Dr. SHS. adult neurologist, Step 1 - 261 Step 2 - 266.So I will start with the very basics. This is a very basic guide for anyone who wants to pursue medical training in the US and wants to have some idea about the USMLE. For others, you may skip this part if you are already done with your USMLE exams.
What is USMLE?
USMLE stands for “United States Medical Licensing Examination”. It is a 3-step examination process, which every doctor or a medical student has to take if he or she wants to practice medicine in the US.
The first exam is Step 1. It is a one-day multiple choice question-based exam about basic non-clinical subjects that include anatomy, physiology, biochemistry, genetics, pharmacology, pathology, and biostatics. How long is step 1 exam? Step 1 exam is divided into 7 blocks consisting of one hour each, 45 minutes of break time, and 15 minutes of optional tutorial, so a total duration of 8 hours. It is conducted at Prometric centers in various countries. You do not need to travel to the US for this exam, which is a great news for IMGs. Since the step 1 exam comprises the basic subjects, it is often considered the toughest of all the USMLE examinations.
The second exam is step 2. It used to be divided into two parts, Clinical Knowledge (CK) and Clinical Skills (CS). Previously, for Step 2 CS, one had to travel to the US as the exam was not conducted outside the US. Due to pandemic, instead of Step 2 CS, a satisfactory score on the Occupational English Test (OET) Medicine will temporarily suffice.
Step 2 CK is also a one-day exam, similar to step 1 but it is about the clinical subjects. It is divided into 8 blocks consisting of one hour each with one hour of break time and an optional tutorial, so a total duration of 9 hours. It is conducted at Prometric centers in various countries. You do not need to travel to the US for this exam. Most of the IMGs find this examination easy and get good scores, in comparison to step 1.
You may give Step 2 CK after USMLE step 1 or before Step 1, it depends upon you. There is no obligation to do Step 1 first. After passing these exams, one gets ECFMG certification. This ECFMG certification is important in applying for residency in the US.
Why one should do USMLE prep?
This is a fundamental question that everyone pursuing training in the US should ask themselves. Why do they want to go towards the USMLE STEPs pathway? You should be honest with yourself. You are the one who has to go through all the struggles. Some of the following points will help you in deciding.
Some of the Reasons for training in the US:
The training in the US is one of the best in the world. You get exposure to one of the best healthcare systems in the world. You work in great hospitals with globally renowned experts. You learn new techniques, which are not available in your country. There are so many opportunities for your career to grow. Research opportunities are endless if you are interested. Work and life balance are better than most of our developing countries. Pay is good, especially after you finish your training. You may always come back and serve your people and make great healthcare facilities in your home country if you are not inclined to settle in the US permanently.
But all good things come at a price.
1. The USMLE Step examinations are tough but doable. I have done it. Most of the people pass them and you will also pass them, there is no doubt about it, but it will require focus, determination, and hard work. For the preparation for each examination, you may have to stay in your study rooms or libraries, for say 4 to 6 months, at least. You may not be doing any job because, with a job, it will take more time to prepare. Program directors often think that IMGs must have high scores because graduates have opportunities to prepare well.
Your colleagues may go on with their postgraduate training in your country, they might have started earning, and you are only sitting in the library or your rooms studying, so it may make you feel a bit low at times, which is common and understandable. Remember, “Patience is bitter, but bears a sweet fruit.”
2. USMLE step 1 cost for IMG can be quite expensive. The current Step 1 exam fee at the time of writing is $985 + International test delivery surcharge applies if you are taking the exam outside US and Canada in your own country. This surcharge is about 180$, so a total of about $1165. These prices do change and you should review the official website for the current prices. The current exam fees for step 2 CK is also $985 + $200 of International test delivery surcharge will apply if you are taking the test outside US and Canada, making a total of $1185. So the exam fees of two exams will cost you $2350. Further, the cost of ECFMG registration, costs of study books and materials, online question banks and assessments, etc. will make the total go beyond $3000. This is quite a handful sum of money, which is many times difficult for students to arrange, especially in the developing countries.
3. For the training in the US, you may have to be away from your family, your parents, siblings, and friends. You may change your marriage plans. These things also have to be looked for. Please discuss with your families all these things so that you all may be on the same page before going forward with this journey.
