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Sunday, November 14, 2010

MRCP 1, First hand experience

 The original article can be found here.

The MRCP(UK) Part 1 Examination has a two-paper format. Each paper is 3 hours in duration and contains 100 multiple choice questions in one from five (best of five) format, where a candidate chooses the best answer from five possible answers. Candidates will be tested on a wide range of common and important disorders in General Medicine as set out in the published syllabus.

The Examination may include pre-test questions (trial questions that are used for research purposes only).

The composition of the Papers is as follows:

Specialty Number of questions*

Cardiology 15
Clinical haematology and oncology 15
Clinical pharmacology, therapeutics and toxicology 20
Clinical sciences** 25
Dermatology 8
Endocrinology 15
Gastroenterology 15
Neurology 15
Ophthalmology 4
Psychiatry 8
Renal medicine 15
Respiratory medicine 15
Rheumatology 15
Tropical medicine, infectious and sexually transmitted diseases 15
* This should be taken as an indication of the likely number of questions - the actual number may vary by up to 2.

** Clinical sciences comprise:
Cell, molecular and membrane biology 2
Clinical anatomy 3
Clinical biochemistry and metabolism 4
Clinical physiology 4
Genetics 3
Immunology 4
Statistics, epidemiology and evidence-based medicine 5

for preparation u need Philip A Kalra as the prime book of medicine and rest is all about practising as much EMQs as possible from some recommended websites.these
outov these onexamination and passmedicine are specially good ones.
i also used 2 books consisiting of past papers one ov them was Benyamin and other was some pastest book.................this stuff is more than enough if u want to go forit..U can also use USMLE 1st AID step 1 for basic Sciences............i think if u go quite relaxed 3 months would be an apprpriate time or prep.Good luck

Thursday, September 23, 2010

An Immigrant's Perspective of AMC and Practice in Australia

 The original article can be found here.

Hi Everyone:

There are a lot of questions and opinions posted on this site. Time for a new forum and leave this one just for the MCQ?

I am just going to give my perspective here. Maybe it will help someone decide whether to come to Australia.

1. Why Australia for you?

Oz is not a bad place to live. It's pretty safe and clean. But it can also be quite boring. If you come here, you are uprooting yourself, saying goodbye to your family and friends, to a strange country where people speak a different language and have no appreciation of who you are, and, unfortunately, the undercurrent of racism is still quite strong here. However, you can strike it lucky and make some good friends here. Most Aussies are simple people, but they are generally stand-offish.

The pay for doctors is not bad compared with most of the world, but there are many other western countries that pay doctors better. Even some developing countries pay doctors better than here. So forget about making a giant fortune. You will be very comfortable as a doctor in Australia financially, but life will not be extravagant. If you want to be a gazillionaire working as a doctor, then you'll need to fight to get into a surgical specialty (see later).

The working environment here is quite different from many parts of the world. In many places, the doctor is god, and patients shut up and listen. Here, it's the other way around. The patient expectation is very high here (not as high as the USA thank goodness). A lot of it depends on your interpersonal abilities. If you speak English very well without much accent, can build relationships very easily with patients, and have strong medical knowledge, it's not bad. However, many overseas-trained doctors fail miserably because they have no interpersonal skills. Aussies are very intolerant of other English accents - even Kiwi accents! Ask yourself if you are the kind of person who can put up with spending two hours with an anxious patient to consent for a minor operation. If you are not, think again about coming here.

Career-wise, I can guarantee right here and then, that your career will suffer a setback for years. (Unless you are invited here as a postgraduate fellow or specialist, which is a totally different story). See later regarding training.

So coming to Australia? I suggest you talk to as many people as you can before jumping on the boat. There are more than 3,000 overseas-trained doctors working in Australia. Obviously there will be some success stories and some disasters. It's not for everyone. So always find out more before you go.

2. Demand for Overseas-Trained Doctors in Australia

If you are a recent medical graduate, you have until NEXT YEAR to come to Australia, pass some parts of the AMC and get general registration. The reason for this is the federal government has set up a huge number of new medical schools in every little town that has a service station and a pub, basically due to a political demand. The result is that in 2009, DOUBLE the number of medcal graduate will come out of Australian medical schools, and by 2012 the number will more than TRIPLE. What this means is the Australian system can't even absorb the new "tsunami" of graduates and offer them qualit internships, and we will probably be an exporter of medical graduates rather than importer. So if you are a recent graduate with little experience and you desperately want to come to Australia, NOW is the time to come. The gate will be forever shut afterwards. They are already talking about cancelling contracts of OTDs who don't have the AMC exams and general registration.

If you are a registrar or specialist level doctor overseas, then you have more time until the tsunami of Australian graduates becomes more senior.

Of course, if you are a GP and want to go out to wop wop (Australian word for middle of nowhere out in the country) to fill an "Area-of-Need" job, they will always take you with both hands. Every state medical board will give you registration on the spot. The problem is, why would you want to go out there when Australians themselves would rather die or fly overseas? These are isolated little towns somewhere in the dust bowl, with little clinical support, no educational opportunities, no chance for specialist training, nothing. Imaging yourself sitting there, having to deal with multi-trauma, obstetric emergencies, paedatric emergencies, and everything else that comes through the door. You make one mistake and one patient complains, you lose your registration from the medical board. You are on call 24 hours a day, 365 days a year, with no break, no holidays, little sleep. Not many people last long in this sort of job. But there are plenty of this kind of jobs going around if you are interested. Just ask anyone.

An additional complication is the UK's Foundation Program and "Modernising Medical Career". It's such a big disaster there that there could be a huge exodus of UK junior doctors to Australia. Of course, they will be taken preferrentially over someone whose English is a second language and has not got white skin. We will still have to wait to see if the flood eventuates.

3. Exams

An oddity, but true. The AMC exam is TOTALLY UNNECESSARY to get a job as a doctor in Australia. I find this very odd as how can you guarantee the quality of doctors coming in, even though the AMC exam is by no means perfect? But desperation for doctors in the "Area of Need" positions means you can go for years without even thinking about it. In the hospitals, it depends on how desperate they are. My feeling is they will become a lot less deperate because of the tsunami of Australian medical graduates.

So if you get into the system and plan to spend more than 2-3 years here, it's worth thinking about passing the AMC. If you want to migrate, the AMC is a must.

The AMC exams are tough but not impossible. If you are smart and willing to spend time studying lots and lots, you will pass. A note of caution - it's great to have lots of old MCQ questions from the website. However, they only indicate the KIND of questions you will be asked. They hardly ever repeat a question, and when they do, they change one or two words in the question so the correct answer it totally different. Therefore, use the questions on the website as a guide only. There is no substitute for solid knowledge.

The clinical exam is very cultural. You need to have very broad medical knowledge, but the interpersonal aspect of interacting with the patient, as well as the exam techniques to pass a viva, are more important. But with practice, all can be overcome. It's just a show.

4. Specialty training

In Australia, specialty training is generally competitive. With the new tsunami of medical graduates coming, the specialist colleges have done very little to open new training positions. So getting into specialty training (including GP) will be harder and harder.

The difficulty of getting into specialty training is directly related to income. In Australia, procedurist are the multi-millionaires, so anything to do with procedure earns lots of money. That's why in specialties such as surgery and ophthalmology, you can forget about it as overseas-trained doctors. Racism is deeply entrenched in the medical hierarchy. In fact, even a white Australian graduate has little hope of getting into ophthalmology if his father is not an ophthalmologist. Just look at the surnames of ophthalmolgists. Nepotism is the word. The same goes for popular internal medicine subspecialties such as gastroenterology and cardiology. If you don't have the right surname, it's tough. Forget about these popular specialties if you dream of specialising in them. Better off doing it at home.

In some less popular specialties, anyone half-decent can still get in without much trouble. These include pathology, psychiatry, medical administration, public health, sexual health, etc. So if you are interested in one of these, you still have a future, although I don't know what will happen when the "tsunami" of medical graduates hits us. My feeling is they will probably all be swallowed up in 3-4 years' time.

So do you think you can come here to get into a good specialty for training and career advancement? Think again. Think again. Australia uses OTDs for labour and pays little regards to their development, welfare, training, etc. But there are exceptions. Sometimes people do get through. They are the rarity rather than the norm.

5. Where to work?

This is a very difficult question, and there is no right answer.

