docslide.us_phloston-usmle-step-2ck-experiencepdf.pdf

Hi, I’m a final-year medical/research student at the University of Queensland, Australia. I sat the USMLE Step 2CK on December 29th, 2014, and I would like to share my experience for those who may find it helpful. Just for the sake of clarity, the Australian academic year is the same as the calendar year, so I sat the 2CK at the end of my third year of medicine. The pediatric, OBGYN and critical care rotations are fourth year in my program, so I didn’t have these under my belt going into the exam. I haphazardly prepped for these externally. The preparation for this exam is much different compared to that for Step 1. There’s no single textbook that is a real trustworthy compendium. And unlike Step 1, where disease pathophysiology or the LM/EM appearance of a microorganism isn’t going to change year after year, management and screening guidelines often do change. In turn, books like First Aid (FA 2CK) and Master the Boards (MTBs 2 and 3) are not very reliable for 2CK. They’re good for merely getting you to be aware of certain things (e.g., coloboma of the eye = CHARGE syndrome), but do not memorize these texts as though their management (Mx) algorithms/Tx delineations are what you should answer on the real deal. The real 2CK questions are patient-specific stories where you have to look at the whole picture/Hx and then choose the most appropriate next step in management. This can be really annoying because whereas on the Step 1 you might look at an image and say “I objectively know that’s a picture of Aspergillus because of the 45-degree septate hyphae,” on the 2CK, the correct answer often tends to be a judgement call that is subjective. Sometimes you will need to elevate the bed, place a NG tube and give fluids (all of which may be answer choices), but which one first? “Oh, he’s unstable? Fluids. Oh no, wait, looks like he’s stable. Elevate the bed first then give the fluids.” Although obviously there can only be one answer, a lot of 2CK feels subjective, rather than objective, when arriving at a conclusion. This is why it’s a common phenomenon for people to walk out of this exam feeling pretty terrible compared to Step 1. We feel good when we have conviction in the actual answers. Many of the questions on the 2CK, however, you won’t necessarily feel as though you’re choosing the answer as much as merely eliminating unreasonable answers. “We would want the MRI, but that’s too expensive and long whereas the CT is quicker. Oh but hold on, the CT is a lot of radiation for this young kid and an ultrasound is simple to do…but CT is better than ultrasound for visualizing kidney trauma, RIGHT?” The heart of 2CK prep is practice questions, UpToDate, the Clinical Mastery Series questions (these are on the NBME website and are 50-question subject-specific exams; there are two per subject; the subjects are IM, surg, obgyn, peds, psych and neuro = 12 exams = 12 x 50 = 600

questions total), the NBMEs and free-131 (not 150 like for Step 1; you can find this on the official USMLE website). UpToDate is really really important for 2CK preparation. And chances are, if you’re still enrolled in med school, you’ve probably got a free subscription, so definitely utilize it. If ever you’re uncertain about the way something is managed, UpToDate gives you the most recent guidelines and recommendations. And it does so with definitiveness. This will save you a lot of time in the long run. You’ll also find that despite practice questions being crucial to prep, sometimes their explanations are vague or conflict with other explanations. And often times they’re not updated for several months (Kaplan is even worse; sometimes it’s years). This was even the case with UWorld. So any time something seemed equivocal, I’d just check UpToDate. Preparation for 2CK What I can say outright is this: The best preparation for Step 2CK is solid preparation for Step 1. I had heard that MTB2 was pretty good so I started with that. I went through this book and pretty much memorized it. I wrote out flashcards for each chapter and rubberbanded them into separate stacks. Once I finished the book, I typed all of the flashcards into Powerpoints. Therefore, writing the flashcards was one layer of reinforcement. Then the PPTs were the second layer. I do not recommend doing this. MTB has some sort of obsession with the best initial test versus the most diagnostic test. But the real exam doesn’t ask questions like that. The USMLE wants to know “the next best step in management,” and sometimes the most accurate test is the best initial test. As I’ve said above, the MTBs are outdated. Don’t memorize these books. Use them to gain a rough skeleton/initial idea of what topics might show up on the exam, but don’t trust any screening guidelines. In fact, had I adhered to MTB instead of UpToDate on my real exam, I would have gotten at least a couple additional question wrong. It frustrated me because I didn’t like answering questions knowing these resources conflicted, but I stayed consistent and answered everything according to UpToDate (which paid off). After I finished making the flashcards for MTB2, I went on to FA 2CK. This book unfortunately did not pack the punch and isn’t very good. I know, how can that be, right? FA was/is the current Bible/Torah/Qur’an for Step 1. But believe it: it isn’t good for 2CK. It’s basically just an ongoing agglomeration of circumlocutory paragraphs that never cut to the chase. And even worse, nothing is emphasized, so there’s no way to pick out what’s HY versus what isn’t. Like

