Hands down the most common question I heard as a tutor in medical school was about finding the elusive “balance” for studying during 3rd year rotations or clerkships. It is definitely a worthy question.
It used to be that during the preclinical years the emphasis was placed on studying and preparing for exams while clinical material took a back seat. The script would then be flipped during the clinical years as Step 2 CK wasn’t as much of a concern. It was far more important to get honors in your rotations and merely maintain the “status quo” for Step 2 CK.
Now that Step 2 CK is the stratification exam of choice for residency applications, you need to ace it. But not at the expense of your rotations. You can’t sacrifice your clinical responsibilities the same way I used to skip out of boring, slow-paced preclinical lectures to study for Step 1. No. That would bring serious consequences in your MSPE Dean’s letter under the “Professional Performance” section.
Challenges of studying during clerkships
Finding a balance between smashing your clerkships and keeping your USMLE muscles primed for action is difficult during 3rd year for three main reasons:
- It’s not clear what you should be studying. First Aid for Step 2 CK just isn’t the same as for Step 1. I’m sure there are several new solutions to this problem being worked out given Step 2 CK’s new found importance. I really struggled to figure out which resources I should be using to learn and review. How many resources will you need? Should you be reading text books or is there a more efficient way? More on this in a minute.
- The NBME and USMLE appear to test one knowledge base, while the attendings for your clerkships test another. Can you study for both? Maybe you have noticed this. You crushed Step 1 and yet, when you show up to your clerkship, you feel like a total noob again. It’s demoralizing! Don’t you know a ton of medicine now? Are we going to pretend that all of a sudden enzyme pathways and countercurrent exchange in the loop of Henle just don’t matter? When you devote time to reviewing for Step 2 or your shelf exam, you might feel like it’s taking you away from reading about your patients, their conditions, and the management you will have to present on rounds. So, if we could study in a way that also prepares us for pimping questions on rounds, that would be great.
- You have far less time than you did in the preclinical years. I know, this one is obvious, but it’s also the most difficult to overcome. Whatever you choose to do for studying has to be efficient and effective even in short bursts.
I don’t claim to have all the answers here. All I can do is speak to my experience and the experience of other students I’ve worked with. Let’s talk about how I navigated the above challenges.
Finding the resources
While I wasn’t a fan of First Aid for the USMLE Step 2 CK, it does exist and you may want to check it out for yourself. I found it to be quite superficial and it just didn’t feel like the First Aid I knew and loved from Step 1. And I just couldn’t be bothered carrying a giant textbook around the hospital.
For Step 2 CK there are truly only a couple of resources I would classify as requisite and the rest I would say are helpful but optional.
- Uworld Question Bank: Excellent. You need it. You can take practice blocks organized by shelf exam to streamline your study for clerkships. It is tremendously representative of the type of questions you will see on the real deal. The explanations provide enough detail that you don’t necessarily have to look elsewhere to understand the topic. This should be your primary resource for shelf exams and Step 2 CK.
- NBME practice exams: Both the shelf practice exams and the ones for Step 2 are excellent. Now that these babies have answer explanations, they are that much more valuable. I would try to do at least 2 practice shelf exams per rotation if you can. Take one about halfway through to see how you’re doing, and then the second one a few days before your shelf. Occasionally you encounter topics not covered in Uworld and it would behoove you to take note of these golden nuggets somehow. I went back through my old NBMEs prior to taking Step 2 and scored several extra questions because of it. If you are running out of new questions during your dedicated study session, then the other medicine NBMEs are definitely worth a look.
- Anki: I know, you either love it or hate it but shut up and listen for a second. The ultimate study hack for Step 2 is to find yourself a solid premade Step 2 deck that is heavily based on Uworld. I used Zanki’s deck because I jived with the cloze deletion style and its size was manageable. If you have been resisting getting started with Anki then now is the time to jump on this band wagon and ride it all the way to your dream residency. You will retain everything you learn from Uworld without having to grind out a billion of your own flash cards. I’m not discounting the benefit of making your own cards. I still recommend you make some yourself if you miss a question and the card isn’t in your deck. This is also the place to incorporate your NBME knowledge nuggets. I ended up adding about 1700 of my own cards to the existing 5000 or so. It’s a searchable library and you can take it anywhere with you. You can be crushing cards while hiding awkwardly in the surgeon’s lounge waiting for ORs to turnover.
- Online Med Ed: Some people rave about these videos but I found them to be much more helpful to get a broad overview of the typical problems you see on the wards. Dustin gives great advanced organizers and points out the diagnostic and management pearls that are hard to come by otherwise. And he does it for free, bless his heart. I didn’t buy any of his other resources so I can’t comment on them. His free videos will help you do well in your clerkships but are probably a bit superficial for the minutia that pops up on the Shelf or Step 2.
- Amboss: This is actually a great overall resource and if you have the funds, I would try it out. Don’t prioritize Amboss over Uworld though. My school bought us all a 3 month subscription as a consolation during the pandemic. I was pleasantly surprised by the quality of the qbank and review materials (library and videos). They also have an Anki add-on that links your own cards to their library so you can look things up with one click if you need more info. The qbank questions are without a doubt much more difficult than Uworld or the real thing and they know it.
