How The National Residency Matching Program ("The Match") Works

Every spring, graduating medical students in the United States stress out in the middle of March over the results of the the National Residency Matching Program (NRMP), generally celebrated by medical school as "Match Day." No other profession operates like this. Lawyers after law school, PhDs after graduate school, MBAs after business school - all enter a competitive job market. Medicine instead has a nationalized system that ostensibly relies on de jure collusion between residency programs to assure a reasonable allocation of residents to programs on a predictable schedule. How did this come to be?

The History of The Match

In the United States prior to 1952, medical students found residency positions much like their colleagues in other fields, through a decentralized, competitive market. However, as residency programs wanted the best residents, they often competed to offer spots earlier and earlier to the brightest candidates, causing undue stress. As Sara Robinson writes:

Medical internships were introduced around the turn of the last century as an optional form of postgraduate education. Because interns were a source of cheap labor for hospitals, Roth explains, slots soon outnumbered applicants and competition for interns was fierce. Salaries and working conditions of the internships were specified ahead of time, even then, and there was no negotiation in the process. Thus, the competition manifested itself in timing rather than price: Hospitals began to insist that their offers be finalized before those of their competitors. The average date for finalizing an internship gradually crept from the end to the beginning of the senior year. By the mid-1940s, internships were being finalized at the beginning of the junior year of medical school, and some inquiries came even during the sophomore year. 

Recognizing that the situation was out of hand, the Association of American Medical Colleges adopted a resolution prohibiting medical schools from disseminating student transcripts or reference letters before a certain date during the senior year. This fixed the advancing-date problem but created a new one: Students tended to hold onto offers as long as possible, hoping for offers from better schools. The hospitals were unhappy with this situation; if a student rejected an offer at the last moment, the hospital might have trouble filling the slot with a desirable applicant. So the hospitals, still battling fiercely for residents, passed a series of resolutions shortening the time a student could sit on an offer. At one point, hospitals had telegrams offering residency positions delivered at precisely 12:01 A.M. on the earliest allowed day; the students were forced to accept or reject these offers within hours. 

In response to this clearly unsustainable situation, all parties decided, in the early 1950s, that it was time for drastic changes in the procedure. The centralized system created as a result had students and hospitals communicating with each other as before, but it replaced the rounds of offers by ranking lists, submitted by both sides to a central authority. Following a standard procedure, the central authority then matched students with residency programs. Such was the inception of the residency-matching algorithm, although it took some fiddling (trial and error) to get a procedure that worked.

The situation improved, although economists and game theorists argued that the situation favored the hospitals.

The NRMP Algorithm

In general, the problem of matching residents to programs is one of two-sided matching, or more amusingly called the "Stable Marriage Problem."  The basic problem is stated as:

Imagine a set of n boys and n girls. Each boy B ranks each girl G, and vice versa. The first boy goes to his preferred girl and proposes. If he is on the top of her list, she says 'Maybe' (for now); otherwise, she says 'No.' If she says no, he goes on to his next choice, until he finally gets to a 'maybe.' Then, the next boy repeats the same process with the remaining girls, which goes on until all the boys have paired off with all the girls.

The original research showed that while this produces a stable set of pairs such that no improvements can be made by any couple re-pairing (ie, no cheating), it was also shown that this process favors the boys (the ones asking) over the girls. Another implication was that the girls could game the system by lying about their true preferences. Economist Alvin Roth and others showed that the original NRMP algorithm was equivalent to the stable marriage problem and that it favored the hospitals. In the 1990s, Roth was recruited by the NRMP to revise its algorithm as well as make it more equitable for couples entering the match.

Despite these changes, several medical students filed an anti-trust lawsuit against the NRMP in 2002, accusing it of abetting medical schools in colluding to keep wages low. The suit was unsuccessful, but the lobbying efforts of the NRMP fared better: President Bush signed a pension law that had an attached rider specifically granting immunity to the NRMP from such claims in 2004.