with MTB2, I made flashcards from FA 2CK, thinking that FA 2CK must be the Torah once again. But this proved to be a waste of time as well. Don’t memorize or overly adhere to anything from this book. Gain a mere idea/sense of what topics might show up, but don’t memorize it. After I finished FA 2CK, I went on to read MTB3 (that’s right, for Step 3). I had heard on SDN that this book was good for covering certain things so I decided to just go through the whole thing. And once I started reading it, I realized the material was pretty much exactly the same as that in MTB2, but with slight differences here and there. In turn, I viewed MTB2 and 3 as one collective resource. After I went through it, I was glad I had reinforced some topics, but once again, don’t memorize any algorithms, screening guidelines, or specific Tx sequences. Merely get yourself accustomed to what tests/drugs could be involved in the Mx of certain conditions, but leave it at that. Furthermore, I do not recommend MTB2, MTB3 and FA 2CK for USMLE Step 2CK preparation apart from cursory overview / fast reading. I had also used SECRETS for 2CK, but I found the text overly vague/basic and I do not recommend this whatsoever. I know people who have aced the exam who had used this book/recommended it, but there’s no real substance to it and at no point during my exam did I feel this book helped me in any way. I read ~3/4 of it before tossing it aside out of sheer boredom/impatience. Designated prep (6 weeks) I spent the first week of my designated prep time in the Maldives, so technically I spent ~5 weeks prepping toward the end. I had haphazardly completed Rx throughout the year (random, tutor-mode, ~81% correct overall), so I started Kaplan QBank in mid-late-November. However unlike Step 1, where I had finished Kaplan QBank in its entirety, for 2CK, I did about 2300 questions before realizing that all of the questions I was getting wrong were lame tricks or minutiae, so I didn’t bother with the rest. I definitely learned a lot using Kaplan QBank for Step 1, but after I had sat the actual Step 1, it was very clear that the real USMLE questions were nothing remotely like Kaplan’s. So for 2CK, I took this as an indicator to not waste my time. Saying goodbye to Kaplan was like finally blocking the psycho ex and not looking back. The reason this proved to be extremely ironic, however, is that during my 2CK, there were two questions I got right specifically because of those 2-300 Kaplan questions I had done. I really was shocked. In other words, as much as I hated Kaplan, they got me two questions on my real deal (this was notable such that mid-exam I was like “wow, this was in Kaplan QBank”; in retrospect, I believe I may have been able to reason through one of them, but the second I know I would have gotten wrong had it not been for Kaplan). So (un)fortunately I’m going to have to say that I do recommend Kaplan QBank for 2CK.

Overall, in terms of question quality, I’d say UWorld > Rx ≈ Kaplan. Rx was definitely higher quality for Step 1 than it was for Step 2, which is why I’d say either Kaplan or Rx could be done prior to UWorld. That being said, it’s important to save UWorld for reinforcement after you’ve done a different QBank first (whether you choose Rx or Kaplan [or both], it doesn’t matter). So after jettisoning Kaplan, I went on to UWorld and completed it in random tutor-mode, usually completing two blocks of 44 questions/day. I completed the QBank at ~83% correct overall, with occasional blocks in the high-60s and others that were hundreds. I made sure I critically read HY topics such as screening guidelines and Tx algorithms (e.g., Strep pharyngitis, blunt abdominal trauma), looked at exhibits for topics I wasn’t excellent at (e.g., ophthalmology), and kept UpToDate open as a separate tab so I could frequently jump to if I needed elaboration. During the time I was going through UWorld, I would occasionally allocate a day to doing the Clinical Mastery Series exams on the NBME website (to break the monotony). I did both 50question forms for IM, surg, peds and obgyn. I didn’t do the ones for psych because that was my best subject going in, and I didn’t do the ones for neuro because it’s not even a HY topic of 2CK (and I felt fine with neuro anyway). I PrntScrned all incorrect questions from extended feedback into a PPT, with alternating slides presenting the correct answers after having researched the questions (I also did this for all NBME, clinical mastery series and free-131 Qs). After I finished UWorld I sat the UWSA (~11 days out). I completed each of the four blocks with about 10 minutes left and scored 260. Then I spent the next day reviewing the explanations for about 2 hours. I then spent the next day doing NBME 4 (~9 days out) and scored 248. When I got this result back I was half freaked out and half apathetic. I spent the next day reviewing my incorrect questions. I then did NBME 6 (~7 days out) and scored 250. Once again, half freaked out and half apathetic. I spent the 5th day out doing Free-131 and scored 93%. I had kept a small notebook of HY bottom-line statements from UW. This amounted to probably 8 pages total of my tiny handwriting. Three days before my exam, I spent ~10 hours memorizing these by converting them into Anki cards. I never actually reviewed them. But the transcription served as a single layer of reinforcement. I also reviewed UpToDate for all important things like screening guidelines, endocarditis prophylaxis, etc. In retrospect, that day having made the Anki cards and reviewing UpToDate was probably the most substantial day of my entire 2CK preparation. The next day I woke up and felt decently prepared.

