Clerkship Lottery Strategy

It can feel overwhelming to have so much choice in your clerkship order and people seem to submit their choices with specific factors in mind -- but what are those factors? First of all, remember that lots of schools offer 0 flexibility in clerkship order because, at the end of the day, it really won’t make a major difference. You will end up learning the same material as every one of your classmates, the only difference is when you learn it and in what context. That’s where personal preference and choices come in, so here are some ways to think about ordering your clerkships. You’d probably be just as fine choosing a random order, and you might not get any of the preferences you submit anyways, but we’ve still written some thoughts down in case you’re an overthinker (like the rest of us). 

I will now establish Rule #1: It doesn’t actually matter. I fully support your choice to stop reading at this point and just trust that it will all work out!

This is uncharted territory for the class of 2025, but I’d split up STEP 1 material into two categories in this context: “Preclinical minutiae” or “Clinical manifestations.” Preclinical minutiae would be the gene deletions, biochemical pathways, etc. that you will likely forget soon into third year. Clinical manifestations will get reinforced by your SHELF* exams and clinical experiences. 

*SHELF exams are the NBME exams you take after almost all third-year clerkships (+/- Family Medicine), and factor in varying weights into your clerkship grade. They often test you on a broader amount of material than what you see in practice, so they do require independent study with UWorld/Amboss.

If you’re a hands-on learner, you’ll probably remember these much better at the end of third year than during second year. Your job is to strike a balance between how much you want to bank your passing STEP 1 grade on [1] doing mediocre in both (depends on your baseline knowledge after preclinical blocks), [2] mastering preclinical minutiae (taking STEP 1 before clerkships), or [3] mastering clinical information (taking STEP 1 at the end of clerkships and SHELF exams). Thus, it probably makes the most sense to do one of the following:

1. Take STEP 1 first and dump all the preclinical minutiae - the benefit here is that along with the preclinical minutiae you will have a good baseline knowledge going into clinical rotations and you will feel more comfortable doing UWorld practice questions as you start preparing for SHELF exams because you would have done a lot of UWorld to prepare for STEP 1.

2. Take STEP 1 at the end of third year and just focus on mastering clinical manifestations - the benefit here is that you will be extremely familiar with a variety of clinical vignettes having done all your SHELF exams, gone through all of the rotations, and having reinforced a lot in real practice. This will help you recognize patterns in STEP 1 vignettes that should allow you to pass more easily based on your clinical knowledge (but you might still have to retain/refresh some of that preclinical minutiae for STEP 1).

• The more difficult/hour-intensive clerkships are: 

  • • • Surgery (8 weeks)

      • Internal Medicine (8 weeks)

      • OB/Gyn (6 weeks)

• The ones with better hours would be: 

  • • • Family Medicine (3 weeks)

      • Psychiatry (4 weeks)

• The in-between ones are:

  • • • Neuro (3 weeks): generally good work hours but has lots of study material for the SHELF

      • Pediatrics (6 weeks): mix of inpatient (heavier hours) with misc/outpatient weeks that are lighter

My Strategy: Alternate easy and difficult clerkships OR have 2+ week breaks between two adjacent difficult clerkships

Frontload vs. Backload: I’ve been recommended to frontload clerkships since people tend to get tired by the end of the year, but you guys have more time to spread out so I don’t think clerkship burnout will be quite as much of an issue for your class. There is no perfect time to do a clerkship:

• Pros of doing them earlier: you will likely be more energetic and enthusiastic and your preceptors will have lower expectations 

• Pros of doing them later: you will be more experienced in the EMR/flow/presentations and have more clinical knowledge

To make this decision, think about which you think will help your performance and confidence more, and assess your ability to stay enthusiastic or to pick up on new environments/skills quickly. 