Navigating the Match

In an ideal world, simply putting down your true preferences and having the residency programs do the same would lead to optimal outcomes. In reality, the process entails much subjectivity as programs want not only qualified applicants but also want to claim they did not have to go very far down their list to fill their spots. This is more an issue of vanity than practicality, but it impacts how programs structure their rank lists. Awareness of this social reality behooves the applicant to clearly state their desires for programs they are interested in during the interview process, despite not having fully considered all their options. It also necessitates clear communication with programs of interest after the formal interviews in order to ascertain if the feeling is mutual. While the degree of communication between applicants and programs is restricted per the NRMP guidelines, if any programs or applicants deviate, it is in the best interests of each applicant to also deviate (to understand this better, check out the prisoner's dilemma). Ultimately, the applicant should take whatever steps necessary to clarify his preferences with programs of interest.

If you are interested in learning more about how to navigate the match, check out:

   

References:

• Robinson, Sara. "Are Medical Students Meeting Their (Best Possible) Match?" SIAM News, Volume 36, Number 3, April 2003
• Antitrust Lawsuit Over Medical Residency System Is Dismissed - New York Times
• National Resident Matching Program - Wikipedia

Being Mortal by Atul Gawande - A Scrub Notes Review

As long time readers of this blog (hi MJB!) likely know, Atul Gawande is quite popular around here. The general / endocrine surgeon at Brigham and Women's Hospital is also a well known contributor to The New Yorker and author of four books. His latest book is Being Mortal: Medicine and What Matters in the End.

Like his other books, this work is a mix of his previous pieces for the New Yorker as well as original writing. Gawande tackles an issue oft overlooked in his prior works and within medicine at large: what to do when medicine has no more to offer. The book unfolds by describing what occurs when medicine (and healthcare in general, including non-physician providers / caregivers) try to go beyond their limitations and fit patients to their models of care, instead of trying to shape care around patients. Anecdote by anecdote, Gawande describes patients, friends, and family members and their struggles with the healthcare-industrial complex. The overall tapestry is one of failure: the system did not work for these patients.

And how could it? The healthcare system is a Frankenstein collection of parts that has been optimized to fix simple, close-ended problems. The ear infection, the ruptured appendix, even the small breast cancer - all of these are easily tackled by the healthcare system. Where we stumble is when we attempt to shoehorn patients with complex or chronic problems into this model of one-and-done care. It simply does not work, and can often do as much harm as good.

In Being Mortal, Gawande attempts to show how in certain corners of the country, patients and providers are pushing back. From Oregon to Boston, initiatives have developed that attempt to create better environments for patients to live and to heal, without sacrificing overall outcomes. Surprisingly, in some cases, patients do better with less than with more care.

If one is to quibble with this book, it is that Gawande neglects to provide enough concrete, actionable advice about what to do regarding the issues he raises. For a general audience, he does not spend sufficient time discussing concepts like durable power of attorney, living wills, DNR/DNI orders, or even how to learn more about it. Gawande spends a chapter detailing his own trip down one flight of stairs to the geriatric center beneath his clinic and what he learned, but most of his readers are unlikely to have such easy access to a place like that. Admittedly, that is not the point of the book as it is not meant to be a self-help book about chronic health, geriatric, or end of life issues. Still, for a book that hopes to effect change, an appendix pointing out where one can learn more would have been nice.

Overall, the book is a worthwhile read for anyone who is elderly, is responsible for an elderly person, or cares for an elderly person. In other words, everyone should read this book. It is not a light-hearted read, but it is something better: an important read. While the ultimate outcome cannot be avoided, we can control how we prepare ourselves and each other for it, and in the process, live better, more fulfilling lives.

Other Books By Atul Gawande:

 

Previous Scrub Notes Reviews:

• Atul Gawande: The Man Behind "Complications"
• Atul Gawande and "Better" - A Medical Student's Review
• Does "The Checklist Manifesto" Apply to Medical Students? 

