How to study during internship with little time

If during your internship study time comes in pieces, like the gap between rounds and the visit, the wait for a test or the night when tiredness leaves little room, you are not alone. In a survey with final-year students in Germany, some reported having no study strategy for certain situations, especially due to lack of time (Corazza et al., 2023).

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

This text is about how to study during the internship with the time that exists: learning from the patient, using short breaks, reading protocols and guidelines with judgment, knowing the alarm signs of common complaints and using the game as a complement. The reasoning script for each patient is in the text about clinical reasoning, and the study routine with games, in the text about how to fit games into the routine.

Main points

• During the internship, most learning comes from taking part in care with support, not from studying alone.
• Short study units, of less than 15 minutes, had a positive effect on knowledge and confidence in the health professions (De Gagne et al., 2019).
• Short spaced questions, with immediate feedback, yielded more retention than the same content in concentrated modules.
• Guidelines help decide and standardize care, but they can be wrong for an individual patient.
• A few dangerous diseases account for a good part of serious harm from diagnostic error; alarm signs help keep them from being missed.
• The game complements the rotation: one case a day trains the guess, and bedside decisions are trained with the patient and the preceptor.

Summary

• Why time shrinks during the internship
• Studying from the patient of the day
• Short blocks
• Protocols and guidelines
• Alarm signs
• Game as a complement
• A possible week during the internship
• Frequently asked questions
• Internship checklist

Why time shrinks during the internship

The internship changes the place of study. The classroom gives way to the ward, the outpatient clinic and the shift, and free time can become unpredictable.

Learning changes place

A scoping review on self-regulated learning of medical students in the clinical environment found that levels of self-regulation change in that environment (Cho et al., 2017). The same review found an association between self-regulation and academic performance, clinical skills and mental health (Cho et al., 2017). In other words: knowing how to plan, monitor and adjust your own study matters more when no one organizes the schedule for you.

The review included 14 articles, with qualitative, quantitative and mixed methods (Cho et al., 2017). It also found factors that can support self-regulation (Cho et al., 2017).

What interns use

In the survey with 43 final-year students, the most used strategy was seeking information on the internet in text form, followed by asking doctors for help and consulting books (Corazza et al., 2023). In ward difficulties, 95.3% sought help from doctors, but only 55.8% did so for written tasks, such as medical letters (Corazza et al., 2023).

The strategy also changed according to the exam: for oral and practical exams, 79.1% used books, and for written exams, 97.7% used a digital tool (Corazza et al., 2023).

The authors conclude that students adapt the strategy to the situation and recommend ensuring access to the resources they prefer: digital tools and experienced doctors as supervisors (Corazza et al., 2023). They also point out that research is lacking on how to deal with limited time in the rotation (Corazza et al., 2023).

What this changes in your study

If time is short and unpredictable, studying needs three things: a starting point that is already in front of you, the patient; units that fit into breaks; and an order of priority, which starts with what cannot be missed. The next sections deal with each one.

Studying from the patient of the day

The patient you followed is the best study index of the internship. They define the topic, bring the context and give a reason to remember.

Taking part with support

A model built from discussion groups with medical students describes the center of learning in the clinical environment as "supported participation": taking part in practice, from observation to performance, with professionals who support and challenge (Dornan et al., 2007). Clear objectives and continuous clerkship periods, with a bond between student and professional, favored this learning (Dornan et al., 2007).

The same model describes two outcomes that reinforce each other: practical competence and a state of mind that includes confidence, motivation and professional identity (Dornan et al., 2007). These outcomes reinforce each other and reinforce the student's ability to take part even more in practice (Dornan et al., 2007).

The authors warn that, for the students interviewed, "self-directed learning" often sounded like a lack of support (Dornan et al., 2007). The practical lesson: studying at home complements what happens in the service, and is not a substitute for it. Truly taking part in care, asking questions and asking to do things is part of studying.