4. It is possible that you may not get the specialty of your choice. In the US, it is comparatively difficult to get the residency spots in surgical specialties say orthopedics, plastic surgery, or neurosurgery as compared to internal medicine, family medicine, psychiatry, pediatrics, or neurology. Some of my friends have matched into the surgical programs, so it is not impossible, but this is something you may need to consider and worth keeping in your mind.
5. What are your plans after your residency in the US? Will you like to continue living in the US? Will you move back to your own country? Will you move to some other country? If you are coming back to your own country, what will be your options? Which hospitals will accommodate you? These questions and plans are important and you should consider them before deciding to pursue the USMLE pathway. It is also possible that if you do the training in the US and come back to your country, your options may become limited as only a few of the hospitals may be good enough to accommodate you but again it varies. In my personal opinion, the best advantage for doing USMLE is for those people who want to work and settle in the US after their residency training. They will have a great work and life balance, great income, security, and expertise. For the rest, the decision individualizes and they need to consider before jumping on the USMLE pathway just due to peer pressure. This peer pressure is common, which not many people realize at that time. Since everyone is preparing for the USMLE exams, you start without considering all these facts.
USMLE step 1 application process for IMG
Since you have made up your mind to pursue the USMLE pathway after considering all these things. Now let me help you in achieving your dreams of getting a residency in the US.
I will start with some of the basics and how to register yourself for the ECFMG.
ECFMG stands for “Educational Commission for Foreign Medical Graduates”. It is a primary source verification body for the verification of credentials of IMGs, as well as making sure that the IMGs meet the minimum criteria required for medical training in the US, also provides status report about USMLE exam for foreign doctors. Our primary medical qualification (medical degree) has to be verified. You need to make sure that your medical school is listed in the world directory of medical schools as ECFMG eligable.
If your school is included in the world directory of medical schools with proper notes, now you need to register with the ECFMG. The process usually starts with making an account on ECFMG. Go to the ECFMG website and then to IWA (Interactive web applications) page. You will make a new account by putting all your details, your medical details, date of graduation, and uploading a passport size picture. It is advised to keep your passport with you so that you enter all the correct details. After 2-5 working days, you will get an email from ECFMG with your username and password. And you can access your account. It will cost you $160. Read the complete list of ECFMG fees. After filling all the details online, you need to download a Certification of Identification Form (Form 186) from your ECFMG account and get it signed either by a solicitor or an oath commissioner. This form will confirm your identity (that you are the same person who made the account on ECFMG). You have to upload this form to your ECFMG account and after 2 to 5 working days, you will receive an email from ECFMG telling you that your account is fully authorized. If you have completed your graduation, you also have to upload your medical degree or medical diploma. Check required medical degree for ECFMG Certification.
ECFMG will then send the documents to your medical school for verification. These documents have to be signed by either the Dean or Principal of your medical school. The documents are then sent back to ECFMG. It takes around 15 working days for ECFMG to confirm your verification after receiving the documents. This part may be tricky for some. You need to follow the process so that your documents are timely verified and sent by your medical school. I had to do this on my own since the staff in my medical school was either too lazy or too uninterested. In short, the whole ECFMG registration and verification process usually takes an immense amount of effort, patience, and time. Therefore, it is advisable to start the process while you are still in your home country, especially in a city where your medical school is.
USMLE exam eligibility
After two years in medical school and ECFMG registration you will become eligible for USMLE examination.
How to register for USMLE step 1?
After the ECFMG registration, you have to fill out the application form for USMLE step 1 registration. You have to pay an online fee of $1165, if you are appearing at the Prometric center of your country, outside the US or Canada. You can pay this fee online from your debit or credit card. I faced one issue that the limit of my debit card was not enough to pay the whole exam fee together. So I deposit the fees in three installments. There is an option on the ECFMG website where you can deposit the fee in installments and all the amount will be saved in your account. You can pay the fee afterward when you have got enough amount deposited. For example, you may deposit the fee in installments like $400, $400, and $365; making the total between $1165. Now you pay them to apply for the exam. I thought to highlight this point because I was quite confused at my time and many IMGs might feel the same problem during paying the fee. During the registration for step 1, you are asked to select a three-month period in which you are expected to appear in the examination. Please select the months as per your preparation and timeline. Suppose you want to appear in January, then select a three-month period from January to March, so that if you feel you are not fully prepared in January, you still have two more months to appear in the examination. If even at the end of the third month, say March in this example, you are not confident enough to appear in the examination, you can extend your three-month period. However USMLE rescheduling fee will be taken (100$ if 6-30 days before, 328$ if 5 or fewer days). This extension is allowed for one time only. Therefore, it is really important to select your three-month period appropriately on sign up for USMLE.
