Overview

Introduction 

The United States Medical Licensing Examination® (USMLE®) is a three-step examination for medical licensure in the United States and is sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners® (NBME®).

The Composite Committee, appointed by the FSMB and NBME, establishes policies for the USMLE program. Membership includes representatives from the FSMB, NBME, Educational Commission for Foreign Medical Graduates (ECFMG®), and the American public.

Changes in the USMLE program may occur after the release of this Bulletin. If changes occur, information will be posted at the USMLE website. You must obtain the most recent information to ensure an accurate understanding of current USMLE rules. If you are unable to access updated USMLE information via the Internet, you may contact the USMLE Secretariat in writing for updated information.

1. Purpose of the USMLE

2. The Three Steps of the USMLE

3. Examination Committees

4. Ownership and Copyright of Examination Materials

5. CBT – Computer Based Testing

6. Step 2 CS (Clinical Skills)

Source: http://usmleworldwide.com/blog/?p=66

Usmle Step 1 MCQ's # 2

Title: Usmle Step 1 MCQ's # 2

Subject: Behavioral Science

Q NO 2: A 25-year-old woman is brought to the hospital by her husband. The patient complains of severe pain and tenderness in her lower left abdomen. She is diagnosed with appendicitis and scheduled for an emergency appendectomy under general anesthesia. A 2nd year resident performs her surgery. Surgery reveals that the appendix is normal and without inflammation. However, the resident notices a large tumor attached to the patient’s left ovary At this point the resident’s best next course of action would be to do which of the following?

A. Biopsy the tumor and terminate the surgery
B. Excise as much of the tumor as possible without coming into contact with the ovary?
C. Exercising common standards of care, remove the patient’s ovary to eliminate the tumor
D. Seek permission to excise the tumor from the patient’s husband, who is sitting in the waiting room
E. Seek the advice of the supervising surgeon
F. Talk with the patient’s husband, who is in the waiting room, about how his wife would probably want to proceed

Explanation:
The correct answer is A. A competent patient has the right to make all treatment decisions for themselves, including refusal of treatment. If you can access the patient’s wishes by direct conversation, then this must be done. After woman recovers from the anesthesia, she is entitled to full informed consent including descriptions of the: 1) nature of the procedure, 2) the purpose or rationale, 3) the benefits, 4) the risks, and 5) the availability of alternatives. With this information presented, the patient herself can make what ever treatment decision seems best to her.
Excising the tumor (choice B) is treatment without the patient’s consent and permission.
Patient’s wishes, not” common standards of care” (choice C), are what guide treatment decisions. Only if we could not access the patient’s wishes in any way, AND the situation was critical, would we act using judgment as to what would be reasonable care.
Choices D and F are incorrect, because the woman has primary say over her own body. If she were in a coma of some duration, then we might ask the husband under the doctrine of substituted judgment. But here, we can wake her up and ask her directly.
The resident has all of the information required to know the correct actions to take without consulting a superior (choice E). In general, consulting a superior will be the wrong answer on the Step 1 exam.

Source: http://usmleworldwide.blogspot.com/2012/09/usmle-step-1-mcqs-q-no-2.html

Usmle Step 1 MCQ's

Title: Usmle Step 1
Subject: Behavioral Science

Q NO 1: A 29-year-old man presents with a dramatic flourish to his physician’s office, dressed in a “flashy” manner, and describes having brief, superficial relationships. On his way out, he asks the nurse for
a date. Which of the following might also describe the patient?
A. Allows others to make decisions for him
B. Has a restricted range ob emotion
C. Is socially withdrawn
D. Is the “life of the party”
E. Participates in criminal behavior

Explanation:
The correct answer is D. This individual has histrionic personality disorder, characterized by acting in a theatrical manner, which would include being the center of attention at a party. Such individuals are sexually provocative and have difficulty maintaining intimate relationships.
This patient would not have difficulties in self-confidence that would warrant having others make decisions for him (choice A). This describes a patient with dependent personality disorder.
Instead of being limited in expression of feelings (choice B), such as a patient with schizoid personality disorder, this patient expresses feelings openly, often in a yew superficial manner.
This patient would be the opposite of being socially withdrawn (choice C), and would be more likely to be socially gregarious and lively. A patient with avoidant personality disorder would be more likely to be socially with drawn.
While at times they make choices that reflect impulsivity, patients with histrionic personality disorder are not more likely to engage in criminal behavior (choice E). Criminal behavior would more likely be seen in those with antisocial personality disorder.