At the start of each clerkship

Dornan's model points out that clear learning objectives favor learning in the service (Dornan et al., 2007). As a practical suggestion, on the first day of each clerkship, ask the preceptor what you are expected to know how to do by the end, what the most common complaints in the service are and which protocols they follow. These three answers become the study map for the following weeks: the common complaints indicate the alarm signs to study, and the protocols indicate the guidelines to read at the source.

Also write down what you already know how to do and what you have not done yet. Each week, compare the list with what happened in the service and ask to take part in what is missing. Studying at home, in this logic, prepares you for the next opportunity to take part.

From the bedside to the book

The script for each patient, from the problem summary to the list of hypotheses and the presentation to the preceptor, is in the text about clinical reasoning, and we will not repeat it here. What this text adds is what to do afterward, with little time:

1. Choose one question per patient. Do not try to study the whole disease; choose the doubt that remained from the day.
2. Write the question down right away. In the next break, it already becomes a study topic.
3. Answer at the right source. For management, the service protocol and the guideline it follows; for mechanism, the textbook.
4. Close with one sentence. Write the answer in one or two lines; that is what you will review later.

Practical suggestion from the Editorial.

Making the most of supervision

The question that remained from the patient is also the best subject for the preceptor. In the survey with interns, asking doctors for help was the second most used strategy (Corazza et al., 2023). There are formats that organize this conversation, such as SNAPPS and the one-minute preceptor, which will be the subject of a separate text about reasoning during the internship.

Short blocks

When continuous time is short, short breaks gain weight. Research on microlearning and spaced education shows that short units can pay off.

Microlearning

A scoping review on microlearning in the health professions included 17 studies, and all had units of less than 15 minutes (De Gagne et al., 2019). The strategy had a positive effect on the knowledge and confidence of professionals and students (De Gagne et al., 2019). None of the studies measured effects at the highest level of evaluation, such as patient outcomes (De Gagne et al., 2019).

The studies in the review used varied formats, such as podcast, text messages, microblog and social networks (De Gagne et al., 2019). Of the 17 studies, 82% assessed knowledge or skill acquisition, and only 29% measured behavior change (De Gagne et al., 2019). The short format, therefore, has a positive signal on what one knows, but still little evidence on what one does with the patient.

One question per day

In a randomized trial with 724 urology residents, spaced education by email brought, each day, a clinical scenario with a histopathology image and asked for a diagnosis, with immediate feedback (Kerfoot et al., 2010). The average long-term increase in scores was 15.2% with spaced education and 3.4% with the same content in concentrated modules (Kerfoot et al., 2010). The authors calculated that spaced education multiplied the efficiency of long-term learning by 4 (Kerfoot et al., 2010).

Adherence was also higher in the spaced format: 77% of residents completed the spaced education, against 66% in the modules (Kerfoot et al., 2010).

A trial by the same author with medical students, also with spaced cases, is summarized in the text about how to fit games into the routine.

Testing yourself with feedback

In a trial with residents, repeated short-answer tests, with feedback, yielded higher final scores than repeated study of a review sheet, with 39% against 26% after more than 6 months (Larsen et al., 2009). Testing yourself with feedback helps retention, and this fits in a short break: a question, an answer, the check.

What fits in a break

As a practical suggestion, some formats that fit in a short break:

Format	What to do	Source of the idea
A question with commentary	Answer before reading the commentary	Test with feedback (Larsen et al., 2009)
A short case	Formulate the guess before seeing the answer	Spaced cases with feedback (Kerfoot et al., 2010)
The patient's question	Answer in one or two lines	Participation in care (Dornan et al., 2007)
The alarm signs of a complaint	Recall the list before checking	Test with feedback (Larsen et al., 2009)

To build the routine around these blocks, without repeating what is already in another text, see how to fit games into the routine.