The Medical Student's Daily Bag

Much like students of any stripe, medical students often have many items they need to have on their person during their daily sojurns to lecture halls and wards. While this may be a bit dated, my go to bag in medical school was an earlier version of the Targus Checkpoint-Friendly Mobile Elite Laptop Bag. The other items I typically would have in my bag were:

• Littmann Cardiology III Stethoscope - a nice gift from a good friend, and quite useful on wards
• Penlight
• Mobile device - at the time, a Palm Pilot, but these days I would highly recommend an iPad Air 2 due to the wide range of medical apps, light weight, and long battery life. 
• First Aid for the USMLE Step 1 - until I passed at least, haha
• Nalgene water bottle
• Clif Energy Bar - my current fav, but any snack works
• Pens - always get clickable, black ink pens. And always have an extra one because they will get stolen. Trust me. 
• Highlighters
• Pocket Medicine - probably should have carried this more during medical school, but was definitely a must-have during internship, so why not start early?
• Pager - [grumbles]

Aww, I'm getting a little nostalgic thinking about my old bag. Anything you think should be in there that I missed? Please let me know in the comments below!

Can A Machine Replace An Anesthesiologist?

It could happen. A recent article discusses the Sedasys anesthesiology machine:

TOLEDO — The new machine that could one day replace anesthesiologists sat quietly next to a hospital gurney occupied by Nancy Youssef-Ringle. She was nervous. In a few minutes, a machine — not a doctor — would sedate the 59-year-old for a colon cancer screening called a colonoscopy.

The Johnson & Johnson device won approval from the US Food and Drug Administration in 2013, but so far only four hospitals are actively using the machine. Of course, anesthesiologists are opposed to the machine, as it threatens their livelihood. So far, they have succeeded in having the machine limited to very restricted indications, mostly simple screening procedures. The benefit of using the machine over referring physicians self-administering sedatives is that the machine can administer more powerful drugs like propofol, and more closely monitors vital signs.

Your next anesthesiologist?
Source: fda.gov

What this means for anesthesiologists of the future is unclear. Will the machine stay limited to such narrow indications? Or will it gradually increase its scope, eventually displacing anesthesiologists in all but the most complex of cases? In some ways, the situation is even more dire for nurse anesthetists, as one can more easily imagine replacing them with such a machine. The question of liability is left open in the article, but I imagine most referring physicians and hospital administrators would take on the increased risk if the machine proves to improve patient volume sufficiently without sacrificing safety.

What about medical students deciding on a specialty? It is always hard to forecast the future and one certainly shouldn't make career decisions simply off of potential risks. Each specialty faces the threat of technological disruption (just ask cardiothoracic surgeons who trained before the advent of coronary cath). The world described by physicians past in books such as The House of God no longer exists, much like the world we now inhabit described in Intern will be considered antiquated in decades hence. What is a medical student considering anesthesia to do?

Each person has to answer this question for themselves. However, if you are passionate about a specialty such as anesthesia, the answer is simple: pursue it. Do not let fears of future change dissuade you from the field where you believe you can be your best. Instead of avoiding the risk, embrace it by keeping abreast of the changes in the field, staying ahead of them, and perhaps even being the game-changer within the specialty. Over time, all medical fields evolve. Make sure you choose a field where you will be excited to change to meet the future.

Advantages of Electronic Health Records

With the requirements and incentives built into the Affordable Care Act, many healthcare facilities will be transitioning to electronic medical records. Read the guest post below from Jenny Richards to find out more about the pros of using electronic or digital medical records:

Medical records are vital as they can often make the difference between a patient receiving care that is appropriate or treatment that is based on just the experience of the attending medical staff and diagnostics performed in a hurry. Often paper records may not be legible, complete or even systematic requiring doctors to make educated guesses about the line of treatment to be followed. It can also be extremely optimistic to expect patients who are travelling to carry all their medical records with them just in case they fall ill or need medical attention for any reason whatsoever. Digitization of medical records that are already in paper form or generating records in the electronic form and uploading them to cloud storage has quite a few benefits resulting in a simpler and better treatment environment.

