochemistry - 83% <--- WTF? this one surprised me :S
Biostats - 81%
Cell bio - 100%
Embryology - 100%
Genetics - 88%
Gross anatomy - 77%
Histology - 100%
Immunology - 75%
Micro - 51% <--- ugh SERIOUSLY?!?  Stupid viruses...
Molecular bio - 100%
Path - 82%
Pathophys - 71%
Pharm - 61%
Physiology - 85%

If I can manage to perform similarly to this on the actual day, I'll be pretty happy. :)  I definitely need to cram some more micro in, since it seems to be my nemesis at the moment.  Ugh but right now I'm soooo bored of it all!! Time for some relaxation and comfort food!  --KM

I think I can do better!

So I have done 350 questions from UWorld, and my cumulative average is 70! :D  I think I can do better than that, though!  Below is a chart of my test blocks and cumulative averages so far:  As you can see, it creeps up v e r y      s   l   o    w     l        y (but it is rising)!  That random 90% spike seems like a fluke - but it gave me a lot of hope.

The biggest thing I am struggling with is still Pharm.  I am going to set aside a couple of hours tomorrow to revisit it, and see if I can bring that average up some more.  My goal is a cumulative average of 80.  Big goal, I know - but I really think I can do it!!  --KM <3

T-2 weeks!

Yay! I'm finally in the home stretch!  I have just been reviewing Goljan's audio lectures to brush up on my pathology, and finishing the Kaplan Qbank.  Kaplan is predicting my score to be 235.  I would be really happy with that!  I want to keep pushing, though!  Today I bought the USMLE World Qbank and self-assessment tests.  For the next two weeks, I will be going through those and re-reading First Aid.

It's almost time! :D

--KM

Vasculitides in a mind map :)

I love mind maps for topics that involve knowing one or two key facts about many related concepts.  Just like vasculitides! :)

It's slowly getting better :)

Well, I'm managing to slog through.  I finally finished all the "general principles" crapola.  My Kaplan average for "general principles" is 60%.  Which is not bad, all things considered.  I really thought that Micro and Biochem were going to eat my soul.  I did Haem yesterday and got 77% on the last question block!  So it's slowly getting better.  Goljan's lectures are keeping me sane at the moment.  He makes everything seem so easy ... if only I can remember it!

Anyway, my plan is to just keep doing questions by system.  I am going to do:
- 2 days (including today) on cardio & resp
- 2 days on gastro
- 1 day on renal and repro (I have already done most of the renal questions and I had repro recently in my coursework so I'm feeling pretty good about those two subjects)
- 1 day on endocrine
- 2 days on MSK and neuro
(I did the psyc questions with my behavioural science questions)

Then I will have finished Kaplan q's entirely!  After that, it's UWorld & review for 2 weeks straight! 

Wish me luck ... :)

--KM

My strategy failing me?

When I first started thinking about the Step 1, I was a bit worried about microbiology.  This was partly because I didn't need to know much as part of my coursework, and partly because microbiology was the bane of my existence during undergrad.  So, about six months ago, I spent a couple of days reading Levinson and making notes into First Aid.  At that time I felt I'd learned heaps, but I finally began revising it today.

As I was reading through, I thought, "Wow, this isn't quite as bad as I'd remembered."  Then, I started doing Kaplan questions.  Mother of god.  I got 46% correct on the first question block.  46%?!?  How can this stand?

The thoroughly abrading thing about all of this is that most of the questions I got wrong were related to things I have never before seen!  Did you know Pseudomonas aeruginosa has two elastases called LasA and LasB responsible for ecthyma gangrenosum?  I sure didn't until today.

Did my high-yield review resources let me down?  Or does Kaplan just suck?  Either way, are they preparing me adequately for the USMLE or am I being led into a dark alleyway for mental assault and battery?

Feeling crotchety, --KM

How studying is (or is not) going so far ...

So it's taken me two weeks to tackle my "tough subjects" of biochemistry, pharmacology, and embryology.  (I threw in a bit of path last week just to keep myself sane.)

