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Medical Student Perspectives: Breaking down the Boards

The United States Medical Licensing Examination (USMLE) is a set of three examinations medical students and residents must take and pass in order to obtain a license to practice medicine in the United States. “The Boards” are currently divided into three “Steps,” with the first two taken during medical school, and the third traditionally taken any time after one year of postgraduate training. Mention the boards to a first or second year medical student and the same feelings of uneasiness and trepidation precipitated by the MCAT begin to resurface. This article presents background information and study tips focused mainly on Steps 1 and 2, as these are the examinations taken during medical school.

A passing score is all that is required on the USMLE examinations for the purpose of licensure, but the Step exams are also numerically scored and at present the scores from Step 1 (and sometimes Step 2) are used by residency programs in part to determine whom to interview and ultimately offer positions for training. An excellent resource to demystify the competitiveness of different specialties, provided by the Association of American Medical Colleges, is called Careers in Medicine (CIM) and is available free online at www.aamc.org/cim. On the CIM site there is a PDF version of a yearly report, “Charting Outcomes in the Match,” which lists the average board score and score ranges for matched and unmatched applicants for different specialties.

For students who know what specialty they wish to pursue, having an idea of a score to aim for on Step 1 can be helpful when taking self-assessments prior to the real exam. Last year, the mean Step 1 score for students who successfully matched in internal medicine, for example, was 222, with 207 being the 25th percentile of a successfully matched applicant, and 237 being the 75th percentile marker for the same group. While students with scores both above 237 and below 207 matched in internal medicine, the Charting Outcomes data on the CIM web site can be a helpful guide for students. This report looks at characteristics of successful versus unsuccessful applicants ranging from research experiences, publications, and Ph.D. degrees and helps give students a good idea of what the “typical successful applicant” for any given specialty looks like on paper.

Preparing for Step 1
Relax. Your pre-clinical years of medical school are designed to help prepare you for the boards, so while you have been studying for in-house exams, without knowing it you have already begun to study for Step 1! Step 1 is usually taken by students at the break between their pre-clinical and clinical training, normally the summer after their second year of medical school. There is no one right way to prepare for Step 1, but making a plan and sticking to it is critical; do not change review texts and study plans halfway through your formal preparation for the exam. Many students find First Aid for the USMLE Step 1 to be a useful general review text. New editions of the book are released every year that incorporate feedback from students and correct any errors found in previous editions. The majority of students currently dedicate between four and eight weeks of time to prepare for Step 1.

Step 1 is a computerized test composed of seven one-hour blocks of 48 questions, with a 15-minute computer tutorial, and a total of 45 minutes for breaks/lunch. Altogether, the test is scheduled for eight hours. You may take breaks in between your 50-minute exam blocks, not to exceed the total break time allotted. Because this is a 336-question exam, building up your endurance is a key part of mastering Step 1. There are many online question banks (referred to as Q-Banks) that offer practice Step 1 questions with explanations, analysis, and feedback. Students who obtain very high scores on Step 1 often attribute their success to having completed a large number of practice questions in a simulated exam format so that on the test day they were not exhausted halfway through the real exam. A good tip is to talk to upper-level students at your school to see how they prepared. Does your school offer a review course or discounts on review books? It is worth talking with your curriculum or student affairs deans to know what resources your school has made available to you. Most important, make a study plan and try to stick to it. Consider preparing for the exam with 1-2 other classmates you enjoy studying with to help keep everyone on track. Over 93% of U.S. MD medical students pass Step 1 on their first attempt (76% for U.S. DO students and 71% for foreign medical students).

If a student does not pass the exam on his or her first attempt, the USMLE allows the student to take the exam a second time. Each medical school has a different policy regarding students who fail Step 1 initially, and it is important to be familiar with your school’s policy. Students who are unsuccessful in passing Step 1 on their first two attempts are allowed to take the exam a third and final time, but must pass on this attempt to remain in medical school. It is important for a student who has had difficulty with the exam to evaluate the reasons why and take additional time to prepare before taking the exam again. Meeting with your academic affairs dean to discuss a new study strategy and get connected with academic support resources available through your school can be helpful for struggling students.

Step 2
Step 2 is broken down into two separate parts, a Clinical Knowledge (CK) exam similar in format to Step 1, and a Clinical Skills (CS) exam where students actually interview and examine standardized patients. Step 2 CK and CS are usually taken by students after the completion of their third year core clerkships (Medicine, Surgery, Pediatrics, Psychiatry and Obstetrics/Gynecology). Just like Step 1, schools set different deadlines for when their students must have completed the Step 2 exam. The focus of the exam material on Step 2 is less on pure basic science and more on the practical application of medical science to clinical scenarios. There is a First Aid for the USMLE Step 2 text available along with Step 2 Q-banks. A passing score on Step 2 is all that is needed for licensure, but a high Step 2 CK score that comes back early enough in a student’s fourth year to be reported to residency programs can help an applicant be more competitive at high tier programs, especially if his or her Step 1 score was not extremely high. The Step 2 CS examination is only offered at specific sites around the country, currently Atlanta, Chicago, Houston, Los Angeles, and Philadelphia www.usmle.org/Examinations/step2/cs/CSECAddresses.html. Picking an exam date that allows you time for the necessary travel arrangements is critical to minimize stress and help you focus on doing well on the exam.

When preparing for the boards, keep in mind that it is impossible to use every review text and Q-Bank resource available. No matter how tempting, resist the urge to buy review books you know you will never have time to use, and familiarize yourself with your review materials as early as possible during your first two years of medical school so that you are not looking at them for the first time several weeks before the boards. Take a deep breath and know that with adequate preparation you can join the many thousands of medical students who have successfully passed their boards and moved on to be skilled and dedicated physicians.

For official information regarding the USMLE, visit the official website: http://www.usmle.org/.

Matthew Rudy
Council of Student Members Representative, Southeastern Region
Medical College of Georgia, Class of 2010
Email: mrudy@mcg.edu

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Back to January 2009 Issue of IMpact

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