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katieli: Step 1 experience Mar-2013
作者:USMedEdu
发表时间:2014-04-23
更新时间:2014-04-23
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发信人: katieli (nina), 信区: MedicalCareer
标 题: step1 experience Mar-2013
发信站: BBS 未名空间站 (Tue Apr 22 10:42:34 2014, 美东)

感谢多年来从mit上获得的帮助和信息,今天贴上自己的考经,希望对后继者有帮助。
一下大部分文字是考前两月写下的自己的感悟,由于考前高压,可能会条理不清,词不
达意,见谅。
不变应万变
对于难题要做到镇静,想想我不会的题目,多数人也未必会,镇静,镇静!镇静下来之
后才能慢慢寻找解题思路,难题的难点在于,题目信息不熟悉,备选答案内容不熟悉,
不要慌,想一想,出题者的思路在哪里,用自己熟悉的知识点去解决不熟悉的信息,这
就是apply的过程,比如genetic的题目。以不变应万变。
对于不会的题目,不要粘题,没有思路,跳过去,回头再想。有时是瞬时block out一
叶障目,后头再看的时候会发现豁然开朗。不值得浪费太多时间在一道题目上面。
关于排除法的应用,首先排除自己熟悉的选项,再排除自己不熟悉的选项,如果自己熟
悉的选项不能排除,怎么能排除自己根本看不懂的选项。解决方案:如果最后自己熟悉
的选项不能排除,还是选择自己熟悉的选项。因为太超范围,太偏太远的东西考的可能
性毕竟比较小,较大点的可能是可能是自己熟悉的,但是自己没有做到很好的apply或
者没有找到题干和答案的connection。最后,万一正确答案为偏远选项,大家可能都会
失分,也不要太计较,谁都难免有知识漏洞。回归镇静!
有些难题是些咬文嚼字的题目,看清题意,不要被果筋的描述方式给绕得找不清楚方向。
NBME form尽早做,1 form/1.5月, 帮助熟悉出题思路,考前1-2月之前结束做完所有
form,因为有些题目不是短时间能解决的,我的意思是,比如,群比如七月初做form12
,即使到了八月底,我也不能完全解决所有的题目,因为有些题目,我找不到答案。但
是如果给予更长些的时间,我在复习到某些subject的时候,会突然发现,咦,这个知
识点不正好解释了某某题吗,这个感觉对于一道题目会多次出现,那么在这段时间内,
对于这一个题目,你从不同的角度不同层次展开了自己的理解。 在这一点上,比考前
一个月解决多个form,并在一个月内解决所有的错题,从学习知识的角度要好得多。因
为在短时间内啃掉多个错题,搜索的知识面难免局限,理解可能有些片面,下次同个考
点换个马甲出现,可能会败下睁来。这是我对“吃透”的理解,吃透需要时间,狼吞虎
咽,消化不良。比如muscle type grouping (form 12), 刚开始,我始终不能理解为什
么the same type muscle fiber can move around by themselves and group by
types, 多方查询未果,怀着这个疑问,每次阅读muscle 的topic的时候,我就会留心
看看有没有这方面的解释,后来在阅读其他资料的时候才发现,not muscle fibers
move, but rather type re-adapt to its new motor unit. 还有一个更早期form5
的题目, 判断cortex areas responsible for planning movement, take several
months to find an optimal answer, 刚开始面对这个题目是,根本不知道答案,学习
了一段过程后,我选择了prefrontal cortex,再学习一段时间之后我觉得得
supplemental mortor area of cortex 更合适。 在这样一个反复揣摩的过程中,更容
易抓住出题人的predilection,