I will start with Embryology because it turned out to be way better than I was expecting.  Basically we all start out as a little ball.  Then that ball gets squished into a pancake.  Then the pancake splits up into three layers and we fold up into a mushroom.  In the mushroomation embryo phase, there is a big groove all the way down the back which gets "zipped up".  If the fly stays down, it = neural tube defect. If something goes wrong at the head, you get anencephaly.  If something goes wrong at the bum, you get a myelomeningocoele.  Either way, it sucks.  Also, the pharyngeal pouches - funky ruffles on your cheeks that kind of look like Captain Hook's shirt, and turn into your ears and face and stuff. 

Oh yea, and your heart, thyroid gland, and pituitary all start in the mouth.  Weird as!

Anyway moving on.

Biochemistry is rough for me.  I really struggle with remembering the names of enzymes, and all of the lysosomal storage diseases sound the same to me!  I made awesome flash cards, which have helped a little bit, but I still find that I second-guess myself when I'm answering practice questions.  I worked on biochem for several days, but I just had to leave it and move on.

Pharmacology would be easy if it were just remembering the drugs.  I am really good at mechanisms of action, overdose/withdrawal and all of that.  What I suck at is anything involving a graph.

**PREPARE FOR RANT**

Seriously, the person who decided that those stupid graphs of heart rate and blood pressure with sympathetic antagonists/agonists were a good idea can eat shit and die as far as I'm concerned.  Why the hell would I care about a hypothetical experimental antagonist that is never used except for USMLE questions?  So it tests knowledge of receptors and crap?  Who the fuck cares!  Is it clinically useful? I think not. *Le sigh* 

ALSO - the next Lineweaver-Burke plot I see may drive me into a hysterical fit.  If they ask me a question about enzyme affinity and reaction rates in words I am fine, but as soon as it is in a graph - it's like a kaleidoscope of weeping, uncontrollable swearing, and inappropriate laughter!  People may think I have the "Happy Puppet" Angelman syndrome!  (See, I did learn something studying that biochemistry crap.)

Anyway, it took me two weeks but I did manage to survive the subjects that I really suck at.  Today I will do behavioural sciences and make a start on micro.  Wish me luck!

Boot camp begins!

Well, school is finally over.  Which means I have 6 weeks to do some hardcore USMLE study!  EEK!

I have read all of First Aid this year and added some extra notes.  From the study and practice questions I have done so far, I have realized the areas I need the most work on are biochemistry, embryology, and pharmacology.  So I'm going to focus on really studying those areas for the first week, and then again at the very end.  The rest of my study is going to be practice questions, practice questions, practice questions!!  I have already done a few questions in Kaplan Qbank and First Aid Q&A, so I'm going to keep using those until I feel really confident about my question-answering strategy.  Then I am going to start UWorld - for the ultimate power study of awesome!

It is really crunch time! --KM <3

Mixed acid-base disorders

Epiphany today!

You know how CO2 and bicarbonate levels change together?  Like if CO2 goes up, bicarb goes up, and if CO2 goes down, bicarb goes down?

Well, then: LET ME BLOW YOUR MIND!

In mixed acid-base disorders, there is both a respiratory and a metabolic acid-base disruption.  So the bicarb and CO2 change in opposite directions!


It totally makes sense if you think about it a little bit.  For example, in cardiopulmonary arrest, the patient stops breathing.  They will therefore accumulate CO2 and have a respiratory acidosis.  BUT because they stop breathing (and cause they're ludicrously ischaemic from no heart pumping), they also become hypoxic.  Anaerobic metabolism ensues and lactic acid accumulates.  They will then develop a metabolic acidosis, saturating all the available bicarb with a proton blitz - leading to a mixed acidosis which messes with everyone's minds.

Holy crap! Amazing.

EEK! Scheduled today!

I finally picked a date today!  28 December 2010!  I'm so nervous/excited!

Meanwhile, school is dominating my life and I have had basically zero time to do proper USMLE study :(  I am hoping to be back on track by the end of this week.