I exhort spending one of the days during the final week reading the HY topics in UpToDate. This saved me on the real deal. There were some borderline questions that I didn’t have to secondguess on. I then sat NBME 7 (2 days out) and scored 260. Because this exam was fairly new, it was hard finding the answers online, but UpToDate was ultra-clutch here. The day before my exam I flew from Brisbane to Melbourne. I spent a total of probably 15 minutes on the plane reviewing my notebook of UW bottom line statements (the ones I had converted to Anki cards), then just ended my prep there. I checked in at my hotel, had an extra-cold ginger ale, watched half of Escape from Alcatraz on my laptop, went to sleep, and then sat the USMLE 2CK on the 29th of December, 2014. Exam experience I got about 7 hours of sleep the night before. My breakfast consisted of a protein drink I picked up at the 7/11 while walking to the testing centre. Because it was the 29th of December, there were only three other test-takers present that day. I was the first to arrive and they let me get started right away. My initial plan was to do the first two blocks back to back with no break (as I had done for Step 1), but I made a really stupid error early in the first block on a 3-question sequence where I couldn’t change my answer, which prompted a mandatory diet Red Bull before starting the second block. I ended up taking ~5 minutes as break time after each block. My overall consumption consisted of three diet Red Bulls, two protein bars and one high-carb protein shake, in addition to the one I had walking to the testing centre. The diet Red Bulls were spaced after blocks 1, 4 and 7. There were 350 total questions (blocks 1-6 and 8 were 44 questions; block 7 was 42 questions). I marked an average of 2-3 questions per block and finished with ~10-12 minutes left for blocks 1-4 and 8. Blocks 5-7, in contrast, were brutally tight on time because the question stems were essentially all massive paragraphs ending in “which of the following is the most appropriate next step in management?” I’m an extremely fast test-taker but these blocks literally came down to the wire with me sitting erect in my chair. The 7th block was notably difficult because it had a drug ad, a complex insulin regimen question requiring analysis and several biostats Qs that required time aside to write out the math (and especially in the 7th block, triple-checking to make sure I didn’t flake out with any calculation errors). I’ll give general breakdowns for each subject as far as what showed up on my exam. But be aware that everyone’s form is different. The following isn’t what would necessarily appear on

your exam. It’s just an example of what is possible. In terms of difficulties that I cite (i.e., easy, medium, hard, etc.), they are my objective assessment of what the questions would be for most test-takers based on what I think the % answering correctly would be. Immunology: The congenital immunodeficiency syndromes are exceedingly HY on Step 2. You will get asked at least a couple. It’s true, this is Step 1 material, but it’s still assessed. Had an easy question on X-linked agammaglobulinemia, a medium-difficulty question on NADPH oxidase deficiency (know the catalase+ organisms well; they gave a bug that was not common here), a question on Wiskott-Aldrich syndrome, a question Dx an image of thymoma, a physio question relating congenital heart disease to an immune disorder, but they wrote lots of clinical jargon in the vignette and you had to pick the cardiovascular changes that were reflective; question on transfusion-related lung injury; question on ABO mismatch; one easy question on influenza vaccination; easy question on pneumococcal vaccination; question on immunodeficiency due to nephrotic syndrome; question on HIV in pregnancy (having read UpToDate a few days before my exam saved me here because MTB2 was wrong and said the exact opposite; make sure you know HIV in pregnancy cold going into the real deal); a couple on next step in Mx of asthma and COPD; difficult question about picking the mechanism of disease in a patient, where four of the answers made absolutely no sense, but the fifth would have equated to a very bizarre presentation of Addison disease (basically you had to realize that autoimmune conditions go together, so a patient with a propensity toward autoimmune phenomena can have concurrent Sx from more than one autoimmune disorder); question on seafood allergy. Micro: Had about 5 questions where I had to pick the organism as the answer. One was on picking Group B Strep and was so absurdly simple that I had to reread it to make sure there wasn’t some sort of catch; one super-easy question on the endocarditis organism in a patient with congenital heart disease; two easy questions that relied on identifying the image of a fungus (one wanted the organism but the other was picking the Tx based on the picture); one question that involved picking the organism looking at a picture of tinea capitis, but the answer was the only fungus listed (felt cheated here); question asking the Tx for golden Staph infection; one easy question on Dx PID then picking the likely organism; clever question on Dx vaginal candidiasis then picking the most likely risk factor; fungal infection question that required you knew the staining method to get it right. Biostats/Ethics: Biostats was actually really heavy on my exam. One block I think may have had four questions. I had THREE that were calculating number needed to treat (one was the first of three questions in a drug ad) and THREE on attributable risk. It occurred to me that this is probably the “clinical” aspect of biostats that they wanted to emphasize on 2CK, versus Step 1 where most of the Qs are basic sensitivity, specificity, etc. Whereas some questions were just

