Everything You’ve Always Wanted to Know About Third Year (But Were Afraid to Ask)

Introduction
So, if you’re reading this, you’re probably right where I was this time last year: I finished boards.
I moved to _______. I’m ready to not rot away in a lecture hall for hours on end.
What now?
Unfortunately, that is gonna be different for each and every one of you, so this document won’t
be as precise or dare I say informative as my document highlighting second year was. What I
AM going to try to do is draw from my own experiences as well as experiences described to me
by my classmates to give you a little bit of insight into the core rotations of third year. This will
include what I used to study, what I used to prepare for the “wards,” maybe some things I wish
I would have done or some things I’ve heard from others that might be useful. I’m gonna try
and include more insight than just my own. I’ll also discuss the fourth year/audition rotation
schedule and how it really went (spoiler: far less urgent and impending than administration
might have you feel), some board study crap, maybe some OSCE stuff, I dunno, we’re kinda
winging it here so bear with me. Hopefully this is as useful for you guys as the document last
year was. If it isn’t, go read more Student Doctor Network or USMLEForums or Reddit or
whatever you kids do these days.

Some General Advice:

- Show up early, be polite to EVERYONE.
- When I say everyone, I mean everyone, no matter what. Your attending is a jerk to
nurses? That doesn’t mean you should be. Everyone says it, but ancillary staff like
Medical Assistants and Nurses can make things very easy for you if you’re polite and ask
appropriate, directed questions. Just remember they’re busy—busier than you or I—so
try to be succinct!
- Contact the number in your portal a week or so prior to your rotation and figure out
details. Dress code, WHERE and WHEN you will meet the preceptor, and if the person
has any advice for you before you start. I generally prefer a phone call to email but
whatever works for ya.
- Be engaged. Scenario: You’re on surgery. Your friend, Jim, is scrubbing in for this case
and you just watch. What do you do? If you said anything besides pay attention and ask
questions, you’re wrong. Not being hands-on doesn’t mean tune-out. Keep your phone
in your pocket or elsewhere. Get close enough to see. Talk to the anesthesiologist,
circulating nurses, whatever. Be present.
- Ask YOUR ATTENDINGS ABOUT TIME OFF. Going through the school is a hassle. If you
need to miss a day and have a reason, just run it by your attending first, explain it and so
on. Chances are they’ll be chill with it and you wont have to suffer the administrative
mess.
- Do questions every night, read about things, watch videos, whatever—but IN ADDITION
TO QUESTIONS, try to study up on something nightly. The shelves aren’t a joke (mostly)
and cramming for them doesn’t go well.
- Have fun. Third year is certified LITTY. Yeah you’re busy, but it’s a different kind of busy.
Study for an hour or two nightly, double it up on weekends, and save the rest of the
 night for fun and stuff. I played a lot of xbox, had time to move in with a girl, ran 9 miles
and hit the gym daily. And also had time to do shit with my dog and friends. You have
TIME to LIVE now. So do it.

