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Shelf Studying for Busy Clerkships, Even Medicine and Surgery

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by Alec Palmerton, MD in Clerkships, Plan, Step 2 CK/Shelf

How you study on clerkships is critical for getting into residency. Sure, “clerkship studying” won’t come up in many interviews. However, it affects most of the criteria program directors use to compare applicants. If you want to stand out, how you learn on rotations will be a significant factor.

Here are the top 6 factors program directors use when deciding whom to interview:

  • USMLE Step 1/COMLEX Level 1 score
  • Letters of recommendation in the specialty
  • Medical Student Performance Evaluation (MSPE/Dean’s Letter)
  • USMLE Step 2 CK/COMLEX Level 2 CE score
  • Personal Statement
  • Grades in required clerkships

I’ve listed in bold the criteria for which clerkship studying has a direct impact. The upshot: how you study during your clinical years affects where you will interview.

The most obvious way clerkship studying impacts residency applications is your scores. Shelf scores make up a considerable part of clerkship grades. Additionally, Shelf exams are prologue to Step 2 CK.

Still, studying impacts other critical elements in your residency application. Remember that your clinical performance comprises the bulk of the MSPE. How can you perform at your peak if your studying is ineffective? Additionally, learning strategy impacts descriptions of clinical performance in your letters of recommendation.

This post will cover the 5 most critical elements for effective clerkship studying so you:

  • Score higher on any shelf exam, even busy ones like surgery and medicine,
  • “Double-dip” and prepare for Step 2 CK simultaneously,
  • Maximize productivity and still get 8 hours of sleep,
  • Master the one critical skill behind any high Shelf/Step 2 CK score,
  • Learn how to be a better doctor and make residents love you, and
  • Much more

Table of Contents

1. Study Before Going to the Hospital, Not After

Do you dread studying after a long day at the hospital? Tell yourself, “this is crunch time” but still end up surfing the internet?

Yes, we’ve all felt the guilt of binge-watching Netflix or Youtube when we should be studying. But what if the problem isn’t our self-control, but rather the time of day we’re trying to study?

Clerkships are mentally and physically demanding. Outpatient clerkships, despite shorter hours, are still draining due to the fast pace.

Hitting the books after a long day of work is like trying to run a sprint after a marathon. You’ve used up your best effort, so studying takes longer with worse results.

Compelling evidence (and common sense) suggest we have at most 3-4 hours of peak concentration in a day. Wouldn’t it be great if we could save our best hours of focus for when we need them most? We could use low-level attention throughout the day. Then we kick into high gear in our after-hospital learning.

Unfortunately, we have limited influence over when those four hours happen. Our concentration peak often occurs when we have the most energy. We can’t “bank” our best hours – we either use them or lose them.

Translation: doing the bulk of your studying after a long day in the hospital is a losing battle.

Most Med Students Waste Their Peak by Waking Up Too Late, Even On Medicine and Surgery

What is your routine? If you’re like most, you wake up, get ready, and go directly to the hospital. However, the clock on your 3-4 hours of peak performance is already ticking. And as we discussed above, by the time you come home, you’re exhausted, and your studying will suffer. Why? Because you’ve already used your four “golden hours.”

Using your maximum attention on hospital tasks is a poor study plan. The truth is that most hospital work for med students doesn’t require laser focus. Morning report may be interesting. However, you don’t need the concentration of a virtuoso violinist. For some tasks, like holding a retractor, you only need an available limb.

As one tutee put it, “sitting in a corner while shadowing doesn’t require attention. You just have to remember to stay awake.”

Instead, Go to Sleep Early and Wake Up Early

Your concentration peak should happen while you’re studying! To do so, go to sleep early and wake up early. To calculate what time you should be sleeping, think of:

  • The number of hours you want to study
  • What time you have to leave

Then build in 8 hours of sleep to ensure the highest quality learning. If you have to leave by 6 AM, plan to sleep at 8 PM and wake up at 4 AM. Why? So you can do your best work before you go to the hospital. Do the hardest tasks as soon as you wake up, and you’ll accomplish more in less time.

I’ve had students double their productivity by going to sleep at 8 PM and waking up at 4 AM. Studying for 2 hours while they’re energized allows them to do more than if they’d studied 4 hours after a long day.

Plus, getting your work done before the hospital feels fantastic. What would it feel like to come home and not have to study for hours? Imagine how blissful (and long!) sleep can be if your to-dos are actually done.

Besides, better, more restorative sleep creates a virtuous cycle. The more rested you are, the better your studying, giving you even more opportunities to relax.

I slept 8+ hours most nights throughout medical school and residency.

So, what time will you be going to sleep tonight?

2. Do Questions in the Morning

We discussed why you should do the most challenging work in the morning before you get drained from your day. So what attention-requiring work should you do before going to the hospital? Mastering QBank questions.

Learning how to approach questions is the most critical skill to get a high Shelf score. Remember, if you only have 3-4 hours of peak concentration, you should use it on the most essential task. That task is doing questions.