picking out the number, many were about drawing a conclusion based on a study. For instance, on Step 1, they might ask in a path question simply “what’s the diagnosis?” Whereas on 2CK, it’s implied that you can get the Dx, but then they want the Mx. Well it’s kind of the same for biostats. It’s somewhat implied that you know how to calculate NNT, NPV, etc., but then you need to be able to apply that information to a study/clinical scenario (e.g., “two hospitals are doing this and that, what conclusion can be drawn?”). Had two easy questions on what would happen to sensitivity/specificity if you changed the cutoff point for a study. Had one question where you had to calculate both specificity and PPV, where the answers were two different %s that you had to choose from; one on generalizability, one on selection bias, one on confidence interval in relation to precision. There was only one biostats question that I’m not sure whether I got right. I was able to pull the conclusion from the vignette, but it was borderline/subjective as to whether no conclusion could be drawn based on the low-medium power of the study; in the end, I tried not to over-think it and just went with the conclusion I drew from the scenario. Behavioral/ethics: One question on how to respond politely to a patient about something; one minutia question on the role of parental consent for a minor participating in a research study; question on HIV and MSM; tough question regarding motives for ending ventilator care that I basically had to guess on (and no, this wasn’t the standard withdrawal = withholding scenario). Safety science: Had two questions in this category and got them both wrong. I don’t really know what to say. One of them was on hand washing, which makes me feel like a bogan. In general, hand washing is always the answer if it’s listed as an answer choice to any question. But this particular vignette threw a curveball in that the disease you had to Dx isn’t really transmitted like that. Either way, I knew going into the exam I’d likely over-think at least one easy question, and this was that question on my form. The second safety science question was about limb marking in wrong limb surgery. I don’t really consider this a surgery question; it was more just a question about safety protocols. Psych: I had tons of psych on my exam. This was my strongest subject going in but some of the questions were long and ambiguous. Had lots of questions on depression presented in different ways, brief psychotic disorder, schizotypal, bipolar disorder, borderline, avoidant, OCPD, GAD, panic disorder, malingering, fibromyalgia, delusional disorder, panic disorder; question on benzo toxicity, question on inhalant toxicity; a few questions on delirium tremens/WKS; question on marijuana addiction; question on presentation of child abuse; couple questions on heroin toxicity; straightforward question on PANDAS (i.e., if you knew what that is); tricky question on electrolyte derangement in anorexia; question on refeeding syndrome in a patient with a normal BMI; tricky question needing to differentiate between schizoaffective disorder and depression with psychotic Sx; question on depression secondary to