- Sketchy Medical: This was a staple of my Step 1 preparation and I didn’t renew my subscription for any period of time during MS3 year. I kept up with my Sketchy Pharm Anki deck though. The pharmacology from Step 1 translates exceptionally well to Step 2. Also for the Psychiatry shelf exam. Sketchy Pharm is still high-yield as an Intern honestly.
- Boards and Beyond: Another favorite of a lot of students I worked with. I never used it because I really just didn’t feel like I needed anything outside of Uworld and Anki. But Dr. Ryan is a genius and his videos have been really helpful to a lot of students.
- Osmosis: This resource is growing and becoming an all-in-one study platform with flashcards, videos, qbanks, and more. I started watching their free videos on YouTube during first year. They are really good for quick review of Step 2 topics and it’s easy to make a playlist of topics to listen to at the gym or while waiting for your senior to finally send you home.
Figure out how to study
Now that we have our resources sorted, I’ll walk you through how to strategically study. Believe it or not, studying can be geared towards success on the shelf and Step 2 CK as well as prepare you for pimping in the hospital and clinic. One method would be to just indiscriminately unsuspend Anki cards by shelf exam and start working through them. I’m sure this would work, but it feels too grindy for me. I don’t like to brute force memorize flashcards. It is painful and I hate it. I want my flashcards to help me reinforce something I’ve learned from another resource. Think of your primary resources for learning as Uworld and NBME exams on one hand and your patients on the other.
Let’s discuss Uworld first.
This part is straightforward. Which is why it’s awesome. Calculate how many Uworld questions per week you need to complete to finish all the questions for the rotation you are currently in. That’s it. You don’t have to exert any more effort than that.
For example, my medicine rotation was 12 weeks long. Currently, there are about 1590 questions in Uworld that are medicine (about 1200) and ambulatory medicine (about 390). That works out to be about 20 questions a day. You don’t have to do all of these BTW, but it is doable. And on some days you may knock out as many as 80.
As you study your “missed” and “marked” questions for the day, you find the topics you need to pull into your Anki deck. Just search the topics and “unsuspend” the relevant cards to start the next day. That way you are staying fresh on the topics you study without having to make the card yourself. If the card isn’t there, then make it.
As you encounter patients on the wards, you take each of their diagnoses and search them in your Anki deck. You will be pimped on diagnostic criteria, labs and imaging studies, as well as typical management. You will find a lot of this in your flash cards. And you can add to the notes section of your cards anything you learn from google, UptoDate, or other clinical reference tool. Add anything that stands out, like why the management for your patient was slightly different, or any complication the patient had. It gives clinical context to your flashcards and will burn these illness scripts into your neurons.
By the end of your third year you will have formed such strong connections between the boards and the wards that you will be crushing practice tests in your sleep. Or as you phase in-and-out of consciousness during your OBGYN rotation.
Finding the time
I already had a 3-year-old when I started my MS3 year. I welcomed my second child 4 months into the year. I picked up an ortho research project while standing at my laboring wife’s bedside. I learned a thing or two about making time when there isn’t any to be had. Here’s what you can try:
- Take advantage of down-time: You will have sporadic breaks throughout the day you can use. I love Uworld and Anki because they both have mobile and web apps that are fully functional. I was prepared to go from zero to hard-core studying at the drop of a scrub cap. Be aware of your surroundings when studying on your mobile phone. There is often a generational disconnect between attendings and students. An attending who sees you on your phone will assume you are on social media or wasting time. This may hurt your grade. I would head this off by mentioning to attendings (and senior residents) that I have all my study resources on my phone and that I would be catching up on flash cards etc. Alternatively, you could use a laptop or access Anki or Uworld online via a hospital workstation. Some attendings were interested to see how I was studying. Many were jealous of the tools we have today.
- Be strategic with assignments: Many of my clerkships required presentations, essays, patient write-ups, or other assignments. For the majority of them I could choose the topic. I always chose a high-yield boards topic to write up. This meant that I was essentially prepping for the shelf or Step 2 and I already had tons of flash cards to draw from. I would just grab a few sources and look over the UpToDate entry on the topic and my presentation was done.
- Appeal to your resident’s human side: Residents are tired and weak. They are easily manipulated. I’m only kind of kidding. If things are slowing down and a med student asks me for advice about studying during busy rotations or asks how they should prepare for Step 2, my immediate reaction is to let them go study. Many will offer to let you go early anyways because they remember what it’s like. If I see med students still at the hospital after 3PM I start dropping hints to the senior to let them go. You will say “Is there something I can do for you before I go?” and then you GTFO.
- Learn on the way: Don’t do flash cards while driving, but you should check out the Curbsider’s podcast and consider making YouTube video playlists that you can listen to during your commutes or while grocery shopping, etc. I also like the Emcrit podcast. These podcasts are probably less boards specific but are a good use of time. Divine Intervention is a more Step 2 CK oriented podcast to check out as well.
The guiding principles for finding time to study and still having time to relax revolve around being prepared, being strategic/intentional, and taking advantage of opportunities as they present themselves. Part of the learning curve of the clinical years is figuring out how to balance competing interests. The competition for your time only gets worse as you go along. Well…maybe not during the second half of 4th year.
You are equal to the task. You’ll be surprised what you can accomplish with so little time if you keep working at it.