I have been in hospitals where the majority of doctors are OTDs. Some places treat them well, give them lots of help in passing exams and mentorship for furuture development. Some places treat them absolutely miserably. They are chucked into jobs no one else wants with no support or supervision, basically set up to fail. I have seen a young Pakistani doc, the day after arriving in Australia, thrown into a rehab ward with 40 80+-year-olds, each with five pages of medications, with NO CONSULTANT AND NO REGISTRAR. He killed a couple of them. Lucky they were old anyways. A Phillipino girl was thrown into two months of night ward-call the day after she arrived in Australia, of course again without any type of orientation and supervision. It's just appalling.

Don't think the major tertiary hospitals are heavens. They can have grossly excessive workload. And their super subspecialisation and impersonal nature may not be so good for passing exams. Because they are staffed mostly by Australian-trained doctors, they are normally unsympathetic to the needs of OTDs.

The suburban and regional hospitals vary a lot in quality and support for OTDs.

In the Area-of-Need positions, the support is extremely variable again. You maybe ver lucky in a town with 3-4 others who work really well as a team, share the on-call and do not hesitate in supporting you. Or you can end up in a one-doctor town where you are it, good luck.

The gist of the story is: ASK before you jump. Check out the place that give you an offer. Ask for statistics. Ask for rosters. Ask them what support they have for you. And most importantly, ASK to talk to the OTDs on the ground there.

So does Australia still appeal to you? Is it the right thing to do? There is no exact right answers, and everyone is different. There are more than 3,000 OTDs working here. Some love it, some hate it. Some find it enjoyable and have no problem fitting into the system and society, and some struggle a great deal. Occassionally there are big disasters.

I hope this information/opinion help people a bit.

An immigrant, and proud of it.

I think you have given a fair perspective of the picture.

My background is Asian, non white, non Indian. I qualified in medicine from a prestigious UK university, am a Fellow of a British College and hold GMC Specialist Registration and came to Oz in 2003 from a UK locum consultant post under a 422 Visa in an AON programme as a specialist in a Regional hospital. My speciality is a non procedural one.

When a local Ozzie qualified, she "eased me out" using a political move by getting the DMS to express concerns about me. This misinformation led the College to postpone my recognition and required a transfer to a Metropolitan hospital for another 6 months.

This is near impossible as no metropolitan hospital will employ a specialist without a provider number or an Australian fellowship: I was given 5 years to achieve this after which "the College will have the right to impose new conditions"

I obtained good support from the AMA for this injustice but the pay off midway through the contract was only 3 months instead of the full contract.

I put up my hand and volunteered for a part time paid post but did full time and following some haggling with DIMIA, obtained a 457 visa and completed the 6 months. The Medical Board then immediately cancelled my registration - as I had completed my requirements - and, this was in a state desperate for doctors.

The College still imposed caveats on my specialist recognition and caused me numerous problems with registration in another state....I obtained conditional specialist registration in NSW without conditions but the College continued to disturb me and disclosed my difficulties with them to my employer. I appealed and after 3 months a new committee completely threw out the caveats imposed by the Censor.

By that time, the damage was already done.

My employer, a regional hospital, gave me a one year contract with a variable part time/full time involvement as a Level 1 Staff Specialist (few OTDs would know exactly what this meant) and seconded me to a privatised clinic without my knowledge or consent.

Within several weeks, Medicare Australia rang me to caution me regarding 'defrauding the system' When I brought this up with my employer, the manager ordered 'disciplinary action' against me.

I received no warning letter about 'concerns' expressed about me and after 8 weeks from the start, I was suddenly suspended and an investigation launched against me.

My case was reported to the Medical Board as a 'high risk' concern not unlike that of Dr J Patel's case.

I was left high and dry to defend my case as the AMA/ASMOF policy was not to assist with cases which are reported to the Medical Board. My legal bill has exceed AUD 50K and I am still repaying it.

To cut a long story short, there were 30 odd published allegations against me, with 28 by the CNC. All but 3 allegations were substantiated. Those substantiated were related to

1. A post anaesthetic case where I was accused of having poor communication with a pt !

2. Two other consultation cases also related to poor communication and poor judgment

The report also described gross dysfunction in the privatised unit. It also raised a possibility that I was paranoid and mentally impaired!!!

Meanwhile, Medicare Australia bulk billing reconciliation statements revealed irregularities of fraudulent claims.

Also, because of the inconsistent work hours given to me, I had complained to DIMIA and my 457 Visa was cancelled. I did not renew my medical Registration.

After I filed the response to the investigative report, my contract was terminated as I did not possess registration (in response to no right of work)

My Solicitor who initially did a good job in drafting my response, took the case to Industrial Court and despite reconciliation attempts, did not work. A hearing led to a determination that I was not dismissed and that I had myself ended the contract by not maintaining my registration.

If I had done so, I would be the subject of a Performance Inquiry which would most certainly have led to further conditions being imposed on my registration.

Meanwhile, I rang 3 patients whose "complaints" had been "substantiated" to genuinely apologise BUT to my surprised realised from them that they had NOT complained about me but that the allegations had been falsified.

Two gave me Statutory Declarations and I made a report to state Police. They have asked the Complaints Commission to completely review the matter (This is a statutory body which is above the Medical Board) and to refer it back to the Police if they found it appropriate.

The case is ongoing with my having been nearly bankrupt with no employment, no certificate of good standing to move on and a huge legal bill. Medicare and the Director General of Health's office continue to inquire into the matter.

I had to leave the country to seek employment elsewhere where I had maintained my registration. I am just recovering but as my family had settled down to study, I left them there - under International Student Visas.

The Shadow Minister of Health recently expressed grave concerns this has happened to an OTD who was vulnerable. It was promised that the Health Minister will be asked to look into it. I am not sure whether this interest is related to opportunities in gaining some political mileage in the forthcoming elections.

The other side is trying hard to divert attention from its alleged malpractice of alleged fraud using an OTD's Specialist Provider number to cost shift from the State to the Commonwealth (Federal) Govt.

This short stay of 4 years in Australia has been the most traumatic in my professional and personal life. Unlike our friend the Immigrant, I did not succeed in staying in Australia although I did succeed in getting recognised as a specialist.

Be warned. There are many ingrained racists. I came with an open mind that Australia is not racist. I have found that racism is prevalent and tolerated. There are also some very nice non racist people. But, you would not find out till you are stung. And, when you come in, they make it a point to make you vulnerable to all sorts of issues.

Dr Haneef's case was the worst but at least he had publicity and some public support: mine has been covered up all along the way.

I also know of another non white doctor from South Africa in my same place of work who suffered a similar fate: his case was publicised in the National Press and his name was removed from the Medical Register: when they found out that they had acted on misinformation, there was no apology but just a simple invitation for him to reregister to work under supervision in an approved hospital.

He did not, registered as a teacher (he was a trained teacher) and earned his keep that way. He has since made plans to return to South Africa.


Tuesday, August 31, 2010

Practicing in Dubai Health Care City

            Dubai is the cosmopolitan hub of the middle east. With projects like Dubai Health Care City, it has opened new doors for doctors. I have been looking up for stuff online about it but like everything else, there is so much stuff that it gets really hard to decide. So I came across this really detailed article about practicing at DHCC. Some of the important points are:

The following examinations have been designated as DHCC Approved Physician Exams:

• Australian Medical Council Exam – • TRAS (Ireland -Temporary Registration Assessment Scheme) Parts I, II, and III –

• PLAB (UK) Parts I and II –

• USMLE (US) Parts I and II (CK) –

• Applicants certified by ECFMG are eligible for consideration without being required to pass an additional examination.

• Applicants who have passed Parts I and II of the Royal College exams are eligible for consideration without being required to pass an additional examination.

• Applicants who have passed the Medical Council of Canada Qualifying Exam Parts I and II are eligible for consideration without being required to pass as additional exam.

The following countries have been currently designated a DHCC Approved Country for Physician Licensing: • Australia • Italy • Switzerland • Austria • Japan • Taiwan • Belgium • Luxemburg • Turkey • Canada • Monaco • United Kingdom • Denmark • Netherlands • United States • Finland • New Zealand • American University of Beirut (chartered) • France • Norway • Germany • Singapore • Greece • South Africa • Hong Kong • Spain • Ireland • Sweden

The full article can be viewed here.  

The official website of DHCC can be accessed here. 

A Fictional Doctor, Who's an Inspiration for Real Doctors!

         He's bitchy! He's sadistic! He's mean and he's Dr.House. How many of you are hooked to that show? God so many hands raised that I can't even count! So I came by this page with many funny illustrations of our hero, thought would make a good share.
Click to enlarge
Click to enlarge

Sunday, August 29, 2010

PLAB Registeration and Exam Pattern

How to approach the PLAB examination?
You will have two answer sheets on the day – a purple one for questions 1-100 and a pink one for questions 101-200. Instructions on how to complete the answer sheet are at the top of the first sheet.