It is so annoying to have to study for 80 gajillion things all at the same time!  Grr....

Acid-base: My Achilles' Heel

ACID-BASE BALANCE IS THE BANE OF MY EXISTENCE!!!

There are not very many things in this life that I naturally suck at.  Basically the list just includes team sports and acid-base balance. 

My strategy for overcoming this obstacle has thus far been identical to my strategy for dealing with team sports: complete and utter avoidance.  Unfortunately, acid-base keeps poking its' ugly snout back into my USMLE business, and I realize I must meet this enemy head-on (or risk having my ass handed to me on a platter on test day).

To date, physiology textbooks like Sherwood and Guyton (both my usual favorites) have failed me dismally.  So it is with a heavy heart that I turn to USMLE Step 1 Secrets in the vain hope that somehow this high-yield review source will explain the mysteries of protons and bicarbonate in such a way as my currently feeble mind can unravel.

God's teeth!  What witchery be this?  It is starting to make sense! (Just a little bit.)

Stuff I didn't know until now:
- The kidney is 'better' at excreting bicarbonate than it is at retaining it.  This explains why renal compensation in respiratory alkalosis (compensatory mechanism = excrete bicarb) is faster and more complete than the renal compensation for respiratory acidosis (compensatory mechanism = retain/synthesize bicarb).

- There are a gajillion things that can cause metabolic alkalosis, but they all revolve around a couple of major mechanisms:

1. Hypokalaemia: three main effects ...
   (1) ↓ K+ secretion at distal tubule --> ↑ H+ loss at distal tubule (serum pH ↑s)
   (2) Cells exchange K+ for H+ --> ↓H+ in serum and ↑H+ in cells (serum pH ↑s)
   (3) Proximal tubule cells excrete excess intracellular proton in the form of ammonium ion (serum pH ↑s)
2. Excessive activation of aldosterone receptor - promotes K+ & H+ excretion in exchange for Na+ retention (serum pH ↑s through direct effect of excreting protons and indirect effect of hypokalaemia)
3. Volume depletion - causes ↑ Na+ retention (attempt to maintain plasma volume) --> ↑H+ loss and ↑bicarb retention at proximal tubule; also indirect effects of RAAS --> ↑ aldosterone activity
4. Proton loss to the outside world - loss of acid to outside world --> ↑ serum pH

So, things that cause metabolic alkalosis include:

• Loop & thiazide diuretics - vol depletion & hypokalaemia
• Bartter syndrome - loss of Na+/K+/2Cl- transporter - mimics loop diuretic
• Gitelman's syndrome - loss of Na+/Cl- transporter - mimics thiazide diuretic
• Vomiting & antacid overuse - loss of acid
• Conn's syndrome - primary hyperaldosteronism
• Cushing syndrome - excess glucocorticoid exerts effect on aldosterone receptor
• Liddle's syndrome - mimics hyperaldosteronism
• 11β-hydroxycortisol dehydrogenase deficiency (essential or secondary to licorice) - decreased breakdown of steroids - mimics hyperaldosteronism

I think it's better to learn the mechanisms than to memorize the list.

Metabolic acidosis coming up soon!  Stay tuned ...

Xo --KM <3

Pre-renal vs. Intra-renal Ischaemia

Holy crap - busiest month ever.  I srsly don't know where the last month went.  It just disappeared. :S

USMLE studying has basically gone out the window lately.  :( But I am trying to get back into it with renal!  Renal physiology is kind of meh but the pathology is amazingly cool.

Acute tubular necrosis is the commonest intra-renal cause of acute renal failure.  It can be caused by toxins or ischaemia.  At first this seemed straightforward to me, but then I realized that pre-renal acute renal failure is ischaemic.  This caused me to question, how in the &$%! do you tell the difference between intra-renal ischaemic acute renal failure and pre-renal ischaemic acute renal failure??