a general medical disorder; two questions on pseudodementia; question on neuroleptic malignant syndrome. Neuro: toughest subject on my exam, but it was fair. This was definitely a step up from Step 1 in terms of difficulty in that they really made sure you knew your presentations; question on supranuclear palsy (if you knew the basic presentation this was easy; you’ll find that for “obscure” conditions they always give classic presentations); really hard question on normal pressure hydrocephalus that did not present with the classic triad and instead had a few other odd findings that could have been mistaken for a different condition (I would exhort reading up on how this can present; Wiki is fine for this); recondite brain image question where I basically had to conjecture that I was looking at an oncogenic process; brain image question on diffuse axonal injury; question on transverse myelitis; tough question on botulism (know the possible presentations of this!); question on ALS; question on myasthenia gravis; question on LambertEaton syndrome secondary to small cell; question on Guillain-Barre; question on Meniere disease; tough question on hearing loss where you had to identify the location of a neurosensory lesion based on the Rinne and Weber tests, but the locations they gave were hyper-specific (make sure you know the neurosensory pathway for hearing and at what level things decussate, etc.); very clever question on restless leg syndrome (I was impressed with how they asked this question; know how this disease works and how to Tx it); question on idiopathic intracranial hypertension; question on congenital TORCHeS syndrome w/ intracranial findings; easy question on Tx of Alzheimer disease; basic question on optic neuritis; question about preventing amaurosis fugax (know which meds to give a patient based on his or her risk factors); a crapload of questions on lower back pain (know your presentations!); one hard question on B12 deficiency where the pattern of neurological dysfunction was nothing I had ever seen before, but I was certain none of the other answers could have been correct, so I just went with the answer that seemed least asinine; question on hypomagnesemia; question on tuberous sclerosis; question on NF1; question on cerebellar lesion. Ophthalmology: question making sure you could differentiate between two conditions on fundoscopy (it was an ambiguous vignette so you needed to know what you were looking at straight-up; even if you knew the verbal descriptions, that wasn’t good enough; my advice is to not ignore the exhibits in the explanations in UWorld; I got this question right only because I had remembered the UWorld image); question on glaucoma, question on macular degeneration (know how vision appears with this condition; I got this right because of UWorld). Nothing on hordeolum/chalazion/orbital/preseptal cellulitis or anything like that. Dermatology: two questions on Tx/Mx of melanoma (pretty much the same question repeated); tough question on identifying a skin lesion with absolutely no vignette (what made it hard is that it didn’t fit the classic verbal descriptions and was a total toss-up; even location

didn’t help; my advice is to look at images of BCCs and SCCs and really pin down the different ways they can look); easy question on identifying herpes zoster; very clever question on Lyme disease (i.e., the appearance was not classic; it’s my impression the USMLE is trying to do it’s best to steer away from classic review book descriptions); question on toxic epidermal necrolysis; easy question describing erythema nodosum (know what it’s associated with); question on strawberry hemangioma; question on pellagra. MSK/Rheum: Several questions on rheumatoid and osteoarthritis; question on septic arthritis; question on gouty arthritis; couple of questions on SLE; question on Marfan syndrome; question on bone cysts (make sure you know the different types!); two questions on congenital hip dysplasia; question on Legg-Calve-Perthes disease; question on slipped capital femoral epiphysis; question on polymyositis; question on dermatomyositis; question asking about recovery in leg trauma; question identifying the type of knee injury; question on identifying the type of shoulder injury; question on Becker muscular dystrophy; question on Paget disease; two questions on hernias, where one was basic but the next was a WTF question where they listed like 12 different obscure eponymous hernias as answers (I narrowed it down to two but ultimately guessed and got it wrong). Cardio: question on venous ulcer; question on stasis dermatitis; question on vasovagal syncope; three heart sound questions; two questions on rheumatic fever; two endocarditis prophylaxis questions; two physiology questions comparing oxygen sats at different locations and you had to deduce the pathologies; question on CHADS2 score; question on Dx of atrial thrombus; question on Dx of carotid stenosis; question on Mx of carotid stenosis; question on reducing risk factors in diabetes; dirty question on renin/aldosterone that I found hard (and this is probably one of the most basic concepts in medicine; basically everything you know about renin and aldosterone you can defenestrate); question on Kawasaki disease; question Dx congenital heart disorder; question where you needed to make a conclusion in a physiological sense based on clinical findings; three questions where you had to make a Dx based on an ECG strip (this wasn’t bad, don’t worry; I get paranoid about this stuff; question on Eisenmenger syndrome; question on aortic coarctation; question on fetal alcohol syndrome; question on aortic dissection; question on mesenteric ischemia; two questions on tamponade; question on traumatic aortic rupture; question on pericarditis; a few questions on cardiomyopathies; question on Wegener; question on HSP; question on calcium channel blockers; question on statins; question on SVC syndrome; question on vascular rings (easy if you were ready for it). Pulm: question on obstructive sleep apnea; question on emphysema, question on chronic bronchitis; question on croup; question on bronchiolitis; question on home oxygen and COPD; a few questions on pneumothoraces; question where you had to Dx improper NG tube placement; question on asthma; various questions on different lung cancers and neoplastic