Reduction of Paperwork

Getting treated for any ailment can generate quite a large amount of paper not only for the patient but also for the care provider or hospital. These records ideally should be preserved for reference. When you take into account the number of patients this can easily amount to a humongous task in terms of sheer physical work, let along the responsibility of ensuring their safety and confidentiality. An electronic health record system eliminates most of the paperwork and can be extremely useful in giving easy and fast access to information with a proper classification and search procedure. The result of this exercise will be that both patients and doctors will have almost instantaneous access to medical records from anywhere in the world without having to locating the required documents and then transporting them to wherever they are required. The vital time that is saved in accessing the medical records can put to better use by the medical staff in treating the patient and having patient interaction that is more meaningful. Electronic records also ensure that the content is legible and not open to any misinterpretation by doctors trying to read often very difficult-to-read handwritten documents.

Reduction of Erroneous Drug Prescriptions

A sophisticated electronic health record system also enables doctors to prescribe drugs electronically. The process automatically compares the medical history of the patient and generates an alert if the drug being prescribed is not suitable for the patient. This electronic system acts as a surveillance system over the doctor’s actions and prevents erroneous drugs from being prescribed. This system acts to substantially prevent a lot of patient distress and hospitalization stress and expenses that would have easily occurred. The electronic health record system also enables doctors to compare between the various drug compositions offered by various manufacturers to select the most appropriate or even suggest a generic alternative that saves money. If you wish to know more, you could browse through recent HFA.co.in guide on DMR's.

Better Care Coordination

In complicated cases, the patient is often attended by a number of specialists, who will need to maintain independent records in the absence of an electronic health record system. Since it may be very difficult for doctors to keep on comparing notes on the diagnostics they may have ordered, it may so happen that the patient undertakes the same test a number of times resulting  in a complete waste of time and money. An electronic system of maintaining health records that can be shared online by multiple doctors can be extremely effective in implementing a treatment plan that is collaborative and effective.

An Effective Tool in Preventive Care

It is a common and unfortunate human foible not to undertake medical checkup tests and screenings unless there are some symptoms that have already manifested themselves. When there is an electronic medical record system that is online and accessible by people with portable connected devices, they can be easily reminded of tests that are recommended keeping in mind the profile of the person, his age, sex, family history, his own medical history, etc. Reminders may be sent to the patient in a variety of ways such as email and SMS to enable him schedule an appropriate appointment. The incremental cost of implementing these warnings is miniscule whereas the potential benefits are unimaginable. Learn more about the importance of digitized medical records by instructables.com.

How to Stay Focused in Med School

Keeping your focus, studying, and avoiding a distractions is a big part of being successful in medical school. This post from Jenna details some strategies for achieving that goal.

The medical school system is designed to try and break us as early as possible so that the weak are weeded from the herd. It’s a cruel way to live, but in the end it ensures the best for our patients. Even so, it’s hard to deal with that kind of pressure. Even the best and most positive among us can become disillusioned and depressed (1).

This is why it is important to do everything you can to stay focused and to keep your eyes on the prize: being a doctor. Here are some tips to help you do that.

Write the Letter
As soon as you get accepted to med school, while you are still riding that high of getting into the school you wanted, write yourself a letter. Talk about how you feel right now and remind yourself of why you’re going to med school in the first place. Encourage yourself to keep going even when things get hard. Then, put that letter in an envelope and hide it away. Pull it out and read it whenever the stress of med school starts to get to you and you start to forget why you signed up for all of this terribleness. That letter will do a better job of reminding you why you’re doing all of this than any pep talk anybody else can give you.

Make Friends
Med students are notorious for trying to go it all alone. Many see their fellow students solely as competition to be bested or resist the urge to bond because they don’t want to have to worry that a friendship will get in the way of their getting ahead. Here’s the truth: your classmates are going to pick up on things you don’t. They are also going to better understand what you are dealing with than anybody “on the outside.” (2) Make friends and support each other. Medicine is a competitive field, but it is also a collaborative one. Remember that.

Have FunWait, what? That seems counterintuitive, doesn’t it? Med school is supposed to be about 100% dedication and focus on your studies, right? No. Everybody needs a break from time to time. It’s good to put the books away once in a while and just hang out and have fun. If all you ever do is study, you will burn out. Trust us on this.

