1. What is the content/format of Step One? How much first year versus second year material? Will there be a lot of hard questions or questions I've never seen before?




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STEP ONE HANDBOOK


FOR CMS CLASS OF 2012


As shared by CMS Class of 2010 


10/16/2012


CONTENTS:

SECTION 1: FAQ

SECTION 2: COMPREHENSIVE RESOURCES

SECTION 3: TIPS (3) FOR SUCCESS

SECTION 4: RESOURCES FOR SPECIFIC M1 AND M2 CLASSES


N.B. The content of this packet is based on the experiences of select students in the class of 2010 and in no way reflects the opinion of CMS/RFUMS. The information below is provided to you as anticipatory guidance for your M2 year and is in no way 100% comprehensive or accurate.


Good Luck!!!


Frequently Asked Questions

1.What is the content/format of Step One?  How much first year versus second year material? Will there be a lot of hard questions or questions I've never seen before?

First of all, take a deep breath and breathe a sigh of relief; the test is multiple choice/ no penalty for guessing.  The bad news is that the questions range from the typical A-E choices all the way to A-O (it could go further but I didn’t have a question with more than that many choices). The content of Step 1 covers absolutely everything you’ve learned in your first and second year of medical school (bummer, we know).  While everything is fair game there is a heavy emphasis on second year material.  BUT, it isn’t that first year stuff is tested much less, it’s just that it’s tested often in association with second year material.  Confused?  Let me explain; a strictly first year type question might ask you a question such as: 

Homocysteine + N-methyl THF + ??  Methionine + THF

The cofactor indicated by the ?? is absorbed in which part of the digestive tract?

        1. Stomach

        2. Ileum

        3. Cecum

        4. Duodenum

        5. Pinky toe

 

It is much more likely however that they will ask this question in conjunction with a second year question like this: 

A 56 year old white male is brought to the emergency room by his family.  He complains that he has had no energy lately no matter how much sleep he gets.  He states that he has noticed a great number of bruises lately and is unsure how he got them.  He also states that he has been losing his balance lately and had trouble walking.  On physical exam you notice that the patient has many petecheia on his arms and hands and that his skin has a lemon yellow discoloration.  He has bilaterally decreased proprioception.  You order a blood smear and the results show large oval shaped red cells and a paucity of all other types of cells.  The compound most likely deficient in this patient is absorbed in which part of the digestive tract? 

        1. Stomach

        2. Ileum

        3. Cecum

        4. Duodenum

        5. Pinky toe

 

Sneaky right?  This example should show you that you need to study for this test in a different way than you are probably used to.  For most of your tests so far you have only needed to focus on a single subject at a time.  Sadly, this test covers all subjects and as you can see you will have biochemistry, anatomy, physiology, pathology, etc. not only in the same block but in the same question.

Now, some of you may be reading this question and thinking; “oh my God, I have never heard of any of this…I’m screwed!” (probably not though….you are a smart bunch).  If that’s the case you may also be wondering if there will be a lot of questions on the test asking about things you’ve never heard of before.  The answer to your question is yes and no.  Yes, there will be questions asking things you’ve never heard of before, but there will not be a lot of them.  If you are well prepared its more likely that you’ll be stumped by questions that are asked in a very convoluted way challenging you to “jump” 3 or 4 steps to get an answer.  Regardless there will be questions asking material that you have never learned before…its inevitable, after all there is a ton of information to learn, and no one person can learn everything.  When you come across a question like this DON’T PANIC!!  This may be an experimental question and won’t even count.  Even if it’s not an experimental question you can take solace in the fact that one question will not make or break you, in fact many questions won’t even make or break you because this test isn’t done by percentage.  There is no way to know what your test is actually out of and getting a good score on this test is no where near the requirements of getting an “A.”  This test bases your score on how well you do compared to everyone else…that may sound scary but believe me, that’s a very good thing.  You have a pretty large amount of “wiggle room” to get some questions wrong and still get a good score.  And as far as passing goes if you’ve studied you should have nothing to worry about.

