Advice for Incoming 3rd Year Medical Students - From a Rising 4th Year

Third year of medical school kind-of comes out of nowhere.

You're hot off of taking boards, which likely devoured all of your time and attention, so before you know it, you're in orientation for third year. It feels like a year that shouldn't be too much of an adjustment, but it is full of sneaky little lessons & learning moments. As someone who is currently wrapping up their third year, I feel like I have a lot of advice to give. Things I've learned that made my life easier, and other things I wish I would have known while prepping for and starting third year. Hopefully, this post can help guide you as you transition from your didactic years to your clinical ones & address the major questions/misconceptions you might have!

Picking a Rotation Schedule:

Depending on your institution, you may have no say in your rotation schedule, you may be able to plan your own rotations, or you will pick a rotation track which determines the order you will do your rotations (this is what we do at my University). Leading up to third year, there was a lot of debate in my class about the best tracks or order of rotations to complete. It was widely believed that you should pick the track which had the speciality you want to go into as your second or third rotation - this is not true. The main reason for this belief was that your 2nd/3rd rotation were peak times to collect letters of recommendation for residency applications. Albeit, it's fine if you do that, but here's why I don't recommend it:

1. Your letter of recommendation writers for residency cannot submit a letter for you until ERAS actually opens, which is at the start of June of the year you're applying. At my university, we were in our 2nd/3rd rotations at the end of the summer/early fall of the year prior to applications, meaning our letter writers would not actually submit our letters until 6+ months later. That's a long time to wait, hoping they will remember what a brilliant student and human you are to write a strong letter. Part of why my class thought the 2nd/3rd rotation was peak time to get letters was that we had collected some knowledge from our 1st/2nd rotation so we weren't total newbies, and that we would be set up with our letters well before applications. I suppose that is true, but this leads me to my second point ->

2. You become a much better medical student in the hospital as you get close to ending 3rd year. The knowledge of each rotation really builds on each other as you go through. As you're rounding out the year, you become far more competent toward the end as all that knowledge goes together. So if you're really trying to show off your stuff, your best performance will be at the end of the year.

3. It is not necessary to get your letters so far in advance. Many people also get letters from their 4th year Sub-Internships or electives which are while ERAS is open (the summer prior to applying) and it always works out just fine. If you wait until the end of your third year to do your rotation of interest, you'll show off your knowledge better, have those letters closer to ERAS opening (less time for them to forget you) and have your letters with plenty of time before submitting ERAS at the end of September.

As I mentioned above, it's overall fine if you do get letters during your earlier rotations. There's not much harm. The biggest concern would be that it might not be a strong letter if they don't remember you well over half a year later, but that's really the only risk.

More importantly, I recommend scheduling your medicine rotations to be at the end of your third year. I really wish I had considered this before choosing my rotation track, because the majority of STEP 2 is internal medicine. If your medicine rotations are at the end of third year (I'm talking internal medicine, and family medicine), your shelf preparation strongly corresponds with your STEP 2 prep at the same time. Yes all the shelf's are on STEP 2 but overall step 2 is hugely internal medicine with a dash of everything else. It's much easier to tackle the bulk of your next board if you're actively studying it, and not trying to remember information you took on a shelf almost a year ago. I would definitely prioritize putting your medicine rotations at the end of your schedule over anything else.

Also on this topic we need to address surgery. The surgery shelf also has a lot of internal medicine content - so why not schedule that toward the end of your year also? The reason I would recommend doing surgery earlier and NOT later is that the rotation itself is exhausting. The hours are some of the most demanding of third year, making it an overall challenge if you're also trying to ramp up STEP 2 studying at the same time. OBGYN is another rotation with long hours and some surgery, however; I personally found that rotation very doable so it's really up to your own discretion.

The last thing you should know regarding your schedule is that the rotations/shelfs you do can very from university to university with one thing in particular being a big difference: some university's have you do a month of neurology while others skip that and do a month of emergency medicine instead. That means if you're interested in emergency med but your university does a neurology rotation instead of EM, you won't see EM until 4th year. Psychiatry is another 1 month rotation your university may swap for. Just something to consider & plan for depending on your interests.

SUMMARY/TAKE HOME POINTS ABOUT SCHEDULES:

1. Most importantly, I recommend doing your medicine rotations at the end of your third year (internal medicine, family medicine) as it's great STEP 2 prep.

2. Don't worry about doing your rotation of interest early on for letters - you have plenty of time & will be a better student later.

3. Do surgery early because it's exhausting.

4. Your university may or may not have neurology/emergency medicine/psychiatry rotations/shelfs so it's good to investigate that depending on your areas of interest.