syndromes (the USMLE is obsessed with the physio in these types of questions); couple of questions on ARDS (know the causes and how this type of stuff relates to PCWP); question on NRDS; question on basic V/Q mismatch; couple of questions on pulmonary embolism; question on fat embolism; question on bronchiectasis; question on cystic fibrosis; two questions on foreign body aspiration; question on pneumoconiosis; question on cor pulmonale; question on pleural effusion; two questions on pneumonia; two questions on pulmonary edema (including one during pregnancy, so know the causes/management for that); question on mediastinitis; question on PEEP settings. GIT: tough question on esophageal cancer (really think about how this would present in a GIT sense relative to other DDx); question on achalasia; question on diffuse esophageal spasm; question on esophagitis; question on varices; question on Boerhaave; question on Zenker diverticulum; question on Meckel diverticulum; question on Barrett; question on GERD; question on gastric bypass surgery (really understand the post-surgical management and adverse possibilities); a Step 1-type question on H. pylori mechanisms; question on Schilling test; very tough question differentiating lactase deficiency from Celiac disease; question on hemochromatosis; question on mesenteric ischemia; question on diverticulitis; question on cholecystectomy; question on cholecystitis; question on choledocholithiasis; question on pancreatitis; various questions on IBD; question on IBS; question on splenic injury; question on hiatal hernia; couple of questions on scleroderma; question on NSAIDs and GI bleeding; question on Hirschsprung; question on intussusception in an adult; question on adhesions and SBO; couple of questions on colon cancer screening; question on colonic polyp Mx; couple of questions on hepatitis; question on hepatic encephalopathy; question on spontaneous bacterial peritonitis; question on Gilbert. Heme: Question on thalassemia; question on vWD; hard question on acquired VIII deficiency in a patient with an ambiguous presentation; one on Tx of sepsis in sickle cell; at least 4-5 questions integrating concepts of sepsis in general (the 2CK is absolutely obsessed with sepsis); a few questions integrating concepts of different types of shock; one on sideroblastic anemia, one on anemia of chronic disease, one question on macrocytosis secondary to alcoholism; question on TTP, question on ITP; question on agranulocytosis secondary to a drug; question on warfarin bleeding diathesis secondary to P-450 inhibition caused by second drug; minutia biochemistry question on methemoglobinemia regarding a detail I had never encountered before (biochemistry was my strongest subject going into Step 1 and I had to guess the answer to this question). OBGYN/andrology: Question on SERMs; question on Pap smear Mx; question on leiomyoma; question on fibroadenoma; question on Leydig-Sertoli cell tumor; two on breast lesion Mx; question protective factors against ovarian cancer; question on hydrocele; question on

testicular cancer; strange question on penile HSV with a presentation that was somewhat nebulous; question on vitamins and pregnancy; question on mastitis; question on twin-twin transfusion syndrome; absolute BS question on diabetes and pregnancy that made absolutely no sense grammatically (i.e., I didn’t know if they were asking about the fetus or mom, and I’m pretty sure I got it wrong as a result); several questions regarding pregnancy Mx (e.g., pelvic ultrasounds, non-stress tests, decelerations, tocolysis, etc.); question on cord blood sampling; question on androgen insensitivity syndrome; one on hematocolpos; one on primary dysmenorrhea; one on endometriosis; couple of questions on contraceptive methods; one on BPH; question on prostate cancer; one on PID; one on premature ovarian failure; one on vasomotor Sx; question on Klinefelter; question on Turner; question on choriocarcinoma; question on hydatidiform mole; couple of questions on preeclampsia and HELLP syndrome; one on abruption placentae; one on placenta previa; one on ectopic pregnancy; couple of questions on anovulation/PCOS; question on ovarian cyst (know the different types and how to Tx them!); question on peripheral edema in pregnancy. Peds: question on bronchiolitis; question on PANDAS; strange question on Sturge-Weber syndrome; question on strawberry hemangioma; question on vascular rings; question on child abuse; question on constitutional growth delay; one on adolescent substance abuse; one on Down syndrome; one on rickets; a few questions on sickle cell; one on otitis media; one on cerebral palsy; one on ALL; one on infant of diabetic mother; one on juvenile idiopathic arthritis; one on lead toxicity; one on PSGN; one on meningitis; one on acne vulgaris; one on ADHD; one on Osgood-Schlatter; one on torticollis; one on Kawasaki; two questions on foreign body aspiration; one on neonatal jaundice; know what PHACES syndrome is. Renal/GU: question on nephrectomy; question on Beckwith-Wiedemann syndrome; one on pyelonephritis, one on asymptomatic bacteriuria; one on ureteric stones; one on basic ACEi physio in relation to the kidneys; various questions on diuretics and drugs acting on the kidney; question on NSAIDs and the kidneys; a few questions on acidosis/alkalosis-related stuff; one on diffuse proliferative glomerulonephritis; one on PSGN; one on tubulointerstitial nephritis; one on acute tubular necrosis; one on dialysis; question on renal tubular necrosis; question on bladder cancer; question on urethral injury; couple of questions on UTIs; question on pre-renal azotemia; question on post-renal azotemia. Endocrine: plenty of questions integrating concepts of ADH (i.e., SIADH, DI), aldosterone, PTH, T3/T4, LH/FSH, prolactin, cortisol (pretty much all hormones you can think of, they showed up); lots of questions integrating diabetes mellitus. Endocrine was pretty much the easiest subject on the exam because it was most heavily tied into physio, which felt a lot like Step 1 stuff. I felt pretty blasted upon finishing the exam – way more tired than after I had finished Step 1. I knew of three questions I got wrong before even leaving the testing centre. I really had no idea