Behavioral sicence:
BRS X3, KHAN’S cases x2, master the boards USMLE medical ethics x2
做题方式:
UW 3遍(61% -> 87% ->96%), NBME 2遍, kaplan Qbank x1, Rx Qbnakx1
1. 对于UW 和NMBE,没有在短时间内重复一个题库,互相交替,在交替的interval里
面,可以淡化short term memory and solid long term memory, 一来避免答案被记住
导致正确率虚高,二来在第二次或者第三次做以前做过的题目的时候,对题干和答案随
着自己对知识理解的加深会有新的见解,出现不同的解题思路,这样达到了second
training的目的,而不是简单机械的重复,简单机械重复会很快丧失对题目的兴趣,厌
倦,不想再做了,早考早托生。题目其实是可以新鲜的,放一放,再嚼一嚼,还是有营
养被吸收的。对于同一道题目,可能会发现,你错的和对的理由与上次相比完全不一样
的,比较一下两次解题思路,发现我的大脑原来这么有趣。
2. 对于NBME里面一些陌生的/不熟悉的/看见后不知所云的备选项,比如一些不常见
的疾病名,解剖结构名,也是需要搞清楚的,比如REM sleep disorder出现在form6的
备选项,但是在form12(?)却是主选项。REM sleep disorder 在FA里面没有,但是
BRS 里面有,如果做form的时候没有查备选项或者看BRS的时候没注意,就增加了丢分
的几率。再说回来,某个知识点在一个不起眼的地方闪过一次,挺难记住,在多个地方
多次闪烁的东西,我们才容易记住。所以多查查,多想想,多前后联系,有助记忆。
3. NBME 2 次的意义:出了前面提到的second training,另外一个用途大概知道
自己最后考分的上限是多少,有时候难免喜欢高估自己,我可以期盼着奢望着我实际考
分比最后一个form 1st 还要涨一点但是不要指望实际考分会高于NBME 2nd 的分数。
更看清楚自己在哪一个水平段。
4. 对于Rx 和Kaplan,做了还是有帮助,不光是理解fa,也可以扩展知识面。如果
要求分很高,理解的深度和知识面的广度,对于晚期冲刺还是有用的。比如需要将正确
率从90%提高到95%,靠的就是深和广。

NBME怪题解析:
1. 偷梁换柱型/声东击西型:
比如题干里面描述了大量的A信息,但是只有最后一句话即问题句,突然话锋急转,提
问B 的信息,如果一直pay attention to A,就会以为问的是A,选错答案,比如一个
gout的题目,前面好几句都描述gout的症状,uric acid在urine有多高啊,用药之后
urine里面排出uric acid增加了多少啊,并给出了详细具体的数值,好吸引眼球,但是
最后问的是serum里面uric acid该怎么控制,跟前边一大通废话一点关系没有。这种题
目适合逆读式攻破,即常说的先读最后一句即能选出答案,再把前面的废话也瞄两眼
confirm一下,不至于被敌人声东击西分散注意力。这种题目并不难,丢分是非常可惜
的。
2. 雾里看花型:
比如题目里面不费笔墨的描述一些完全没接触过的非常前沿的或者平时看都没看到过的
名词,对与我来说,某些genetic, biological molecular,statistic的技术哦,现
象哦。遇到了会顿生恐惧,“完了!”二字遁入脑海。镇静是关键,看看题干看不懂,
那就看看选项,还是看不懂,那就跳,后头再看,回头也还是不认识,那就认命吧。但
是在认命之前,先把自己会的七十二般绝技耍一遍,攻头不破则攻尾,攻左不利则攻右
。有些题目在这种敲敲打打中能敲出头绪。实在不行,千万不能紧张。因为更多的敌人
还在头面。


