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Dr.Khyati Patel, an IMG interested in helping other IMG’s especially the freshman year, shares with us ‘How can I start preparing for USMLE from the first year of medical school?’ so that you can start your preparations well beforehand with just the right resources and making a stronger conceptual base.

I am a post intern from SMIMER, Surat, Gujarat currently preparing for my USMLE STEPS. I thought of writing this post in order to acknowledge and sensitise the upcoming medical students who are about to enter their first year since I have been through that stage where everyone is seeking for guidance.

My main aim is to point out things where I made mistakes during my medical years and could have prevented myself from doing those mistakes if I would have been informed prior to it. So I will be talking about how you can start preparing for USMLE STEPS since the first year of medical school and efficiently managing time during your first year.

First year subjects: 

1. Anatomy inc. histology & embryology
2. Physiology
3. Biochemistry 

I will talk about each subject briefly explaining how you can use your assigned books along with some other resources to simultaneously prepare for STEP 1 too.

ANATOMY

B.D. Chaurasia is by far the best book for anatomy, almost the Bible of Anatomy so I would recommend using it. It is a very informative and factual subject so you can only make it interesting by getting as creative as you can. Additional resources that will help you with USMLE preps are : 

• Dr. Nabil’s Anatomy videos (they are the best and most concise videos, highly recommended)
• OSMOSIS videos ( you can find anatomy sections systemwise)

Histology

I did not pay any attention to this subject during my freshman year but I would suggest that in order to be better in your 2nd-year sub – pathology which involves a lot of histology you should be knowing at least the basic histology of all the systems. I used my histology journal provided by our college which was descriptive enough. The recommended book for histology is Atlas of Histology with functional correlations. 

Embryology

A very important subject which you would want to learn it all. Recommended book- Inderbir Singh’s book of Embryology

Additional resources or USMLE – OSMOSIS videos.

IT IS A VERY IMP SUBJECT!!! You cannot miss out on any details.

I know first year will be a little difficult for you to manage with in the beginning but you will surely figure it out and do not miss out on these minor subjects ( histo & embryo) which I did and would not want you guys to make that same mistake.

PHYSIOLOGY

Recommended books : 

– Guyton (best for understanding)

–A.K.Jain (best for descriptive questions in exams)

Additional resource for USMLE :

• BRS physiology
• OSMOSIS videos(again system wise physiology available)

Okay so there is a lot of confusion between which book to be used out of these three. I will recommend what I did was that I used Guyton to understand the topics which I found difficult but I mostly read A.K.Jain as it was good to write up the descriptive questions( which my seniors told me).

I found about BRS physiology recently when I started preparing for USMLE it is almost a shorter version of A.K.Jain and I would recommend if any of you would want to go for it instead of A.K.Jain.

Also, I would like to mention that DO NOT GO FOR SEMBULINGUM!!! It’s an easy-going book that you can use to pass a test the next day but I am sure you would want to work more on clearing the concepts so a humble request to not use that book.

BIOCHEMISTRY

This subject would really get on your nerves. Not to scare you but it’s a little boring as well as a detailed subject.

Recommended books:

• Lippincott (I didn’t use it but our professors recommended)
• Satyanarayan ( Used it found it to be very good)

Additional resource for USMLE: Dr.Turco videos of Biochemistry Kaplan 2014 ( the best videos that can even surpass Lippincott)

Good for biochemistry as well as Genetics which would be included in USMLE and just some part of genetics in your 1st year.

I would highly recommend if you could watch these videos and do Satyanarayan you  will be good to go.

Once you are done with your first year of course you can take a break but what I would suggest is to take a month or two from your second year beginning and read FIRST AID USMLE biochemistry section, anatomy and physiology sections (systemwise) You can practice the Mcqs from –  Kaplan question banks

• Usmle Rx 
• UWORLD (offline)

Lastly I just want to mention that these subjects will form your base and you should be clear will them and on point as it will be helpful in future to understand the concepts of subjects in your successive years. I would make another post for 2nd, 3rd and final year subjects with simultaneous integration of USMLE preps. Do mention in the comments if you need me to post anything specific.