whatsoever where I fell in terms of score because the entire exam felt so subjective. Well anyway, so I just got the score back today (on my birthday): USMLE Step 1: 262 USMLE Step 2CK: 260 I feel fine about this outcome. I hadn’t felt nearly as prepared going in as I had for Step 1, so I wouldn’t have been surprised if I had tanked it somehow. I was expecting anything between 240 and 270, so I can’t complain about a 260 since NBME 7 two days before matched that. So I don’t really think there’s anything more to say about that. It is what it is. Study resources Internal medicine: I own Step-Up to Medicine. This is an internal medicine book, not a comprehensive USMLE book. I had heard this was really good for the USMLE, but quite honestly, it’s really dense with text. If you’re the type who likes to read endless text, feel free. This book didn’t help me though. I looked at it maybe five times randomly for no more than two minutes. I personally learn better through tables, diagrams, flow charts and questions, not ongoing, superfluous text. I found having studied hard for Step 1 was sufficient to cover internal medicine for 2CK. Bottom line is: practice questions are sufficient for IM for 2CK. But if you want a text for this subject, Step-Up to Medicine is probably the best compendium you can get. There are two 50question internal medicine Clinical Mastery Series blocks on the NBME website. Make sure you do those. Surgery: I found Pestana’s Surgery Notes to be good while I was on my surgery rotation. This book is super-short, so even if you are somewhat close to your 2CK and need a quick surgery review, this will do the trick. It has 180 (or so) questions in the back of the book, which I went through first and then went back and read the corresponding areas from the text. I’d consider Pestana’s notes to be sufficient for fast surgery review, but it’s not essential so don’t lose sleep over it. I own Case Files Surgery as well and went through about ten of the cases, but it wasn’t concise enough for USMLE purposes so I jettisoned it. And especially regarding topics like breast cancer, the information was vague and desultory. This book is OK to use during your clinical rotation, but I’d choose Pestana’s over this one.

Most of my surgery I probably learned through practice questions and UpToDate. If I got a surgery question that I wanted a little bit more elaboration on, I’d just reference UpToDate, which was always very helpful. Bottom line: practice questions and UpToDate are the core elements of surgery prep. Pestana’s is a good review but not essential. I do not recommend going through a tome. That might help for a surgery rotation, but not for the USMLE. There are two 50-question surgery Clinical Mastery Series blocks on the NBME website. These questions were just like the ones on my USMLE. Think of studying for surgery like studying for anatomy for the Step 1 – there’s a million things we could possibly know but consolidation is key. Psychiatry: Case Files Psychiatry was solid for this subject. I would read this on public trans to and from the hospital during my rotation and learned/reviewed quite a bit from it. It also helped me clarify some things that I had been confused about for a while. I did find a couple errors in it, but they don’t undermine the value that the rest of the text has to offer. I have a friend who strongly recommended FA Psychiatry (and the reviews on Amazon are really good), but I personally did not read this because I found Case Files to be good enough. Bottom line: practice questions and Case Files are all you need for psychiatry. FA Psychiatry is an alternative to Case Files that has received strong reviews. There are two 50-question psychiatry Clinical Mastery Series blocks on the NBME website; I assume these are just as valuable as the internal med and surgery ones, but I did not complete these because psych was my best subject going in and I didn’t feel I needed to review it anymore. Pediatrics and OBGYN: Two different rotations, but I’m grouping them together here because I prepped for them the same way. As I said earlier, I sat my 2CK not having undertaken these rotations, so these were the two subjects I was most paranoid about. I found the combination of MTB2 and MTB3 to present a decent introduction to these topics, but these two texts alone are not nearly sufficient for the 2CK. If you already own these texts, the combination of them can be a decent opener if you have absolutely no background in peds/OBGYN, but if you don’t already own these, they’re not necessary. The way I learned the vast majority of my peds and OBGYN was through practice questions (including the Clinical Mastery Series) and UpToDate.

