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How to Study for Step 1 During Clerkships in 6 Simple Steps

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by Alec Palmerton, MD in Uncategorized

How do you study for Step 1 during clerkships? Most of us think that studying for Step 1 on clerkships won’t be too bad. Just take 10 or 20 minutes a day, and do a few questions, right? However, as Einstein noted, “In theory, theory and practice are the same. In practice, they are not.”

Studying on clerkships is hard enough. Studying for Step 1 – which may seem diametrically opposed to what you’re doing in the hospital – may feel impossible.

It is true that studying on clerkships is a challenge regardless of what you’re studying for. However, it is also true that the WAY that we study matters. As we’ll discuss, most people set themselves up for failure. Why? By not having their Step 1 studying overlap enough with what they are doing in the hospital. As they say, “chase one rabbit, catch it; chase two, catch neither.”

In this article we will discuss:

  • The 6 steps you need to take to study for Step 1 on ANY clerkship
  • Why WHEN you study matters just as much as HOW MUCH
  • How much Step 1 overlaps with Shelf/Step 2 CK material
  • The best way to study during a busy rotation without getting dirty looks from your team
  • How to improve patient care while also prioritizing your own learning, and
  • Much, much more

Table of Contents

1. Make Studying Less Miserable by Studying BEFORE Leaving for Work

On your busiest rotations, you may have at most an hour or two that isn’t taken up by the clerkship. So, how best to utilize those hours to study during clerkships?

While you may not have a choice on how many hours you can study, you CAN choose WHEN to study. And you basically have two choices. Either

  1. Sleep/wake early and study before going in, or
  2. Sleep/wake at your typical time and study after you get home.

In theory, studying diligently for an hour or two after a long day in the hospital may seem reasonable. In practice for most of us, it is not.

Sleep Early (and Get 8 Hours), Then Wake Up Early

To combat this, the most effective strategy is to:

  • Go to sleep very early and
  • Wake up early enough to study 1-2 hours before leaving for work

Why focus on when people sleep rather than when people wake up? Because most people interpret “wake up at 3 AM” to mean, “still go to sleep at 10 PM and wake up at 3 AM.” Hence, the key to waking up early is to go to sleep a full 8 hours before your target wake time. Only then will you wake up with enough energy to study for 1-2 hours before heading to the hospital.

Let me repeat this – you should go to sleep and get a full 8 hours of sleep, every day.

This may seem insane. “I don’t have enough time for the things I need to do, and so I will have less time to do them by sleeping more?” It may also go against your “biological rhythm” or even just habits. You may be incredulous that you could study before going into the hospital.

All of these objections may be true. On the busiest clerkships, you may have to go to sleep at 7 PM so you wake up at 3 AM so you can study for an hour before heading into your surgery rotation. Is it easy? Absolutely not – it may be one of the hardest things you do during training. However, is it less miserable than trying to study for an hour after a day of retracting, doing scut, and getting yelled at? Absolutely.

For more on how I made myself into a morning-crushing study machine – and you can too – read this article.

2. Do Anki Cards During the Day on a Hospital Computer (Inpatient Rotations Only)

The second key to studying for Step 1 during clerkships works for ALL inpatient rotations. You may be skeptical that 1-2 hours of studying in the morning will be enough. How could you do QBank material, learn new things, and do Anki cards or other spaced repetition?

What is the trick to mastering new things, doing QBank questions, and reinforcing them with Anki? Do Anki during the day on a hospital computer.

Why a hospital computer? If you do your Anki cards on your phone, everyone around you will assume you are checking your email/social media. What if you show your team that you’re reading UpToDate? They will still default to thinking you are slacking off. Burnout is rampant among residents, and one of the hallmarks is cynicism. Want to guess what a cynical resident might think if you reach for your phone during downtime?

Rather than tempting fate, do your cards on a hospital computer. Anki flashcards are great – especially if they’re not the rote memorization kind but encourage true mastery. Each card can be done in less than a couple minutes. This bite-sized studying is well-suited for the frenetic, concentration-starved hospital environment.

If you use Anki, you can use the Ankiweb web app which can be (manually) synchronized with your phone/computer apps.

3. Avoid Being Hassled for Studying While Being an Exemplary Med Student

If you’re going to study Anki on the hospital computer, you should do so in a way that:

1) Minimizes dirty looks (and sour evaluations) from residents/attendings, and
2) Helps advance patient care and shows how exemplary of a med student you are

Here are a few pro tips on how to study undisturbed while still being an integral member of the team:

Pro tip #1: keep your Anki window sized within one of the windows of the EMR (e.g., Epic). That way, unless someone is looking closely, they won’t see your flashcards. In addition, you should master the “Alt + Tab” (PC) trick of switching quickly between applications.

Pro tip #2: during rounds, make a list of all the things that need to be followed up on during the day. Things like troponins that are being trended, serum creatinine that needs monitoring, consult recommendations, or radiology reads. Then, every 15-30 minutes, check on the things that can be verified by a computer. Not only will you be a huge help to your team, but it will also show them that you being on the computer so much is a good thing, giving you more breathing room to study during your downtime.

4. Recognize the Substantial Overlap Between Shelf Exams, Step 2 CK, and Step 1

Step 1 and clerkship/shelf material may seem diametrically opposed. Isn’t Step 1 all about microbiology, immunology, genetics, and biochemistry? As discussed above, no one wants to study the Kreb’s cycle while on their neurology rotation. It’s hard enough to study during a busy clerkship. It’s even harder when that studying doesn’t relate to what you’re seeing in the hospital.