Apparently it goes like this:

Pre-renal: renal cells are hypoperfused, but tubular function remains intact!  Tubule cells increase reabsorption of sodium, and urea is retained in the medulla.  This is an attempt to create concentrated urine and maintain plasma volume (...and thereby maintain perfusion).
-BUN/Creatinine ratio (quick and dirty, but not specific): Elevated >20:1
-Fractional excretion of Na+ (more specific measure .. basically the clearance of sodium weighted by creatinine clearance): Reduced <1%

Intra-renal: renal tubule cell function is impaired!  Sodium and urea cannot be reabsorbed.
-BUN/Creatinine ratio: Reduced <10:1
-FENa+: Elevated >2%

Also, toxins which can cause ATN:
"Color, contrast, and chemo"
= Heme pigments (Hb and Mb) 
= Radiography contrast media 
= Chemotherapeutic agents: cisplatin, aminoglycoside A/Bs, & Amphotericin B 

Holy ECFMG, Batman!

Holy crap.  Applied for my Step 1 just now.  It was so scary I thought I might puke.

Eight hundred and eighty dollars!!!!  WTF.

 Also, the ECFMG website was clearly written by cyber monkeys and not by actual English-speaking human beings.  Exhibit A:  "...Although you can select an eligibility period as late as the 24th day of that eligibility period, there is no guarantee that you will be assigned that eligibility period, since the processing of your application may not be completed by the 25th day of the eligibility period."

...

Fml.

In happier news - I am starting to have breakthroughs in neuroanatomy :)  I finally figured out what the trigeminal nerve does and where it is! :) --KM <3

It's neuro time!

Got a major dose of reality this morning.  Our pathology lecturer informed us today that "Neurology, more so than perhaps any other area of medicine, revolves around the anatomy of the system for classification of clinical syndromes." Or something earth-shattering like that.  It's time for me to study Neuro anyway, so I thought, "What the hell? - I'll start with neuroanatomy."

Neuroanatomy on a Monday morning is rather like a shot of tequila on an empty stomach.  It seems like a good idea at the time.  "What's one shot of tequila?"/"What's a little neuroanatomy?"  Lol.

Fortunately, tequila goes quite well with salty & greasy food - and SO DOES NEUROANATOMY.  It is amazing how much better something gets when combined with chips and aioli!

Anyway I got through the spinal cord today.  The embryology is quite easy.  Step 1: a patch of ectoderm forms the neural groove.  Step 2: A group of cells migrates to form the neural crest cells.  Step 3: The neural groove is "zippered" up to form the neural tube, starting in the middle and moving rostrally and caudally.  Step 4: The neural tube cells form the alar plate (sensory neurons ... i.e. the dorsal columns & dorsal horns) and the basal plate (motor neurons ... i.e the ventral horns and the corticospinal tracts).

My mnemonic for layers a needle would pass through during an LP is SLEDS Along Snow:
S - skin & superficial fascia
L - ligaments
E - epidural space
D - dura
S - subdural space
Along - arachnoid
Snow - subarachnoid space (from which the CSF is extracted)

--KM <3

Help!! Overwhelmed :(

This is how I'm feeling today :(   HELP!!

For everything I tick off, a thousand other things pop up that I forgot to put on my list.

Augh / *le sigh*

--KM <3

SSRI / SNRI mnemonics

SSRI's:

Drugs:

Effective - Escitalopram
For - Fluoxetine, Fluvoxamine
Sadness, - Sertroline
Panic, - Paroxetine
& Compulsions - Citalopram

- the mnemonic includes the main indications: Depression (Sadness), Anxiety disorders & PTSD (Panic), and OCD (Compulsions).