Case Files Pediatrics and Case Files Obstetrics and Gynecology were solid, but I only went through about one-third of each. I really liked them but just didn’t have enough time to finish them. On my real USMLE 2CK, I felt I was able to handle the peds and OBGYN questions just fine. I had encountered two very obscure peds questions, but it’s tough to say if any resource/rotation would have even covered these. I had heard UWise (that’s right, UWise, not UWorld) questions were good for OBGYN, so I did the free 10-question sampler and really liked it (granted only n=10), but I didn’t end up using UWise because I didn’t have enough time. Bottom line: practice questions and Case Files is the way to go for peds and OBGYN. If you own MTB2/3, the combination of these provides a good intro to peds/OBGYN but is not essential. UpToDate is ideal for learning more after going through QBank explanations. And 100% make sure you do the Clinical Mastery Series questions; these were very similar to the actual 2CK questions. UWise is known to provide a strong QBank of OBGYN questions for those who want extra help in this subject. Critical Care/Emergency Medicine: Critical care/emergency medicine is exceedingly HY for 2CK. This was really frustrating actually because no one I had spoken to beforehand about the 2CK had ever mentioned this subject as being core to the exam. And furthermore, even standard threads on SDN never emphasized this subject; you always see people freaking out about surgery or peds, etc., but emergency medicine is possibly the highest yield subject on 2CK. That being said, I had no idea this subject was so HY until I got to UWorld and it seemed like every 6th question was “guy comes in after a MVA with BP of 90/60, RR30, HR120, etc. Here’s his chext x-ray.” And the real deal was similar. At least every 10th question on my real deal was emergency medicine. In turn, the only preparation I did was practice questions and UpToDate. That was it. Even FA 2CK, MTB2 and MTB3 don’t really touch upon critical care. Bottom line: Fortunately these questions on 2CK are largely problem-solving/intuition-based, so practice questions + UTD are enough. Just make sure you know how to manage common cardiopulm pathologies and can interpret basic CXRs. Biostats / ethics: I didn’t study this subject for the 2CK. As long as you adequately covered this stuff for Step 1, doing lots of 2CK practice questions will more than sufficiently cover your bases here. Question and answer

Q: So everyone feels like that, good to know I guess lol :/. Do you think the NBME's are worth it? I was planning on doing all of them and UWSA1 before I go in for the real thing. I noticed that you only did the UWSA. A: I think it is wise to do the NBMEs. They are the USMLE. Q: Phloston, what you think helped you the most throughout your preparation? You still think UW & uptodate and NBME? A: Yeah. UW, UpToDate, the NBMEs, the clinical mastery series and Free-131 were the staple. I'm mixed about the MTBs. On my real 2CK yesterday, had I adhered to MTB, I would have answered at least one question incorrectly. For instance, they had an HIV(+) pregnant woman with a normal CD4 count; MTB says initiate ART if CD4>> Kaplan notes for obgyn. The only thing that's going to get you points on the exam is questions. There's a big difference between reading stuff and actually applying it. Obgyn is one of those areas where questions are hardcore key. And make sure you’re using UpToDate to clarify the details if you aren’t already. Q: In terms of knowing peds vaccines, do you think knowing how far apart they're spaced is important? Tbh, that's where I struggle the most with those vaccines. I'll know them the scheduling and then forget it a few days later.

A: Yeah, knowing the spacing/timing of the peds vaccines is very important. I found it was easier to memorize certain time points (e.g., "what do I give at 2, 4 and 6 months?") as opposed to memorizing the separate timings for a single type of vaccine (e.g., "when are all of the times that I give pneumococcal?"). I'd say the yield of this stuff for 2CK would be the equivalent of the embryo (e.g., aortic arch derivatives, clefts, arches, pouches, etc.) for Step 1. That is, they could easily tell you what a 12-month-old's vaccination Hx is and then ask what he needs to be given now. I just think you'd end up kicking yourself if you were posed with a straightforward question on this and couldn't quite remember. There are enough nebulous questions on the 2CK that it's actually a relief if you can just say "wow, I know there's a clear-cut answer here." I didn’t have any peds vaccines questions on my exam, but I just got lucky because I hated that stuff too. Q: How were the AIDS/HIV on your exam? Should I be very specific about CD4 counts in my preparation? A: And yeah, MTB2 would have ****** me on the real deal because IIRC, it says something like you only give HAART in pregnancy if the CD4 is