Prioritizing Clerkships based on Specialty Interest: Even if you have no idea what specialty you’re interested in, it can be helpful to think about when you want to gain exposure to particular fields. If you’re struggling to decide on surgery vs. medicine, doing one of those clerkships earlier on may give you some peace of mind. If you know you want to do OB/Gyn, you can do it after surgery so you already know the flow of the OR (and vice versa). If you are interested in a subspecialty (ex. derm, ophtho, radiology) that doesn’t have an associated clerkship, ask your advisor or upperclassmen if there’s a particular core clerkship that would be good to get a letter of recommendation from. If you don’t prioritize first, then the rest of the advice you read will be extremely contradictory. Prioritizing means putting things first, but it also means putting things last, so this is when you remember Rule #1: It doesn’t actually matter.

Mastering each specific clerkship: It is possible to do incredible in each and every clerkship, but by nature of learning, it’s likely that you will improve each subsequent time you are in the operating room or inpatient or outpatient setting, or after you’ve seen more pathologies, done more differential diagnoses, or done more presentations. If, for example, you know that you really want to impress your Family Medicine team, you should probably do it after you’ve learned the breadth of knowledge in internal medicine. As mentioned above, you want to first prioritize which 1-2 clerkships are most important for you to do well in based on specialty interest and other factors. Below are the strategies that will help you “master” those 1-2 prioritized clerkships. 

The lottery should have a comment portion where you indicate your preferences. The strategies are listed in decreasing order of importance (ex. If you want to put yourself in the ideal position for doing well in IM, then ask for it after pediatrics as your first priority, after family medicine as your second priority, and after surgery as your third priority).

• Internal Medicine: After Pediatrics (inpatient experience) > FM (similar exams) > Surgery (similar exams)

• OB/Gyn: After surgery (OR skills) > after IM (inpatient/outpatient familiarity)

• Family Medicine: Standalone clerkship and not too stressful, but taking it after IM can help (similar exams)

• Surgery: After OB/Gyn (OR skills) > after IM (similar exams)

• Pediatrics: January/February/March (winter = “respiratory season” = lots of sick kids and hands-on experience) > after IM (inpatient experience) > near STEP 1 (lots of congenital diseases)

• Psychiatry: Standalone clerkship and not too stressful 

• Neurology: Standalone clerkship with lots of material so give yourself time to pre-study

• Emergency Medicine: If you want to apply EM, you can do it during 3rd year since it’s an early application cycle**

**must complete during third year as of Class of 2025

• Rule #1: It doesn’t actually matter!!!

• Family Medicine is a great place to start since it's standalone material and non-SHELF (as of 2022)- it’s mostly USPSTF guidelines and Aquifer. You’ll have a light schedule, and the preceptors are very nice and will teach you how to use Epic and get familiar with the outpatient setting.

• Psychiatry is a great place to start because it’s standalone material and you get to see a mix of inpatient and outpatient with decent hours, but you should be prepared to work at other sites outside of Mayo Clinic which have more varied preceptors/EMRs.

• OB/Gyn is good if you don’t want to go into it, because it preps you for other specialties and a lot of the SHELF is pretty standalone material. This can be more hour intensive and Gyn surgery will be at Mayo but the OB portion will be at an outside institution.

• Neurology is a good place to start because it is short, but there is a lot of material on the SHELF so it might be easier to balance studying after you’ve gotten the hang of things. On the plus side, most specialties outside of neurology won’t care about your grade.

• Pediatrics is good if you want to get used to the inpatient setting, work with extremely friendly people, but are okay with learning how to use Epic/navigate the Mayo hospital later on. Phoenix Children’s Hospital uses a different EMR system, but they have pretty low expectations on how much we actually use it. 

• IM and Surgery are famously the “big bois” but people who start on them tend to do well so I wouldn’t write it off! They can be really nice to get out of the way, just be mentally prepared for trying to get used to the flow of clerkships while also working long hours. They will be intensive but you will learn a lot in those 8 weeks and will be set for future rotations in terms of navigating Epic and feeling comfortable in the hospital. 

If you’ve read all the way down here, Rule #2 is that you are awesome and you deserve a nap or a walk or a good meal. :)