Studying for the Step exams while working: A doable challenge

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In January 2019, I decided to take the leap and pursue a residency in neurosurgery in the United States. I knew the significant sacrifices that would be required and that I would have to take all three Step exams to qualify. So, I did what many of us do; I went to YouTube and listened to how other people had studied. But I quickly became overwhelmed; there were so many videos, and so much conflicting advice that it was difficult to know where to begin. Furthermore, many of the study plans did not feel sustainable or well-suited to my style of learning, especially as they were geared toward students who were currently in medical school.  

I had just graduated from medical school in December 2018and had accepted a full-time job at Cedars-Sinai. Initially, I questioned whether I could reasonably balance the demands of a full-time research job with the intensive study needed to perform well on these career-determining exams. In the end, I pulled it off, taking Step 1 in October 2019 and Step 2 CK in May 2020.

But before I start with the details of how I studied and managed my time to achieve this goal, I want to give peace of mind to those who find themselves in a similar situation of having to juggle full-time work and other demanding personal responsibilities with boards preparation.   The key is to take stock of your strengths, whether it be time management, laser-like focus, or a knack for distilling complex subjects into their essentials and to use those skills to overcome whatever economic, social, or educational challenges you may be faced with. The most you can ask of yourself is to make the best of your conditions and to marshal your unique capabilities to adapt to challenges.

What was your approach to work and study at the same time?

The first thing I did was to talk to my boss, Dr. Gonzalez, and my coworker, Juan. I was upfront with them, letting them know that while I would fulfill my job responsibilities to the best of my ability, that I would be dedicating all my spare time both at and outside of work to intensive study.  

I believe it’s crucial to let the people you work with know what other stressors you might be facing, as they are more likely to be understanding should something else come up later. There were times when Juan offered to take over simple tasks from me so that I could have extra time to study. Additionally, because my boss knew I was taking this exam, I was able to take two weeks off beforehand to dedicate 100% of my time to study.

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For how long and how did you prepare for Step 1 and Step 2?

I began my Step 1 preparation on the third week of January 2019 which was the same time I started my job. During the first three weeks, I tried to get a sense of my day-to-day schedule to identify which hours would be ideal for various forms of study, especially for question banks and other active forms of learning.

Total study time for Step 1: February – October

Studying for Step 2 was somewhat easier in that, by this time, I had an organized schedule and study framework from Step 1 that I could follow.  After Step 1, I took a month’s break before starting my Step 2 preparation in November. In total, I studied from the beginning of November until May 28, 2020.

My approach was pretty similar to Step 1, with the caveat that I started doing questions on Day 1, and I also took one week of vacation to dedicate full time to Step 2 preparation. However, the pandemic changed my preparation timing since I had to deal with the multiple Prometric cancellations owing to COVID.

What was a regular workday during Step 1 and Step 2 preparation?

I would wake up at 6:00 every morning, and during the first 3 months, I commuted to work by bus, which was approximately 2 hours away 😳. During these bus rides, I would read First Aid. To help with concentration, I used noise-cancelling headphones. I would highlight or repeat content areas that gave me trouble or that I found to be important. By the time I got to work, depending on the time, I would do 10 questions from any qbank before clocking in at 9 AM.  Usually, I would leave work by 4-4:30 PM and head back to my place. 

On the return commute, I would continue by reading First Aid so that, on average, I had read it for three hours every weekday.  I would get home around 7:00-7:30, cook dinner and lunch for the next day, and, after some brief relaxation watching Friends, I would resume studying at 9:00 PM. From 9 until 1 AM, I would watch Pathoma, Kaplan, or Sketchy videos. My goal from Monday to Friday was to study at least 6 hours per day, and I usually slept from 1 to 6 AM (since med school, I have only ever needed about 5 hours of sleep each night).

In March, to make my commute more manageable, I got a bicycle, so I was biking halfway to work and bussing the other half.  This allowed me to get in some exercise, which I realized I had been missing from my routine. This helped me to be more relaxed and focused on my work and studies. From March until mid-June, I followed the same routine of reading First Aid or doing my Anki cards on the bus and then coming home and studying from 9 PM until 1 AM (or whenever I felt tired).  Some days, I had spare time at work, so I would fit in extra studying with review questions or reading First Aid. 

From June through September, I aimed to increase my study time and maximize my use of any free time. But my routine of study/work with no other activities was exhausting and stressful, and I knew that I needed something for my mental health. I decided to join the gym while sin addition to maintaining half of my commute as a bike ride. I converted all the Pathoma videos into mp3 files so I could listen while riding my bike. Then I would do Anki or read First Aid on the bus, and at work, I would review questions that I had not gotten around to from the night before. Anki became my favorite study tool, as it was easy to use during breaks or when waiting in lines at lunch or at the bus stop.  After work, I would get home at the same time (around 7 PM), eat dinner, and study until 9 PM. Then I would go to the gym and disconnect myself from anything related to the Step.  After my workout, I would study again until 1 AM. Even though I had added gym to my schedule, thus taking away study time, I now felt more energized to tackle my lengthened study periods, and was now averaging closer to 8 hours of dedicated study each day.

I continued this pace up until September before my two weeks of dedicated, with a few modifications. The closer I got to my October 8th exam date, the more I cut back free time, transitioning this into listening to Pathoma and supplementing with Boards and Beyond videos for weak areas (which I had converted to mp3 files per Sebastian Gallo’s suggestion). I would listen to them instead of listening to music during my bike rides, while walking, and even at the gym. This passive learning was a way to get the most of my time and to reinforce concepts with which I had struggled.