One last thing on format; as you already know this test is done on computer and you lucky people will be asked media questions.  These are questions that have video and audio and ask you to answer a question based on what is played for you (think heart sounds).  For example, last year there was a question that had a picture of a chest and four yellow circles over the four points corresponding to the auscultation sites for the aortic, pulmonic, tricuspid and mitral valves.  If you clicked on one of the circles the computer played a recording of a heart sound, if you clicked on a different circle you would hear the same heart beat recorded at that location.  After analyzing all four spots to your satisfaction you are asked a question related to the heart sounds regarding pulmonic stenosis or something.  These questions are at the end of a block and as such you will have all of your remaining time to try and answer them.

If you want to see what the test is like (for yourself) and what type of material is on it use this link: http://www.usmle.org/Examinations/step1/step1.html !pay attention to: Orientation/Practice (150 Free NBME questions)


2. Experimental questions…what are those? 

Experimental questions are just what they sound like.  They are questions that are new and that the NBME are testing out.  They are “experimental” in that the NBME is using you as a test group to see if enough people can get the question right (but not too many) suggesting that it’s a good question.  Reportedly, as many as 15% of the questions on your exam may be experimental.  This means that 15% of your test doesn’t even count.  You may recognize these questions when you come across them.  They are probably a question that is totally out of left field, BUT this may not be the case so obviously you should try your best to answer every single question regardless of how ridiculous it seems!!!! 

3. I hated the MCAT, is this anything like that? 

Only in that it is a multiple choice format.  The MCAT tested all sorts of random stuff that you learned throughout four years while also learning things like western history and speech.  The USMLE step 1 is a much more focused test.  In medical school so far you have been learning only material that will be on this test.  Furthermore, the way the test writes the questions, even the more esoteric subjects like biochemistry and MCB are tied into the questions in a way that makes them somewhat more relevant to medicine.   

The biggest difference is the format of the question stems.  These questions are much much longer than you are used to.  The majority of questions are vignettes and will take you some time to get used to picking out the relevant information.  If you are worried that this test is like the MCAT you shouldn’t be.  In a sense you have been studying for this test for two years and you will simply be “reviewing,” albeit intensively, for this test.  If you did “not-so-hot” on the MCAT don’t fret, that doesn’t mean you will do poorly on this test, the two really are very different tests.  Besides, this one doesn’t have physics which is always nice. 

4. How long is the exam; how much break time do you get?

 Step 1 is a 1 day 8 hour exam with 350 questions, divided into 7 blocks of 50 questions each.  You are allowed 60 minutess for each block, or 72 seconds per question.  You are provided 45 minutes of break time.   

There is a 15 minute tutorial at the beginning of the exam which you may choose to skip and add to your break time.  This allows a cumulative total of 60 possible minutes of break.  The tutorial is available online, so you may want to review it before the exam so you can confidently skip it on test day.  You may disperse your 45-60 minutes of break time between blocks as you wish.  For example, some students will take a few minutes after every block, while others will take one long break.  Remember, your lunch is included in this break time, so make sure you leave time to eat! 


5. Can I use a calculator during the exam?

 No.  Fortunately, any calculations required will be straightforward and easily performed on the dry erase board provided.  Think:  CO = HR * SV 


6. What should I bring to the exam?


Make sure to bring your scheduling permit and a state/ federal issued picture ID to the exam. These two are the most important.  Your names need to match exactly on these two; it is probably not a good idea to change your name (recently married, etc.) too close in time to the exam. Bring food, snacks, chocolate to shove into your mouth during your breaks for energy. Also bring water, coke, etc. whatever works to keep you hydrated. But don't get too hydrated because then you will need to run to the bathroom all the time! Bring First Aid in case you want to stuff up during the break. Bring some paper towels to wipe your pits, because you will be sweatin' fo sho. You are not allowed to bring anything with you into the rooms (i.e. earplugs, Kleenex,) but these are usually provided at the sites. Ear plugs/headphones are good quality, but remember there might be other people in the room taking all different kinds of tests. You do get your own cubicle though so it is just like the library.

7. How and when do you register for the exam/ get that permit?

Dean Lazarus will inform you of this when it is time to do it; however, November/December/January is a good time to register. The earlier you register, the earlier you can choose a test date so keep that in mind. Also, you need a passport photo, so get that ready. This is for a form that verifies your enrollment at CMS which you should find at the website below, bring to the registrar and then mail to NBME. You will not be able to proceed with the registration process without this form. You initially register for a certain three month period, i.e. May-June-July or June-July-August, when you want to take your exam. Later you pick your actual date from that three month period after you receive your scheduling permit (via e-mail for the NBME) . To register, sign up at this site and carefully follow the directions provided: https://apps.nbme.org/ciw2/prod/jsp/login.jsp

8. How much does it cost to take the exam?

USMLE just increased their fees for 2009. The cost of the exam alone is $495. This does not include any costs for preparation. If you are on Financial Aid, the fee is distributed within your disbursements throughout the year and not separately given to you in December. 