5. No matter what your schedule ends up being, it will be okay. You'll get all your letters and you'll crush STEP 2.

Studying for SHELFs:

You've come off of STEP 1. During that time, you may have found a study groove or you may have really struggled your way through it (like myself). I feel like I've finally got the studying for shelfs/boards thing figured out so here is what I would recommend you do as you start third year.

First, if you prepare well for your SHELFs, you will be prepared for STEP 2. SHELFs are direct preparation for your next board; they cover the same content in the same question style. You will take a SHELF after each rotation & it will be specific for that topic (aka just internal medicine or just pediatrics, etc). You can think of them like mini sub-sections of STEP 2. I recommend you build a system to study for each SHELF well, so that when STEP 2 comes around you're in a good place.

1. Uworld will be your best friend (just like it probably was for STEP 1). Uworld for STEP 2 has a SHELF tab and a STEP 2 tab. They are essentially the same question bank with just a few question variations between the tabs. I recommend you complete all of the Uworld questions for each SHELF topic while you're on that rotation. AKA do all of Uworld pediatrics while on pediatrics.

2. Review all of your questions thoroughly and really use it as a learning tool. My biggest mistake with STEP 1 was doing a huge volume of questions but not really retaining the learning objectives. When you're doing that you'll notice you repeatedly get the same topics wrong, because you aren't learning it well. The volume of questions doesn't matter if you're not really absorbing the content. I recommend you make questions off of your Uworld question banks about things you need to learn/don't know. That includes anything you don't know/don't understand from questions you got wrong, but also questions you got right. Some people like Anki for these questions/topic review, but I personally like to write down my questions in a notebook.

3. Start taking NBME Shelf Practice Exams as you get closer to the end of your rotation. I recommend either taking all of the practice tests (4 out of 4 tests) or almost all (3 out of 4 tests). In general, if you're passing your NBMEs you will pass the SHELF. These are the best indicator of your score / passing chance. They are also a great learning tool so review them thoroughly just like Uworld!

4. Supplement numbers 1-3 with other learning tools. Uworld, question review, and NBMEs are absolutely the most important things to do to prepare for SHELF and STEP 2. If you add anything else, make sure you are not subtracting those. For me personally, I enjoy some learning videos here & there as well as First Aid for Step 2 on top of numbers 1-3. Other people like the Case Files books, Aquifer, or other tools.

Things to Expect About 3rd Year:

As you transition from complete didactic years to clinical years, there's a lot of lifestyle changes.

1. Expect your schedule to become a lot more rigid and your free time to drop dramatically. Your first two years of medical school are full of self-directed study time. You're studying a lot and it's incredibly stressful, but your schedule is a lot more in your hands. If you need a break, you have the ability to just go take one. Third year is not like that. It will feel like a job - you're schedule to arrive to Unit A at 6am to pre-round before 7am rounds. You'll get there, do everything you're told by your residents and attending, and will get released when they say. Sometimes that's 8 hours later, sometimes that's 12 hours later, or even 14-16 hours later on long surgery days. You'll come home exhausted. You'll be told to work nights and weekends some weeks. You won't be allowed much time off as you have a certain number of hours to hit to complete the rotation. Suddenly when someone invites you out, you have to say no a lot more because you're scheduled to work or you need to study in your limited time off. You won't have the flexibility you once had. You'll feel sleep deprived far more than before and burned-out because of it. Good news is, you'll probably be happier than years 1 & 2. At least I was. Even with a less flexible schedule I was so much happier. Being in the hospital, running around all day, feeling apart of a team and interacting with patients is so rewarding. You're finally doing the things you've wanted to do, everything you've studied for. You do have to study when you get home, but truly SHELF prep feels far more manageable than STEP 1 or the first two years. Life is more enjoyable even though you're busier.

2. You will learn a lot and often feel like you don't know anything despite all your years of studying. The learning curve in 3rd year is fast and furious so just hold on for the ride. You'll improve rapidly at basic clinical skills and tasks so by the end of 3rd year you should be comfortable talking to patients, doing specific exams/skills, presenting, writing notes, and being a member of the team.

3. You'll be receiving a lot of feedback from attendings, residents, rotation directors, and even peers. You're here to learn so approach feedback with an open attitude. Ideally the feedback you receive is constructive and respectful, all of my feedback in 3rd year has been. Of course, you do hear stories about "malignant" environments which can happen. Luckily they are few and far between (at least where I am), and your university should have a way to report these incidents when they happen. Otherwise, feedback is an excellent opportunity to grow so take that opportunity to ask questions, practice under-supervision, and implement their recommendations!