Study Tools
So the hardest thing, in my mind, about third year is that you don’t have truly definitive sources
to study from anymore. Throughout second and first year you’re given slides and told that the
test questions come from THIS. Learn THIS. And that was (mostly) true. Third year represents a
departure from that and asks you to basically…figure it out for yourself. Below are some study
tools I used, some I tried and some I know of but didn’t fully employ.
- Online Med Ed: In my mind, this is a mandatory resource. The videos are free and are
sufficient for a solid pass on just about every shelf (however you can’t just “one and
done” skim them, in my mind). Many people bought the premium version, and while I
didn’t personally, I became the beneficiary of the written notes and found that using the
written notes was immensely more productive than just the videos. Whether you want
to shell out for extra questions, whiteboard photos, etcetera is on you, but at the very
least, use these videos.
- Case Files: If I’m being honest these were helpful but not a must-have. For the
uninformed, they are books containing several cases (like 60 I think? 60 or 30 I can’t
remember but either way) that cover the bread and butter topics you’ll see in a given
specialty. I found them solid for learning how to communicate about pathology and
treatment with residents and physicians but not awesome for shelf exam studying.
- Topic-Specific “Required Textbooks”: Are a joke and I would avoid them unless you
need to look something up specifically.
- Pestana’s (Surgery Only): It’s cheap, it can be read in a day or two and it covers just
about all the big surgery topics. I HIGHLY recommend it. The questions are pretty
gimmicky and only decent because the weekly quizzes will draw from Pestana
questions, but all things being equal, just read the textbook a couple times.
- First Aid for the ______ Clerkship: These are hit or miss. The psych one is an excellent
resource, as is the family medicine one. Surgery I found too dense and focused on ward
communication to be a reliable shelf study resource. I didn’t bother with Peds or
OB/GYN.
- UWorld: This is always a topic of contention—and after step 1 one studying, the last
thing I wanted was to shell out my own money for a UWorld membership. HOWEVER, in
my mind, UWorld is one of the four must-have study tools for Year 3. It is indispensable
for the NBME IM Shelf, and has a lot of good peds, OB and psych questions The surgery
questions are too focused on trauma in my mind, but still solid.
- COMBANK: You get it for free, and while it’s super easy to make jokes about Combank
(especially if you’re team UWorld), Combank is actually a great resource for most of
your shelves because, like it or not, the shelves are NBOME/COMATs—so using a bank
that emulates that format and question style is key. Plus there are, on average, 150
questions per topic plus whatever you wanna do out of the COMLEX bank. Easy peasy.
- COMQUEST: Like combank’s beefier, meaner brother. I used it intermittently but I know
many people swear by it over combank.
 - AMBOSS: Amboss is lit. I didn’t use it too much because I stuck with the tried-and-true
Uworld, but if you used Amboss for Step 1, keep on keeping on. Plus Amboss doubles as
a great way to look up additional shit. Medbullets is also a solid resource for
USMLE/COMLEX-directed topic studying.
- UWise: limited to OB/GYN, recommended by many but I was not stoked on how it
worked so I barely used it.
- UpToDate: You’re gonna be using a lot of UpToDate. Be it on rotations “boning up” on a
topic or to make a presentation for an attending, you will. Accept it. Master it. PLUS, if
you keep getting Afib or pulmonary effusion questions wrong, read about it on
UpToDate.
- SketchyMedicine: Apparently this exists? Wild.

How I Studied.
First off, this will change. Your surgery rotation will have different hours than your peds
rotation. But this is the approach I took to each rotation, and I managed to make As on just
about every shelf and in actually every rotation.
Pre-Rotation: OnlineMedEd Videos; try to make it through them once before the rotation starts
OR by the halfway point of week one. This is to avoid looking like a dummie. I took notes on the
videos alone during my first pass of the videos.
Intra-Rotation: Questions nightly/daily. These goals vary by how many questions you want to
do, which rotation it is, etcetera. I made it through UWorld for each subject twice (except IM,
just once) and COMBANK twice or more (except NBME IM, didn’t touch it). But that’s just me.
More is generally better though.
- Additionally, keep up on videos/reading. Be it a book, OnlineMedEd repetition,
Amboss/Medbullets/UptoDate, whatever. Carve out time.
Days Leading Up to Shelf: get a sheet of the “memorizables” and drill it. Things like Parkland’s
Formula, Murmur Recognition, Personality Disorders, whatever. Also do the incorrect/marked
questions from your passes.

Note: Ultimately HOW you study these things is up to you. Those who know me know I love
whiteboarding shit. Maybe you’re into Anki, maybe you just read things over and over, hey,
whatever worked for you 2nd year will DEFINITELY work here.

I’m going to append a very very very subjective x/10 difficulty to each of the shelf exams. I’m
trying to keep it balanced but bear in mind I cant tell you how difficult YOU are going to find an
exam.

Short version:
VideosNotes+videos+questionsmore questionshammer home the deets.