Extended matching questions
Extended matching questions are grouped into themes. Each theme has a heading that tells you what the questions are about.

Within each theme there are several numbered items, usually between three and six. These are the questions and the problems you have to solve. There are examples in the next section.

We recommend that you begin by reading carefully the instruction that precedes the numbered items. The instruction is very similar throughout the paper and typically reads ‘For each patient described below, choose the SINGLE most discriminating investigation from the above list of options. Each option may be used once, more than once or not at all.'

We recommend that you consider each of the numbered items and decide what you think the answer is. You should then look for that answer in the list of options above the items (each of which is identified by a letter of the alphabet). If you cannot find the answer you have thought of, you should look for the option which, in your opinion, is the best answer to the problem posed.

For each numbered item, you must choose ONE, and only one, of the options. You may feel that there are several possible answers to an item, but you must choose the best one from the option list. If you enter more than one answer on the answer sheet you will gain no mark for the question even though you may have given the right answer along with one or more wrong ones.

In each theme there are more options than items, so not all the options will be used as answers. This is why the instruction says that some options may not be used at all.

Alternatively a given option may provide the answer to more than one item. For example, for two different patients the most likely diagnosis could be the same. In this case the option would be used more than once.

Sample extended matching questions
Causes of pneumonia
  1. Bacteroides fragilis
  2. Coxiella burnetii
  3. Escherichia coli
  4. Haemophilus influenzae
  5. Legionella pneumophila
  6. Mixed growth of organisms
  7. Mycobacterium tuberculosis
  8. Mycoplasma pneumoniae
  9. Pneumocystis carinii
  10. Staphylococcus aureus
  11. Streptococcus pneumoniae

For each patient described below, choose the SINGLE most likely causative organism from the above list of options. Each option may be used once, more than once, or not at all.
  1. A 25 year old man has a three day history of shivering, general malaise and productive cough. His chest x-ray shows right lower lobe consolidation.
  2. A 26 year old man presents with severe shortness of breath and a dry cough which he has had for 24 hours. He is very distressed. He has formerly taken intravenous drugs. His chest x-ray shows bilateral peri-hilar hazy shadowing.
  3. A 35 year old previously healthy man returned from holiday five days ago. He smokes 10 cigarettes a day. He presents with mild confusion, a dry cough and marked pyrexia. His chest examination is normal. His chest x-ray shows widespread upper zone shadowing.
  4. A 20 year old previously healthy woman presents with general malaise, severe cough and breathlessness which has not improved with a seven day course of amoxicillin. Physical examination is normal. Her chest x-ray shows patchy shadowing throughout the lung fields. The blood film shows clumping of red cells and cold agglutinins are present.
  5. A 55 year old farmer presents with a five day history of fever, malaise, muscle pains and headache. He has an irritating but non-productive cough.

1. K
2. I
3. E
4. H
5. B  

Single best answer questions
We recommend that you consider each of the questions and decide what you think the answer is to the question given at the end of each scenario, which typically reads ‘What is the SINGLE most likely diagnosis ?'. You should then look for that answer in the list of options below (each of which is identified by a letter of the alphabet). If you cannot find the answer you have thought of, you should look for the option which, in your opinion, is the best answer to the problem posed.

For each question, you must choose ONE, and only one, of the options. You may feel that there are several possible answers, but you must choose the best one from the option list . If you enter more than one answer on the answer sheet you will gain no mark for the question even though you may have given the right answer along with one or more wrong ones.

Sample single best answer questions
A 55 year old man presents having recently noticed a lump in his right groin. He smokes heavily, has a persistent cough and has previously had an appendicectomy.

What is the SINGLE most likely diagnosis?

A Epigastric hernia
B Femoral hernia
C Incisional hernia
D Inguinal hernia
E Spigelian hernia

Answer 'D'

How can I register for the PLAB?
To register for PLAB 1, applicants can either send their forms with required documents to their local British Council office or register on-line.

Visa, Fee and Other Issues About PLAB

What type of visa do I need to apply for PLAB 2 examination?
You need to apply for a visitor's visa. 

I was refused a visa for PLAB part 1. Will it effect my visa application for PLAB part 2?
It depends on the reason for refusal, but if it was only because part 1 could be taken in your home country then it is unlikely to have an effect.

Is the result of PLAB 1 better in UK. Compared to overseas centres?
It may be true that result is better in UK. But this is due to the fact that most of candidates who have come to UK. To take the exam are more serious and well prepared and may be availability of good quality material.
What is the fees for Plab test?
PLAB Part 1-£145.00
PLAB Part 2-£430.00
Is it better to take exam in UK than in Pakistan or in any other country?
There is no difference in standard of exam between these centres, and now there are some good courses conducted in Pakistan. We advice to take Part 1, in Pakistan as there is no added benefit of taking it in UK. It is an extra expense of around £1200 for every attempt you take. There will be a gap of at least 3-4 months between the exam dates and it is traumatizing to stay in a new environment.

Is it easier to get a job if one has a post graduate experience.
To get a training post, post graduate experience is not a must, it differs with the hospital. Some hospitals may prefer experienced candidates where as some other may prefer fresh candidate. Postgraduate experience helps in getting a Locum jobs rather than a training post. So it may be easy to get the first job (as locum) if one has postgraduate training.

What are the benefits of having a post graduate training before coming to UK.
If one is interested in the specialties like Medicine, Surgery, OBG, Paediatrics, where the chances of getting a registrar training is less, it is better to have a post graduate training in Pakistan (or in your country) in that specialty before coming to UK. Idea is not to increase the chances of getting a registrar post but to safeguard your self. If you start your SHO training after MBBS and could not manage to get in to registrar training, you may feel that your training is not complete and you will be left with the option of getting in to a staff grade job. Or to go to some other country for training.

Introduction to PLAB

Click here for the original article.

What is PLAB?
PLAB means Professional and Linguistic Assessment Board. General Medical Council (GMC) of United Kingdom conducts this test to ascertain the suitability of an overseas doctor to work safely in a first appointment as a senior house officer in a British hospital. 

Who is required to take this test?
All Overseas doctors who are seeking limited registration must first pass, or be exempted from the Professional and Linguistic Assessment Board (PLAB) test conducted by the GMC (General Medical Council), which is the statutory body responsible for the regulation and standards of the medical profession in the United Kingdom. In order to carry out any sort of medical work or training, a doctor must first obtain registration with the GMC.

What is the test like?
The test assesses suitability to undertake hospital employment at Senior House Officer level (SHO) in a UK hospital by examining the candidate's medical knowledge and clinical and communication skills. In recent years the exam has tested clinical problem solving across specialties and has moved away from simply testing factual recall. To pass this exam you should become familiar with the style of question and identify your areas of weakness - not simply try to memorise past questions!. The PLAB test currently consists of the following examinations.

Part 1 is conducted in the UK as well as in some other countries including Pakistan and consists of 200 questions in Extended Matching Question (EMQ) and single best answer format. It lasts three hours. The proportion of SBA (Single Best Anaswer) questions may vary from examination to examination but no more than 30% of the paper will be composed of SBA questions. The emphasis of the test is on clinical management and includes science as applied to clinical problems.
  • The test is confined to core knowledge, skills and attitudes relating to conditions commonly seen by the SHO's to the generic management of the life-threatening situations, and to rarer, but important problems. It will contain 200 questions, dividing into a number of themes. The duration of the test will be three hours.
  • The United Kingdom’s international organisation for educational and cultural relations. Registered in England as a charity.
  • Extended Matching Question: For each group of questions there will be a list of options. Candidates are required to select the most appropriate option for each question.
  • Single Best Answer: Consider each of the questions and decide what you think the answer is to the lead-in question given at the end of each scenario, which typically reads ‘What is the SINGLE most likely diagnosis?’ You should then look for that answer in the list of options below (each of which is identified by a letter of the alphabet). If you cannot find the answer you have thought of, you should look for the option which, in your opinion, is the best answer to the problem posed.
  • One mark is awarded for each correct response, but no marks are deducted for any incorrect answer. Candidates will be required to enter their responses on special answer sheets, which can be read by an optical mark reader. The examination will be marked by computer. (Please contact the GMC for further information on the new test).