All the best for your preparations.

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About the Author

Dr.Khyati Patel, an IMG interested in helping other IMG’s especially the freshman year, shares with us ‘How can I start preparing for USMLE from the first year of medical school?’ so that you can start your preparations well beforehand with just the right resources and making a stronger conceptual base.

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If you have any questions, use the comments section below. For personalized consultation and help with your timeline, resources and strategies, fill out the consult request form and I will get back to you.

To submit your USMLE experience, go to the Contribute page. Your experiences can help other IMGs in their journey! You can also email us at theindianmedicalstudent@gmail.com

One of the most widely accepted definitions of Pain given by The International Association for the study of pain is ‘’an unpleasant sensory & emotional experience associated with actual or potential tissue damage , or described in terms of such damage’’.

Everything from our genes to our psychological makeup can affect our sensitivity to physical pain. What might be considered one person’s niggle might be another person’s nightmare! A simple blood pressure cuff with increasing pressure may cause tingling pain in those susceptible and might not be discomforting at all for a few.

Thus what can be deciphered as a baseline to this is that “pain threshold “(the level at which we feel a stimulus is painful)  & ‘’pain tolerance” ( how much a person can take pain before breaking down )  aren’t always the same.

For example, chronic pain patients can have a lower pain threshold because they process pain very quickly, but a higher pain tolerance as they are used to living with pain and adapted to it. Pain itself is not just a reflection of noxious input but also an expression of plasticity in the brain.

Factors affecting pain perception in individuals includephysical, psychological, emotional, neurological & genetical, cultural, lifestyle induced to name a few.  The reason why some people are more sensitive than others comes down to how our body modulates pain — from the skin to the brain — and the structure of the brain itself.

Reasons

It all begins with a bunch of sensory receptors (known as nociceptors) detecting an unpleasant stimuli. These are transformed into pain signals that are then conducted throughout the central nervous system via a series of ‘pain pathways’.

There is a pathway that falls from the periphery (the skin), into cell bodies contained in the ganglion and up the spinal cord. From there, the fibres ascend to the brain. Firstly, individuals each have a different expression of the receptors that respond to a particular stimulus — whether this be thermal (for example, heat) or mechanical.

Secondly, the pain pathways are complicated. In each of these layers through which the information passes, there can be some modulatory effects (even in the cortex in the brain) that either reduce or increase the level of pain experienced. This is where our emotional status comes in. There are connections between various areas in the brain that can modulate this system as well.

Factors associated with chronic pain can be modifiable or non modifiable.

Modifiable Factors

1. Pain: It is perhaps the most important clinical risk factor for chronic pain. The more severe the acute pain, greater the number of pain sites, the more likely it is that chronic pain will develop

2. Mental Health: Anxiety, depression & catastrophising beliefs about pain have been associated with poor prognosis in patients with chronic pain.

3. Multimorbidities: Upto a Third of people with coronary heart disease experience chronic pain & almost a similar percentage of patients with chronic obstructive pulmonary disease experience similar symptoms. Conditions like diabetes, hypertension have shown to reduce pain thresholds.

4. Smoking: Heavy smokers tend to report more pain locations and increased intensity compared with those who have never smoked. Although some have postulated  that the direct aversive physiological effects of smoking cause or aggravate painful conditions , concurrent depressive symptoms may also mediate the effect of smoking on chronic pain outcomes.

5. Obesity: The relationship is much more complex than simply mechanical overload where familial (environmental & genetic) are significant contributors to the association. It is the impact of pain on functional status and health related quality of life that is greater in the obese than in those with normal BMI

6. Nutrition:  findings from a recent research suggest that dietary omega-3/omega-6 ratio may have significance for inflammatory pain. Increasing omega-3 intake (found in fish) reduces patient-reported joint pain intensity, morning stiffness and the number of painful joints in patients with rheumatoid arthritis or joint pain secondary to inflammatory bowel disease.