Set Firm BoundariesAt the same time, be firm with the rules you set for yourself. Do not let yourself get tempted into blowing off a study session for a movie when you know that you’re having a hard time in a class. And don’t let your desire to be the first in your class get in the way of your connections with your family and your friends. Set a schedule, stick to it and commit to it. Learn to be okay with saying “no” sometimes, even if it is to yourself! This is the other half of the socializing coin. You can’t be everything to everyone and to yourself. It’s okay to be selfish.

Stay SoberMed school will run you ragged. This is a given. It is also a given that you are going to be tempted from time to time to look for help staying awake, staying energized, staying focused. And when coffee stops being enough, it’s tempting to turn to something stronger. Resist this urge. Studies show that people who use drugs actually increase your feelings of disinterest and distraction. (3) You might be more awake, but you won’t be able to put that energy to good use. Plus, addiction is harder to beat than med school. Trust us on this.

Everybody has heard that the deluge of information you are expected to smash into your brain is so intense it’s like “trying to drink from a fire hose” (4).This is absolutely true. Know this going in so that you aren’t surprised and overwhelmed by it when you get to school. Advance prep is a good idea. The aforementioned schedule is another. Take steps to keep the fire hose from drowning you.

Sources:

1. "How a Doe-Eyed Pre-Med Student Changes into a Jaded Doctor." Medical School Success. Web. 29 Apr. 2015.  http://www.medicalschoolsuccess.com/how-a-doe-eyed-pre-med-student-changes-into-a-jaded-doctor/
2. DeCoste-Lopez, Jennifer. "Med School Friendships from Classroom to Clinics." Scope Blog. Stanford Medicine, 9 Apr. 2014. Web. 29 Apr. 2015.  http://scopeblog.stanford.edu/2014/04/09/med-school-friendships-from-classroom-to-clinics/
3. "The Impact of Education on Addiction - Michael's House Treatment Centers." Michaels House Treatment Centers. Michael's House. Web. 29 Apr. 2015.  http://www.michaelshouse.com/drug-addiction/impact-education-addiction/
4. "What Is Medical School Like? Think Fire Hose!" Happy Hospitalist. Web. 29 Apr. 2015. http://thehappyhospitalist.blogspot.com/2009/09/what-is-medical-school-like.html

5 Effective Ways To Study Human Anatomy

Every medical student has to pass through the gauntlet of anatomy lab. Whether or not this is relevant to a modern medical student is debatable, but the rite of passage persists. This guest post by Krystle discusses several ways to enhance your anatomy study techniques.

Human Anatomy has to do with the study of the structure of the body which includes cells, tissues, organs and systems.  It is usually coupled with the study of physiology which is the study of how biological processes function within a living body. The reason being is that in order to understand the various parts of the body properly, it would make sense to have a knowledge of the functionality that they each carry out.

Anatomy can be one of the most daunting subjects for early-year medical and nursing students because of the magnitude of parts that are covered in the human body. A recollection of the technical terms used can prove overwhelming unless proper systems are implemented to assist the mind in recalling each part and function. It is better to strategically approach this study for successful retention of content. The human body consists of 206 bones held together by over 600 muscles, and knowing all this in detail does require above ordinary skill. It is with this that we have put this piece together to assist the Anatomist in absorbing the knowledge of the beauty and intricacies of the human body.

Understand Body Language

In this context body language has less to do with human attraction than it does the syntax and tone – the pronunciation of the words that make up each body parts labeling – so that information is always easily accessible. Having a standard for anatomical terms also makes it easier when communicating those terms. Look at prefixes and suffixes for example; those used in anatomy generally follow a pattern that once understood is like unraveling a scientific code that leads to better retention. Examining the brachiocephalic artery for instance, can tell you what it is, where it’s located and its function if one understood the language of anatomy. That language would tell us by prefix that brachio is a reference to the upper arm, and cephal has to do with the head, and with a general understanding of arteries – a blood vessel that carries blood away from the heart – it’s then simpler to make connections that may infer that the brachiocephalic artery is a blood vessel that carries blood to the such regions of the body as the arms and head.

