Path to US Medical Residency Part 1 #Exams #USMLE #Steps #NBME

This blog is to assist IMGs who is looking to do a residency in the US. This blog won’t get into technical details of each exam, but to give a broader sense of what lies in the path of applying for residency in US. Plan is to publish a series of blog as the spectrum to cover is huge. This is Part 1 of many.

Introduction

Residency is the path to become a licensed doctor in US. Even if you have completed residency in your country, you have to complete 3 years of residency to procure license and start practicing in US. I am an Indian and might quote examples from an Indian MBBS graduate standpoint from time to time. Residency is a 3-year course, with 1 year of internship and 2 years of being a resident training doctor.

Speciality

The first step towards doing a residency is to decide your interest in a particular speciality. It could be internal medicine, pediatrics, family medicine, psychiatry, neurology which are relatively easier to get in or surgery, radiology, orthopedics, etc which are difficult to get in, but not impossible. For more details, refer this nrmp link.

Exams

Applicants are expected to complete USMLE steps to apply for residency, namely Step 1, Step2 CK, Step2 CS. All these are mandatory to apply for residency. Strictly speaking, these are required to have been completed (with scores available) by the time of ranking (more on this later), but being an IMG, our steps are one of the most important factors to even secure interview invites. So, try to complete all steps before you apply for residency, because these are requirements to get ECFMG certified, which in turn, is a necessity for a program to rank you. Brief details about each of these exams are covered below. Apart from these exams, USMLE Step 3 is expected to have been completed in order to get licensed, but not mandatory to apply for residency. You can choose to give this exam during your residency as well.

Scores

I can’t emphasize this enough. Both step 1 and 2 ck scores are very very important. It is desirable to have step scores above cut off set by most programs. For eg, average step 1 score is 230(Don’t quote me on that, just based on our observation). Minimum passing score for Step 1 is 194, for Step 2 ck is 209 and for Step 3 is 196. Having observership or research will add to your profile, but step scores are the ones that gives the first impression.

USMLE Step 1

Step 1 exam tests your basic science knowledge. They test you on Anatomy, Physiology, Biochemistry, Microbiology, Pathology, Pharmacology and Biostatistics. This exam is for a total of 8 hours. There are 7 blocks of 1 hour each with 40 questions. You have 45 mins break in total, which you are open to take up in between blocks as you wish. For eg: after completing 2 blocks, you can take 10 mins. And then 2 blocks, followed by 15 mins for lunch. 2 blocks and then 10 mins break and then 1 last block. In case of urgency, you could take a break during a block as well, just that the timer (for the block) will be in progress. So it is wise to take breaks in between blocks. But do keep in mind about the total 8 hours for 7 blocks. Step 1 can be given in any prometric centre, so you can choose to give it in your own country or in US as per your preference.

If you know upfront (during your UG) that you want to do residency, you could start preparing from 1st year so that you can plan to finish all 3 exams by end of your UG. Usually preparation roughly takes anywhere between 6 to 10 months if you start preparing after your UG if you put in 10 hours a day. But it is subjective as well, depending on how serious one is with preparation. Step 1 will be very tiring and exhausting compared to other steps. Don’t worry, everyone has gone through a similar phase. You will definitely get through it. Just keep working towards it with cent percent determination.

USMLE Step 2 CK

As the name suggests, Step 2 CK tests your knowledge in clinical subjects like surgery, medicine, OG, pediatrics, ophthal, ENT, etc. This is also MCQ. Total duration of this exam is 9 hours. There are 8 blocks and the questions per block will vary but not exceed 40. And the rest are pretty similar to step 1 like break timings, exam centers, etc. It is advisable to give step 2 ck immediately after step 1 in which case 3 months of preparation is good enough. But if you take a break, then you are looking at roughly 5 to 7 months of preparation for this exam.

