Two years building the science, two years caring for patients on teams, with clinical skills practised from the first semester. Here is what each year asks of you, and how rotations, OSCEs and shelf exams actually work.
The four years at a glance
Year 1
How the healthy body works
You build the science of normal structure and function: how cells, organs and systems keep a person well. Doctoring starts here too, so you meet patients from the first months.
Year 2
How disease happens, and how drugs act
The focus moves from normal biology to disease, organ system by organ system, with pharmacology, microbiology and immunology woven through. Most students take USMLE Step 1 or COMLEX Level 1 at the end of this stage.
Year 3
The core clerkships
You join hospital and clinic teams full-time, rotating through the core specialties. You take a history, examine, present and write notes on real patients, under supervision, and each rotation ends with a national shelf exam.
Year 4
Sub-internships, electives and the Match
You act as an intern on a sub-internship, choose electives, may rotate at other schools, and apply to residency. The year ends with the Match and graduation.
Year by year
What you study, how you meet patients, two cases typical of the year, and the exams that close it.
Year 1
How the healthy body works
What you study
Anatomy and physiology
Gross anatomy and dissection, the musculoskeletal system, heart and lung mechanics, neuroanatomy, the gut and the kidney.
Biochemistry and cell biology
Metabolism and its rate-limiting enzymes, enzyme kinetics, signalling, genetics, gene expression and membrane transport.
With patients
Doctoring: the full patient history, the head-to-toe exam, communication skills and your first SOAP notes, often with a half-day a week in a primary-care preceptorship.
Cases you might work through
Radial nerve palsy
A mid-shaft humeral fracture explains wrist drop and numbness on the back of the hand.
Von Gierke disease
An infant with fasting hypoglycemia, lactic acidosis and an enlarged liver traces back to one missing enzyme.
Exams
Course and block exams. Board-style questions begin quietly alongside coursework.
Year 2
How disease happens, and how drugs act
What you study
Pathology and pathophysiology
Cardiovascular, respiratory, renal, endocrine, gastrointestinal, blood and cancer, and reproductive disease, with histology side by side with normal tissue.
Pharmacology, microbiology and immunology
How each drug class works and what it can harm, antibiotic coverage, hypersensitivity and autoimmune disease.
With patients
Doctoring moves to focused 15-minute encounters built around a chief complaint, differential diagnosis, and harder conversations such as delivering bad news.
Cases you might work through
Nephritic or nephrotic syndrome
A child with swelling and heavy protein loss (minimal change disease) next to post-streptococcal glomerulonephritis with blood in the urine.
Anaphylaxis on a beta-blocker
A severe allergic reaction to a penicillin-class antibiotic is harder to treat when the patient takes a non-selective beta-blocker.
Exams
USMLE Step 1 (pass or fail) or COMLEX-USA Level 1, usually after a dedicated study block. Some schools move it to after the first clinical year.
Year 3
The core clerkships
What you study
Inpatient and surgical
Internal medicine and surgery: ward rounds, the acute abdomen, care around an operation, fluids, and acid-base problems.
Outpatient and primary care
Pediatrics, obstetrics and gynecology, psychiatry, family medicine and neurology: development, pregnancy, mental health and long-term conditions.
With patients
Daily patient care: pre-rounding, progress notes, presentations on rounds, clinic visits and supervised procedures.
Cases you might work through
Appendicitis or diverticulitis
Telling two causes of abdominal pain apart at the bedside, with the exam signs, labs and CT that confirm it.
Preeclampsia with severe features
A patient at 32 weeks with high blood pressure, a severe headache and visual changes needs urgent care.
Exams
An NBME subject (shelf) exam at the end of each core rotation. Many students prepare for Step 2 CK through the year.
Year 4
Sub-internships, electives and the Match
What you study
Sub-internships and critical care
Acting-intern responsibility in medicine or surgery, intensive care and emergency medicine: resuscitation, ventilators and trauma priorities.
Ready for residency
Structured patient handoffs (I-PASS), cross-cover calls, discharge planning, and medical ethics and law.
With patients
You carry your own patients, with more independence and closer to an intern's workload, plus away rotations for your chosen specialty.
Cases you might work through
Septic shock
Resuscitating a patient whose blood pressure will not hold, with rising lactate and failing organs.
End-of-life decisions
Working with surrogate decision-makers, advance directives, DNR orders and the ethics committee.
Exams
USMLE Step 2 CK or COMLEX Level 2-CE, ideally before residency applications. Step 3 or Level 3 comes during residency.
The doctoring course
Every US MD and DO school teaches clinical skills across the first two years, under names like Doctoring, Clinical Skills, Practice of Medicine or Foundations of Clinical Medicine. It connects the science you are learning to the person in front of you, so you arrive on the wards ready to take a history, examine, reason and write it up.