Look at the thing

One of the best ways to study human anatomy and physiology is via the use of either physical or digital study aids. These come in the form of flash cards, handy interactive 3D apps, charts and beautifully illustrated e-learning platforms designed with medical students in mind.

Flash cards are by no means a replacement for detailed book-content but they quickly assist your mental capacity to draw for information. Specific to anatomy are e-learning gateways such as Kenhub’s Library of Anatomy which covers information such as the upper and lower extremities of the body, the trunk wall, head and neck, thorax, abdomen & pelvis and neuroanatomy. Utilizing resources such as the afore-mentioned, can dramatically improve your ability to obtain better grades in human anatomy courses. Platforms such as this one provide quality illustrations of anatomical structures in a detailed yet easy to remember manner.

Looking Deeper

Now if ever you’re in the position to be able to look at models of the human body don’t hesitate to. Perhaps it’s a model in class, or you may be privy to viewing certain operations in a medical facility. Any chance you get to peer at the human dissections gives you an opportunity to see and recall all the things you’ve been studying. You may not be fortunate to be able to see man-made models, or worse, the real thing, and so you can practice drawing parts of these models and labeling them on a board or on sheets of paper wherever possible. You will find that being able to constantly re-imagine the systems and body parts and to call them out on your own, as if teaching yourself, goes a long way in retaining the material. Having someone close by to talk to while doing your demonstrations helps meditative retention immensely as well.

Pick your brain

Any system that offers quizzes are good for keeping your mind focused on anatomy and physiology. Most popular 3D apps come with these and others are easily found online. By constantly training your mind to remember even short questions on a particular body system or function, helps to boost your memory of it. And remember, when you find that you don’t have your usual quiz materials handy, from just your memory, draw diagrams, label them, and then quiz yourself orally.

Always Review

The importance of reviewing cannot be understated. Not only should you review all that you have studied, but if there’s an anatomy review session by your tutors, make yourself available.

Simply put, anatomy students need to re-read, review illustrations, re-draw, re-contemplate, and review short quizzes, and take breaks from studying. It’s never best to cram this information but to moderately and consistently go back to the content. In the end you will acquire knowledge far greater than any amount of information-hogging could accomplish; your ultimate aim being knowledge and mastery of the art of the human body and functionality.

Krystal Crumbie is an Anatomy Geek at Kenhub.

Medical School Graduation Gifts

It's almost that time of year again, the so-called "Dads & Grads" season for gift buying. However, if you have a special someone graduating from medical school (or PA school or NP school or nursing school etc), the occasion is particularly special. As with past gift guides, the goal is to find a gift that is particularly relevant for someone graduating with a healthcare-related degree. Whether the gift is silly and fun, or more serious and intended to help them form good habits and become an outstanding health practitioner, as always, it's the thought that counts.

This time around, I will try to break the gift guide down by budget: under $25, $25 to $100, and over $100.

Under $20
The always popular Giant Microbes have a wide range of medically-themed plush toys. For example, the budding neurologist or neurosurgeon may appreciate the brain cell:

 

For a more introspective gift, many medical memoirs are available in paperback, including Scrub Notes favorite surgeon/author Atul Gawande:

 

$25 to $100
Love the Giant Microbes, but want more? Get the whole set!

For devices like the iPad suggested below, a Bluetooth keyboard case is an excellent addition. Kensington is a solid brand, and the keyboard case allows use as both a note-taking device and a reader, simply by flipping the cover. The backlit version is particularly useful in dimly lit lecture halls!

Over $100
The budding scholar will need something to port all their notes and knowledge around in. Both for reading as well as for medically related apps, the clear leader is the Apple iPad. With the introduction of the iPad Air and the Mini, the tablets have become small and light enough to carry around all day in a hospital, with the battery life to match. Remote access apps also make it easy to check electronic medical records or imaging remotely when needed. Increasingly, digital devices are becoming the 21st century's stethoscope.