9. What is a good score and how much does my score actually matter

This is a toughy. You are going to have to determine what score is good for you, and it really depends on the specialty and where you want to do your residency. See page 16 of http://www.nrmp.org/data/chartingoutcomes2007.pdf for some ideas of what a competitive score is by specialty, but keep in mind that these are averages. My best advice would be to set a goal for a score with which that you will be happy.

10. How likely is that I pass? 

You need a score of 185 to pass. It is very likely that you will pass if you take the exam seriously. Greater than 95% of first time takers nationally pass the exam.  Remember, CMS prepares you very well for this exam.

10. How long do you wait for your score?

Scores can take around 4-6 weeks to report, depending on when you take your exam. Scores for 2008 test takers were released on July 16th. If you are an extreme spas and you “just must know” you can log onto the NBME website (the same one that you used to register and get your score at 12:00 am on the date they anticipate to release it). If not you can just wait for the email they send you in the morning and follow the link.

11. What if I fail Step One?

If you fail Step 1, you can retake it.  The failure will be reported to CMS and they will discuss a plan with you for a retake. Students who fail step 1 will be allowed to continue in whatever clerkship they are on, but will have to come out of the next one to restudy and retake the exam. Almost all students are successful on the second attempt. For those very few who may not be, the school offers an intensive review course in January-May and all students who have taken this have been ultimately successful. It does mean delaying graduation by a year, but the school only allows three attempts on Step 1 before a student is considered for dismissal. So, the time spent in the course is well worth it. I know they offer a "crash" review course for those students that have failed and from what I hear those students go on to pass, almost without exception, on the second attempt.  Honestly, there will only be a VERY small number of you (hopefully none) who have to worry about this, so get it out of your heads right now.  Put in the work and you will be fine.    

12.  What if I do not or cannot complete Step One?

If you start the exam but do not finish that is exactly what will be reported in your USMLE score transcript.  However, no official score will be reported unless you complete the entire exam.  You will be able to retake the exam if you do not complete it.

13.  What if I complete the exam, but am unhappy at the end of the exam?  Can I cancel my scores?

If you complete the exam, that is it—it is a done deal.  You are not allowed to retake Step 1 to improve your score.  

14.  What if my score does not fall into the estimated range for a specialty?  Should I even bother to apply to my program of choice?

You will hear many rumors about what you "need" to get if you want to go into plastics, radiology, dermatology, etc.  In general nothing is ever entirely out of reach.  It is true that more competitive residencies will often have applicants with overall higher board scores but that is not all that residency directors look at.  Your grades (especially in your clinical years and in the specialty of your choice) along with letters of recommendation, research, and your interview (which is always very important) will all contribute to the likelihood of a successful match.  Also many people recommend taking Step 2 early (before you apply to residency programs) and, of course, really nailing it.

15.  When should I begin preparing for Step One?

You have already begun studying for Step 1.  Concentrate on doing well on your M2 material and you will be well prepared for boards.  It is the most important thing you can do to prepare yourself.  After winter break (in January) is when most people start studying.  WITHOUT neglecting your M2 stuff try to do some M1 stuff or practice questions as often as you can, but don’t burn out early.  There is a long way to go—this is marathon, not a sprint.  Unless you KNOW you are going to use it early I would not rush to get QBank, USMLE World etc (described in detail shortly).  Get it after winter break and save yourself some money.     

16.What should I study for this exam? How do I balance class work and the USMLE?

Pls see each subject and the comprehensive section for individual class details. Generally, focus on subjects that you found challenging during 1st and 2nd year.  Freshen up on those subjects with review books: DO NOT USE CLASS NOTES AS YOUR MAIN STUDY MATERIAL.  Gradually transition to subjects you feel comfortable with, and leave time to re-freshen up on troublesome topics. 

