Table 3 Themes and illustrative quotes from students’ descriptions of how exam preparation influenced them personally and professionally

Opportunity for synthesis of medical knowledge

“It was a great final review of all the material I had learned over the first two years of medical school and my knowledge base grew a lot.”

“I appreciated being able to only focus on the exam and not having to deal with other random assignments or responsibilities, and I loved being able to finally synthesize and understand the content we had learned over the past two years. It reinforced my love for medical knowledge.”

Exercise of endurance and self-discipline required for professional practice

“My preparation made me realize that dedication it takes to practice medicine, having to be willing to test myself and learn new information every day in order to master the breadth of medical knowledge.”

“The routine for studying every day was definitely an exercise of discipline and trusting the process …. the discipline and motivation that helped get me through board prep will hopefully stick with me in my career as a physician.”

Dissonance between exam preparation resource content, formal curriculum, and professional values

“Step prep tore down all the faith I have in medicine …. I don’t think that knowing all the biochemical pathways and all the minute details like that are necessarily going to make us better doctors.”

“I feel that the importance of Step 1 scores is inflated in a way that benefits students who skip lectures and “social medicine” learning, and focus solely on memorizing First Aid. This isn’t the way that medical education should be. I don’t see how high performance on Step 1 could possibly be an adequate measure of how successful someone will be as a doctor, but it seems that this is the favored way to evaluate our value as students and future residents.”

Isolation, deprivation, and anguish in a competition for the highest possible score

“Step study time was a dark time where your whole life revolves around getting one score with the feeling that failing to achieve that score will prevent you from doing what you want. Your mental health suffers inevitably. Your relationships with family friends suffer. There is a great deal of anxiety as the test date approaches and you begin comparing your progress to colleagues.”

“Studying for Step 1 was emotionally demanding, and was the most isolating experience of my life. For my goal score, I knew that I had to give up a lot that was important to me. This meant minimizing contact with my close friends, and only maintaining my relationship with my partner and parents. I discontinued exercise, and did not take many breaks, which I regret.”

“Every time I would see my classmates in the library, I felt immense anxiety and nausea. Some of my classmates would be in the library 12-14 h a day and it was just extremely disheartening. I never got to spend time with friends and the time I didn’t spend studying was time spent feeling guilty for not studying. Every question I got wrong made me feel worthless.”

Effects on well-being extending beyond DPPs

“I did not realize until it was over and I began my clinical rotations how much it was affecting me personally. I was having insomnia in the months before that has completely disappeared, as well as mild symptoms of depression that are significantly better now.”

“I have never been so burned out before during medical school. This feeling of being burned out has carried over to my rotations. I currently still feel burned out.”

“I felt like I changed as a person after dedicated. Now I jump to conclusions faster about people and am generally more impatient. I also feel unhealthy, both physically and mentally. I feel like I am constantly bearing the weight of high expectations, my patients, and the fear of failure.”