The Rotations Themselves

Internal Medicine (NBME/NBOME)

General: Starting with the bad one first. This is split into two four-week chunks, one of which
will be with a resident team (NBME Exam), and the other will likely be preceptor based (NBOME
Exam). This rotation is as bad as third year gets from an academic perspective, and how difficult
the exams are varies with when you have them in your year.
- Advice for everyone: Study nightly, study hard, do questions.
- Advice if it’s EARLY: Big picture, broad strokes, and hammer the questions super hard.
- Advice if it’s late: Go after the organ-based stuff and dial in on topics you struggled with
in OB/Surg/Family.
Having this rotation close to boards can be a great means to review, but it also means you’re
cutting it close if it doesn’t go well.
Performance on the Rotation: Widely variable, some will have good hours, some not-so-good.
The big takeaways I found and heard were to be polite and work hard with your residents. Start
strong and chances are you’ll get some freedom and trust as the rotation carries on. You will
likely be responsible for rounding on your patients and doing notes for them; again, it really
comes down to how much your resident team will want to pimp you, task you or expect from
you. However if you put in the work, show that you’re reading and learning, at least TRY to
answer the questions (never just say “I don’t know” and leave it—“I’m not sure, but…” was a
favorite of mine) and you’ll be okay. SOMETHING I WISH I WOULD HAVE KNOWN before this
rotation was to watch the Intern Content on OnlineMedEd. It wont help for your shelf much,
but it will help a SHIT TON for getting pimped.
The Exams—NBME: This one is a bitch. Curved 16 points (for us). I found it heavy in GI, Renal,
Cardio, Derm. A couple ethics, stats questions in there too. OnlineMedEd+Step Up To Medicine
for reference in conjunction with UWORLD was enough to do very well, however, and I had it
dead middle of my year. This is one exam I think it REALLY pays to have UWorld for. If you don’t
have it, try to find a friend who already had this shelf and borrow their login.
- Overall Difficulty: Personally, 7/10—early on it could easily be a 9 or 10, and late it
could be a 5 or 6, but this exam is as close to board studying intensity as you’ll get all
year (until boards).
The Exams—NBOME: Chill, but also asks weirder question in the true NBOME spirit. Expect
bioterror, ethics, derm, STDs, cardiopulm with VERY LITTLE OMM (in my experience).
COMBANK was a big help for this, I did very little UWorld during this rotation. Again, OME is a
fine resource when used with a question bank.
- Overall Difficulty: BEFORE the NBME Shelf it could be a 7/10 or so. AFTER the NBME
shelf it’s a 5/10.

Family Medicine
General: Content wise, family med is like a slightly more general but slightly easier take on
Internal Med. This means that if you’ve already had internal, you’ll be in good shape. If you
haven’t, you might have to make up some lost ground. Either way, it’s a broad exam and as
such, the more crap you have BEFORE family med, the less you’ll have to actively learn new
stuff. With this in mind, if IM has you hittng the books DAMN hard, FM stands to have you
hitting it hard-ish. Questions become key—for those of you who shelled out the money for
UWorld, guess what, there is no dedicated UWorld bank for family. However, the Family Med
COMAT for Combank is a decent start, and doing some mixed questions on Uworld definitely
helps. An additional and very valuable free resource are the AAFP Board-Style Questions
available if you register, FOR FREE, on their website. The process takes 2-3 days so plan
wisely, and they’re designed for the FM Boards so some will be too detailed for a student, but
it’s still good and free review.
Performance on the Rotation: Family medicine providers are widely variable. I found that most
of them tend to heir on the side of not letting you do as much, but some of the rural providers
are very down to let you go wild. Be engaged, pay attention, ask questions—more than other
providers, I found that family med docs have their own way of doing things and are always
happy to explain why they don’t always follow protocol by-the-books.
The Exams—NBOME: This shelf I found to be one of the more fair shelves. Using sparse
UWorld, the Combank COMAT 2-3 times through and 20-30 of those AAFP practice questions
daily or so, you should be set. The OnlineMedEd schedule (posted in their blog, google it) has a
schedule for FM with high-yield videos. Also Review the A and B recommendations given by
the USPSTF. OMM is negligible but basic viscerosomatics are present. Overall difficulty: 7/10
with no IM or Peds prior; 5/10 otherwise.
The Exams—Aquifer: Man, good luck. This exam might be the hardest of the year in my opinion
just because studying for it is such a shit-show. General FM studying will get you farther than
Aquifer studying, but there are some questions that you need to review the Aquifer cases for;
so make sure you split your time wisely. I’d give it an 8/10 just because studying for it is
ambiguous. In reality its anywhere between 5-8.