Balancing class work and studying for the USMLE is challenging, and varies per student.  Some prefer integrating the two, e.g. reviewing pulmonary pathology for class, then integrating pulmonary anatomy, physiology, pathology, etc. for the boards.  Others will only focus on schoolwork or board studying....this is it's up to you.  Either way, it's probably beneficial to quickly review material in First Aid after the material is covered in class to ensure that you have understood the key points.  Remember to include time for practice tests, e.g. NBME exams, into your study schedule.


17. When should I take the exam? Can I move back my exam date? Is it a good idea to move back my date?


Most students take Step one between 2 and 4 weeks after finals end.  Many factors may affect this decision - getting married, feeling extra prepared/unprepared, vacation time, etc.  Remember, you will most likely spend the majority of your days after finals studying for Step 1 - if you get bored easily, take the test sooner.  If you feel extremely unprepared, plan to take the test later.  JUST REMEMBER, YOU MUST TAKE STEP 1 BEFORE THE CLINICAL SKILLS COURSE BEGINS. 

Most students would only recommend pushing back your test date under extenuating circumstances - If you plan an accurate study schedule and follow it, you should be plenty prepared by the time your test date.  Pushing back your date may increase anxiety and stress and cause more detriment than harm. And after all of this year, you will need to leave some time for vacation.  Dr. Lazarus will talk to you more about it: we second everything she says!

If you change your date or location more than 5 business days in advance, there is no fee and it can be done online.  However, dates and locations will be limited.  If you change you date or location less than 5 business days in advance, you must contact the Prometric Regional Contact Center and pay a rescheduling fee. 


18. How do I know that I am ready to take this exam?


Most people never feel like they're ready, but you still might be!  Getting through your planned study schedule is a great start, as well as completing as many practice tests (NBMEs, USMLEWorld, Kaplan Comprehensive Exams, shelf exams, etc) as you feel necessary.  The correlation with these scores and your actual test score varies per student - use them as a gauge, but do not rely on them as your sole evaluation tool.  When you feel like you can't study or take practice tests anymore, it's a good sign that you're ready!


19. It is 2 weeks before the exam and I am continuously failing the above self-assessments or have another emergency that would interfere with my ability to take the exam. What should I do?


TALK TO DR. LAZARUS in the Office of Student Affairs.  She understands that difficult situations and emergencies occur, and will guide you appropriately. 


20. How much will it cost to prepare for this exam?

 

Be prepared to drop a bit of coin on preparing for this exam.  You are going to need some review materials and which ones you buy are up to you but there are a couple ways to save some money.  For starters, if you are really strapped we recommend that you at least have First Aid and a question bank. Then, get all (we mean all) of your books from

half.com or other discounted sites such as http://www.amazon.com/

Half.com is a site run by ebay specializing in media (dvd’s, video games, BOOKS, etc.) and can get you books in like new condition while saving you quite a bit of money. Furthermore, editions that are an year or two older are much cheaper and definitely a better alternative than opting to not buy the book at all.  Qbanks are a very very very useful tool and I really believe everyone should use at least one.  USMLE  World is (at least at the time of this publication) the cheaper option and is regarded by most to be slightly superior to Kaplan.  However, you can score a pretty sweet deal through Kaplan when the come to the school (see under QBanks). 

 


21. Can I receive special accommodations during this exam?

If you do have a learning disability, ADHD/ADD, hearing/vision impairment or any other conditions that you believe will require special accommodations for the exam please visit: http://www.usmle.org/Test_Accommodations/test_accommodations.html

The requirements are quite extensive so do this earlier rather than later.

22. I don't have any of the above but I don't consider myself a good test taker; I am really worried about this long and comprehensive exam. What can I do to deal with that? Start early, this can’t be emphasized enough, even if you are worried you should at least have First Aid so you can see what areas in your current studies you should focus in on.  Secondly, take as many of the NBME self assessments (see under comprehensive resources) as financially possible so that you are continually reassured that you will do ok.  If panic comes during the exam think of that and put forward your best guess, after all you have been right before.  It can also help to visit the facility ahead of time.  Finally, one of the best things to remember while taking these tests is that unlike the tests you have now, these people aren’t trying to trick you.  Don’t overthink the questions if there is an answer that seems too obvious that’s only because you are used to being a paranoid test taker.  On Step 1 the vast majority of the time the answer that seems too obvious to be correct is in fact the correct answer. You can always seek help at school either at the OSA or Office of Student Development.