 Knowing that the central nervous system has specific nutritional requirements, clinical studies suggest that reducing polyamine-containing foodstuffs (e.g. bran, nuts, soyabean) may reduce hyperalgesia and has shown some early promise in cancer patients with metastatic disease.

Other dietary constituents that show early promise include some flavonoid compounds, alpha-lipoic acid (found in broccoli, spinach, yeast) and vitamin E for diabetic neuropathy. 

On the other hand, there is some preliminary evidence to show that medically supervised modified fasting (300 kCal/day) for a defined and limited period (7–21 days) could be useful as an adjunctive therapeutic approach to enhance mood in chronic pain patients who are often affected by depression and anxiety.

Non-modifiable factors

1. Old age :  There is generally a higher prevalence of chronic pain in old age,and the occurrence of more severe disabling chronic pain increases with age.

2. Female sex: Chronic pain syndromes generally have a higher prevalence in women. They are found to have lower pain thresholds and lower pain tolerance, experience greater unpleasantness (or intensity) with pain and have different analgesic sensitivity.

3. Influence of ethnicity and cultural background: Pain is a complex personal experience influenced by multiple interactive biopsychosocial processes. However, there exists a similarity in the prevalence of chronic pain between developed (37%) and developing countries (41%) according to WHO World Mental Health Surveys.

4. Genetics: It is clear that there is no unique ‘pain’ gene, but that a complex combination of genetic factors interacts with the psychosocial and lifestyle factors to produce chronic pain. Genes may act at a number of levels to influence the expression of chronic pain, including biological processes and behavioral and emotional responses. Identifying specific genes and their roles, and distinguishing these from other sources of variation (gender, ethnicity, socio-cultural, psychological, etc.) is currently an important challenge.

Take home messages

• The existence of both individual-level and population-level risk factors for the onset or persistence of pain suggests that opportunities for intervention exist at more than one level.
•  Chronic pain management dominated by analgesic medication will fail to address adequately the role of activity, psychological factors and social factors in maintaining daily function.
•  Clear opportunities exist for all health professionals to facilitate changes in lifestyle that have the potential to improve morbidity and function in patients with chronic pain, simultaneously reducing the risks and impact of common co-morbidities.
•  Further research is required to identify the most effective approaches, and this should be a priority for all health services.

This article has been written by Dr. Aishwarya Aiyar who is a Physiotherapist from Seth GS Medical College.

Ask your questions/ Comment in the Comments section below.

The most common tumor of the urinary tract is transitional cell carcinoma. It is associated with Phenacetin, smoking, aniline dyes and cyclophosphamide.

Squamous cell carcinoma is due to chronic irritation of the bladder as seen with S.Hematobium infection, chronic cystitis and smoking.

Renal cell carcinoma is the most common primary renal malignancy. Gene deletion on chromosome 3. Often golden yellow due to high lipid content. Can present with hematuria, palpable flank mass, secondary polycythemia. Associated with paraneoplastic syndromes.

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Post-graduation is the next step for most MBBS students. Becoming a surgeon, a physician, a paediatrician, etc is something we have dreamt of since our childhood.

Today, what stands in our way like a seemingly insurmountable wall is NEET PG. (1.5 lakh doctors will appear for this exam, and seats are limited.) 

Final year and internship are easily the toughest 2 years of MBBS.  Everyone works hard more or less. So, what should be your plan?  How to crack NEET PG and remain healthy and fit at the same time?

First, I will elaborate the broad strategy for Cracking NEET 

Fundamentals

The foundation of your knowledge will be laid in the years of MBBS. Here comes the role of standard books – Robbins, Harrison, Bailey, Reddy, etc.  Books which might not fetch you marks in University exams but are needed to build your concepts.