Year 1
Patient encounter fundamentals
The complete history
Chief complaint, history of present illness, past medical, surgical, social and family history, and the review of systems.
The physical exam
Vital signs and a systematic head-to-toe exam using inspection, palpation, percussion and auscultation.
Patient-centred communication
Active listening, empathy, rapport and drawing out the patient's concerns, often taught through the Calgary-Cambridge or SEGUE models.
Notes and presentations
The SOAP note (Subjective, Objective, Assessment, Plan) and a short oral case presentation.
Year 2
Clinical reasoning and harder conversations
Focused encounters
From a 45-minute complete history to a 15-minute focused history and exam for complaints like chest pain or shortness of breath.
Differential diagnosis
Turn findings into a prioritised list of possibilities, a workup and a first plan.
Challenging conversations
Delivering bad news with the SPIKES approach, anxious or angry patients, substance use, sexual history and cross-cultural care.
Ready for the wards
A transition course before year 3: handoffs, the electronic record, sterile technique, teamwork and emergency drills.
Standardized patients
Standardized patients are people trained to portray a patient's history, symptoms and emotions the same way every time. You can practise, stumble and try again with no risk to a real patient.
People from the community
Standardized patients are recruited across ages, backgrounds and body types so cases look like real practice.
Trained to the script
Each learns a case over roughly 2 to 12 hours: the history, social background, exam findings such as tenderness, and the emotional tone.
The same case for everyone
Everyone portraying a case trains together so every student meets the same patient under the same conditions.
Feedback from the patient's side
Straight after the encounter you hear how your clarity, empathy and respect landed.
Teaching the exam
Some serve as physical exam teachers, guiding stethoscope placement, landmarks and gentle palpation.
How an OSCE station runs
The Objective Structured Clinical Examination is how doctoring is assessed: a circuit of timed rooms, each with a standardized patient. The same format returns in clinical skills assessments and, in Canada, the NAC exam.
The four phases of an OSCE station
Phase
Time
What you do
Who assesses it
Door note
1–2 min
Read the patient's age, vital signs and chief complaint posted outside the room.
Your own preparation.
Encounter
12–15 min
Take a focused history, examine, and share your first impressions with the patient.
Faculty checklist, live video or a one-way mirror.
Patient feedback
2–3 min
Hear from the standardized patient on communication, empathy and conduct.
The standardized patient's rubric.
Post-encounter note
10–15 min
Write the history, exam findings, differential diagnosis and plan.
Physician faculty, against a scoring rubric.
Clinical rotations
Rotations move you from lectures to patient care on hospital wards, in clinics and in specialty units. Exposure grows each year.
Years 1–2
Early exposure
A half-day a week or every other week with a preceptor, usually in primary care: shadowing, histories and exam practice.
Year 3
Core clerkships
Around 48 to 52 weeks of required rotations across seven core specialties.
Year 4
Advanced rotations
Around 32 to 40 weeks: a 4-week sub-internship, intensive care and emergency medicine, electives, away rotations and Step 2 CK study time.
Third-year core clerkships, typical length
Internal medicine8–12 weeks
Surgery8 weeks
Pediatrics6 weeks
Obstetrics and gynecology6 weeks
Psychiatry4–6 weeks
Family medicine4–6 weeks
Neurology4 weeks
Inside every rotation
Day 1
Orientation
Hospital badge and records access, privacy training, the syllabus, and goals agreed with your attending or chief resident.
Every day
Daily patient care
Pre-round on your patients, write progress notes, present on rounds, and join procedures and clinic visits.
Midpoint
Mid-rotation feedback
A one-to-one review of your skills, notes and charting, while there is still time to improve before the grade.
Final week
Clinical evaluation
Attendings and residents rate your knowledge, reasoning, communication and professionalism.
Final day
Shelf exam
A national NBME subject exam, combined with your clinical evaluation for the final grade.
What the team expects from you
Reasoning
Build a prioritised differential diagnosis, suggest a sensible workup, and read labs and imaging accurately.
Communication
Take a thorough, kind history, keep patients updated, and present a patient clearly and briefly on rounds.
Procedures
Basic skills under supervision: drawing blood, arterial samples, urinary catheters, suturing and, with close supervision, lumbar punctures.
Professionalism
Arrive on time for pre-rounds, chart promptly, work respectfully with nurses and staff, and protect patient privacy.
The skills it all builds toward
Doctoring, rotations and residency share the same competency language, so the habits you form in year one carry straight into training.
Patient care
Accurate histories and appropriate exams across diverse patients.
Communication
Clear, compassionate, culturally aware conversations with patients, families and teams.
Professionalism
Ethics, privacy, respect and personal accountability.
Learning from feedback
Using faculty, standardized patient and peer feedback to keep improving.
Next: the board exams
Step 1, Step 2 CK and Step 3, COMLEX for DO students, and the Canadian MCCQE and NAC, with a study plan for each.