Adverse effects:

3 S's:

Stomach upset - GIT symptoms

Sexual dysfunction

Serotonin syndrome - with other serotonergic agents (i.e. MAOs) - hyperthermia, muscle rigidity, flushing, diarrhoea

SNRI's:

Drugs:

Vexed & Depressed - Venlafaxine, Desvenlafaxine (active metabolite of venlafaxine) & Duloxetine
  - the mnemonic includes the main indications: Generalized Anxiety Disorder (Vexed) and Major Depressive Disorder (Depressed)

Adverse effects:

SHAT:

Same adverse effects as SSRI's, plus

Hypertension

Adrenergic effects (awake [insomnia], anxious, agitated)

Tachycardia

Gram +ve bacteria

Diagram of Gram +ve bacteria :)

Productive procrastination

Photographic evidence of my flash card organization! :)

Micro :)

Found a GREAT Micro text! Lange Review of Medical Microbiology and Immunology is the shiznit. I wish I had discovered it 18 months ago when I was struggling through Immmuno in first year!

Anyway, I have been a busy bee. I have started the process of registering for the step 1, and I have a realistic and organized (for me) schedule written up. I'm sure if anyone else looked at it, they would think it is the ravings of a lunatic. But it is tailored to what I anticipate my life for the next few months will look like. Also, I organized all of my flash cards by system, so I can just stick a pack in my purse for the week I am working on that system, and take them out whenever I am on the bus or have a few moments to flip through them.

As far as studying goes, I have gotten through all of the Bacteria, so now I am on to Viruses, Fungi, and other tiny creatures. I am working on mind maps of the Gram -ve's, Gram +ve's, and the random others. I will post them soon.

In other news, I noticed that in the Psych section, First Aid does not have the SADAFACES mnemonic for depression! What is this "SIGECAPS" nonsense?!? The best part about SADAFACES is that there are nine criteria which correspond (although the wording is different) to the DSM criteria for a major depressive episode. According to the DSM, the patient should have 5 / 9 for >2 weeks, and these must include dysthymia and/or anhedonia. I know this is quite clinical and perhaps more Step 2-ish, but really!

S - sleep disturbance
A - anhedonia
D - dysthymia
A - appetite / weight changes
F - fatigue
A - agitation & psychomotor changes
C - concentration & cognition changes
E - esteem problems
S - suicidal thoughts.

XO --KM <3

DNA mnemonics

The purine bases are adenine and guanine. I remember this by "Pure as Silver (Ag)."

Hydrogen bonding is the strongest between G & C because they have three hydrogen bonds (whereas the A-T or A-U bonds have only two H-bonds). I remember this by "G and C rhymes with three, A, T, U rhymes with two."

My USMLE To Do List

I'm starting to get serious about this whole USMLE thing. I've got my books, I've gotten halfway through year 2 med, and now it's time to get to work!

Things I need to do:

1. Register
I really really really want to put this off! Reason A - it's a PAIN. Reason B - it will mean I have a deadline ... eep!

2. Find a micro text!
I really need to find a good, concise microbiology text. I suck at micro and it can eff off and die for all I care, BUT I know it's important and I know it will be tested. Ergo ... must find a micro text.

3. Stick to my study schedule
I am using a systems-based approach so that I can fit everything in with my med curriculum and just add the bits and pieces of extra USMLE stuff here and there ... time will tell if this is effective or not. I know a lot of people find it easier to compartmentalize Anatomy from Physiology from Embryology etc. but I prefer learning all of this in context.

And in the midst of all of this, I have to conquer the rest of year 2 med! AWESOME! *Sarcastic smile!*

Inspiration for my study journey arrived this weekend in "The Longest Mile", a poem in the novel The Year of the Flood by Margaret Atwood, courtesy of one of my dearest friends, AK. The last bit of the poem reads:

Take heart, oh dusty Travellers:
Though you may falter,
Though you be felled along the way,
You'll reach the Altar.

Race on, race on, though eyes grow dim,
And faint the Chorus;
God gives us Nature's green applause --
Such will restore us.

For in the effort is the Goal,
'Tis thus we're treasured:
He knows us by our Pilgrim Soul --
'Tis thus we're measured.

--KM <3

~* Coming Soon! *~

As part of my ongoing quest for productive procrastination tools, I have decided to start a blog of my study journey through the USMLE. Unfortunately, I have another exam in like 6 hours so I kinda need to get going.

brb!

--KM <3