Part 2 is only available in the UK and takes the form of Objective Structured Clinical Examination (OSCE), which includes an assessment of clinical and communication skills. It takes the form of 14 clinical scenarios or ‘stations', a rest station and a pilot station. Each station lasts five minutes. You must pass Part 2 within three years of passing Part 1. You must be granted limited registration within three years of passing Part 2 of the test.

Is IELTS compulsory for overseas doctors to take PLAB?
Yes, from January 1997, the IELTS became a pre-requisite for admission to the PLAB Test. The GMC will only accept the Academic module of the IELTS and test results are valid FOR UP TO TWO YEARS from the date which appears on the IELTS certificate.
(Please note that doctors who are accepted for exemption from the PLAB test are required to score 7.0 or above in each band of the IELTS test)

Can I take part 2 of PLAB before appearing for part 1?
NO. Candidates may not enter Part 2 until they have passed Part 1 and must take Part 2 within three years of having passed Part 1.

Re-sitting the PLAB test
Part 1: You can have an unlimited number of attempts but a doctor who has failed severely will not be admitted to re-sit part 1 of the test for at least four months.
Part 2: If a candidate fails, he/she will be sent forms enabling re-application for part 2 of the test. However, if the test is failed at the fourth attempt, the candidate will be required to re-sit the IELTS test and also both parts of the PLAB test (unless you are exempted).

Is passing the PLAB test guarantees the job offer in the United Kingdom?
NO. Finding a job always remained a difficult part for Pakistani and other Asian doctors and recent UK immigration legislation for doctors has made the situation worse then ever. Read more facts about how this law can effect your future
How can I best prepare for the PLAB test?
The examination is testing your ability to apply knowledge to the care of patients rather than how well you can remember and recite facts.

All the questions relate to current best practice, and you should answer them in relation to published evidence and not according to your local arrangements.

Names of drugs are those contained in the most recent edition of the British National Formulary (BNF).

Remember that you are being tested at the level of a doctor who has qualified and completed one year of clinical practice.

Specialist courses for the PLAB test are available in the UK. The courses cover either the combined English and professional component or just the English. The GMC does not inspect these courses and cannot recommend or comment on any particular course. Contact NACPME or your local British Council office for details and a list of available courses.

The Personal Statement

(The article is taken from "Another Road to Residency" compiled by class of 2003 and 2004 of Agha Khan University, Karachi Pakistan.)

                 Umbereen S. Nehal

        You should start working on this as early as possible. I revised my personal statement eight times before I sent it in. This should be what it says: “personal”. You want to describe specific experiences that inspired, motivated, shaped you. If you mention a patient, give that patient a name (make up a name if you don’t remember). After reading your PS, a person should have a sense of who you are, what your goals are, what is important to you, why you chose the field you are applying to, and what you are looking for in a residency program (you may, but don’t need to, explain why you chose medicine). You want to highlight all your strengths.
You should ask lots of people to help you edit your statement. Even if you don’t agree with that person’s advice, you should take it into consideration. Who is to say that a residency director won’t think the same thing after reading it?
DO NOT LIE OR EXAGGERATE. If you write something really impressive in your personal statement, your interviewer might just ask you about it. You should remember that doctors are not literary people. You don’t want to impress them with your vocabulary; you want to impress them with your clarity. You want the reader to remember the content, not your writing style. Americans like simple, straight-forward language so don’t make your personal statement too flowery. And try to keep your sentences short. You definitely should not exceed a page (mine seems to, but with the proper formatting, it stays on one page). [Editor’s note: Although the website gives the provision for a three page personal statement, it is an unsaid rule to keep it limited to one printed page. This will keep it crisp and will prevent rambling.] Try to avoid the passive voice; use words that are energetic and expressive. Start and end paragraphs with strong statements. Ideally, the first sentence of every paragraph should grab the reader and make him/her want to read the rest of the paragraph. Remember, residency directors read hundreds of personal statements; they only have a few minutes to spend on yours.
 It might be helpful to make an outline before starting to write, of all the topics you want to cover.
Website:The following link has some useful tips on this subject:


SAMPLE PERSONAL STATEMENT          Umbereen S.  Nehal
"Walk around feeling like a leaf. Know you could tumble any second. Then decide what to do with your time." -Naomi Shihab Nye
My decision to leave Wellesley College and attend medical school in my parents' homeland turned out to be a deeply satisfying experience. I was motivated by a desire to learn about my cultural heritage and to be closer, both physically and emotionally, to my parents. I had been at the Emma Willard School, a boarding school in upstate New York, since the age of 14. My father's job required my parents to live half a world away and I felt that I was losing touch with my roots.  While learning about my cultural heritage enhanced my personal growth, it was studying medicine in a developing country that was the most rewarding experience. I was fascinated by the spectrum of disease that existed in our patient population. The obese banker receiving streptokinase in the emergency room of the Aga Khan University Hospital presented a shocking contrast to the emaciated child with measles I saw in the community clinic. Visits to squatter settlements taught me how to prioritize care, making the best use of limited resources.  I learned how to apply my textbook knowledge to the imperfection of real-life situations. Despite the frustration of seeing patients denied care because of financial constraints, I had a sense that I was making a difference.  I felt I made a difference for Yasmeen, a 35-year old grand multipara, when I administered her first tetanus vaccine and offered contraception.  Ultimately, my five years in Pakistan gave me far more than just a medical education.
Some consider pediatrics depressing because it forces us to see children in pain or children who have debilitating illnesses. I find pediatrics uplifting because I see the resilience of a child's body and the triumph of the spirit. During my pediatric neurology elective rotation at Brown University, the child with cerebral palsy who proudly drew a picture with her foot inspired me. The most appealing aspect of pediatrics is the special relationship with the patient and the family that develops. It is a privilege to be part of the team that monitors and safeguards a child's physical, emotional, and social development.
Continued growth, especially in my professional life, is a priority for me. After completing my ECFMG requirements, I began a research project with Dr. Julie Ingelfinger and Dr. Eric Grabowski at Massachusetts General Hospital. We are studying the pathogenesis of hemolytic uremic syndrome. It is exciting to be working on an NIH-sponsored project that may contribute to a cure for the most common cause of acute renal failure in children. My research background has helped to develop my inquisitive mind, critical thinking skills, and meticulous attention to detail. At the same time, I have maintained my clinical skills by attending rounds, participating in consults, and observing clinics.
Diversity has been the cornerstone of my life.  Born in Arizona, raised in Saudi Arabia, educated in the U.S. and Pakistan, I believe I have a unique perspective.  As a teenager I worried that I would never "fit in" somewhere. As an adult I feel that, in fact, I can fit in anywhere. Because I am not defined by a single culture, I believe I can relate to almost anyone and easily build rapport with my patients and their families. During my elective rotations at Baylor University, Brown University, and at University of Texas at Houston, I recognized the importance of Spanish in the medical profession and subsequently enrolled in a language course. My recent courses in Spain and France, coupled with my fluency in Urdu, facilitate effective communication with patients. I hope to always have the opportunity to educate myself to better serve those around me.  To that end, I am eager to take on the challenges and responsibilities of residency training. I seek a program that balances academics with community exposure, that has patients ranging from Kawasaki Disease to otitis media, and one that prepares its residents to assume real world responsibilities.


When to Apply for Residency

(The article is taken from "Another Road to Residency" compiled by class of 2003 and 2004 of Agha Khan University, Karachi Pakistan.)

Applications for residency positions are sent via Electronic Residency Application Service (ERAS(r)). ERAS office starts transmitting your applications to the programs on September 2nd every year. Therefore, the earliest you can apply to any program is September 2nd.

The timeline of important events can be found at relevant web sites. However, here is the pointer that I want to give you.

- If you apply in September, you are applying early and you will get the advantage of early bird.

- If you apply in the first two weeks of October, your application is "in time". You are OK.

- If you apply in late October or worse yet, in November, your application will suffer. You will end up with less interview calls.

Why is that? The programs analyze applications in order of the date of application. If you are a regular candidate but you have applied early, programs will look at your application first and decide there and then whether to give you an interview call. They are more likely to end up calling you because it’s early season and a regular candidate is acceptable.

Now consider the same regular candidate applying in late October. Most of the programs have already called a lot of applicants. There are very few slots left so the programs tend to become more selective. A regular candidate may or may not be acceptable depending upon other options available to the program.

Now the question arises "I will only have my Step 1 score in September… Should I still apply? Will I suffer if I do not have my Step 2 score?” The answer to both the questions is yes.

Let’s go through it step by step.