I took two weeks off work during which time my mom dropped in for a surprise visit, which, while it sidetracked some of my study plans, also gave me the energy boost and support I needed to wrap up my studies. During this time, I was studying for 9 to 11 hours a day up until the day before the test.

After conquering Step 1, I was onto preparing for Step 2. This time around, things were more manageable on several fronts. I had moved to be just 15 minutes away from the hospital, and the decrease commuted had a significant positive impact on my quality of life and happiness. My working schedule did not change, but the rest of my routine certainly did. Because I was living so close to the hospital, I arrived at 6:40 every morning and headed to the library to complete a block of UWorld and otherwise study until my workday began at 9. I would work until 4:30 PM and then head to the library until 9:00 PM to keep doing questions or reviewing questions before heading to the gym and working out until 11-11:30. I would return to my place and go to bed at around 12:30 to 1 AM, repeating this same schedule up until when the pandemic hit. 

When COVID forced everyone to work remotely, I had to adapt to maximize my productivity, especially considering that I was on different schedules from my roommates, who tended to be a bit on the noisier side.  I briefly shifted to a nocturnal schedule, going to bed at 6:00 PM and waking up to begin my day at 11:00 PM. This allowed me to enough space and time to study when others were asleep. After finishing work at around 4 pm, I would run 3 miles while listening to mp3 files of MedEd, then have dinner and go to bed. After 3 cancellations from Prometric, I was finally able to schedule my Step 2 for the end of May. 

How was your schedule on the weekends?

My weekends were catch-up days, where I would study much longer than during the weekdays to make up for studying that I had not gotten around to.  But I would also break up the monotony by going grocery shopping, cleaning my apartment, and all the other fun adult activities that comprise the dull every day. Generally, I would study 8—9 hours on Saturday and Sunday. My goal per week was to hit at least 42 hours. Some weeks were more brutal at work, or I was tired and couldn’t finish my 6 hours daily on the weekdays, so the weekends the perfect time to make up for it. The weekends were also ideal for assessments, namely UWorld self-assessment or NBMEs.

My one regret was that I didn’t incorporate the gym into my schedule sooner, as it had a marked impact on my mood and focus during the earlier stages of my preparation. 

How did you manage your time?

In the beginning, I would just check my phone’s clock periodically and write down how much I was studying per day on an Excel sheet. Then I found an app called aTimeLogger that changed my time management forever. It enabled me to set goals per day, week, and month depending on the activity I was doing so that I could precisely allocate time for work, study, exercise, and even frivolous, wasted time on things like Instagram, Facebook, and YouTube. It was tremendously helpful for reducing screentime during the pandemic.

As I mentioned before, my goals were to reach a doable 6 hours per day/42 hours per week and to fit in at least 6 hours of exercise per week for mental and physical health as well as a minimum of 5 hours sleep each night.

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How did you balance your social life and working/studying?

Significant endeavors like the boards entail enormous sacrifices, so during this working/studying period, I tried to minimize use of all my social media (Facebook, Instagram, Twitter) and only kept WhatsApp to communicate with my family and close friends.  I also tried to ingrain the habit of using Anki whenever I grabbed for my phone instead of using Instagram. 

My social life was practically nonexistent during my study period. I did go out with my friends and coworkers maybe six times from January-December, and I saw my family a couple of times during this period. Because I had moved to a new country and new city, isolating myself from people was doable and was also beneficial for focusing my energy solely on studying and work. My first “vacations” during 2019 were for my dedicated two weeks for Step 1; obviously not the ideal version of a vacation, but nonetheless necessary to study.

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Any final suggestions for someone that is in a position similar to you?

These exams are tough not only because of the amount of time invested and information one must learn but also because of the emotional pressure having a test largely determine your future career path.  

So, I would suggest:

  1. Committing thoroughly to studying and working and trying to isolate yourself from most social engagements; they will understand your absence and your need to focus on your goals.
  2. Minimizing social media usage on your phone and laptop. This will improve your focus on the exam and help you to not feel so sad/anxious (which happened to me) from seeing your friends and family partying or having fun while you are chained to your desk and struggling through UWorld. Remember this part of your life is temporary; it will no doubt improve after finishing the exams.
  3. Surround yourself with people that are going through the same process and with those who have taken the exam before you. They will know how it feels and will be empathetic with what you’re going through. I wish I had more of this kind of social support during my study period, but even among many of my friends who were not planning to go to medical school, it was helpful to be able to vent to them on occasion.
  4.  Make time, even if just a little, to engage with your hobbies. In my case, my primary hobby was going to the gym. It really improved my mood and gave me the mental stamina and fortitude I needed to get through this sometimes-grueling process. 
  5. If you feel tired or burnt out (because at some point in this process, everyone does) don’t be too hard on yourself; take a break. I used to get so frustrated with myself when I was trying to study but couldn’t focus or was falling asleep. Taking breaks is crucial to maintaining sanity during extended periods of intense studying/working.

Last, but not least, is to not lose sight of the big picture and what’s at stake. It’s easy to get caught up in the minutiae of random factoids that the boards want you to know and to forget why you entered medicine in the first place. This studying period was one of the most difficult of my life, but the difficulty of working and studying simultaneously taught me how resilient and adaptive I was to challenging situations. I’m glad I was able to deal with long commutes, working/studying, moving to a new country, and living alone for the first time in my life all in the same period. It ended up being great preparation for the rigors of residency, and in the end, it was all worth it. Ultimately, I passed Step 1 (239) and Step 2 (236), and I’m thrilled that my dream to become a neurosurgeon is still well and alive. 

By Miguel David Quintero Consuegra
PGY 1 Neurosurgery Resident
Department of Neurosurgery
Cedars-Sinai Medical Center

and Malke Asaad

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