While Step 1 and what you see in the hospital may seem different, in reality there is much more overlap than most think. To illustrate, try and name all of the subjects on Step 1 that do NOT show up on Step 2 CK. There are a few: embryology; a moderate amount of immunology, genetics, and biochemistry; and maybe a few others. However, the majority of Step 1 material will show up on Step 2 CK (and thus your shelf exams/clerkships).

Many Step 1 Basic Sciences Come Back – Especially on Pediatrics

All the organ systems (e.g., cardiology, renal, etc.) form the foundation of much of each clerkship. Less obvious is how often the basic science-heavy topics like genetics or biochemistry show up. For example, virtually all the biochemistry pathways show up on Step 2 CK in some shape. Maybe it is understanding acute fatty liver of pregnancy on Ob – glycolysis and fatty acid oxidation. Or ketogenesis and glucose metabolism in diabetic ketoacidosis on your IM rotation. Or perhaps it the glycogen storage diseases common on pediatrics questions.

In fact, pediatrics brings back many seemingly obscure Step 1 topics. Congenital/inherited conditions involve a wide variety of basic science topics, like:

  • Immunodeficiencies,
  • Genetic disorders,
  • Biochemistry, or
  • Even embryology

Want to prepare for Step 1 during rotations? Recognizing and accepting the overlap between clerkship material and Step 1 is essential. Next, we’ll discuss the best way to do so.

5. Study the Portion of Step 1 that Overlaps with Each Clerkship

Why studying for Step 1 during clerkships is virtually impossible – chase one rabbit, catch it; chase two, catch neither

The key is to recognize that while Step 1 and clerkships material overlap ON THE WHOLE, each clerkship only overlaps with a PORTION of Step 1.

Let’s take neurology, for example. Obviously, this is a subject that overlaps heavily on Step 1 and Step 2 CK. However, if I were to study, say, neurology for Step 1 on my surgery rotation, I’d find that there is minimal overlap.

What should you do instead? Study ONLY the portion of Step 1 material that overlaps with the clerkship you are on. You should MAINTAIN your knowledge in other subjects by doing all of your “old” Anki reviews. However, you should not attempt to learn anything NEW from anything that doesn’t overlap with the current rotation.

For example, on your neurology/psych rotations, study only neurology/psych. (And do your old cards to maintain your knowledge). On internal medicine, you would want to study most of the organ systems; internal medicine (and its shelf) is basically the organ systems from Step 1.

What Step 1 Subjects Best Overlap with Each Clerkship

Here’s a list of the core clerkships and what Step 1 material would overlap:

  • Internal Medicine: all organ systems (minus, perhaps, neurology if you plan to do it separately) + microbiology
  • Neurology: neurology +/- psych
  • Surgery: all organ systems (remember, most of the surgery shelf is actually internal medicine)
  • Pediatrics: biochemistry, genetics, immunology (plus organ systems if you haven’t already)
  • Ob: ob + endocrinology (if you haven’t covered it already from IM/surgery)
  • Psychiatry: psych +/- neurology
  • Family Medicine: all organ systems (FM has very similar content to IM with bread-and-butter peds + Ob sprinkled in)

If you master the Step 1 material that overlaps with each individual clerkship, you’ll have very little you haven’t covered. So what do you do for the remaining subjects?

6. Save the Remaining Material for a Later Dedicated Study Period

So you’ve studied the overlapping subjects between Step 1 and each clerkship. What do you do with the remaining subjects you haven’t covered? And what should you do if you weren’t able to cover all of the subjects on the rotation you wanted to?

Most people have a dedicated study period who are trying to study for Step 1 during clerkships. So, if you’ve mastered the Step 1 material of each clerkship – and made/done excellent Anki cards to never forget it – what next? During your dedicated studying, you should have only a few things left to study. These would include:

  • Embryology
  • Immunology (whatever wasn’t covered during pediatrics/other rotations)
  • Biochemistry (whatever wasn’t covered during pediatrics/IM/other rotations)
  • Microbiology (whatever wasn’t covered during IM/other rotations)
  • Other subjects that come up during your QBank studying/NBME practice exams

Don’t have a dedicated study? Some rotations are less intense than others, and may have less material to cover. A good example is psychiatry – often, this is a less intense rotation, and has less material to cover for the shelf. This can be a good time to cover other material you don’t anticipate being able to learn on other rotations.

Concluding Thoughts

Because I teach both Step 1 and Step 2 CK material, the overlap between the two is abundantly clear. I’d estimate that at least 80-90% of the material on Step 1 shows up in some form on Step 2 CK. The amount shared between these two board exams is so much, in fact, that the Yousmle Online Course is COMBINED for Step 1 and Step 2 CK students. Having a shared approach for both tests (with a few lectures that are specific to one or the other) allows:

  • Step 1 students to prepare to not only pass Step 1 but also build a foundation so they can peak on their Shelf exams/Step 2 CK,
  • Clerkship students to choose to prepare for Step 1 simultaneously with their Shelf exams, and
  • Step 2 CK students to learn the foundations well enough to understand and explain clinical presentations and management rather than memorizing

Regardless of whether you choose to be in the Yousmle Online Course or study on your own, you can take advantage of the overlap between Step 1 and Step 2 CK. Follow the 6-step process to studying for Step 1 on clerkships. You can create a strong foundation not only to pass Step 1 comfortably, but also excel on your Shelf exams and Step 2 CK.

That said, despite our best intentions, rotations (not to mention life) happen. There are any number of things that can make studying for Step 1 during rotations difficult. We would love to understand your unique circumstances so we can help you. Sign up for a free consultation where we can honor your dedication to a career in health care and help you find the best way forward.

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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.

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