Source: http://usmleworldwide.blogspot.com/2012/08/usmle-step-1-mcqs.html

USMLE Step 2 Clinical Knowledge (CK) Minimum Passing Score

USMLE examinations are mandatory for all first and then a clinical internship, engage thereafter as a doctor. Preparation for USMLE Step 2 Clinical Knowledge can be a stressful business. It comprises of multiple choice questions on clinical applications of medical knowledge divided on eight 44 question sets. It requires many hours of dedication. USMLE scores are unfortunately the only real way to a residency program can evaluate the qualifications of a candidate. For this reason, many students feel extreme pressure to get the highest score possible. This pressure is even greater on foreign graduates. For many, they begin to lag the United States without any clinical experience, a language barrier and many years of lay-off of a traditional classroom. But despite these obstacles, it is worth the challenge.
  
    Most foreign graduates are married, have children and have a job, the usual scenario. The most important thing a student has to do is set a time line and transmit this timeline to your significant other very clearly and honestly. Without (or in some cases parents) your spouse's full support you will not achieve your goal. They need to know how long it will take, where do you stand now and what is your plan. If you share this information with them openly and completely your trip will free ride, and especially you have zero stress from your life, which is invaluable, while preparing for the USMLE Step 2 in particular.

    The score of USMLE Step 2 Clinical Knowledge is reported in 2 digits and 3 digits scores. The minimum score required to pass this exam is 75 in the two digits score and 189 in 3 digits score; however, from 1st July 2012 the passing score is increased to 196. Good luck and work hard. Hard work always pays.

Source: http://usmleworldwide.blogspot.com/2012/07/usmle-step-2-clinical-knowledge-ck.html

Can Bipolar Disorder Be Cured?

I sometimes encounter mental health-related blogs and articles which represent the kind of black and white thinking that ends up being more harmful than helpful. An example is a recent internet blog titled "Change Bipolar Disorder by Changing Your Mindset." The author's premise is that bipolar disorder is a creation of the mind and through the process of coming to terms with reality and facing one's past trauma, the symptoms of bipolar disorder can be conquered. The author's perspective is conveyed through statements such as: "The medical society comes from a typical solution of medications, which are drugs... Bipolar Disorder comes from a person not facing reality and their fears... Drugs stop the ability to grow emotionally beyond the basis of past trauma... The manic and depressive episodes are just a signal that you are maladjusted to life and running from reality."

These efforts to espouse hope that cure is within reach is potentially guilt-inducing for those with bipolar disorder who experience the prospect of cure as being beyond their reach. From the author's perspective, those who take prescribed medication are using pharmaceutical treatment to run from their fears! The implication being that if they alternatively chose the right kind of psychotherapy, they could free themselves from drug treatment and from a bipolar future fraught with recurrent relapse.

I know many a bipolar individual who would mightily disagree. I too can't align with this position, though I also can't fully dismiss the implication that unresolved personal issues sometimes do contribute to bipolar symptoms. The important distinction entails knowing when personal issues do exacerbate bipolar symptoms rather than proffering the broad-sweeping and misinformed assumption that unresolved personal issues cause bipolar disorder.

There's also the converse side of the argument, the more predominant medical model, which holds to the view that bipolar disorder is biologically based, chronic and lifelong. Essentially, if you've got it, you're stuck with it and there’s little to no chance of resolution. For most with bipolar disorder this is more familiar territory. If you've been hospitalized or experienced recurrent episodes of moderate to acute instability, then you've likely had a psychiatrist suggest that you need to accept the permanence of your condition and learn to live with it. Generally speaking, I agree with this though I don’t want to discount the possibility that we sometimes see unusual and unexpected outcomes. However, the reality is that most longitudinal studies do support the notion that bipolar disorder is a chronic lifelong condition.

Where this gets tricky is with those on the mild end of the bipolar continuum who are somewhere between 16 and their mid-twenties. Consider the profound transformation that most individuals undergo while going from adolescence to young adulthood; or better, imagine taking a version of yourself at 19 and visiting with him or her when you turn 32. You'd probably feel like you were encountering a very different individual. That's the beauty of maturation - we really do change with time.