Surgery
General: Surgery is another rotation where you might be very busy or not busy at all. Chances
are you will be very busy. However, the late-summer months, apparently, were a little less
busy than some of the others, and depending on your preceptor(s), earlier in your rotation year
they might be a little easier on you. The take-away is that it’s variable and you should prepare
to be very busy most of the time. OnlineMedEd videos are very solid and if you can make it
through the general surgery videos before your rotation starts, it might get you a couple easy
pimp points. Surgical Recall is a good resource for pimp questions and pre-operative studying,
whereas Pestana’s Surgery Notes is a good source for more general review. Between those
three things, UWorld and Combank you should be pretty well set. I found UWorld to have way
more trauma than was needed, and Combank has way more stupid anatomic detail than
needed for the shelf, but hey, again, pimp points. Reviewing Dr. Tullot’s GI Pathology Lectures
was also pretty useful, as well as revisiting some brachial plexus crap.
Performance on the Rotation: Show up, be engaged, always at least TRY to answer everything
and you should be in good shape. It isn’t expected that youll have every answer to every
question, but if you study the cases before you scrub in, be ready to give an educated guess if
you don’t know the answer and have a good attitude, you’re gonna do just fine. Every
preceptor is different, and some are more “stereotypical surgeons” than others, so if some days
are rough, go home, sleep it off or watch a movie or lift weights or whatever you do and go
back the next day ready to give it hell.
The Exam: It’s a GI medicine exam. If you have this after IM, you’re golden. If you don’t, make
sure to hit the GI Medicine questions on UWorld, also Endocrine too maybe. Most of the
surgical questions come from pre-operative clearance stuff, a couple legal recourse questions
and “do you operate or nah?” type shit. In all honesty 75% of the exam was medicine, and 50%
of that was GI. 6/10 if you haven’t had medicine, 5/10 if you have, 8/10 if you don’t get
around to the GI medicine questions.

Pediatrics
General: My pediatrics rotation was inpatient based, SO, my experience is different.
Fortunately I spent a lot of time talking with homies who had a more generic peds experience
so hopefully I can do it justice. Inpatient peds had hours very similar to most IM rotations; but a
good amount of downtime (unless you’re there November-February). Outpatient is very similar
to FM in hours (again, more hectic during flu, cold and croup season). So the hours or workload
probably won’t kill you. Fortunately, the studying is also fairly concise, with a big focus on
pathology and management of major chief complaints.
Performance on the Rotation: Most of it comes down to having a good attitude; the
pediatricians I worked with liked to ask questions on management of basic things (asthma, DKA,
appendicitis, fever, urosepsis, UTI, blah blah blah), but in an outpatient setting I’d guess it
focuses more on preventive care. That said, do your best to have a friendly and open demeanor
when interacting with patients and their families.
The Exam: Major focuses (as I recall) were management of fever, uti, burns, URIs plus obscure
Step-1 style pathology (tuberous sclerosis comes to mind). The OME videos did a good job of
covering the stuff you need for a solid pass. Hammering down developmental stuff, preventive
stuff, the rare “is this an OB/GYN shelf or a peds shelf?!” question from UWorld will fill in the
extra stuff. 6/10 exam difficulty, 3-4/10 if you’re close to your step-1 date and still remember
obscure stuff.