Previously, when I gave the exam, a three-digit score was given for Step 1. Most of the IMGs used to take their time to prepare. Some of my batchmates took more than a year of full-time preparation to get good scores. Recently ECFMG has stopped issuing the scores and they only report the result of step 1 as pass or fail. This change in reporting has its pros and cons. Now, the stress of getting a high Step 1 score is lessened and a lot of preparation time will be saved. The disadvantage is that previously by securing high scores (above national average) in step 1 and step 2 CK, the IMGs used to get an advantage over their US counterparts in showing their adequate medical knowledge in the CVs. Now this advantage will be lost during the US residency application. The other factors will be of paramount importance in the US residency application, such as US clinical experience (observerships, externships, electives), extracurricular activities, research publications, as well as the time since graduation.
USMLE Step 1 preparation
During my USMLE test preparation, I kept things very simple and I also advise you the same.
It took me around 6 months for the preparation.
During the first two months, I read all the Kaplan series books.
The Kaplan series was good, except for the Pathology.
I thought a lot of stuff in the pathology was missing. Students used to read pathology from Pathoma, Board Review Series (BRS), or Rapid Review Pathology by Edward Goljan. You may read any of them, they all are excellent books. I went through BRS one, most of my colleagues read Pathoma. I listened to videos of some subjects, particularly biostatistics, genetics, and some of the physiology lectures related to the cardiovascular system. These were some of the topics and subjects, I felt I was not good at during the early stage of my preparation. Nowadays many students read Board and Beyond instead of the Kaplan series and this is fine. I have not read Board and Beyond but I have heard good reviews.
The most important advice that I would like to emphasize at this point is that for the USMLE examinations, you must understand and clear your basic concepts. These exams are not about testing memory, or how well you may recall things. These examinations are about the basic concepts and the practical application of these concepts. So please clear your concepts. There will always be some topics, which you are not good at. You have to read these topics from any resource you may find to make your concepts stronger. You may go through these selected topics from the textbooks, you may browse through the internet, using PubMed, you may watch videos, take help of a colleague or a senior. The bottom line is “clear your concepts”. You cannot leave any topic as this might be the one tested on your examination.
After the first read of all the Kaplan books, I went through a fast revision of all books within the next three weeks. This time I also read First Aid along with the Kaplan books. Suppose, I did a chapter from Kaplan, I read the same chapter from First Aid quickly. Usually, the points in First Aid are summarised and it doesn't take much time to read. If anything was missing from First Aid, I used to annotate. Because I wanted to read First Aid just before the real examination because this was the only book that I can revise quickly.
Afterward, I started Uworld online question bank. I used to do random mode, timed questions, so to get practice for the real examination. Daily, I used to do one and half blocks along with the explanations. The Uworld explanations are awesome and these are the best in the world. You will clear your exam because of these explanations. You should concentrate on every line, every point is important.
Again, I annotated the important points on First Aid from Uworld. The Uworld images are also beautiful and easy to understand. I used to take photos of these images on my cellphone. I used to go through these pictures at least once daily whenever I had some free time when I was watching TV or sitting idle. In the beginning, when I started Uworld question bank, my correct answer percentage was quite low but it improved with time. I completed my Uworld question bank in around 2 months. Then I quickly revised the First Aid book in one week. I gave online NBME assessments and got good scores, which increased my confidence. These NBME assessment scores correctly predicted my real examination scores. I went through a last quick read of First Aid in 3 days before appearing in the real examination.
One day before the examination, I was particularly stressed which is understandable. I closed my books around noon. I went out for a short walk, came back, watched a comedy movie, and got relaxed. I had dinner around 8 pm and went to sleep around 10 o'clock. I will like to add that during my preparation, my sleep schedule was very much haphazard. I used to study till late at night and wake up late in the morning. About two weeks preceding my exam, I adjusted my routine back. I started sleeping early and started waking up early in the morning. I believe this helped me to sleep the night before the exam. I will advise all to please kindly adjust your schedule at least one to two weeks before the exam to avoid pre-exam insomnia. My second piece of advice is to please try to be relaxed one day before the examination. Do not study. You have done all the hard work and have prepared well. Trust yourself, you will ace it.