- Ideally, you should have both Step 1 and Step 2 scores and passed the CS by the time you send in an application. That will give you the maximum advantage. However, that means studying hard and fast, going to US just for the sake of CS and getting it all done and over with before September. Thank God, we do not live in an ideal world so we can get away with less.

- The minimum you need to apply for residency programs is a Step 1 score. That's the bare minimum and most international applicants do that. It is acceptable. In fact, if a program likes your application but requires your Step 2 scores before they grant you an interview, they will wait for you and put your application on hold till than. They will make their final decision whether to call you for an interview or not only after they have received your Step 2 scores.

- The best approach which is both economical and fruitful at the same time is to have Step 1 and 2 scores before application (i.e. September). You take your CS when you go to US for residency interviews. Thus there is only one trip to US and you get the advantage of Step 2 scores as well.

Conclusion: The advantage of early application outweighs the disadvantage of applying without Step 2 scores. Therefore apply early!!!!!!!!

WHERE TO APPLY                                      Class of 2003

If you know nothing about the various hospitals in the USA – don’t worry. Neither did I, until a month or two before I sent my application. Many people gather this information during medical school. If you did, Great! If not, join the club.

How to find out? Ask your seniors! The reason for this is simple. They have already done their homework! Else, find out where your seniors have gotten into. This is very important. You see, the fact of the matter is, if a program has a history of taking students from your university, they will probably continue to do so, so long as their experience has been worthwhile. Hence, there is a gradual development of so called ‘hubs.’ Some programs are AKU hubs. They love AKU students. Others are DMC hubs, etc. The university that you have studied at has a major impact on how much importance they give your application. I will illustrate this with a simple example. At one of the programs where I interviewed, an authoritative member of faculty informed us of the following: When that particular program interviews candidates, it gives them points for their various qualities. One of the things which gets points is the medical school. If a graduate from the home institution, they get 20 points. If from another US institution, they get 10 points. IMGs get 5 points. However, AKU students are the exception to the rule, and they get 10 points… Think about it… So, you see, if they are familiar with your school, your chances increase. Of course, even the fact that students are called for interviews is a positive sign, even if no one has matched there yet. After all, a program will only spend its resources on you if you have some chance (however remote) of matching there. So, keep in touch with your seniors.

Of course, you do not always have to stick to the beaten path. Someone has to take the initiative in applying to previously uncharted territory. If you have done electives in a great university and you feel that you have been able to ensure that you have been well noticed, by all means, apply! If you have been looking at websites and have found a program which suits your interests, apply! After all, if you succeed in securing a spot, you’ll be pushing boundaries for your own juniors. However, keep in mind, applying is an expensive process. Furthermore, the more places you apply to, the more expensive it gets. The first ten places that you apply to will cost you $60. Programs 11-20 will cost $8 each, 21-30 will cost $15 each, and 31 onwards will cost $25 each! To put that in perspective, 10 programs cost $60, 20 programs cost $140 and 30 cost $290… It keeps doubling… Keeping this in mind, decide upon the number of places which you should apply. The main factors that should determine this number are the strength of your application and the program specialty for which you are applying (and your bank balance, of course). If you have a decent application and are applying to a non-competitive specialty like internal medicine or pediatrics, 30 programs are more than enough, as long as the list of programs is primarily made up of the places which are AKU friendly. You could even get away with less, but, I don’t think it is worth the risk. Of course, if you feel your application is weak, apply to more. If you are applying for something more competitive (like surgery, ophthalmology, radiology, etc.), apply to more. If you are couple matching, apply to more. I couple matched internal medicine with pediatrics, and we consequently sent out our application to fifty programs. Your aim should be to get yourself about ten interviews. If you achieve that, your chances of matching are quite good. Statistically speaking, applicants with at least six interview calls have almost always matched.

Another tip would be to mark all the cities that you are considering on a map of the USA. Make sure you understand the distances which the map represents. I minimally understood USA geography prior to this exercise. Trust me, it made a huge difference – both to my knowledge base and to my choice of application. The reason for this is… THE USA IS ENORMOUS. And most of us travel by greyhound. I applied to places in Florida, but, I later realized that it was completely out of the way. I was even going to apply to Maine and Seattle… but then I saw where they were on the map. Eventually, I restricted my program sites to central and eastern time zones. Even that was quite a ride… The map will also be useful when you are planning your interview calls. See where you will be at a given date and where you have to go. This way you will be able to plan better. You don't want to spend time going back and forth, because it will exhaust you. Remember, although the residency trail is not that much of an intellectual challenge, it is physically exhausting as it requires a lot of traveling. Save your energy as mush as possible.

Being a senior myself, my further two bits. Attached within this zip file is an excel file with all the information which I could muster. I also scanned the map which I made for myself. Help yourself!

Do check out program websites. They will give you a feel of the program. Look at their requirements. They usually stick to what they state, however, they some programs overlook some of their requirements at times. Be wary of the language used (e.g. “6 months of US experience required” is different from “6 months of US experience recommended” etc.) If you feel that you need to know more, write to the program to ask them your questions. Ask them things like whether they take IMGs, visas offered, specific requirements like US experience, application deadlines, etc. Another thing to keep in mind is that some programs may suddenly become non-operational! So, make sure you check out the list of programs which are participating with ERAS. The website is

To repeat an above mentioned statement, make sure you apply to as many AKU friendly places as you can. Also, apply to an appropriate mix of programs. As in, some great places, some back ups, and lots of in betweens. Keep in mind though, at the end of the day, there is another thing that you will be told time and time again. “Never rank a program which you would hate to go to… It is better to go unmatched and go for the scramble than to be stuck in a place where you will be miserable.” Since that is the case, why bother applying to a place where you have no intention of going?

Another place where you can find out information about residency programs is FREIDA (Fellowship and Residency programs Electronic Interactive Database). ( ). This enables you to search for residency and fellowship programs in terms of specialty and location. Hence, a very useful tool. It will give you a good idea of what kind of program it is (university, community, etc.), size of the program, and, probably most importantly, the contact information for the program director and the program secretary. This is where you get the keys which open the door the ancient ritual of bugging the program administrative staff. There is a ton of information here. Keep in mind, the contents of this site have been written by the administration of the programs themselves. None of the information has actually been authenticated by anyone, and thus does not have to be all true. I came across program which claimed that the average amount of time that a resident works is 65 hours. If you come across something similar, make a mental note to hear the residents there laugh. During your interview trail, you will often notice that there is an interesting gap between how many hours the residents work and how many hours the program director thinks the residents work. So, don’t believe everything you read. The only drawback of FRIEDA is that it does not have the information specific for IMGs. For example, it has no information on willingness to accept IMGs, IMG requirements for application, visa sponsorship availability and type, etc.  All such information on FREIDA is pertinent only for US Medical Graduates (USMGs). Therefore, do not get excited if you find a certain program on FREIDA which states that applicants have to take USMLE Step 2 CS exam anytime before starting residency. That's only valid for USMGs, not IMGs.

US News rankings are alright too. It’ll give you a general idea of how great the place is. Most of the details are in the Premium bit. Admittedly, I bought it, but I don’t think it taught me anything worthwhile. So, I don’t advise it. I did some extensive work on US News. I read the rankings in many different ways. Looked at medical school rankings. Looked at rankings of internal medicine, pediatrics and family medicine programs:
Looked at the rankings of the best hospitals for everything:
In doing so, one can get a pretty good feel for how good the hospitals are. Keep in mind. Just because a hospital is good for something, it is not necessary that the corresponding residency program will be good. Sometimes you may wind up in a fellow run slump. So, look out! Another point to keep in mind is that US News Rankings are dependent on many factors, many of which do not concern the average resident. On the flip side, US News does not consider many factors which are of significant importance to the average resident. So, do not treat them like scriptures. Programs which are not ranked can be much better than those which are ranked. Better faculty contacts may lead to better fellowship placement. Board pass rates may be higher. Environments may be far more friendly (big shot programs are usually quite arrogant). The hospital may be excellent in the area which you want to sub-specialize in. Remember, your priorities will determine the ultimate list of program rankings.

Another website is . Here, you’ll find a bunch of program reviews. Admittedly, I didn’t use it, however, I mention it as it was recommended by Umbereen S. Nehal in “Road to Residency.”