USMLE Step 2 CS

This is the only practical exam you need to take for the residency application and it has to be taken in one of 5 centers in US(LA, Houston, Chicago, Atlanta and Philadelphia). International graduates come to US with B1/B2 visa to take up this exam. Here is the brief overview of the exam structure. High level idea is that you need to give differential diagnosis and workup plan for patients (actors impersonating as patients). In total each student will get to meet 12 patients in a total of 7 to 8 hours. Roughly 25 mins for each patient with some breaks in between. 1 to 1.5 months preparation is good enough for this exam. One usual strategy IMGs follow is to stay in hotel near the exam centre for a month and do study sessions and mock encounters with other applicants having exam dates in proximity. Study partners form the essential part of this exam. There are no online model exams for step 2 CS. But there are courses offered like GOLD (3-day course), NYCS prep, etc which might be useful if you want to give it a shot. Applicants will be graded on Integrated Clinical Encounter (ICE), Communication and Interpersonal Skills (CIS) and Spoken English Proficiency (SEP). Unlike other exams, there is no score for this exam. Result is binary, with just pass or fail under three components: CIS, SEP and ICE. For further reference, see this link.

Note

One major catch with these steps in general is that, you have only one attempt for the most part. If you fail, you can retake. But, if you pass, you are locked with the score for 7 years. In any case, all the attempts and scores go into your transcript even if you leave a gap of 7 years since your score are really bad. So, do ensure you are getting your desired scores in your model exams before you appear for the actual exam. It is very common for folks to postpone the exam just 2 to 3 weeks before the scheduled date, to another 2 to 3 months as they feel they are not prepared to take it and that’s completely okay. Most important factor is that, you should feel confident and comfortable about taking the exam. You could only extend your testing period (3 months series) twice. For eg. If you have booked your exam period as Jan, Feb and March, you could postpone it to April, May, June once and again for July, August and September. If you fail to take the exam even after this, then you have to restart and send a new application form and get verified from ECFMG again for booking the exam.

Model Exams

There are a lot of model exams that you can pay and take online for step 1 and step 2 ck. There are approximately 6 online NBME exams and 2 UWSA exams. In addition, there a lot of offline NBME tools available in the Internet with answers. These may not be for 7 or 8 hours, but 4 to 5 hours. In any case, these will help you gauge your level and also train your mind to not get fatigued by the long hours of the exam. If you are getting desired scores in these model exams, you can book the actual exam. But do remember that some of these model exams are easy and some are very hard (you can find correlations between these model scores and actual step scores in different forums like USMLEforum, SDN, etc.). Please do pace your model exams wisely so that you have something left just before your final exam. For instance, even after taking all exams if your scores aren’t as you expect, after the final round of preparation you may not have any exams left to check your status. Beware that one good score in models may be an outlier. So, make sure your average scores towards the end is in your desired score range for the final exam.

USMLE Step 3

Step 3 is an exam required to be completed during the course of residency (deadline differs for different programs). There are two parts of the exam: 1st day with MCQs (Foundation of Independent Practice) and the second day of MCQs in the form of computer-based case simulations (Advanced Clinical Medicine). Finishing Step 3 will allow to take care of the patients unsupervised (but not while in the residency program). This step is bit tricky compared to other steps as its optional for residency application. If you end up giving step 3 before your application, it’s a double-edged sword. If you get good marks, you are good, if not, it’s going to be a black mark in your profile. So not many folks will give Step 3 before application. But this step is mandatory for most programs that sponsors H1B before you join them. If you wish to join a residency program with H1B, you will have to have your step 3 scores on file before the Match day. So, folks who are looking to join in H1B, choose this route. But in general, you are required to complete this step during PGY1 or PGY2 years as it’s a requirement to get license to practice medicine on your own.

This is the end of Part 1 of the series. Will cover USCE in next part.

P.S: I am a non medico, a techie working in silicon valley. My wife is a medico and we are publishing this blog based on our experience. Many thanks to my wife who lend a helping hand in writing and reviewing these blogs.