4. Preparing for SHELFs can be stressful just like preparing for any other exam, however; if you start early and consistently you may not feel much pressure at all going into your exam week. Passing SHELFs is all about putting the time in to learn the material. If you're consistent, you can be passing practice exams long before your test and not have to sweat it too much. That being said, take note of your schedule and be intent about when you study. If you have a two month rotation where the first half has better hours than the second half, stay on top of your studying and front load your work so you'll be less stressed later. Third year is it's worst if you're behind on studying and experiencing long clinical hours, meaning you're stressed on top of sleep deprivation. If you can minimize that, trust me, you'll thank yourself! :D

Tips for Comfort & Surviving Long Clinical Hours

The small things you do can make a BIG difference here. There will be times you're standing/walking on the internal medicine floor for the entire day or on a 14 hour surgery shift & literally standing 12 of those hours, holding heavy, hard to move objects in surgery. The way you prepare for days like these will greatly increase your comfort, literally decrease pain you experience, and help take the edge off what can be exhausting days.

1. Invest in compression socks and where them ANY time you know you will be standing or walking for extended periods of time. That would include being on any inpatient service as rounds can take hours walking around to each patients room, as well as surgical assignments, OBGYN assignments like labor and delivery, etc. Without a little bit of compression around your lower legs you will start to notice swelling, increased foot pain just walking about, and overall discomfort. The compression socks really helps improve your longevity on these days, and you go home without swelling or pain.

2. SHOES: Get very comfortable tennis or walking shoes for when you're on inpatient services. Like I said, you can be on your feet for long periods at a time. For surgical or OBGYN inpatient services where you may get physically dirty, invest in really comfortable crocs or surgical shoes. You're looking for something supportive and squishy so you're feet are comfy while you stand, but also a completely rubbery texture so you can wipe every inch of that shoe with hospital wipes if you get showered in *any fluids*. This is especially true for labor and delivery - do not wear any shoe you cannot completely wipe there! Trust me, many people lose their trusty tennis shoes while on L&D.

3. Only pack the essentials in your backpack and avoid bringing textbooks. Trust me, you will not have enough time to crack open a textbook. You can have a heck of a walk from your car to wherever you're stationed at the hospital and a heavy bag will destroy your back. For studying while on campus, focus on doing questions on your laptop (which you'll need anyway) to help decrease the number of items you need to pack.

4. If you're on surgery, think a lot about ergonomics! You're first days on surgery you will literally come home in a lot of pain. Often times your job will be to hold retractors or other tools in place for hours during surgery. Contracting a muscle and staying completely still for literally hours is not something I did a lot prior to this rotation. When you're doing these tasks, think about sitting up straight, aligning your back and joints as much as possible to decrease pain later. Also, as your body adjusts consider carrying some ibuprofen with you to help alleviate achy muscles. I also would take ibuprofen prior to my shift to get ahead of the aches.

5. ALWAYS carry water and snacks on you. You won't always have the time to run and go get food, so having something to nourish yourself is really important on busy days. I also always recommend bringing your morning coffee with you because these start times are earlllllyyy.

6. Meal prep your meals on weekends, or get some healthy pre-prepared foods stocked up in your fridge. A lot of times you will come home absolutely exhausted where the idea of preparing a healthy meal is completely out of the question. You can help yourself out a lot by putting some fore-thought into this so you don't have to stress when you're exhausted. It's also important to do this to help nourish yourself with healthy foods instead of eating out all the time. You'll notice having some healthy foods prepared will really improve your energy and even decrease your burn out through the week compared to eating out all the time. I personally love trader joe's for some delicious and healthy pre-prepared foods for the weeks I don't have the energy to meal prep!

7. Recruit friends or family to help out when you need it! For me personally, this last year my family has saved me by bringing me food or groceries when I need it, taking out my dog when my partner and I gone a long time (he's also a busy med student), and even folding my laundry and helping with things around the house. Asking for help when you need it can make a big difference in your wellbeing!

Grades & Academic Success in Third Year

The way your institution grades your rotation may be completely different from mine, so take that in account while reading this. However, as a general rule of thumb:

• You can certainly pass SHELFs with distinction if you start early and are very consistent. It's definitely doable if that's your goal!

• Getting high marks in the other areas of your rotation are also a lot more doable than you may think. Most importantly, if you show up with a good attitude and are excited to learn, you're pretty much there. This should go without saying but always be kind and respectful of your peers and team. Your ability to score well on your rotation is a completely independent game - so don't stress over what others are doing. Focus on your learning and your goals!

• Lastly, you don't need to pass everything with distinction to be a good student and good doctor. Be kind to yourself, respect your body's need for rest and nourishment, and know that you are plenty qualified to be an excellent physician!

That about wraps up my advice for starting third year! I hope this post was helpful and addressed common questions or concerns. If you have any additional questions, let me know & I can follow-up with a part 2!

Until then, have a happy & healthy rest of your day friends :)

Natasha LaGrega