I have also added an extract from Road to Residency below:

“The things I was looking for in a Residency

-Good program

-Takes foreign medical grads (had at least one in their residents!!) although I did apply to a few programs which had really good names and no FMGs (did not get calls from those guys)

-If there was an AKU grad there

-Places that people in AKU apply to in general

-Places which were not badly talked about or which did not get bad ratings from the previous classes. Because you spend a lot of money traveling to these places and time and effort, if you know in advance that a reasonable person really did not like it, then it is a waste of time and effort to go there I thought...unless, you are in the area and can interview there at the same time as your interview in another place nearby...... (Like I was in Houston so interviewing at UT as well as Baylor was something easy and convenient for me)

-Places in clusters...if you are applying to one program in a city and serious about going there for an interview if you get a call then apply to a program close to that...if you get a call and want to interview there you can schedule the 2 together...even so don’t apply to programs you will certainly not want to end up in and might not even interview at cause it is a lot of waste of money which happens every year to almost all of us cause we worry about not getting enough calls.

Things to think about when going to an interview

-What are your priorities in a place? Mine were location (I had family in Texas), the kind of program, residents, the sort of faculty, did I fit into that place, was it psychotherapeutic or pharm-oriented, was research necessary, did everyone seem happy or were really stressed out or even worse, bored...etc

- Can you see yourself spending 4 or 5 years at this place and if you are thinking of a fellowship can you get one after this place? Or if you are thinking of an H1 or private practice, then what are the chances?

-Do people moonlight and if so how does the program feel about it and do you want to.”

Shaheen Mithani

How to Apply for Residency

(The article is taken from "Another Road to Residency" compiled by class of 2003 and 2004 of Agha Khan University, Karachi Pakistan.)
THE APPLICATION PROCESS                          Zainab Samad
Updated by Class of 2003

I have attached the chapter of Road to Residency that was written by Zainab Samad. I have edited the chapter in order to update. Updates and comments are written in non-italicized bold text:

The above links have the answer to most of your questions. How to use the site? What are the steps in applying…etc?

There is a wealth of information in the above two website links. I went over all of it and my application process went by very smoothly. I would advise that others do the same.

Almost all programs require applications to come through ERAS (Electronic Residency Application System). This has made the process and applying a whole lot easier. Since the programs start downloading applications on September 1st, the ERAS tokens become available in July. Requesting the token has become an online process. . The application fee is around $75. Your Token will be sent to the email address in your ECFMG record. You will have the opportunity to add or update your email address when you request your Token. To check your email address, access OASIS at On July 1st you will be able to log on to MyERAS at (You’ll have to register before you are able to log in).

As soon as you get the account, you can start working on the Common Application Form (on your account). This can even be printed out if you want to work on it in your spare time. The following link might help you in filling out the CAF - (I think this link is dead… a worksheet which will help you fill the CAF is available at ). Once the common application form is filled out, it is automatically converted to a CV. This form is sent to ALL programs. So submit it after checking everything a couple of times. Beware of typos and spelling errors since the ERAS program does not have spell check. The following link might help you in filling out My Profile - (I think this link is dead too).
Before applying to programs you need to be registered with the NRMP at Click on ‘Match Site’ and then click on ‘Register for NRMP matches’. Besides, the CAF requires the AAMC ID, which can not be obtained without registering with the NRMP.

Start early and work hard on your personal statement (PS). Show it to your seniors or juniors - anyone with a good head on his or her shoulders and anyone who can give you an honest opinion. You can make a number of personal statements. You can use different ones if you are applying in more than one specialty.

In the mean time, the ERAS office will send you an information booklet about how to use their site, and stickers. Have the following ready.

1) A copy of the dean’s letter (Give your CV to Nasreen Sheikh, well in advance as the dean’s letter takes time to make.)
2) A copy of the medical school transcript (if you are in the top 15, get one which mentions rank)
3) Copies of recommendation letters. (You can have a max of eight letters on the site…but only 4 can be sent to a particular program) Send as many as you can so that you have the option of choosing - 4 American letters and 4 AKU letters (including one from the dept head). Give your CV and PS to the letter writer so that he or she can add a personal touch to the letter.
5) A picture of you. The size should be 2.5 X 3.5 inches.

These documents are labeled using the stickers [Stickers are no longer available. Read about it at under the heading “How do I identify my documents”).  Also, now you need to send the ERAS Document Submission Form along with your documents. It is available at ] and then sent to the address that ERAS provides. These are then scanned by the staff and put in your folder. After sending these documents, you can create them in ‘My documents’ and then assign them to various programs once they are scanned.

The Transcript, Dean’s letter, Common Application Form, CV, your picture and the USMLE transcripts are sent to all programs that you apply to automatically. The only thing that you have to decide while applying to a certain program is a) which LoRs to send b) which personal statement to send c) whether you want to release the USMLE transcript or not.

Before selecting programs, SEARCH and SEARCH. Look up the Green book and the Internet for programs. You need to know, if the program is participating in the match, whether it is accepting applications through ERAS? What are its deadlines? Does it have specific requirements in terms of LoRs? Does it require a year’s US clinical experience? Does it accept only those with a green card or US citizenship status? What kind of a visa does it offer?

Applying is really easy...just a click away.

After you have applied, you can check the status of your application using ADTS (Applicants Documents Tracking System). This will allow you to see which programs have down loaded your application, how much of it, and when.

With in a few days of applying you will start hearing from programs on the email address that you have provided in your Common Application Form. So provide a reliable email address, one that you can even access in the States.

Factors that count in securing interview calls:
USMLE Step scores
U.S. Recommendation letters
Externships/Research Experience in the US
Medical School Performance
Calling up the Program Secretary repeatedly and sounding *really* enthusiastic about the program.(in fact this might be the single most important factor in a lot of programs, and I can’t stress it more)

Zainab Samad
Class of 2000

(Extract ends here)

Another analysis of one’s application has been added below:

“An important question that arises at this point is ‘How is my application judged?’ and ‘what makes an application stronger than others?’

Following factors play an important role and in that order:

1- USMLE scores (the higher the better...simple. This is the first and the foremost thing. Programs screen applications based on Step 1 scores. For example, a certain program decides that it will only call applicants whose Step 1 score is higher than 90. If your application has a lot of other strong points but your Step 1 score is 85, you will not be granted an interview call).
2- US Experience/electives (clinical experience in the USA; Observerships don't count. Some places equate UK or Canadian experience to US experience).
3- Strong Recommendation letters from Gora Saab (if you have done electives in US).
4- Strong Recommendation letters from your Medical School Faculty (or any other guy you have worked with).
5- Your performance in medical school (Class rank being an important indicator).
6- Reputation of your medical school in USA. (Yes, good reputation helps but lack of reputation does not prevent you from getting in).
7- Research experience is low on the list but is a definite advantage if you want to get into a University program.
8- Green card or American passport is an advantage because then there are no visa issues to solve for the program. However, I am not sure where to put it in the list. For some programs, it is an important advantage, for others it does not matter what your passport looks like as long as you prove to be competent.”

Class of 2003

Step 2 CS, All You Need to Know

  (The article is taken from "Another Road to Residency" compiled by class of 2003 and 2004 of Agha Khan University, Karachi Pakistan.)

        The Step 2 CS (Clinical Skills) is the examination that was formerly known as the CSA. To put it as simply as possible, it is just an OSCE with loads of frills. Nothing difficult, I assure you. AKU graduates rarely fail the exam. However, you have to pass it in order to secure ECFMG certification (and hence any chance of matching). So, I would strongly advise that you do not take it too lightly, regardless of what anyone says. Imagine how embarrassing it would be to get a pre-match at the place of your dreams… and having to call them to tell them that you will not be able to join their program because you flunked the Step 2 CS…

Earlier, the TOEFL examination was also a requirement for ECFMG certification. However, since the transition from CSA to Step 2 CS, the TOEFL examination is no longer required. The Step 2 CS itself will be used to check your ability to communicate.

The examination is available to be given throughout the entire year, however, it must be given before a certain deadline. In the Match of 2005, this deadline was December 31st 2004. In the Match of 2004, the deadline was January 31st 2003. So, it keeps changing. You’ll have to check the ECFMG website ( for the latest information. (Note that the deadline for the Match of 2006 is December 31st again).

There are some recommended times that one should give this exam. The vast majority of applicants are going to visit the USA on a three month visit visa. In this period, it would be highly desirable to give the Step 2 CS, interview at a dozen programs, and perhaps even sit for the Step 3 examination, if you have time. The biggest constraint is the fact that the interview season lasts from November to January – itself being a three month period. So, in order to maximize your chances of getting everything done before your visa expires, schedule the Step 2 CS somewhere in early November. You’ll get it out of the way before you start interviewing. Also, since you’ll land in the USA in early November, you can continue to stay till early February, potentially enabling you to sit for the Step 3 examination.

