The Boards

The United States Medical Licensing Exam, or "The Boards," is a three part exam taken by all medical students. A medical license is a prerequisite to practice medicine in the United States, and you must pass this exam in order to become licensed.

The first portion of the test, Step I, is a comprehensive review of basic science information. The test has been designed to ask basic science questions in a clinical format, so clinical experience does help. Currently, the test is computerized and is given in one day, lasting 8 hours.

Step II is a review of all of the material you were supposed to learn during your clerkship year. It includes questions on gynecology, internal medicine, obstetrics, pediatrics, and surgery. Currently, the test is computerized and is given in one day, lasting 8 hours.

Step III is similar to Step II, but cannot be taken until after one year of residency. Currently, the test is computerized and is given in two days, lasting 8 hours each.

Any test can be scheduled on almost any date - up to the student - with sufficient (usually 1-2 month) notice to the testing center. Prior to this, however, an application which requires your photograph and a stamp from the Dean's Office, must be received and processed by NBME (the National Board of Medical Examiners). Allow 1-2 months lead time for them to process your paperwork - they're in no rush and are basically accountable to nobody. For this same reason, allow 4-6 weeks for them to mail you the printout of your scores - even though the test is computerized, efficiency in processing is not one of the NBME's virtues.

Step I

In most medical schools, students take this exam at the end of their second year, immediately after completing the basic science curriculum. At UVM, however, students typically take the exam in February or later, midway through third year. The additional year of clinical experience seems to offer an advantage, as some of the basic science stuff is actually clinically relevant, so you may know it better than people who have just read about it. For example, when someone on antibiotics has diarrhea, you automatically think c. diff and pseudomembranous colitis (if you don't already, you will soon) - it doesn't seem like a textbook fact anymore, it's just this common thing that happens to patients. Students from other schools may only know about it because they read about it, however, so it's much less second nature to them and they're more likely to get that question wrong. Maybe 15-20% of the questions play to that strength for Vermont students.

However, letting a year pass between your last class and this test obviously makes recall more difficult. Also on the downside, some medical schools require successful completion of Step I prior to allowing their students to work on the wards. This can be a problem for UVM students if they plan to do away rotations at these hospitals before their scores have been returned.

Many students report that re-learning this material after a year of clinical experience is much easier than having learned it originally (without clinical context).

In any event, there are many strategies for preparation. The vast majority of UVM students take a complete month away from clinics and dedicate that time to studying - this is one of the reasons that we take the test later than our colleagues. Some students have taken additional time - however, students typically report no additional benefit from this approach, and the ones we've spoken to about this universally regret "wasting" the additional time.

Study materials are obviously a personal decision - be sure to choose a format with which you're comfortable. First Aid for the USMLE Step I is considered required reading. Many students claim that if you can effectively memorize the "high yield" material from this book, you're effectively done studying for the test. This advice may be overly optimistic for students who did not perform extremely well in the basic sciences, however.

Additional resources that have been helpful to many students can be found in the First Aid book, in the Review Resources Section. The sample schedule listed below assumes you're using the Kaplan study materials and the NMS CD, but any general review series and any source of USMLE-style questions can be substituted for these. There are many materials available in the university bookstore, and each January there is a sale and representatives from the major publishers come in and are available for questions.

This sample schedule assumes you have 4 weeks set aside to study. This approach has been effective for many students, although there are other methods that have also achieved good results. Some students advocate 200 questions a day, starting on day one - with each morning dedicated to reviewing topics missed the day before. Some students review by organ system. Some wait until the last minute. Know what works for you.
Week 1Spend each day memorizing, as best you can, a given section in First Aid. This can take many hours, and it's tedious, but the stuff is all relevant and you really get tested on it. If you learn it well this first week, the rest of the month is easier. Figure 4-5 hours a day, then go sailing or something. Don't just "read" it, though - make sure you can almost recite it.
Week 2Start over in First Aid, but it will only take an hour or two each section this time. I guarantee you will have forgotten most of what you thought you learned last week - that's the point. Use the other 2 or three hours to skim through the Kaplan book of the same topic. The Kaplan books have too much detail to be a primary study guide, but they're invaluable in helping you flesh out the topics you had memorized from First Aid. And many areas you'll be able to skip entirely in Kaplan, because you'll know what you need to know. Again, 4-5 hours a day, the rest is for relaxing. If you're feeling anxious, you can start doing practice questions this week, although it seems more useful to do this once you've thoroughly studied all of the topics.
Week 3Restart First Aid and Kaplan - this time both will take about an hour or two combined, but you'll definitely pick up important stuff that you missed last week. The rest of the day gets spent with the NMS CD doing practice questions - you have to start now, even though you may want to procrastinate another week before you start questions - don't procrastinate. Do 50 - 200 questions a day, and do them in "tutorial mode," where it tells you if you get the question right and will give you explanations if you ask for them. Hugely useful, but should wait until you've been through First Aid twice.
Week 4By this point, you'll know where you need work. Whatever you do, restart First Aid again, and early in the week make sure you do the USMLE CD. You get it from the Dean's Office. It has 150 questions, in the exact format the real test is in. It will scare the daylights out of you, and will help you figure out where to focus those last few days of cramming. Also, it's nice to repeat questions from the NMS thing, this time in "test" mode, just to see what you remember. If you have access to another source of questions, it's useful to start practicing for the test. Do blocks of 50 questions at a time, with no more than 1 hour for each block. On test day, you'll need to do 8 blocks, with limited break time, so it's good to get used to the pacing.

That's it. You'll end up getting days off with this format, and the days "on" are pretty low-key, too. The trick to using this schedule successfully is to work at it every day. The benefits are huge - First Aid is where the money is for important facts, so you need to know it cold, but you also need to have a context to help you remember those facts (Kaplan) and practice in applying them (the CD's).

Many people need to study away from home (some of us use Barnes and Noble) in order to get work done. Establish a routine and stick with it. Again, know your study strengths and weaknesses, and apply them.

Step II

Around the country, medical students take this at the end of their third year, after completing a year of core clerkships. At UVM, this test can be taken at any time. Students take it any time after completing the Clinical Core (it can be taken before taking Step I), and as late as the week before their residency begins. Note that again, some hospitals may require successful completion before allowing you to do some rotations.

The focus of this exam is purely clinical. Preparation consists of reviewing the concepts you were taught during your lectures and on the floor during your clerkship year. First Aid tends to be less helpful for this exam - most students prefer Prescription for the Boards: USMLE Step II as their primary study guide. The highest yield study technique seems to be to do as many questions as possible - books from NMS and Appleton & Lange are useful for this. Also, an excellent study resource is the Blueprint series - five books, covering the five major clinical core areas (i.e. Blueprints in Surgery, Blueprints in Psychiatry, etc).

It's easy to lull yourself into a false sense of security with this material - you've gained significant clinical experience and it seems very easy to review and not terribly difficult. Be warned, however, that the actual test questions can be extremely difficult, and although two weeks should be sufficient to prepare, they should be used well. The review materials available tend not to ask questions in the same style as the test is currently written, with the exception of the USMLE CD that you can obtain from the Dean's Office.

It's difficult to predict the clinical areas that might be stressed in any given exam, although it's always useful to review common pathogens and their treatments ("Bugs & Drugs")..

Good luck!