With 2-3 hours of solid studying before going to the hospital, you could do 10-30 questions. That is a fantastic pace, and much better than you’d likely do if studying at night.

But just doing a large number of questions won’t lead to higher Shelf scores. Instead, it is HOW you approach your QBank that will determine the final results. In other words, you need to master the skill of question interpretation.

3. Focus on Question Interpretation Over the Acquisition of Knowledge

Question interpretation is the skill to know what every sentence means in a vignette. This skill allows you to identify the diagnosis earlier, even from the first sentence. Read the following example, and write down what you think is going on:

A 73-year-old man is brought in by his wife for evaluation of recurrent pneumonia.

Stop and think about what that means. Resist the urge to look at the explanation, and come up with your BEST guess based only on the first sentence. Ready?

Here is what someone skilled in question interpretation might think:

Likely diagnosis: a man with dementia who has recurrent aspiration pneumonia

Let’s unpack how we came to that conjecture.

An elderly man is brought in by his wife. As such, he is either:

  • Not well enough to realize he has a problem, and/or
  • Is incapable of bringing himself in

This is a standard giveaway for Alzheimer’s on tests, as it is often the patient’s family that brings them in. If the patient has enough awareness to recognize they have a problem, it’s likely not dementia.

But guessing he has dementia isn’t enough. Next, how can you connect possible dementia with recurrent pneumonia? CNS problems (e.g., vascular dementia) could lead to both cognitive and dysphagia/swallowing problems. Poor swallowing could lead to repeated aspirations and, ultimately, aspiration pneumonia.

What was your answer? If you thought about post-obstructive pneumonia from lung cancer, it’s not unreasonable. Maybe he had COPD, and was so weak his wife had to bring him in? It’s not impossible. However, the typical USMLE reason someone brings you in is for cognitive deterioration. And if you thought, “ok, old guy with recurrent pneumonia,” you missed some vital clues.

How Much Higher Would Your Score Be if Your Interpretations Improved?

How often do you say, “I’m not sure what this means”? Or find yourself stuck between two answer choices…then choose the wrong one?

Every time you make sense of a clue, you are one step closer to getting the question right. Knowing the significance of a man’s likely dementia helps piece the puzzle together. Conversely, the more unexplained details in a vignette, the more likely it is to get lost.

Want to know how many points you’re missing due to question interpretation? Try this: go back to an old UWorld block or – even better – an old Shelf NBME. Assess whether the critical sentences that led to the correct answer were things you knew or not.

Did you know that a PE should have clear lungs, but got confused they didn’t have a classic DVT? Or fixate on an unimportant detail you couldn’t explain and then changed your answer to the wrong one?

You’ll often find that a lack of knowledge was not the reason you missed a question! Instead, you likely missed many questions because you couldn’t sort through all the facts and “noise.” In other words, it was your interpretation – not knowledge – that was the missing piece.

Many students have benefited by mastering question interpretation. Melody went from a below-average Step 1 score to 260 on Step 2 CK. Minills did the same, scoring 261 on Step 2 CK. Many other students have mastered question interpretation for better Shelf and Step 2 CK scores.

To learn how the Online Course can help you master question interpretation for better scores, schedule a free consultation today.

4. Do Anki During the Day (Especially on Inpatient Clerkships)

This next strategy is mostly for inpatient clerkships. (Note: the goal of getting your cards done before you come home applies to all rotations).

Want to know the dirty secret of (most) inpatient rotations? The hours are long but filled with downtime and lots of waiting. Think about it. On internal medicine, mornings are hectic. You pre-round on your patients, discuss your plan with the residents, and present on rounds. After that? The rest of the day is spent implementing the day’s plan. And much of that plan involves waiting: for labs, imaging, or consultant recommendations.

During this downtime, you should be doing your Anki cards. (If you’re not already doing Anki, I implore you to start).

Why You Shouldn’t Do QBank Questions In the Hospital

Why should you do Anki cards in the hospital, and not QBank questions? Because Anki is well-suited for the (very) short periods of hospital downtime. QBanks are not.

To learn effectively with QBank questions, you’ll need to focus at least 5 minutes per item. You need to do the question and review it. If you get interrupted, even once, it’ll take minutes just to remember where you left off. This constant need to re-orient yourself is a waste of time.

In contrast, a typical flashcard takes 20-30 seconds to review. Have a few minutes before a lecture? Waiting in line at the cafeteria? Taking a bus/subway? These are all great times to do your cards! Get in the habit of using any scraps of downtime to review. You’ll be amazed at how much you can do before leaving for home.

Your goal: finish your Anki cards in the hospital before you leave. This way, you will have little to do after work, when your energy is at its lowest.

Note: if most of your cards take more than a minute to review, they may be too long. Look at the rules for making good Anki cards here.

Don’t Do Anki on Your Phone; Use Hospital Computers Instead

Remember, when you do Anki, don’t do it on your phone or tablet! Instead, use the hospital computers to log onto Ankiweb.