Of course, the earlier you give the Step 2 CS, the better. It’ll speed up the process of ECFMG certification and enable you to get an earlier date for the Step 3. This, in turn, will allow an earlier processing of an H1B visa (if that’s what you’re going for). So, you see, everything is connected. Another fact is that program directors will be more keen on interviewing you and ranking you when you have passed more examinations. If you can secure a six month stay in the USA, sit for the Step 2 CS in, say, mid-October. Some people flew to the USA specifically for the purpose of giving the Step 2 CS early. However, to do this, you’d have to have a long term visa to start off with (e.g. five year multiple) and plenty of funding.

Being the fortunate ones you are, another opportunity has opened up for you lot – one which was not available to us. Earlier, passing the USMLE Step 1 examination was a prerequisite for application for Step 2 CS. That rule has been abolished. All you need now are two years of medical school. Consequently, my advice would be that one should sit for the Step 2 CS during one’s final year electives (if one is doing these in the USA). Any earlier would probably result in insufficient clinical and OSCE experience.

There are five centers in the USA where the Step 2 CS examination can be given:

·    Philadelphia, Pennsylvania
·    Atlanta, Georgia
·    Los Angeles, California
·    Chicago, Illinois
·    Houston, Texas

Where you sit for the exam should not really make a difference. It did make a difference when the centers first sprung up in 2004 (earlier established centers dispatched results earlier).  However, since they have been functioning for more than a year now, I don’t think it will affect anybody anymore.

As for the fine print regarding the examination, I have quoted an extract (slightly edited in order to update), written by Zainab Samad, from Road to Residency. Updates have been written in non-italicized bold text. A couple of comments before I attach her material:

There is a new book in the market called “First Aid for the USMLE Step 2 CS (Clinical Skills Exam),” written by Vikas Bhushan and others. I would recommend this book for everyone. If one reads this and nothing else, it is more than sufficient. After familiarizing yourself with this book, if you feel you need more practice, then, go ahead and attempt the dozens of cases available in the Kaplan photocopy. More practice is always good. I spent a week of relaxed studying on this exam. However, one can get away with less. People pass the exam with a day or two of preparation (not that I would advise it!). The exam is all about being able to deal with the patient as a reflex. Therefore, grab a friend and practice, practice, practice. As far as Bates is concerned, one does not need to go over it if one is comfortable with physical examinations.

The Step 2 CS has three components (on the basis of which you’re marked):
o    Integrated Clinical Encounter (ICE) Subcomponent (Data gathering, Documentation)
o    Communication and Interpersonal Skills (CIS) Subcomponent (Questioning Skills, Information-sharing skills, Professional manner and rapport)
o    Spoken English Proficiency (SEP) Subcomponent

(Extract commences here…)


Before going for the exam, watch the video and the Candidate Orientation manual that they provide (the candidate orientation manual is now available online - If you are feeling very apprehensive, then read up the 47 cases given in the Kaplan CD photocopy. That gives a fair idea of what is tested in the exam. You can even go through the basic history and physical examination from Bates. The cases that generally come are very common complaints like chest pain, headache, backache, etc.  These have been time and again tested in our OSCEs and therefore do not pose a problem. And when you take the history, you’ll find that there is a wide differential. The history usually does not point to one specific diagnosis because they want to check whether you know the ‘right’ questions for those common complaints.
During the physical exam, check the relevant systems e.g. in a patient with chest pain, you would want to check the pulse, JVP, listen for crepitations in the lungs, feel the cardiac impulse, percuss the heart borders (or pretend to), listen to heart sounds, check for sternocostal tenderness, palpate the abdomen for any epigastric tenderness, and check for pedal edema. Most patients do not have physical findings. But in some cases, the patient may have real signs - crepitations with a COPD lung, an inflamed joint, etc. The patient may even mimic signs - loss of sensation or paralysis. So bottom line - keep your eyes and ears open.

During the patient encounter, you might get a ‘mean’ and ‘un-co-operative’ patient. Don’t worry. They are being deliberately mean. The trick is to be firm. Remain polite and try not to lose your temper.

There are 10-11 patient encounters (the 11th is usually not graded but you will not know which one is the 11th patient). One gets 15 minutes with each patient and then 10 minutes to write the patient note.  SO that makes 25 minutes for each patient encounter.
The actual encounter is marked on a checklist by the patient. The checklist is for communication skills, the questions in the history that you asked and the maneuvers you performed in the physical exam. The patient fills this out once you leave the room. So what matters is not how you percussed the patient but whether you did it at all or not. This makes it much easier than our regular OSCEs. There are also points for knocking before entering, washing hands, draping the patient etc., so one needs to remember those.

The Basic Format (that my friend Sultana came up with and that I found very useful), one should follow so that you don’t forget anything:

(Editor’s Note: Before you even knock at the door, pay attention to the case introduction written on the door. Read it carefully and jot down points on the clipboard. It is imperative to have your thoughts organized at this stage in order to avoid awkward pauses during the actual encounter. Write the name, age and any abnormal vital signs. You may even list your differential diagnoses. Write whatever mnemonic you use for history taking. Take your time at this stage and you will save time further on.)
1. Knock
2. Enter and address the patient by Mr. / Mrs. Surname
3. Introduce yourself as Dr. Surname
4. Walk to the sink, wash your hands and while you are at it, explain that you will  be doing a brief history and physical exam and will be discussing your impression with the patient.
5. Walk back to the patient and drape the legs (they are usually uncovered)
6. Sit or stand; whatever you find comfortable. Spend 5 minutes taking the history. Avoid using medical jargon. Ask both open ended and close-ended questions.
7. While taking the personal history, if the person smokes or drinks, counsel there and then...or one tends to forget near the end.
8. Spend 5 minutes on doing a focused and relevant physical exam.
9. Spend 5 minutes summarizing/reconfirming the history that you got, explaining to the patient what you think, he or she has, what investigations you think he/she should get. Remember to ask if he/she has any questions. (Editor’s Note: - Also ask the patient if there is anything else that he/she would like you to know. This provides the patient to guide you if you have been misled. Remember, the simulated patient is not out to get you).
10. Tell the patient when you would like to see him or her next. Say that it was nice meeting them. Walk out.
11. If you are done before time…then walk out and start on the note.
12. The patient note has to be written in legible clear handwriting. Practice on the sample sheet that they provide in the information booklet. Since there is less space on the paper, put only relevant points and important negatives down.

Avoid speaking to anyone inside or outside the exam center about the exam. You are not going to do any better by sharing your case histories or exams. But you might certainly end up paying for it if you do!!

Only people with serious problems in communication fail the exam (those who don’t know how to speak English) and since you are not in that category, you don’t need to worry.

Things to take with you to the exam center:

1) White Coat
2) Stethoscope
3) The CSA permit
4) Passport
5) They provide a pen
6) Dress professionally but comfortably (the way one dresses for a viva)
7) Panadol, lunch (if you think that the salad, fruit and chips that they provide will not whet your appetite. They have turkey sandwiches for those who are not too particular about halal food), and Chocolate if you want to. Coffee, soft drinks and water is provided.

Travel and Places to stay:

You can search yahoo for making a reservation at a hotel. Usually, the rates are lower if you book on the Internet.

Regarding the Philadephia center, the Marriott and the Divine Tracy are right opposite each other and 3-minute walk from the center. There are plenty of other places to stay. You can find them on the net.

Try and make it to the city at least a day prior. It is important to keep room for contingencies. Remember to put all the things that you are going to take to the exam center in a hand bag as one runs the risk of losing checked-in luggage.

For more detailed information, use the following link - “

(Extract ends here…)

Another thing which may prove useful… After giving the Step 2 CS, one tends to wait impatiently for the result, because one can only apply for the Step 3 after passing it (along with all the other exams, of course). At that point in time, even the wait between the dispatch (as told by OASIS) and the actual receipt of the result (by mail) seems long. A simple way of finding out if you have passed is by trying to apply for the Step 2 CS again (don’t worry, you will not be charged for trying!) After inputting your information, the website will tell you that you cannot apply for this examination because you have already cleared it. If this happens, you have passed! Apply away for your Step 3! If not, well, better luck next time!