Study Material

Once you are in internship, you will have to choose your study material.  It depends on whether you have joined any class or are going to do MCQ books. Both are equally good – I had joined Dams in 3^rd minor and used MCQ books during internship.

The most important thing is stick to the same thing!

Either, class notes or MCQ books. Revise from the same source again and again. The material is not inadequate.

Number of revisions

You should do at least 3 revisions before the exam. Some might even go for a fourth (like I did for short subjects). You can plan a 6, 2,1 schedule (months) or a 5,3,2. Anything that works for you.

The most important thing here is Speed.

I had set a target of 100 pages per day.  Do big subjects like Medicine, Surgery, Pathology in 15,5 and 2 days for 1st, 2nd and 3rd revisions respectively.

Giving Mock tests / Grand Tests

Once you have finished 1st reading, you can start giving Mock tests or GTs – Dams / Bhatia / marrow / prep ladder etc.

Tests serve many purposes – time management, identifying your strong and weak subjects, getting an idea of number of negatives so you don’t attempt too much or too less. You should reach 200 positives at the least for a good rank.  Then try to slowly minimize your negatives.  That will improve your rank.

Identify your strengths and weaknesses

During 2nd revision, you know what subjects you are weak at. Revise them more. Give them more time.

By this time All India mock tests will be conducted – around September.  You might not finish your 2nd revision by then but it’s OK! You might not get a good rank but that’s also OK. 

If you are within 3-4K you have a very good chance of improvement.  I myself jumped from 3K in CBT (Conducted by DAMS) to 53 in NEET PG.

The last month

You should focus on high yield subjects and topics. Dermatology, psychiatry, biochemistry, anaesthesia, FM, are subjects that can be quickly revised entirely.

For other bigger subjects be selective. Read high yield notes, tables etc.  You may even leave a big subject like Medicine. But among the final year subjects do OBGYN well. 

A few days before exam

Revise only high yield things. Do tables, markers, genetics, chromosome numbers, etc. Stay calm, everyone is going through the same stress.

The one who handles it well in the last moments will win.

On the day of the exam

Read till the last moment – you never know!  What you read a few hrs before can be asked in the exam.  And in such exams even 1 mark can mean a rank difference of 100

How to Remain fit during this 1 year?

Most people will ignore their health.  Internship is stressful, you might not get time to sleep, eat, exercise. But, try to manage whenever you get time. Exercise has many benefits – it keeps your mind fresh and body healthy.  

From my personal example – I am a cyclist, trekker and gymmer.  At the start of internship, I completed Mumbai – Goa solo cycling – 523 km in 5 days which was my long-held dream. 

As monsoon came, I went on treks – any holiday I could find in the busy schedule, I would go on a trek and come with a fresh mind.  Nature does heal you.  I did 6-7 treks in monsoon alone.

Walk whenever you can, avoid cabs for short distances. Say no to alcohol or smoking.

For being fit, you might not get time, but there are certain things of omission – Avoid junk food, too much oil and salt is not good.  Avoid free sugar in the form of Soft drinks. These you can easily manage.  

Today the risk of sudden cardiac deaths, chronic diseases, are all rising. Doctors are an especially high-risk group. Despite knowing this fact, if we don’t change our lifestyle then that’s the most idiotic thing possible.

One exam doesn’t decide your future.  But bad health will eventually. Longevity is more important in our field.  And for that one must be fit.

Value yourself!  Your body and mind are precious! Success will come sooner or later.  Don’t spoil your health for your rank.  Both can be achieved together like I did.

All the best! The society and India need you Doc!  

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This article has been written by Dr. Abhijeet Shukla who is an intern at Seth GS Medical College, Mumbai. He scored an All India Rank 53 in NEET PG 2019. Dr. Abhijeet Shukla is an avid cricketer, trekker, cyclist and gymmer.