However, the 20th century's stethoscope still remains an essential tool of the clinician as well as a classically stylish gift:

Speaking of classic gifts, a leather doctor's bag certainly fits the bill:

Hopefully these gifts bring a smile to your medical graduate's face. Don't feel like buying something? You could always go the more personal route and either make them something yourself or cook them a nice meal. Have a gift idea that I missed? Please include it in the comments below. Cheers!

Changes Coming to the MCAT

For those of you considering applying to medical school, the MCAT is about to be revised for the first time in 25 years. Per the Wall Street Journal:

The 8,200 aspiring doctors expected to take the Medical College Admission Test, or MCAT, this week will find a very different exam than their predecessors took. 

The new test, the first major revision in 25 years, is longer (by 3 hours), broader (covering four more subjects), and more interdisciplinary than past versions. Throughout, students will need to demonstrate not just what they know, but how well they can apply it, according to the Association of American Medical Colleges, which develops and administers the MCAT. 

The changes are designed in part to mirror the evolution of health-care delivery and even the nature of illness, the AAMC says.

 Regardless of the changes, the same keys to succeeding as an applicant will apply: strong grades, competitive MCAT scores, well-rounded extracurriculars, outstanding recommendation letters, and a promising interview. Speaking of scoring well:

 

Additionally, the QBanks are essential for practicing test questions, because you will perform as you practice. Want to know how you might perform? Check out Kaplan's FREE MCAT practice test today! - Good luck!

USMLE Step 1 Study Schedule

While I have previously posted about USMLE Step 1 study techniques, tips, and strategies before, I think many people have concerns about how to study for the test, specifically what study schedule they should use. How many hours per day? Days per week? Weeks before the exam? While it would be nice if there were a one-size-fits-all answer, the reality is that everyone studies in a different manner. Therefore, I thought it would be helpful if I focused a bit more on different types of study schedules out there. Many of these schedules are pulled from various sites around the web (see References below) but I thought it would be useful to collect them in one post about USMLE Step 1 study schedules.

Before getting to the schedules themselves, the main tools these schedules rely on are:

First Aid for the USMLE Step 1

Kaplan USMLE Step 1 Qbank (or USMLE World, etc)

 

Subject-Specific Books as needed


The Four Week USMLE Step 1 Study Schedule
This schedule is a bit aggressive, but if you are in a bind, at least it gives you some framework for how you could study for the exam.

	Morning (9-12 AM)	Afternoon (1-4 PM)	Evening (7-11 PM)
Day 1: Mon	Biochem/Genetics	QBank
Day 2: Tues	Pulm:Embryo, Anat, Phys	Pulm: Path, Pharm	Pulm: Micro
Day 3: Wed	Cardio: Embryo, Anat	Cardio: Phys	Cardio: Micro
Day 4: Thurs	Cardio: Path	Cardio: Pharm	QBank
Day 5: Fri	GI: Embryo, Anat, Histo	GI: Phys	GI: Micro
Day 6: Sat	GI: Path	GI: Pharm	QBank
Day 7: Sun	Catch up/Review/Break
Day 8: Mon	GU: Embryo, Anat	Male repro: Phys, Path	GU: Micro
Day 9: Tues	Endocrine & Female Repro: Phys	QBank
Day 10: Wed	Endocrine & Female Repro: Path, Pharm	QBank
Day 11: Thurs	Renal: Embryo, Anat	Renal: Phys	QBank
Day 12: Fri	Renal: Path	Renal: Pharm	QBank
Day 13: Sat	Early embryology, branchial arches, basic histo	QBank
Day 14: Sun	Catch up/Review/Break
Day 15: Mon	Path: apoptosis, neoplasia	Oncology: Path, Pharm	QBank
Day 16: Tues	Heme: Histo/Phys	Heme: Path	QBank
Day 17: Wed	Immunology	Immuno Pharm	HIV: Micro, Pharm
Day 18: Thurs	Rheumatology: Path	MSK/Derm: Path	MSK/Derm: Micro
Day 19: Fri	Behavioral Science
Day 20: Sat	Practice Exam, Kaplan	Break
Day 21: Sun	Catch up/Review/Break
Day 22: Mon	Neuro: Embryo, Anat	Neuro: Phys	Neuro: Micro
Day 23: Tues	Neuro: Path	Neuro: Pharm	QBank
Day 24: Wed	Micro Review
Day 25: Thurs	Pharm Review
Day 26: Fri	Review First Aid/QBank & QBook Practice Questions
Day 27: Sat	Review First Aid/QBank & QBook Practice Questions
Day 28: Sun	Review First Aid/QBank & QBook Practice Questions
Day 29: Mon	USMLE Released Items	Break
Day 30: Tues	Take the boards	Celebrate!