Rest also counts

There is no ideal study time that works for every internship, and this text will not invent a number. What the studies above show is that short, spaced units can pay off; what each person manages to fit in depends on the rotation, the shift and the tiredness. On a heavy day, one question answered is already study.

Protocols and guidelines

In the internship, much of what is decided follows a department protocol or a society guideline. Knowing how to read these sources is part of studying.

What guidelines offer

A classic article about clinical guidelines describes that they can improve the quality of decisions, give explicit recommendations to those in doubt and make care more consistent (Woolf et al., 1999). Guidelines based on critical appraisal of the evidence also show which interventions have proven benefit and what the quality of the data supporting them is (Woolf et al., 1999).

The limits of guidelines

The same article points out that the main limitation of guidelines is that the recommendations may be wrong, or at least wrong for an individual patient (Woolf et al., 1999). Evidence about what to recommend is often lacking, and recommendations involve value judgments when weighing benefits and harms (Woolf et al., 1999). Inflexible guidelines can cause harm by leaving little room to adjust care to the circumstances and history of each patient (Woolf et al., 1999).

How to study a protocol

With little time, it is worth reading the protocol with three questions, as a practical suggestion:

1. Who is it for? Which patient does the protocol cover, and who is left out?
2. What is the central decision? Which step changes the outcome, and at what moment?
3. Where does it come from? Which guideline or study supports this step, and with what strength of evidence?

The third question links the protocol to the source. Read the original guideline, through the link from the society or the journal, instead of summaries without references; and remember that the department protocol may adapt the guideline to the local reality. Decisions on management are always up to the responsible team.

An example: definitions of sepsis

The international consensus that redefined sepsis and septic shock in 2016 is a good example of a document worth reading at the source (Singer et al., 2016). It defines sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al., 2016). The document also explains why it abandoned previous criteria and the term "severe sepsis" (Singer et al., 2016). Reading the reasoning behind the definition helps you understand the service's protocol, and not just follow it.

The same consensus describes septic shock as a subset of sepsis with deeper circulatory, cellular and metabolic abnormalities and a higher risk of death (Singer et al., 2016). In clinical practice, it is identified by the need for a vasopressor to maintain mean arterial pressure at 65 mmHg or more and lactate above 2 mmol/L, without hypovolemia (Singer et al., 2016).

Warning signs

With little time, the priority in studying is what cannot be missed. Warning signs help you recognize, in a common complaint, the patient who may have a serious illness.

Why prioritize the dangerous

A modeling estimate for the United States calculated that 15 dangerous diseases account for 50.7% of serious harm caused by diagnostic error (Newman-Toker et al., 2024). The top 5, stroke, sepsis, pneumonia, venous thromboembolism and lung cancer, account for 38.7% (Newman-Toker et al., 2024). The authors group these diseases into three categories: vascular events, infections and cancers (Newman-Toker et al., 2024).

In the same estimate, the weighted average error rate per case of dangerous disease was 11.1%, and that of serious harm was 4.4% (Newman-Toker et al., 2024). The authors conclude that, since only 15 diseases account for about half of serious harm, the problem may be more treatable than was thought (Newman-Toker et al., 2024). As a practical suggestion for those with little time: start with the warning signs of the dangerous diseases that appear in your stage.

Diagnostic error is also common outside the hospital: combining three studies in the United States, the estimated rate of outpatient diagnostic error was 5.08% (Singh et al., 2014). The authors estimate that about half of these errors could cause harm (Singh et al., 2014).

An example: headache

For headache, a review gathered warning signs for secondary headaches in the SNNOOP10 list (Do et al., 2019). Among them are systemic symptoms such as fever, history of neoplasm, neurological deficit, sudden onset, onset after age 65 and change in pattern or new headache (Do et al., 2019). The list also includes positional headache, triggered by cough or exertion, papilledema, pregnancy or puerperium and overuse of analgesics (Do et al., 2019).