 


Comprehensive Resources


1. First Aid

Important: FA offers a time line and a general guide to the exam/ exam preparation. Read this section early it will give you another perspective on the issue (and will release some anxiety)! – As most of you know this book is a must. Buy it early and memorize it (all of it), it will definitely pay off. No one is saying start memorizing everything now, but as you learn new stuff for class flip through the corresponding section in FA just to make sure you are taking in the basics. It also helps you to pick out the most important points out of the sheer volume of reading you are assigned for class. You can also write in info you learn from review books/ class/ Qbanks that you think is relevant in the corresponding sections and continuously review it. As such, this book becomes your #1 unified resource for learning and review. This strategy has been helpful to many people and the earlier you start, the easier reviewing for the test will be at the end. Here is a direct quote:” This book is a gold mine of information.  Let me repeat that…a GOLD MINE!!  If you don’t already own First Aid, put this down and go to the book store and BUY FIRST AID.  This book will allow you to focus your energies on specific sections of your class studies.  If you integrate the two, ie add the extra detail from class that seems important to your first aid you will be an unstoppable force of Step 1 domination.” The First Aid also has a good outline of what to expect on Step 1:  The proportion of each topic covered in First Aid is generally proportionate to how much will be tested in Step 1, as is the manner of presentation.  For example, spend significantly more time on Pathology than Histology, and anatomy is incorporated into other subjects rather than tested directly.  Use this as a guide to studying!

Be aware that the new edition will be available on 12/29, but since versions don't change significantly, if you want to start studying early, the 2008 version will work well.  Some students also buy 2 copies of the book: 1 for the heavy highlighting & note writing, and another to start fresh with a couple weeks before the exam. Again, now is a great time to buy the book (but be careful do not go crazy with it and burn out!), Christmas is definitely good (i.e 5-6 mos before hand). April will be too late/ not advisable.

Rumors are that memorizing the FA will get you at least a 220, this is really hard to prove as people invariably use other resources to prepare such as BRS, class notes, Qbanks. Also, FA does not provide explanations just formulas/facts so if you do not understand a concept you invariably have to look for an explanation somewhere else. Be aware FIRST AID CONTAINS MISTAKES! There was a website with mistakes in the 2007 edition; currently such website does not exist for the 2008/9 version but surely will surface so be on the lookout for it!

Rating of resources in the FA/ is it accurate? : FA provides student rating for each resource on the back. Generally these are very accurate (a great place to find even more resources) but if you find a resource is not working for you do not continue using it just b/c FA gave it an A. Do try to stay away from lower rated resources however.


2.Qbanks: As a medical student preparing for the shelf exams and the USMLE exams it can be overwhelming to make your way through all of the resources. There are many options and only a limited amount of time.

2.1 Kaplan is definitely a very useful Qbank with appropriate content and it is the one that most people in our school use. They got a score estimator which is fairly accurate but usually underestimates your actual score. Kaplan also comes with free palm software for pharm and anatomy flash cards (the pharm cards are definitely very useful). There are only 2 disadvantages to using Kaplan:


#1. The Q bank is somewhat expensive. However, CMS students get a deal so some of this disadvantage is offset. Speaking of which: Wait for the Kaplan rep (who comes to you (yes at CMS) at a time specified by your class officers) to purchase Kaplan so you can take advantage of this discount!!! Pls. do not purchase the Qbank on your own if you want to save $.


#2. Some of the questions last year tended to be “out there” but they are continuously improving it so these issues might have already been addressed. Another quote to better illustrate this point: “There are a fair amount of questions that might freak you out because you have no idea what they are talking about.  Don’t worry, you’re not alone.  Before you worry about the material covered in a question that was really hard check to see how many people got it right, if it’s less than 20% I wouldn’t worry about it too much.  You can come back later and learn this stuff after you’ve learned the more high yield stuff but chances are pretty good that nothing like this will show up on the exam”.

Generally, explanations to the questions are shorter than USMLE World.