3. 排除法的应用(知识积累的间接效应):在知识积累的后期,有这么一个过渡阶
段,知识积累的价值体现在你能排除比别人更多的选项,you win。并没有直接反映在
能积累到能选出正确选项的程度。比如ABCD四个选项,比人只能排除2个,而你能排除3
个,虽然剩下的一个,你也不sure是否是题干想问的东西,那么win的几率大很多。我
想这是为什么有些人猜题正确率比如daoban很高,因为有能力排除非正确选项。这个过
渡阶段的benefit除了体现在排除备选项,也体现在筛选题干信息,比如题干提示多条
信息1,2,3,4,其实都是某个疾病的indications,在早期,我们也许只对一条最明显的
信息比如信息1敏感,而对其他的信息2,3,4不敏感,而在积累后期,我们开始明察秋毫
了,发现信息2也指向某种疾病,那么在这种情况下,你对这种疾病的判断就多了一条
砝码,天平开始向正确的方向倾斜。Win的几率也更大。
4. 时态题:比如were还是will。出题模型disease- medicine (treat disease)-
complications---出题---medicine again (treat complications),这号题目里,
有2套信息, original disease AND complications, original treatment AND
complication treatment, 而选项里面cover了both, 这个时候就要注意题目提问的
语态了,发现complication后,问 which of the following were administered to
this patient 还是which of the following will be administered to this patient
, 答案完全不同。这种题目不是不会而是眼神不锐。
5. 公理-定律-phenomenon 题 (physiology):对于FA,我称之为公理,因为里面
是最基本的,需要最熟悉的,不假思索的一些知识, 对于UW,成为定律,因为它在一
定程度上市FA 细节的延伸,
FA的优点在于精,UW的美妙在于细节的展现。对于UW里面一些基本的结论和现象跟FA是
一样的,需要非常熟悉,定律延伸于公理,熟悉定律,考场上就能直接拿来运用了,不
需要再从公理推算定律了。举个例子, nitroprosside vs isoproterolol vs
labetalol 在cardiac contracitility, preload, afterload 上的变化,就能灵活分
析其他的volume-pressure loop 了。这种方法对physiology较实用,涉及到一些生理
病理学现象的解释以及infer what’s supposed to occur in any given conditions
in the real exam. 再举一个例子, congestive heart failure vs obstructive
pulmonary disease, 看起来两者毫无关系,实际上两者pathophysiology非常相似,都
是failure-compensate-exacerbate failure发展模式, COPD: small airway
obstruction – airway resistance increase- increase lung volume to decrease
airway resistance- more air retain in the lung – emphysema,如果熟悉了UW里
面的这些信息,you can easily handle the variables such as cardiac output,
peripheral resistance, left ventricular end diastolic pressure in a
congestive heart failure patients, OR you know how to solve expiratory flow
rate issue by an previously familiar xx’s Law ( lung volume-airway
resistance- expiratory flow rate )
6. 众里寻他型:也属于偏难题系列,咋一看没有任何思路,多看几遍会发现线索,
这些线索多是隐藏在字里行间的一句“废话”,他们可以使排除性线索(排除某个选项
),也可以使引导性线索(指向某个现象),比如form11block4q11, 分析一下这个
writer write question的方式,有那么一句话,writer多费了一下笔墨,这点画蛇添
足的笔墨,正好指向答案所在,就是,writer描述了patient bicyle的具体时间,
hours Of weekday, and hours of weekend, 为什么要多写这一句,他可以完全end在
he lifts weights regularly and train on his bicycle,正因为这后面补了一句,才
指向了答案。还有个排除性线索的题目,nonalcoholic steatosis 的题目,因为题干
中已经描述了patient 的drinking habit,这样的描述已经排除了alcoholic steatosis