OB/GYN
General: This rotation is another variable one; you might be as busy as your surgery rotation, or
as chill as a family med rotation. You can expect to see a little OR, a little hospital rounding and
a lot of OB-follow up visits. Some preceptors (mine) will see 40-60 patients a day and still
schedule in deliveries/surgeries. Some preceptors won’t. You can count on always being behind
schedule and answering a lot of the same questions from concerned mothers on a weekly basis.
As far as studying, preparation and questions go, UWorld is good but hard; Combank is a bit
easier than shelf difficulty (which is generally par for the course). Doing both is recommended
if you can make time. UWise is another great resource but, in honesty, I didn’t use it all that
much (I didn’t care for the explanations). A lot of people tried various books and hand-guides
with some success but I just hit the questions.
Performance on the Rotation: Surprisingly, I found that this rotation was the one where I had
the most hands-on learning (besides Surgery and Derm). A lot of opportunity to Doppler,
ultrasound, measure, interpret, all that stuff. If you have questions, ask early because (if it’s like
mine), you’ll be operating nearly independently by the end of week 1, and if you give patients
wrong info and the doc corrects you, itll be embarrassing when they come back in one or two
weeks for their next follow up. Additionally, many patients won’t want students. It isn’t
personal.
The Exam: I have a personal bias because OB/GYN is my least favorite of the practices covered
in third year (sorry if I offend anyone! I don’t mean to). So this exam was a little tougher for me
than most, but with a good combination of UWorld/UWise/Combank, the odd ACOG search for
guidelines (“Can pregnant women go boulder crawling?”) and good ol OME, you’ll do just fine.
If an OME topic doesn’t make sense, DEFINITELY look into it more. Of all the shelves, this one
asked me the most OMM, which I did not expect—fortunately, it was viscerosomatics and
general principles. The shelf will also toss you some early pediatric stuff (hours-days), so touch
up on that. Difficulty is around a 7/10 for all comers; I found it an 8, others thought it less.

Psychiatry:
General: Well, many people call this a psy-cation, and depending on your rotation, it probably
will be. Hours are generally chill, and the content is essentially pharmacology and big-picture
psych. Other things that the shelf likes (or mine liked) to include were rudimentary neurologic
causes of delirium (and how they ARENT dementia) and substance overdose syndromes. Im not
trying to cast aspersion on psych, but it’s pretty easy to study and the exam doesn’t pull many
punches. Of all the fields, it’s the most focused (except Cardiology).
Performance on the Rotation: As much as I don’t want to, I have to skip this section for this
rotation—my month was spent at Sierra Tucson and, well, frankly, I don’t know what a “real”
psych rotation is like.
The Exam: You WILL select SSRIs more than you think is possible and it will probably be the
right answer the whole time. Review psych pharm, review personality disorders and review
bipolar vs schizophreniform/phrenia vs substance intoxication. They aren’t hard if you have
the criteria nailed down, but if you aren’t rock-solid sure on them, the shelf will have you
second guessing yourself in no time. The lines get blurry fast if you aren’t counting your
SIGECAPS. This shelf felt like a 4/10.
BONUS ROUND: Use the extra time on this rotation to study for your next shelf or boards or
work on VSAS crap or all of the above. You’ll have a lot more time than you need to study
psych, study your next rotation and still have a life.

Cardiology:
General: This is a weird one. You get a Dr. Peppo penned exam so study materials get…tricky.
OME Cardio videos are good, Cardio comquest, uworld and combank questions are good, and
that alone will get you a solid pass. Try to read some UpToDate articles on management of
basic cardiac path (Afib, hypertension, whatever else) if you wanna round things out. In general,
enjoy the relative paucity of material to study—this is as focused as third year gets.
Performance on the Rotation: have a good idea how to read EKGs, know basic cardiac meds
and when you need em, get those listening posts down and probably review vascular anatomy
of the heart (Where’s the LAD again?). The last one especially if your cardiologist is
interventional. You don’t have to go into the rotation knowing how to interpret an echo, don’t
stress.
The Exam: Well, it’s a D-Pep exam, so there will be some sort of…obscure questions, but most
of it is EKG, med management and murmur identification. Review electrolyte abnormalities
and their effect on EKGs, but not the obvious ones. Some of my friends said that reviewing
Peppo’s lectures on shock and cards from Year Two Clinical were helpful. 5/10 difficulty, less if
EKGs are easy for you.
ELECTIVES
Well, electives don’t have a shelf. Lit, right? Enjoy it. Hopefully, if it’s an elective, it’s something
you LOVE doing and you’re gonna be stoked off your ass the whole time. NOW, if you happen
to have some down time, there are a couple things you can do:
- Got IM next? Family next? Surgery next? Study a little bit.
- Got boards soon? Study a little bit.
- Got peds, psych or cards next? Wow lucky.
If you’re on your elective and you love it, you should probably try and get a letter of rec or
something. I’m not really gonna address letters of rec because everyone has their own
scruples. Some people try to get one from everyone. Some people don’t. There isn’t a right
answer.

