the secret is there is no secret. Some students memorize. Others memorize but spend considerable time understanding the underpinnings. The USMLE picks a perfect blend of questions to reward the latter student enough to get him or her a better job.
Yes, first aid is the bible. They say know pathology "goljan style," but that's only because Goljan spends so much time making you understand the underpinnings of the content you are expected to know.
I cannot stress how often I see a USMLE question start out with a presentation of findings and then at the last second pull the ol' switcheroo and say, 'so *why* is this patient like this?' They assume you know the diagnosis; they ask questions that are tangential to it. Students with backgrounds in physical sciences, who have spent their collegiate careers doing calculus-based derivations, have the advantage because they tend to be interested in justification of the facts or observations. (Another poster wrote, "One study from a group at the University of Colorado Denver presented their study at a medical education conference this year that showed that MCAT physical science score, number of test questions studied, and total hours spent studying were significant predictors of USMLE scores"). No shock here because these students are interested in understanding the fundamental underpinnings that justify the facts they know. At first, this strategy works against them in year 1 because there is just so much underpinnings that are not presented and that are unknown, making navigation difficult. With continuous effort, however, they will start doing better, and they will have a distinct advantage come year 2 with pathology because a huge portion of pathology is justifying what you observe under the microscope.
That being said, there is a certain amount of material that you simply must know and can get correct even if you don't know why. This is especially true of pharmacology (because the cure to any side effect is simple: remove the drug), and knowing what tests to order. I read somewhere that at a NBME conference they all declared that their single goal was to make a test that, if the student did well, meant s/he could perform his/her job on his/her own *without* supervision.
I do well on our shelf exams, and I anticipate I will do well on the step I (fingers crossed!). I have a study guide I'm making for first pass of the material, well before I sit down to memorize. As you can see, my focus is on using the underpinnings to combine several phenomenon so that I can have the same mentality with similar questions. For me, this elevates my score on the boards. Here is an excerpt:
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CD8+ type IV hypersensitivity
1. virus or intracellular bug infects organ tissue
2. expression of non-self antigen using MHC I
3. CD8+ T cells secrete perforins and gramzymes, liquefying area
* occasionally, persistent viral infection or molecular mimicry can lead to repeated episodes or autoimmune disease (HLA subtype dependent)
- CD8+ T cells also secrete IFN-γ to activate macrophages
THYROID: any intracellular pathogen
1. de Quervain's (subacute) thyroiditis (viral cause)
VESSELS: any intracellular pathogen
1. Kawasaki's (new haven coronavirus; all viruses are intracellular)
KIDNEY: any intracellular pathogen
A. glomerulus – diffuse proliferative glomerulonephritis; FSGS
B. tubules - interstitial nephritis
LUNGS: any intracellular pathogen
A. all viral infections are intracellular
1. RSV
2. parainfluenza (croup)
B. certain bacteria are intracellular
1. Mycobacteria tuberculosis (interstitial pneumonia)
2. Chlamydia pneumoniae
PNS:
A. type I diabetes
1. coxsackie B, via MHC I molecular mimicry, causes CD8+ type IV immune reaction (viral deja vu theory)
2. later in life, via HLA DR3 or DR4, an MHC II-dependent autoimmune reaction can occur (not CD8+)
B. Guillian-Barré
1. C. jejuni, via MHC II molecular mimicry, leads to CD8+ type IV autoimmune reaction
ENDOCRINE: any intracellular pathogen
1. diabetes type I (coxsackie B, mumps)
CNS: any intracellular pathogen
1. multiple sclerosis (MS-associated retrovirus; chlamydia)
KIDNEY: chronic pyelonephritis
1. "thyroidization of kidney" refers to CD8+ T cells liquefying the area with perforins and granzymes
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