When the lifestyle patterns of the late adolescent evolve toward adulthood, we often see the establishment of regular employment routine, healthier sleep hygiene and increased consistency of day-to-day functioning. This is why adolescents are prone to see adulthood as boring!

Similarly, when recreation doesn't entail frequent drug and/or alcohol use and when one becomes more skilled at managing external stressors as well as the impact of complex emotions, then mild bipolar symptoms can sufficiently diminish and no longer meet the threshold for the bipolar diagnosis. I am not saying this commonly occurs, but I can report that anecdotally, I do see it happen from time to time. In other words, sometimes growing up also means smoothing out.

Maturation is one of those things that happens apart from our volition. In fact, the cerebral cortex, a part of the brain involved in judgment, decision-making and impulse control continues to develop into the mid-20s. You don't just wake up one day at age 19 and say I'm going to become grown up today. More accurately, you gradually develop better insight, perspective and impulse control through experience and with continued cortical development over the course of late adolescence and young adulthood. That's where the hope lies for those in their late teens with mild bipolar symptoms.

If you’re much beyond your twenties and looking towards the influence of maturation upon bipolar symptoms, it’s unlikely to occur. That doesn't mean maturation and personal growth don’t continue throughout the life-cycle; but realistically the degree of maturational change we experience begins to level off as we progress into adulthood. So if you can’t bank on maturation, then where do you invest your hope and your efforts to change? My own admittedly biased answer to this is – psychotherapy. Before going there, we need to first consider the important distinction between internal and external influences upon mood.

Let's begin by thinking of bipolar disorder as being akin to the volatile substance, nitroglycerine. When agitated, the substance rapidly changes from being relatively inert to highly explosive. If the substance remains undisturbed explosion can be avoided. There's much in life that can be agitating. Environmental and situational stressors are pervasive: fast-paced employment environments, high academic volume, the approach of work submission deadlines and difficult individuals who don’t always treat us kindly… these are all in the realm of external stress. They’re out there and, short of becoming a recluse who lives off the grid, it’s difficult to avoid this kind of stress within our lives. At the same time I’m not suggesting that we are all doomed to react like a vial of agitated nitroglycerin.

Think of two people with very different temperaments or personality styles. One is usually calm, even-tempered, rarely anxious and mostly has positive self-esteem. The second person, by contrast, approaches most things with apprehension and doubt and often feels that stress undermines his or her capacity to think clearly and make good decisions. These are people who approach life quite differently.

Imagine these two people both experience the same difficult and challenging day. While their external stress may be comparable, these individuals' capacity to manage their day is quite different. For the one with anxiety and deficient self-soothing, their fearfulness and difficulty remaining calm are stressors in and of themselves. In other words, the psyche of the individual absolutely plays a significant role in how the day is experienced. The notion that circumstance or other people make us feel anyway in particular is inaccurate. Life comes at us, but our response is our own creation.

Now let’s loop back to the psychotherapy issue. If self-awareness, stress management, decision making processes and interpersonal skills are all in the realm of things we may have some influence upon, then it only make sense that improvement of these functions could potentially improve one’s overall sense of emotional equilibrium. And if our own internally generated stress or “how we are in the world,” doesn’t lend itself towards stability, then it would also seem self-evident that becoming involved in psychotherapy as a means of improving one’s coping style is a reasonable thing to do.

I don’t want to replicate the perspective that I criticized at the outset of this blog. Psychotherapy won’t likely resolve the symptoms of bipolar disorder. Even the most insightful, self-aware, self-accepting bipolar individual will still experience some mixture of highs, lows and/or irritability that will be difficult to manage. That’s life with bipolar disorder.

I also don’t want to suggest that psychotherapy oriented towards significant personal change is a simple undertaking. There aren’t three easy steps to equilibrium and serenity. It's more the opposite: serious, in-depth, trans-formative psychotherapy is hard work. Facing unresolved personal issues is something we typically avoid rather than meet head on because the process often involves a fair amount of emotional pain. But if you’re motivated towards therapy and can find a skilled professional to facilitate the process, then meaningful personal change is truly possible.