What is the Hardest Part of Each Year of Medical School?

What is the hardest part of medical school in each of the years? I wish there was a simple answer to this question. I get it every time I meet with pre-med students.

Any answer I give will lack the external validity required to be generalized to every school and every individual.

For example, my school organized my 3rd and 4th-year rotations and provided housing or a housing stipend if I had to rotate outside my home base city. I know of schools that do none of those things and basically say “good luck” and make you figure out your own clinical rotations yet are still happy to charge you $50K+ a year for tuition. That would’ve been pretty hard.

For simplicity’s sake, and for the sake of actually providing you with useful advice, let us focus on what is expected of you as a learner, and not what is required of you to navigate the inefficient and borderline extortionate world of medical education.

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MS1 (First Year)

Getting Comfortable

Picture this, you walk into orientation on day one. All your new classmates are slowly filtering in and taking a seat. You feel deep within your bowels that you are on the cusp of something significant. And it kind of makes you sick. You are nervous to talk to people because you think someone might discover that you’re actually too dumb to be there and that the admissions committee made a mistake. This feeling is growing as you go around the room and learn about all the interesting people in your cohort and all the great things they’ve done. You think “Oh crap, what have I done? What if I can’t do this?”

You’ve just had your first brush with imposter syndrome, my friend. And this likely won’t be the last. This will likely be one of the hardest things to deal with during your first year of medical school.

Imposter syndrome is the first foe to vanquish in your first year. You will get there little by little as you become familiar with the pace and style of instruction. The proverbial “firehose” opens up and you feel overwhelmed until you realize that you’re actually learning the same information you’ve seen before. It is now just presented more quickly and more focused on human physiology and its intersection with disease.

Adopting Sustainbly Learning Habits

The challenge of MS1 is settling into a rhythm of sustainable studying that translates into acceptable scores. You will experiment with a couple of different methods. It will feel uncomfortable, but eventually, you will find the winning combination. Here’s a hint, the answer is found in some combination of a decent study group, incorporating outside review materials, and making sure you’re retaining information (Anki).

You have already had academic success. Now you’re going to distill that during MS1 and level up your efficiency. The hardest part of MS1? Finding your confidence and learning how to learn quickly.

MS2 (Second Year)

Feels a lot like MS1, only now you’ve got a solid foundation to build on. It’s time you start looking ahead to Step 1, which looms less ominously over your shoulder because it is pass/fail. But remains a beast of a test. You also start feeling the pressure to squeeze in some research and extracurricular type of activities into your routine because you don’t know for sure what you want to do, but you want to be competitive no matter what. The little free time you have quickly dries up as you add in Step 1 review and specialty shadowing/leadership activities.

You start to get annoyed more easily with your instructors when they cover material you think represents minutia. You’re certain you could cover more ground on your own with your library of review materials.

You experience the growing pains associated with taking what you’ve learned so far in medicine and applying it to standardized patient experiences (and hopefully real patient experiences). It’s awkward and sweaty, like a middle school date.

You’ve got a lot to do. You’ve got a big test to pass. You may feel more stressed than you did in the first year and little things about your program—that you were happy to overlook during MS1—are starting to make your eye twitch.

The hardest part of your second year of medical school is keeping your cool and being nice to those around you while you struggle to juggle coursework, study for (and pass) Step 1, and learn how to be a clinician, so you don’t look like a total shmuck on your third-year rotations.

MS3 (Third Year)

Starting Clinical Rotations

If your school follows the traditional format, the MS3 year will be….unique. If you ask me, which you did, I’d tell you it’s the absolute worst. You get thrown into clinical rotations with very little preparation. Even though you had some pretend rounds and patient interviews during MS2, nothing truly prepares you for what’s next. It’s shocking and surreal.

As a reminder, you will get a grade for clinical rotations. And the majority of your clinical grade comes from a subjective assessment of somebody you might work with once or twice in a 6-12 week period. You take a test as well, but it really only accounts for 10-20% of your final grade. Oh, and there’s no dedicated time to study for this test.

After you take Step 1, you feel like you have all the answers. But on the wards, you realize you’ve essentially been studying “theoretical medicine” up until this point. Real medicine is much less clear-cut and frankly unsatisfying. Once in a while, you get a classic presentation of something and you absolutely smoke the pimping questions from your attending and that restores your confidence.

First Two Versus Second Two Years of Medical School

If you hated the first two years of medical school, you will probably really enjoy the last two. Conversely—as in my case—if you loved the first two, you may not care so much for the second two. (In which case I’d invite you over to Radiology or suggest our lovely friend, Pathology).

You are getting a taste of what life will really be like as a doctor. Working long hours and weekends is your new normal. You will have to keep up your studying habits because the NBME and USMLE decided the fate of your future rests with your performance in Step 2, rather than Step 1. If you put in only a minimum effort to pass Step 1, you may have a hard time studying for Step 2.

Little by little you get your routine figured out. After your first couple of rotations, you understand your role on the team. You get to scrub into surgeries, take care of your own patients, make real medical decisions, and do all the things you’ve always dreamed of. Pretty soon, you realize you are having a lot of fun. You meet interesting people and get exposed to a bunch of different specialties. You learn what you are interested in and what you need to stay far away from.

(If you’d like some tips about adding value as a medical student, check out this other post I’ve written.)

The hardest part of the third year of medical school is the stress of the first 2-3 months of rotations while you figure out what the crap you are supposed to do, and how to do it.

MS4 (Fourth Year)

Ah, fourth year. The apology for third year.

You actually know what you’re doing.  Students now get to rotate through specialties that they are interested in while they solidify their choice of residency. You still have stress because you have to study for and take Step 2. But Step 2 is testing more of the common day-to-day knowledge that you already know pretty well from rotations.

You take electives that you know will have a light schedule so you can build up some more volunteer hours and start working on residency application stuff. You start researching residencies and meeting with specialty advisors to figure out how to put together your residency application. Maybe you plan out a few “away” rotations at institutions you are interested in. These are more intense, but at least you’re doing what you’re interested in.

The first half of MS4 is full of hard work and planning, but the second half is very light as you start interviewing for residency. The Match is an exciting and stressful time, but it’s a lot of fun.

The hardest part of MS4 is finishing your required rotations strong, filling out your ERAS application, and dealing with the anxiety of awaiting The Match results.

I’m sure you will get varying opinions about the challenges through each of the years of medical school. These were the experiences that were most salient in my mind. Each block and clinical rotation will have its unique challenges and you’ll have lots of practice juggling life and learning along the way.

My final pieces of advice are to not lose sight of why you started this journey in the first place and to always look out for your own mental and physical health. You’ve got this!