The Six Week USMLE Step 1 Study Schedule

This schedule is more manageable. I imagine most medical students will conform to a schedule of roughly this length. Although, given how some schools cram MS2 finals very near Step 1 exams, you may want to consider the 4 week schedule if needed. 

	Morning (9-12 AM)	Afternoon (1-4 PM)	Evening (7- PM)
Day 1: Mon	First Aid Introduction + NBME Exam	Anatomy	Behavioral Sciences
Day 2: Tues	First Aid Microbio	First Aid Microbio	First Aid Physiology
Day 3: Wed	First Aid Pharm	First Aid Pharm	First Aid Pharm
Day 4: Thurs	Lippincott Biochemistry	Lippincott Biochemistry	Lippincott Biochemistry
Day 5: Fri	Lippincott Biochemistry: Metabolism	Lippincott Metabolism	Lippincott Reviews
Day 6: Sat	Anatomy: Spinal Cord, Pelvis	Anatomy	Kaplan Qbank
Day 7: Sun	Catch up/Review/Break
Day 8: Mon	Anat: Extremities	Anat: Head & Neck	GU: Micro
Day 9: Tues	Endocrine & Female Repro: Phys	Kaplan Qbank
Day 10: Wed	Endocrine & Female Repro: Path, Pharm	Kaplan Qbank
Day 11: Thurs	Renal: Embryo, Anat	Renal: Phys	Kaplan Qbank
Day 12: Fri	Renal: Path	Renal: Pharm	Kaplan Qbank
Day 13: Sat	Early embryology, branchial arches, basic histo	Kaplan Qbank
Day 14: Sun	Catch up/Review/Break
Day 15: Mon	Path: apoptosis, neoplasia	Oncology: Path, Pharm	Kaplan Qbank
Day 16: Tues	Heme: Histo/Phys	Heme: Path	Kaplan Qbank
Day 17: Wed	Immunology	Immuno Pharm	HIV: Micro, Pharm
Day 18: Thurs	Rheumatology: Path	MSK/Derm: Path	MSK/Derm: Micro
Day 19: Fri	Behavioral Science
Day 20: Sat	Practice Exam, Kaplan Qbank	Break
Day 21: Sun	Catch up/Review/Break
Day 22: Mon	Neuro: Embryo, Anat	Neuro: Phys	Neuro: Micro
Day 23: Tues	Neuro: Path	Neuro: Pharm	Kaplan Qbank
Day 24: Wed	Micro Review
Day 25: Thurs	Pharm Review
Day 26: Fri	Review First Aid/Kaplan Qbank & QBook Practice Questions
Day 27: Sat	Review First Aid/Kaplan Qbank & QBook Practice Questions
Day 28: Sun	Review First Aid/Kaplan Qbank & QBook Practice Questions
Day 29: Mon	USMLE Released Items	Break
Day 30: Tues	Take the boards	Celebrate!

There are eight week schedules floating around out there as well, but essentially the two above comprise the major approaches. If you have more time, simply do more practice questions. However, realize that there are diminishing returns if you extend your study period too long: by the end, you start to forget what you learned at the beginning! Plus, study fatigue starts to set in. Anyway, if you are taking the USMLE this year, good luck!



References:
http://forums.studentdoctor.net/showthread.php?t=108020
http://forums.studentdoctor.net/attachment.php?s=282accf7bef0af86f814357dfea27d12&attachmentid=4810&d=1112967292
http://www.cramfighter.com/