Kaplan books and additional resources come in as a supplement to the basic Qbank. As already mentioned, your class officers will organize a meeting with a Kaplan rep (if they have not already) and he or she will explain in detail what additional resources Kaplan offers. You can surf the web yourself here (this website can be confusing so if you are lost, just wait for the rep): http://www.kaplanmedical.com/Medical_Licensing/Step-1/View-Kaplan-Programs/IMG_step1_overview.html?cid=438312


Generally speaking, the Kaplan books are a good resource (there are many success stories of people who just used Kaplan and Kaplan books to prepare for the exam and did wonderful) however given the cost and the need to buy other resources (some CMS specific such as BRS and others more general such as FA and NBME self assessments (see below) people have done great on this exam without buying these books. There are also people who bought the Kaplan Books (as a reflex from taking the MCAT) and never used them. It is really up to you whether to use these books/additional resources but the point here is buy the books/additional Kaplan resources only if you think that you need them/ will have time to use them and not out of fear that you will be missing out on essential info for the test if you do not. Again, whatever you decide to do, wait for the Kaplan rep.


NB: That being said, do not shy away from getting a review resource (of any kind) on a particular subject if you think you need work in that area!


NB: the Kaplan comprehensive book which is similar in format to FA is in our humble opinion not superior to FA.


NB: Getting a comprehensive exam included in your package can be a good idea (this will put you into Qbank Plus or something like that again wait for Kaplan Rep) but it is not an absolute must especially if you consider getting one or more NBME self-assessments. It all depends on how many practice tests you want to do before you go for the real deal. If you do get it, here is a word on the percentage you will receive on that exam.  To give you an idea; a 72% on the full length simulated exam corresponded to 251 (on Kaplan’s scale). This was also roughly comparable to % correct on Qbank to Kaplan Step One predicted score. 


2.2 USMLE World http://www.usmleworld.com/step1QbankMain.asp#SimExam


While Kaplan is a great QBank and many of us actually used both, some people believe that UWorld is slightly superior for the following reasons:

#1. Explanations are more detailed and cover other areas/topics in addition to the question asked. It has good explanations of not only the reason why the correct answer is correct but why each other option is wrong. As they say in their website, the Qbank is meant as a study resource in addition to being a review tool. (A side: It also contains a self-assessment exam. %’s about comparable to Kaplan’s).

#2. Content is very appropriate.

#3. The interface is EXACTLY like the real test, EXACTLY the same.

#4. It is cheaper; so it allows you to get both Qbank and UWorld. (no rep comes to our school/no discount).

Overall the two Qbanks are comparable.

2.3. USMLE Rx— http://www.usmlerx.com/USMLEFlash/Login.aspx

USMLERx is an online question bank that was put together and managed by the same company that make / publishes the First Aid book series. There are 2800+ USMLE style questions with full explanations. The explanations are actually copied pages out of the First Aid book.  By going through the questions and reading the explanations you actually read the entire First Aid book 2 – 3 times. Most students are reading and studying from First Aid anyways, so this question bank offers an additional way to work through the First Aid a couple more times.  A paid subscription to USMLERx includes an integrated online version of the First Aid text. Also USMLERx is less expensive when compared to other question banks; students who are AMSA members get a further discount.

Some students thought that Rx questions were not as difficult as some of the other online question banks due to maintain a higher average on Rx than on Kaplan or USMLE World. Ultimately, USMLERx questions were inline with the USMLE Step 1 exam. Many students also complained that some questions on Kaplan and USMLE World were too difficult or esoteric and not helpful. Much less of these types were included in Rx. Overall, it is beneficial to use either Kaplan or USMLE World and also use USMLERx as a second or third source for questions.  

The software used for USMLERx is identical to what you see on the USMLE Step 1 exam. Finally USMLERx offers free web lectures and forums that put you in touch with other students preparing for the USMLE Step exams. 

Aside:

#1. A word on getting more than one Qbank Whether or not is worth getting more than one QBank is only for you to decide. You can view demos on these product’s websites and decide for yourself how to proceed. It truly depends how much practice you believe that you need. Remember QBANKS ARE A VERY IMPORTANT RESOURCE TO PREPARE FOR THIS EXAM! However, getting too many qbanks can be overwhelming, burning out conducive, and stressful for some again no good answer this is for you to decide. Two is generally sufficient for most people.

#2. A word on the length of subscription

Again up to you. Generally 5-6 mos is a very good period 3 mos is REALLY pushing it (not advisable). If you end up getting 2 qbanks you can have a primary one for the five-six mos and supplemental one for maybe 2 or 3 mos. If your time expires you can always renew (fee).

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