我对弱项科目的理解: 某前辈曾经说过,要拿高分就得让所有的科目都在test的时候
变成有星星,那么所谓的弱项,我的理解是,在复习得不同阶段,弱项科目在一个不断
变化的动态平衡中,弱项是相对的,当你不断积累的过程中,弱项变成强项,以前的所
谓强项在新的平衡中又变成相对弱项。 如期太早期就定下什么是弱项,不如眉毛胡子
一把抓,多有科目一起乱炖,等沌到正确率到了90%以前,弱项才真正浮出水面。因为
如果正确率只有80%,其实意味着你的弱项太多了,只补充vit-d or c workless,需要
的是vitamin complex。
反复FA,反复UW,
知识点的前后联系,横向发散,相互比较,没一个细节的比较才能更清楚地认识疾病与
疾病的不同,think like a doctor, based on a case description, respond
immediately what is the diagnosis and differential diagnosis, what is
miscroscopic findings and lab work up, what’s treatment and the potential
complications & side effect.
1. Trophus (gout) vs calcinosis (CREST syndrome) vs hyperparathyroidism (
calcium deposit); hand manifestation: OA vs RA vs Psoriasis
2. 看到某种疾病的描述,想想他们的microscopic findings, CT or X-ray
Child abuse 的spiral fracture (how it looks like under X ray)
Portal vein is merged by splenic vein and superior mesenteric vein. How to
differentiate the triple vessels in an abdominal CT is shown
3. Gulain barre syndrome: why motor function is affected often? (motor
neuron nerve is highly myelinated compared to sensory peripheral nerve or
autonomic nerve)。
4. Lipoprotein lipase (insulin sensitive, type I hyperlipidemia) vs
hormone sensitive lipase (glucagon sensitive)
5. Breast cancer: skin pitting vs dimpling, (lymphatic edema vs
suspensory ligament invasion)
每一次反复,不能使简单的重复,必须从中获取新的知识或者巩固延伸旧知识,简单反
复很容易让人丧失学习兴趣。Fa只是提供一个大框架,能把这个框架建成什么样的工艺
品非常individualized的,越细越精致,才能卖出个好价钱,如果只是个毛培的架子,
真的是非常不值钱。把UW融入fa,这个架子才有点主心骨,再把其他的学习资料,再加
入这个架子,让他不仅牢固,而且精致而丰富。这并非意味着FA无足轻重,正因为有FA
,我们的知识才成体系,否则是一盘散沙或一滩烂泥,无法成型。FA是肉身,知识是灵
魂,只有肉身,是行尸走肉,只有灵魂是孤魂野鬼,二者合一才是鲜活的生命。FA反复
多次,可能会觉得厌倦了,再看会引起呕吐反射,这个时候不妨换个花样,改换Kaplan
或者BRS,其实同样是内容的重复,但是不但不会引起不适,而且会增强记忆效果。比
如trastazumab的cardiotoxicity,FA里面看到多次,在一个不起眼的地方默默的躺着
,总也记忆不深,如果在其他的study materials的时候也多次看到,并且是从其他的
角度提到它的cardiotoxocity,机制(downregulate neuregulin),表现(
congestive heart failure),应用限制( benefit overweight risk when HER2/neu
positive only), 这就体现了记忆曲线的作用,重复,变换花样重复,思考,理解,记
住。

NBME题型解析二
总的来说,每套NBME题目,纵观是高低起伏,错落有致,难题难得想让人头撞南墙,吐
血而亡,易题,没有医学backgroud的人也能做对。在这里重点说下难题,难题有几种
难法。
一难,实为偏,out of your knowledge, 只能靠猜,但实际上,如果知识点cover住了
,一步都不用推,答案豁然眼前。
二难,为复式楼型,多个知识点的糅杂,但如果把每个知识点分开出题,并非难题,惊
险的是连环设局,一小步出错,导致全盘皆输,得靠多练习,不慌张,寻找切入点,砸
时间。这种题目最具挑战性,玩起来最有意思,是真正意义上的“解”题
三难,为急性突变题,题干全懂,预期的答案却不在选项内或在选项内但却是错答案,
策略是individualize,这种题多半是以前见过做过的题,但是答案和知识点转换了,
这个时候就要做到individulize (具体问题具体分析,please erase以前记住的答案
,因为备选项里可能有这么个fake answer,similar to the one you memorized),
擦亮双眼,千万不要上卧底的当。这些突变株,体现了题目的灵活性,同样是
suprasellar lesion,在released forms里面,即可以考diabetes insipidus (
compress posterior pituitary),也可以考hyperprolactinemia (pituitary stalk
lesion)。
四难,题干看不懂,这个时候只需看懂最后一句问什么,就最后一句选答案,不用纠结
题干里说的啥病,不要让看不懂的scenario提升体内的cortisol,稳稳稳