The authors note that prospective epidemiological studies on these signs are lacking (Do et al., 2019). The list is an aid for triage, and not a rule that decides on its own.

An example: infection that may be sepsis

Outside the ICU, the sepsis consensus proposes a bedside score, qSOFA, to identify adults with suspected infection at higher chance of poor outcome (Singer et al., 2016). It considers at least 2 of 3 criteria: respiratory rate of 22 per minute or more, altered mental status and systolic pressure of 100 mmHg or less (Singer et al., 2016).

How to study warning signs

As a practical suggestion, for each common complaint in your stage:

1. Find the list at the source: a review, a guideline or the service's protocol.
2. Recall before checking: try to write the signs from memory and only then compare.
3. Link each sign to the disease it suggests: why is fever in headache concerning?
4. Check in the patient: the next time the complaint appears, ask about and examine the signs on the list.

Complaint	Dangerous diseases to remember	Source
Headache	Secondary causes, such as those the SNNOOP10 list helps triage	Do et al., 2019
Suspected infection	Sepsis	Singer et al., 2016
Acute neurological deficit	Stroke, among the 5 diseases with the most estimated harm	Newman-Toker et al., 2024
Dyspnea	Pneumonia and venous thromboembolism, among the 5 diseases with the most estimated harm	Newman-Toker et al., 2024

The "complaint" column is an organization by the Editorial team; the diseases come from the cited sources.

Prioritizing the serious hypothesis in the list of differential diagnoses is the topic of the text about clinical reasoning.

Game as a complement

The game fits into breaks and trains one part of the work: forming the hypothesis from clues. The patient, the preceptor and the protocol remain at the center of the clerkship, and the game adds to them.

What the evidence allows us to say

A systematic review on gamification in the health professions found that it can help learning, but most studies did not have a well-defined control group; the details are in the text about gamification in medical education (van Gaalen et al., 2021). What is known more reliably is that testing yourself with feedback helps retention (Larsen et al., 2009), and a clinical case with an answer and an answer key is a form of testing. If you research medical education and want to study the effect of case games in the clerkship, NEXO Researcher receives study proposals.

NEXO during the clerkship break

In NEXO, each case arrives in up to six clues, and you form the hypothesis from the findings, as you would with a patient. The Daily brings one case per day, the same for everyone, and renews at midnight: a good format for a clerkship break and for comparing with your class later.

Adrenaline is a case against the clock: before playing, you choose the dose, and the higher it is, the less time you have. There is one Adrenaline case per day, a training of reasoning under time pressure. The Archive gathers the previous daily cases, good for a review block by area when you have more time. To understand the limits of each mode, see the NEXO economy page. To bring the case of the day to the clerkship, the league or the residency program at your school, learn about NEXO Closer. Doctors who want to review cases in their specialty take part through NEXO Curator, and those who create content for students can learn about NEXO Creators.

From the game to the patient

As a practical suggestion, use the game case as a bridge to the clerkship. If the case of the day was about a complaint you will see in the service, review its alarm signs. If you got the diagnosis wrong, write down the doubt, as you would with a patient, and answer it in the next break.

Keeping what you learned

The short answers of the day only help if you return to them. As a practical suggestion, keep the questions and answers in one place, organized by clerkship or by complaint, and review them by testing yourself: read the question, try to answer and only then check. Repeated tests with feedback yielded more retention than rereading the same content (Larsen et al., 2009). At the end of each clerkship, this notebook becomes the summary of what you actually saw.

A possible week in the clerkship

The plan below is a practical suggestion from the Editorial, to adjust to your clerkship. It does not define study time; it defines what to do in each type of moment.

Moment	What to do
In the service	Take part in the care and write down one question per patient
Short break	One commented question, one game case or the alarm signs of a complaint
End of the day	Answer the questions of the day in one or two lines
Freer day	Read an original guideline from the clerkship and review one area in the Archive
After a shift	Rest; if possible, just review the answers of the week

How to adjust

In clerkships with a lot of waiting time, short breaks multiply; in heavy shifts, they almost disappear. What matters is having the formats ready, so that the break is not spent deciding what to study. If the week goes off plan, the patient's question remains the best starting point.