Ankiweb is a cloud-based service that syncs with your phone/desktop Anki apps. You can access it from anywhere that has an internet connection. Because you can do it on a hospital computer, you can have it open while doing your EMR work.

Why should you not study on your phone in the hospital? Because studying on a smartphone is like going to a strip club and saying it’s for the food. It might be true, but no one will believe you.

The default assumption when a student looks at their phone is that they’re on Facebook. The reverse is true, however, when you’re on a hospital computer. When a student is on a hospital workstation, they’ll assume you’re taking care of patients.

Pro tip: listen for critical items your team will be waiting for that day. These are things like serial troponins, a CT scan read, or consult recs. Then, while you’re on the hospital computer, “refresh” those results every 20-30 minutes. (Residents are busy! Even if you check every 60 minutes, you’ll see more than most residents can.)

Troponin comes back negative? CT scan confirms your suspicion of a PE? Tell your residents! They’ll love you, which is a fantastic way to make friends and get good clerkship evaluations. Your team will also learn to value the time you’re on the computer.

In the time in-between, keep doing your flashcards. You’ll do important work, and you won’t have to explain why you’re always looking at your phone.

Keeping Up With Anki Prepares You Well for Step 2 CK

Remember, the content of your shelf exams comprises virtually everything on Step 2 CK. The better you learn the material – and the more you do Anki to never forget it – the better your future Step 2 CK score.

To achieve the highest Step 2 CK score, be sure to continue ALL old cards you’ve done for previous clerkships. If you want to save time and have useful pre-made Step 2 CK cards, I recommend the Yousmle Step 2 CK deck. You will spend less time making cards and more time mastering the information. This frees up more time for QBank questions, which, as we discussed, is critical to your Shelf/USMLE scores.

5. Save Less Intense Work for After the Hospital

So, you’re going to wake up early and do QBank questions before you go into the hospital. You will also finish your Anki cards in the hospital – on a hospital computer – before you get home.

So what should you do when you get home?

If you’ve followed the plan, you shouldn’t have much to do! What remains is low-intensity work. Your best studying should take a sculptor’s concentration. After-hospital work should take the focus of Play-Doh.

Here are some examples of low-intensity work you should do at the end of the day:

  • Watching videos, like on the Yousmle Online Course
  • Preparing for a presentation on a topic for rounds
  • Clerkship assignments
  • Researching residencies, away rotations, etc.

The Yousmle Online Course is especially suited for use after a long day on the wards. Why? Each content module has pre-made Anki cards so you can get more questions right, even months later. Master the cards, and you will maximize your retention and score higher on other Shelf exams/Step 2 CK.

We made these cards because we know what it’s like to watch a video and forget everything two days later. It’s frustrating to spend hours watching lectures but only retaining a small fraction. Instead, by understanding more of each vignette, you can get more questions right. And with our pre-made cards, you can remember everything without taking hours of notes.

To check out a sample video, click here.

To learn how the Online Course can help you master more in less time, schedule a free consultation.

Concluding Thoughts

Here are the principles we discussed:

1. Study Before Going to the Hospital, Not After
2. Do Questions in the Morning
3. Focus on Question Interpretation Over the Acquisition of Knowledge
4. Do Anki During the Day (Especially on Inpatient Clerkships)
5. Save Less Intense Work for After the Hospital

Successful studying on clerkships doesn’t have to mean late nights and endless memorization. In fact, often, it is maximizing the quality – not the quantity – of studying that leads to the best results.

How will you study on clerkships? What have you found is the best way to master and retain material? Let us know in the comments!

  1. Alister Collins says:

    If I’m unwilling to make my own Anki cards, what is the best way to review wrong USMLE questions?

    1. Yousmle says:

      If you don’t want to make your own, then you need to make sure you find the best possible cards to use instead. The Online Course has a lot of cards based on vignettes, that can help especially if you are pressed for time and aren’t able to make your own cards.

  2. Colin Goodman says:

    Hi Alec,

    Do you have any tips or recommended resources for mastering patient presentations as a medical student? I’m finding this to be a challenge in third year.

    Thank you,

  3. Colin Goodman says:

    Hi Alec,

    What do you recommend using as a primary source to generate Anki cards during clinical rotations? Should I mainly just base them on UW questions? Or should I make some based on something like case files or pretest?

    Also, how do we know we’ve covered all the relevant topics for the shelf exams? Is going through UW for that rotation enough? I know the questions are more focused on interpretation and reasoning skills, but I know there will also be lots of new things to learn that I won’t know coming into the rotation.


    1. Yousmle says:

      Great question – I’d recommend focusing mainly on UW questions, and studying based on the things that you are missing. As you point out, much of Step 2 CK/shelf exams involves question interpretation, even more than Step 1. As such, the key is to use the questions to fill gaps and to improve your question interpretation.

      Thanks again for doing a testimonial – how has that been coming?

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Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.