USMLE STEP 1 Examination Day
I woke up early and reached the Prometric center about half an hour before my scheduled time.
I brought with me my passport, sandwich, chocolates, tea, and paracetamol.
I kept all my things in my locker, whose keys they gave. Please bring some tea or coffee if you like or energy drinks maybe and something to eat but not carbohydrate-rich otherwise the high carbohydrate diet may cause you dizzy.
I went through my block one by one, I skipped the 15 minutes tutorial.
I had two breaks, one of 35 minutes after block no. 4, and the other break was of around 25 minutes after the seventh block.
During my last block, I was very tired and I just wanted the examination to end. During the exam, they bombard you with all these questions with long question stems that after the examination, you will be blank. I was unable to comprehend what I did, whether I did it correctly or not, but I was relieved that the exam ended. After the exam, I met my friends and we went shopping and sightseeing. After about three weeks, I got my result and my score was 261. I could not believe it, and I was extremely happy.
Some of my friends wrote the questions after the exam and they used to check their answers. This created immense anxiety among them. I request all of you to please avoid this practice. Everybody makes mistakes in the exam. By checking and recalling, you will only stress yourself. You are not going to change the answers anyway, so try to relax, enjoy the moment, and hope for the very best.
USMLE Step 2 CK preparation
For this examination, the basic idea is very much the same, “clear your concepts”. The examination is not to test your memory, but it tests your concepts and how you apply these concepts in different situations. You may select a book series, which you will read as your primary source but you have to clear all your concepts by hook or by crook. Use your internet, textbooks, research articles, take help from your colleagues or your seniors, take whatever it may but you clear your concepts. Period. I prepared for step 2 CK in four months. I read Kaplan's book series for step 2 CK in six weeks. The medicine book of the Kaplan series is excellent and covers almost all the topics very elaborately. The surgery book is smaller but it's enough for the examination. After completing the first read from Kaplan, I read Master the Boards (MTB) book for step 2 CK. I completed it in two weeks. I kept MTB as my main go-to book, where I made all the necessary annotations because MTB can be easily revised in 3-4 days, which you need before appearing the examination. Afterward, I did Uworld question bank online. Similar to the USMLE Step 1 preparation, I did the Uworld in a random-mode and timed way to get the feeling of the real examination. I completed the Uworld in about 6 weeks. Uworld explanations are the best. Your concepts will become solid by reading these explanations. Every word, line, and paragraph of Uworld's explanation has to be read keenly. These are the same points that come in the examination and these are the very same points that you will see in real practice. The images of Uworld explanations are beautiful and knowledgeable, I used to save them on my cellphone. I used to revise these images, whenever I got free time. I also used to search for various images on Google whenever I read them. These images may with clinical (e.g. Ashleaf spots, neurofibromatosis, blue sclera, etc.) or it may be radiological images (e.g. ischemic stroke, hemorrhagic stroke, glioblastoma multiforme, pneumothorax, etc.) Again the reason is very simple, clear the concepts. Similar images come in the real examination. It will be easy for you to recognize these images once you have seen them multiple times. I did Uworld self-assessment tests and got pretty good scores so I was quite confident. I went through MTB again in 3-4 days and appeared in the examination.
USMLE Step 2 Examination Day
I followed the same routine on my exam day, as I did during step 1. I carried my passport, sandwich, tea, and painkillers and kept them in the locker room. The night before the exam, I slept early but unfortunately, I woke up around 3 a.m. and had difficulty sleeping afterward. This happens because of exam anxiety. I tried to normalize my sleep schedule about two weeks before the exam and this helped me in sleeping early. I advise all the same, to adjust your sleep schedules at least one to two weeks before the examination. Try to sleep early and wake up early so that you do not feel sleep-deprived on the exam day. At the start of the exam, I did not hear the tutorial. I took two breaks. The first break was about 15 minutes, which I took after block 3 to use a restroom and half a cup of tea. The second break was about 30-35 minutes, which I had after six blocks to have some sandwiches, tea, and prayers. After the examination, my head was completely numb and I was in no position to recall questions or check the answers. I just went with my family to watch a movie.
After 3 weeks I got my score report and I secured a score of 266, which was the highest score from my medical school at that time. The score was about 10 points higher than the Uworld self-assessment exam. I advise all of you to follow three rules during the preparation: Keep things simple, clear your concepts, and trust yourself.