Common mistakes

• Studying the whole disease for each patient: with little time, one answered question yields more than one chapter started.
• Replacing the service with studying at home: learning in the clerkship depends on taking part in the care (Dornan et al., 2007).
• Reading only protocol summaries: the original guideline shows the strength of the evidence and the limits of the recommendation (Woolf et al., 1999).
• Studying only the most likely: dangerous diseases concentrate the harm of diagnostic error (Newman-Toker et al., 2024).
• Leaving everything for the weekend: short, spaced units also yield results (Kerfoot et al., 2010).

Frequently asked questions

How to study in the clerkship with little time?

Start from the patient of the day, use short intervals with questions and cases, prioritize alarm signs and read the guidelines at the source. Units of less than 15 minutes had a positive effect on knowledge in a scoping review (De Gagne et al., 2019).

How many hours a day should you study during the internship?

The number of hours varies from rotation to rotation, and no value has good evidence. Studies show that short, spaced units can pay off, such as the daily question with feedback with residents (Kerfoot et al., 2010).

Is it worth more to study at home or to learn on the ward?

The ward is the center. The model of learning in the clinical environment describes "supported participation" as the central condition (Dornan et al., 2007). Studying at home complements it, answering the questions the patients left behind.

How should you study protocols and guidelines?

Ask who the protocol is for, what the central decision is and where the recommendation comes from. Guidelines can be wrong for an individual patient, as a classic article on the topic reminds us (Woolf et al., 1999).

Why study alarm signs?

Because few dangerous diseases concentrate the harm. In an estimate for the United States, 15 diseases accounted for 50.7% of serious harm from diagnostic error (Newman-Toker et al., 2024).

How should you present the case to the preceptor?

There are formats of their own for this, such as SNAPPS and the one-minute preceptor, which will be the subject of a text on reasoning during the internship. The script for each patient is in the text on clinical reasoning.

How does a case game help during the internship?

It helps as a complement to the rotation. Testing yourself with feedback helps you retain (Larsen et al., 2009), and a case with an answer key is a form of testing; the decision at the bedside is still trained with the patient and the preceptor.

Why study the patient's question and not the whole disease?

Because time is short and the question already brings context. Learning during the internship depends on taking part in care (Dornan et al., 2007), and the question the patient left connects studying at home to what you saw on the ward.

Does microlearning work in Medicine?

A scoping review with 17 studies in the health professions found a positive effect on knowledge and confidence (De Gagne et al., 2019). No study assessed outcomes in patients, so the effect on practice has not yet been measured.

How should you study for the residency exam during the internship?

With the same principle of short intervals: testing yourself with feedback and spacing the review. Repeated tests with feedback yielded 39% against 26% for repeated study after more than 6 months (Larsen et al., 2009), and short spaced questions yielded more retention than concentrated modules (Kerfoot et al., 2010). The patient of the day remains a good index of what to review.

How does NEXO help during the internship?

The Daily brings one case a day in up to six clues, good for a break during the rotation. Adrenaline trains reasoning against the clock, and the Archive gathers previous cases to review an area.

Internship checklist

1. Do you write down one question per patient?
2. Are the day's questions answered in one or two lines?
3. Do you take part in care, and not just observe?
4. Do the short intervals have ready-made formats: question, case, alarm signs?
5. Do you test yourself before checking the answer?
6. Do you read the original guideline for what you see on the rotation?
7. Do you know who it is for and where each protocol comes from?
8. Do you know the alarm signs of the common complaints on the rotation?
9. Does the game come in as a complement, linked to what you see on the ward?
10. Is rest also in the plan?

Want to train today? Play the case of the day on NEXO.

References

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