Step 3, All You Need to Know

  (The article is taken from "Another Road to Residency" compiled by class of 2003 and 2004 of Agha Khan University, Karachi Pakistan.)
By   Shehzad Sami
Updated by Class of 2003

A few comments of update:

The fee for Step 3 is now $625, not $570 as mentioned below.
At the time of application, you will be asked which state board you would like to sit for. Do not be confused. Simply click on “Connecticut” and move on. Different states have different requirements for when one would be eligible to sit for Step 3. Some places require completion of postgraduate training. Others require an application for state licensure. The Connecticut board has no special requirements except ECFMG certification. Hence, the reason for applying for it. Furthermore, the state board which you sit for has no impact on anything. You can apply for the Connecticut Board of Step 3 and sit for the exam in any city in the USA (not just in the State of Connecticut). Furthermore, you don’t even have to match in Connecticut. There will be no need to convert anything to anything just because you have matched at a different state. So, click on Connecticut and move on!
I’d like to differ (partially) with the mentioned timeline. I applied for my Step 3 on January 29th (the day I receive my Step 2 CS result) and I gave my Step 3 on 1st March. [I was officially ECFMG certified in early Feb.] I could have given it earlier, but I opted not to. Since I sat for my exam in the earlier half of the week, my result was  dispatched in three weeks, that is, March 23rd. Admittedly, I received the score after the match, however, it did not interfere with the processing of my state license, and hence H1B visa. This is because it takes the program at least a few days to send out your information packet (containing state license documents). Thus, you can easily manage if you give Step 2 CS in November. However, as Shehzad mentions, the earlier the better. After all, the more exams you’ve passed, the more interview calls you’ll get. Another point of notice is that certain programs have been known to wait for up to six weeks after match day for Step 3 scores. So, one can actually get away with a highly delayed Step 3. However, visa delays in recent years have forced programs to be sterner regarding these timelines. Ask program directors regarding their current policies.
The application form requires you to submit the date of issue of your ECFMG certificate. Hence, the natural assumption is that you cannot apply until your ECFMG certificate is issued. Fortunately, this is not the case. The time lag between the dispatch of the Step 2 CS result (if this was the last certifying exam you gave) and the issuance of the ECFMG certificate is quite short. About a week, perhaps. For some odd reason, if one just enters the date of dispatch of the last certifying exam that one gave (that is, usually, Step 2 CS) instead of the date of certificate issuance, the Step 3 application gets accepted. Why? I assume it is because there is also a time lag between your sending your application and FSMB’s receipt. That covers for the earlier mentioned time lag. So, FSMB checks as to whether your certificate has actually been issued. When they see that is has, FSMB forgives you for your stupidity in making such a simplistic error, and processes your form anyway. The benefit of doing this will only be realized when you are counting days at the end of interview season because your three month visit visa is about to expire. However, don’t be so over efficient that your form gets to them before your certificate is issued!
TOEFL is no longer required for ECFMG certification.
I cannot personally comment on the books mentioned as I used none of them, however, I have been told that “Crush the Boards for Step 3” is indeed the single best resource for Step 3 preparation. I opted to read both the Kaplan Step 3 books and tried to solve as many Q Bank questions as I could. If, however, you have not given Step 2 CK recently, they will be insufficient as these books are not exhaustive. Perhaps, Step 2 books can be used then. In case your wondering how I fared in my Step 3, my score was a few points lower than Shehzad’s. So, have a look and see what suits you. Also, don’t forget to go over the CD sent by USMLE.
As Shehzad mentions, the Step 3 is a two day exam. The first day is exactly like Step 2, format wise. However, it is more difficult (naturally). Each block is an hour long. The second day is quite different. The first half consists of four blocks, each forty five minutes long. The second half are clinical cases which are based on a completely different computer program. This is the true challenge as you will be managing a patient in an undirected environment. All you are given is a brief history. Now, you decide what to do. You can choose to take further history. If so, further history is revealed. You can choose to examine certain systems. You can choose to start certain medications. Whatever you do, the simulated time keeps ticking. Take too long to manage a critical patient, and the patient dies. What you do affects what will happen next. It is like role playing a “Choose your own adventure book.” If you do unnecessary investigations, you lose points. If you manage efficiently, you gain points. It is loads of fun when you get the hang of it, even during the exam, as you always have more time than you need. So, the second day seems to go better than the first.

Why should you read this article? 99/98/94…..need I say more!!!!

Why give Step 3 before starting residency: If you want an H1B visa, it is essential that you give Step 3 before starting the residency.

The other reason which many people thought in my class was valid enough to take Step 3 before residency was that you won’t have to study other subjects ever again once you get on with your residency. So in a way, it never hurts to give Step 3 before the start of your residency, even if you don’t want an H1B visa, especially when you are in the US for the interviews and all.

Requirements: You need to be ECFMG certified before you can apply for Step 3.

How to Apply: Go to and and from there please print the Step 3 application. You need to send a copy of ECFMG certificate and AKU degree.

Be sure to take all the original documents along with you to the US because you will need them for various reasons, including Step 3 application. Not to forget the money, $570. So if you plan to give Step 3, please include the fee in your total expenditure calculations which you need to take from here.

The Strategy (The most important part of the whole discussion): Why does not everyone give Step 3 before the start of their residency?  As mentioned earlier, you have to be ECFMG certified before you can apply for Step 3. This means, you have to take your CSA in time for you to be ECFMG certified, preferably well in advance of the end of interview season, which is by the end of February. That means you have to follow a fairly tight schedule from the beginning, right from starting your studies for Step 1 after graduation. Here is a rough calculation of the time periods and how to negotiate them:

It is advisable to take Step 3 latest by mid March, preferably mid Feb to end of Feb.
It takes 4 weeks for the Step 3 permit to reach you. So you have to be ECFMG certified by the end of Dec to mid January. It usually takes 6 weeks for the CSA result and approx 1-2 weeks for the ECFMG certificate to reach you. So you have to take CSA preferably in October. This will mean that you have to take Step 2 before October, which is always the advisable thing to do. Therefore, I will just summarize the timeline which needs to be followed if one is considering giving Step 3 in order to obtain an H1 visa.

Step 1: Start of March-Mid April. Although in a perfect world, everyone would be done with their step 1 by the start of March.

Step2: September. No later than 30th of September. This will make sure that you will be able to leave for the US in October.

CSA: Apply soon after you receive your Step 1 score card. Give TOEFL soon after step 1. Schedule CSA in October, perhaps by 15th October.

Step 3: In February.

The whole timeline should be shifted to earlier dates if anyone thinks he/she can. Because the earlier, the better.

The reason to give Step 3 as soon as possible is that most places like the candidates to have Step 3 result by the match date. Some even want you to have the Step 3 result in your hand at the time of the interview. You cannot do anything about that, but you can still go ahead and tell them about your plans and try to convince them that you are a winning horse and won’t falter in Step 3 and will pass it without any trouble. All they are afraid of is lest you may fail after they have agreed to sponsor you for an H1B. Even then, it is not their headache that you have failed Step 3. They will just give you a J1. But they just don’t want to get into the hassle of dealing with failures. You have to convince them that you will pass Step 3 without any problem in light of your Step 1 and Step 2 score.

Study Material: “Crush the Boards for Step 3” is the single best source for the preparation of Step 3. It is one book that every one should do before taking Step 3. Swanson is good too. Do it. But I don’t think that it helps a great deal. But due to dearth of good material for Step 3 preparation, it is well worth the effort to go through this book. Better than Swanson are the Step 2 Medicine notes. I personally think that doing medicine notes should take precedence over Swanson. These 3 sources should prepare you enough to take on Step 3 in a very strong way. Also try to get your hands on the Kaplan Step 3 CD. It is available in the US through students and friends, though I am not sure whether it is available here in Pakistan or not. (Editor’s note: It is available in Urdu Bazaar)

Format of the Exam: It is immaterial right now for me to tell you about the format of the entire exam. When you get around to taking the exam, I assure you, you will get to know about all the details. In short, it is a 2 day exam. First day is just like Step 2. But you just have to pass it instead of acing it. That helps boost the morale. Next day, half of the exam is like Step 2, other half is cases. When you get down to studying for the exam, send me an e-mail at and I will try to help you in this regard. But only if I like you.

How long to study: 4 weeks is good enough. I studied for a little over 3 weeks. I got 94. For those of you who know me, I am no genius. Smart and intelligent hard work is the key. Without this, even 3 months is not enough.

Summary: Step 3 is more of a hassle than a difficult exam. Nonetheless passing it requires a considerable amount of planning and hard work, which is very much doable and less stressful than many of the other things in life. Everyone should try and plan to give Step 3 while they are in the US for their interviews. 

Thanks: Special thanks to Zainab Samad for her noble efforts to compile this guide. May God bless her with lots of love and happiness in her future life. I hope that it proves to be helpful for many to come.