For those that score a 250+ on Step 1..

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topsurgeon2010

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I just started reading this section of the forum and had some questions for those who did really well on step 1..

Can you guys give us any advice on how to answer those 2nd order and 3rd order questions? I know what 2nd order questions are but not sure about 3rd order..can some give me a hypothetical example of a 3rd order question? 2nd order seems difficult enough but how do you even study for these? I know doing questions helps but are there any other ways to help me get in the mindset of answering 3rd order questions?

Also, how did you guys go about answering the "wtf" questions---the ones that you have no idea what they were talking about? Were these types of questions that you would have known if you had studied more or were the questions just getting at a concept that you had studied but in a convoluted way?

Also in how much detail/depth do you have to study some the material? Do you just have to know high-yield information and learn to apply it? or do the boards often ask questions that have a very specific and detailed answer?

My school doesn't teach to the boards and I have been an average student so far and will be starting 2nd year but am interested in a specialty that unfortunately requires a high Step 1 score so I REALLY appreciate any help and advice...thank you!

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Example of a 3rd order question:
A patient is on pharmacological treatment for auditory hallucinations, disorganized thinking, and delusions. If the drug is modifying dopamine pathways, which if these is most likely to be a long term consequence of this treatment?
a ) "Red man" rash
b ) Involuntary tongue protrusion
c ) Esophageal hemorrhage
d ) Clostridial infection
e ) B12 depletion

answer: b

First we have to figure out that it is schizophrenia that they're talking about.
Then we have to consider that this patient may be on a typical antipsychotic
Then we have to know about tardive dyskinesia and tongue protrusion is a common finding. 3 layers of thinking.

Example of a wtf question:
Which of these muscles does the ulnar nerve innervate most proximally?
a ) Flexor digitorum
b ) Extensor carpi ulnaris
c ) Flexor carpi ulnaris
d ) Extensor digitorum
e ) Interosseus muscles

answer: c
This is an example of a question where you just either know it or you don't, making many people throw up their hands and go wtf.

Disclaimer: I just made these up on the spot and are not actual questions on the usmle

As a beginning 2nd year, i'd have been blown away by these questions. As a beginning 3rd year, they seem almost easy now. Goes to show how much you learn in just a year.

There is no magic formula to getting 250+. Look in the step 1 experiences thread for guidance. However, statistics say that a 250+ is >93th percentile. A good way to set yourself on that path is to study harder than 93% of your classmates during 2nd year.
 
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Here's two more examples:


A 37-year-old HIV-positive man is hospitalized for confusion and sleep disturbances. He is a known IV drug abuser. Physical examination reveals yellow sclerae, abdominal distention with fluid wave, and bilateral ankle edema. Jerky, involuntary hand movements are also present upon wrist dorsiflexion. Laboratory findings are shown below:

Anti-HAV IgM (-)
Anti-HAV IgG (+)
HBsAg (-)
Anti-HBsAg (-)
Anti-HCV (+)

Which of the following is most likely to improve this patient's confusion?

A. High-volume paracentesis
B. Crystalloid infusion
C. Urine alkalinization
D. Intestinal content acidification
E. Immediate portacaval shunting




Answer: D. The patient has cirrhosis caused by long term exposure to hepatitis C. His mental symptoms are caused by hepatic encephalopathy, which is due to increased levels of ammonia in the blood (which in turn is due to a failing urea cycle). Giving oral lactulose will be unabsorbed and eaten by intestinal bacteria, who produce lactic acid that causes the ammonia in the intestine to become charged ammonium ions, which are unable to be absorbed.





A 62-year-old male is treated for ventricular arrythmia. One year after his therapy is initiated, he returns to the clinic with dyspnea, cough, chest pain, and malaise. Physical examination reveals bilateral inspiratory crackles. Chest CT demonstrates fibrotic interstitial infiltration of the lung parenchyma. Which of the following drugs is most likely responsible for the patient's condition?

A. Beta blocker with partial class III activity
B. Class I antiarrythmic
C. Cell membrane destabilizer
D. Cardiac glycoside
E. Local anaesthetic




Answer: C. A describes sotalol, which is used in the acute care setting for AV nodal tachyarrythmias. B describes procainamide (among others), which can cause drug-induced lupus in slow acetylators. C. describes amiodarone, a highly iodonated antiarrythmic used for severe refractory V-tach and V-fib. It's side effects include thyroid dysfunction, interstitial fibrosis, liver damage, and visual impairment. D. describes digitalis, which is used in the setting of severe congestive heart failure, and E. describes lidocaine, which is a class IB antiarrythmic used to prevent and treat arrythmias in the acute care setting after a heart attack


These ones are definitely a bit "worse" than the 3rd order question that Rapplix made up, but I think they really demonstrate the level of knowledge you should be striving for to get a top notch score. For question 2, you may have easily been able to figure out that the drug being described is amiodarone, but you may not have known the mechanism of action of the drug. For question 1, you need make a diagnosis, know how to treat it, and know why the treatment works.

As Dr. Goljan said in his Kaplan lectures, the USMLE is all about why. They know that you can memorize information - they want to test whether or not you can understand those concepts and synthesize new information from them.
 
As Dr. Goljan said in his Kaplan lectures, the USMLE is all about why. They know that you can memorize information - they want to test whether or not you can understand those concepts and synthesize new information from them.

You got that right. That's the important thing Step focuses on. You have to figure out why the symptoms are there, what process is going on, and what is happening one step below that process.
 
I just started reading this section of the forum and had some questions for those who did really well on step 1..

Can you guys give us any advice on how to answer those 2nd order and 3rd order questions? I know what 2nd order questions are but not sure about 3rd order..can some give me a hypothetical example of a 3rd order question? 2nd order seems difficult enough but how do you even study for these? I know doing questions helps but are there any other ways to help me get in the mindset of answering 3rd order questions?

Also, how did you guys go about answering the "wtf" questions---the ones that you have no idea what they were talking about? Were these types of questions that you would have known if you had studied more or were the questions just getting at a concept that you had studied but in a convoluted way?

Also in how much detail/depth do you have to study some the material? Do you just have to know high-yield information and learn to apply it? or do the boards often ask questions that have a very specific and detailed answer?

My school doesn't teach to the boards and I have been an average student so far and will be starting 2nd year but am interested in a specialty that unfortunately requires a high Step 1 score so I REALLY appreciate any help and advice...thank you!

I don't think you'll see many 3rd order q's. The only 3rd order q's I remember ever seeing were some of the micro questions in the Kaplan qbank. That being said, there are a ton of 2nd order question on the real deal. My advice here is complete the uWorld qbank.

The wtf questions are exactly like that--wtf. You either know it or you don't and if you don't, you take an educated guess and move on immediately. One of the wtf questions I got right only because I was having a conversation w a family member (who is a nurse) the day before the exam and she just happened to mention something about a disease that I have never known and that factoid just happened to be on my test. So yeah---wtf.

The books I used to get a 250+ were FA, RR Path, RR Biochem, BRS physio. uWorld is money--complete 100% of this. What you will soon realize is that Step 1 is much more of a "thinking" test than you would otherwise have thought. Strict memorization will get you a 230. Being able to think on the spot is a skill that will get you a 250+ since many questions will present laboratory like situations (not unlike some MCAT questions actually now that I think about it) and will require you to put together a lot of info.

Hope this helped...good luck.
 
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