解题训练手册
训练两个关键点
关键点一: 弹药充足,冰冻三尺,非一日止汗,平日多看,多学习,没什么捷径可走
关键点二:找靶准,有这样一类题,错掉是非常可惜的,看错题,会错意,用错知识点
,如果把知识点挑明,定能收入囊中。这就要练习“瞄准”。瞄准关系到阅读,关系到
题感,可以在相对短时间内练就。每一套练习题,我们都在重复瞄准-开火的套路。“
瞄准”不是独立的,货不足,相对难以瞄准,明明只要一个靶点,而眼里看出了多了靶
点,没有办法剃掉伪靶,没有办法凸显实靶,只能乱射。
模考成绩:
5-10-2013 NBME 6-520/226
6-30-2013 NBME7-610/247
7-21-2013 NBME11-520/226
8-28-2013 NBME12-580/240
9-15-2013 UWSA-1-800/265 (85% correct)
10-15-2013 UWSA-2-800/265 (87%correct)
11-5-2013 NBME5-670/261
11-7-2013 NBME13-650/257
Dec-2013 CD (home) 90% (first time test)
2-3-2014 NBME15-650/257
2-27-2014 CD (promestric center) 100% (second time test)
3-7-2014 NBME16-630/256
3-24-2014 STEP1-260+

Systemic Review books
FA2013 X 6/7
High yield embryology x1 (very early stage)
High yield neuro anatomy x1 (very early stage)
High yield behavior science x1 (very early stage)
Clinical microbiology-make ridiculous simple x1 (early stage)
Kaplan series x1 (middle stage)
BRS series (exept pathology) x1
Goljan pathology x 2 (one time in middle stage and one before final exam)
MTB2 x1 (very rapidly, before final exam)
Systemic pathology http://library.med.utah.edu/WebPath/webpath.html x1
Pathology slides http://usmlepathslides.tumblr.com/ might out of date
Behavioral science: BRS X3, KHAN’S cases x2, master the boards USMLE
medical ethics x2
QBANKS:UW 3遍(61% -> 87% ->96%), NBME 2遍, kaplan Qbank x1, Rx Qbnakx1

Reference books/websites:
Rubin’s pathology (仅作查询和参考,)
Clinical essential anatomy (查询参考)
Medical physiology (查询参考)
Basic and clinical pharmacology (查询参考)
Kuby immunology (查询参考)
Langhan’s medical embryology (查询参考)
The human brain: an introduction to its functional anatomy (查询参考)
Tulane pharm wiki (free)
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1   [USMedEdu 于 2014-04-23 18:22:35 提到] [FROM: 72.]
发信人: dongyang (dongyang), 信区: MedicalCareer
标 题: step3 experience with updates on CCS
发信站: BBS 未名空间站 (Sat Apr 19 18:06:12 2014, 美东)

Finally, finished the step3.

Preparation material: UWorldx1.5 times, MTB3 briefly, Google, wiki
Study Time: PGY1, 2 week vacation time (~8hours/day except one weekend) +2-
3 week (3-5 hours/day on no-call day, had one week NF, had hard time study),
mostly by myself, had several Skype discussion with friends for CCS.
Pre test score range: UW 50-70% Sim 227, NBME3 offline 73% (the day before
the test)

The first day is much harder than the 2nd day, I got many statistic
questions, almost 3-5 every blocks, and the question are not straightforward
, you have to really know the concept to get it right, unfortunately,
Statistics is one of my weakness. Also, there are quite some dermatology
questions, usually with a simple nonspecific history, then one picture,
almost impossible to figure out from the question directly, so better to
google the pictures when you encounter the dermatology questions. There are
some questions testing very basic concept, like Step1, it gives you a case,
you diagnose the disease, but it’s asking you what the pathophysiology is,
so take a look step1 FA if you have time, especially all the genetic
inherent disease.

Time management: Questions are in general medium size, but there are some
quite long ones, I have to scroll down to see all. The time is very very
tight, I usually able to have 10-15min left from the UW and NBME, but in the
real test, I still have 2 questions not done when the 5 minutes warning
popped out in 3 blocks, which made me nervous. Another lesson from me is
that don’t marked too many questions and hope to take 2nd look. Only mark
the questions that you really want, you probably won’t have enough time to
review if you mark too many.