A Brief Word on Preparing for 4th Year

Generally, I spent most of third year feeling like I had no idea when I should be applying for
audition rotations, or working on letters or anything. Hopefully, you develop a good
relationship with your clinical coordinator and are able to figure out how things go. If not,
however, here’s a couple tips, or at least things I’ve noted.
It’s worth mentioning that these don’t apply to certain fields with different schedules—
dermatology, orthopedics/ortho surg, urology and emergency medicine tend to kinda have their
own flow for things. Also if you’re in a military program, then this is also bunk.
The earliest you need to start giving a shit about VSAS/Auditions is, in my opinion, mid
November. Use a little time you get off around Thanksgiving (preceptor dependent) to look into
some programs. Start an Excel sheet, a note on your phone, a good ol’ spreadsheet, whatever.
Note when their VSAS applications open, what requirements they have, stuff like that.
I’d get your VSAS “profile” finished up by the time the new year rolls around. Again, at this
point it will be too early to apply for shit on VSAS (however I felt like I had been doing
something wrong because no one actually told me how it works). You will likely see
opportunities for rotations in the coming months; those aren’t meant for you right now.
Usually around the turn of the year is when NON-VSAS programs will accept applications. This
isn’t true across the board, and non-VSAS auditions aren’t super duper duper common, but
they’re out there. Dr. Middleton and the clin-ed department will give you several resources to
use to track down residency programs and audition rotations—be thorough!
Around early February is likely when you’ll see things in VSAS start to “turn over” and open up.
Note that if you “saved” programs from your previous searches, those are the OLD YEAR (2019-
2020) pages and not the ones for the year YOU want. Which means you have to re-search and
re-save them. For this reason it MIGHT be best to just keep them written down on a sheet or
note somewhere.
By April 15th most places are rock’n’rolling. Hammer in those applications early, send out a shit
ton, be broad with dates. You can always turn down acceptances if a program you prefer
offers you a spot. The number of auditions you will want to do varies greatly depending on
program, parallel plans, so on so forth.
Probably start your personal statement around May? I don’t know. It depends. I love writing
and stuff so I enjoyed working on mine. If you aren’t about it, start earlier and pace yourself.
Work on it with your friends, family, neighbor who was a doctor or something—the more eyes
the better, and make sure it’s been vetted thoroughly before passing it on to faculty.
I’m still figuring out the rest, sorry.

Throughout this whole mess you’ll have a meeting with a faculty member representing the
office of the dean to talk about strategy and your noteworthy traits and stuff. Don’t sweat it,
but also don’t be shocked if you get hit with some blunt ass truth. Don’t be afraid to ask
questions and ask for explanations, BUT, also don’t be rude or condescending. While they may
not be giving you the news you want to hear, they are trying to help.

I took my Step 2 boards A week ago and a day ago respectively, so I can’t speak on how
studying went. My shelf scores were generally good with my worst being a high B in OB/GYN,
achieving honors in 4 core rotations, so I feel like my study strategy worked pretty effectively.
For Boards I went through UWorld for a total of ~5,000 questions during the year, reset it
halfway through my second to last block and went through the whole mess again during
dedicated (three weeks, ~120-ish questions/day). I also reviewed Online Med Ed, Step Up 2
Medicine and used Medbullets/Amboss/YouTube videos on Law/Ethics as needed. Whether or
not that was enough, I’ll know in a month or so.

Closing thought: Enjoy third year, it kicks a whole lot of ass. It’s hard in its own way and the
shelf exams can be very frustrating, but don’t let that stop you from really diving into each
specialty. Be polite, be engaged, ask questions, and be nice to everyone.

Go get that bread.