Day2, the questions are much shorter and easier, although the last block got
little harder and longer than the first 3. I will say the length and
difficulty are similar to NBME3.

Ccs part is fun, enough time for most of the cases. I took a break after the
first 4 case, then I used up all my break time before returning back to the
seat, as I know I will have extra time there. Cases are pretty classic, 1
pediatric, 2 OB/GYN, no surgery, others are IM. One of 20min case ended at
6min!

It’s definitely easier for resident to do the test, as there are some ethic
questions I probably wouldn’t know before residency. And it’s doable to
finish the test in 2-4 weeks if you can squeeze 6-10hours/day.
UWorld is good material to study, but make sure you understand the concept
inside and know the incorrect answers as well; I get couple easy questions
wrong just because I didn’t pay attention to that.

Finger crossed! Best wishes to all step3ers.

How to manage CCS is on floor 6.


How to manage step3 CCS?

It’s hard in the beginning, kind of clueless for me. But you will be able
to get the idea pretty quickly after 5-6 cases in computer. Here’s my
thoughts how to manage it quickly and try not to miss things.

1. Differential if need urgent care.
All Chest pain, SOB, AMS, post-trauma, little infant all need to be ordered
with ER order before physical exam.
ER order mnemonic will be POC IV, ( have to poke someone for IV line)
Pulse oxygen
Oxygen
Cardiac monitor and BP monitor
IV access

Then if post-trauma: Cervical immobilization.
Chest pain: EKG
AMS: Accucheck, NPO, bedrest, head elevation.
Advance to see the SpO2, if low, ABG stat, possible need for intubation.

2. Now Physical exam, always do focus first, you can always do the left
over when you are waiting for results or response. Cardio/Lung/Abd are must
have.

3. Think of differential, order tests: U PIC BF (you pick boyfriend)
Urine: UA, urine tox
Pre-OP panel: PT/INR, PTT, T&S.
Imaging: CXR, Xray of joints, US, CT, MRI
Culture: blood, sputum, urine, wound, CSF
Blood: CBC/BMP/LFT, amylase/lipase, LDH, D-dimer depending on the case
Fluid: joint- synovial fluid, CSF, pleural, pericardial, etc

4. Treatment: what’s the treatment you need to give? Of course depending
on the presentation and findings.
The rule of thumb is “any critical care to stable the patient?” like
bronchodilator, ASA+Nitro for ACS, tPA for stroke, Heparin for thrombus,
Nitroprusside for HTN urgency. This is the most important part they want to
test on.
“treat symptom”: pain- morphine, nausea/vomit- Zofran, fever- Tylenol, etc

5. Time management: To me, this is the hardest part, you have to
consider how long the patient may need before showing response while you don
’t want move too fast to miss something. Office cases are easy, order
things, then send home and you should have all the results before next
appointment.
For ER cases, if real time allows, go slowly, advance to next available
result. Or q30min, 2 hr depending on pt’s condition. You can order vitals
as qx times, then advance to next result, so you will see all the updates.
Make sure to order interval history and focus PE or complete PE if you haven
’t done one between, which will also advance the time.

6. Counseling: SAME DOC. Fit almost everyone.
Smoking
Alcohol
Medications: side effect, adherence, etc
Exercise
Diet: low Na, low fat
Others: relaxation, sex
Car: seat belt

7. Stop: when patient improves, don’t forget to stop things, like NPO,
bedrest, and change IV to PO if possible.
And order screening test if pt not done yet, like pap smear, mammogram,
colonoscopy.

8. Good habit: when you practice, form a good habit; write down the
important information on the paper like age/sex/Chief complain/duration/
associated symptom/important PMH/social hx (for SAME counsel)/abnormal tests
/any thought during the review process. Thus you won’t miss anything.

Good luck, all step3ers!

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