PGY-1 to PGY-3: Year-by-Year Roadmap to Specialty Board Readiness

The biggest lie residents believe is that “I’ll get serious about boards next year.” That is how people end up in PGY-3 with a red-flag in‑training exam and a program director quietly panicking.

If you treat board prep as a 3‑year project—not a 3‑month cram—you will walk into your specialty boards annoyed, not scared. That is the goal.

Below is a year‑by‑year, then quarter‑by‑quarter, then month‑level roadmap from PGY‑1 to PGY‑3 focused on one thing: being truly board ready on graduation day.

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Big Picture: Three-Year Board Strategy

At this point you should stop thinking “exam” and start thinking “system.”

• PGY‑1: Build habits, foundations, and question bank consistency
• PGY‑2: Aggressive content consolidation and in‑training exam leverage
• PGY‑3: Targeted remediation, high-yield drilling, and exam logistics

Here is the rough distribution of board‑focused effort over residency:

Relative Board Prep Focus by Residency Year

Category	Value
PGY-1	25
PGY-2	45
PGY-3	30

Your actual calendar will look different by specialty (surgery vs psych vs IM), but the structure is the same. You anchor everything around:

• Annual in‑training exam (ITE) date
• Specialty board exam window
• Heavy rotations (ICU, nights, consults, wards) vs lighter blocks (clinic, electives, research)

We will walk straight through PGY‑1 to PGY‑3 with “at this point you should…” clarity.

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PGY‑1: Build the Machine, Not the Myth

PGY‑1 is not about “crushing boards.” It is about never letting yourself become the PGY‑3 who is starting from zero.

PGY‑1, Quarter 1 (July–September): Survival + Tiny Habits

You are learning how to write notes, not kill patients, and find the cafeteria. Fine. But even here:

At this point you should:

1. Pick one primary resource for boards

   • Internal medicine: MKSAP, UWorld IM, or equivalent
   • Surgery: SCORE, TrueLearn, ACS SESAP
   • Peds: PREP, MedStudy
   • Psych: PRITE-style Qbanks, board review texts
     The actual choice matters less than sticking to one main path your program director respects.

2. Set a bare-minimum question habit

   • Week 1–4: 5 questions per day, 5 days per week
   • After that: 10 questions per day, 5 days per week
     Do them after sign-out, before bed, or during your post-call recovery. But do them.

3. Create a dead-simple tracking system

   • One spreadsheet or note with:
     • Daily question count
     • Topics missed repeatedly
     • “Red list” concepts to review (e.g., hyponatremia, anticoagulation reversal, ventilator basics)

At this stage, consistency beats volume. A tired intern doing 10 focused questions a day wins over a heroic 150-question weekend that dies after two weeks.

PGY‑1, Quarter 2 (October–December): Build Understanding

Now you are not drowning quite as much. This is when most interns either build momentum or drift.

At this point you should:

• Increase to 10–15 questions/day on most non-call days

• Link questions to real patients

  • Missed a question on DKA? Review it on your actual DKA admission that week.
  • Write 1–2 teaching points in the chart for yourself (even if you never show anyone).

• Start a micro‑review system

  • Once a week (e.g., Sunday evening), spend 30–45 minutes:
    • Skimming notes on your “red list” concepts
    • Re‑doing 5–10 questions you got wrong that week

This is your foundation for long‑term retention. Not glamorous, but it sticks.

PGY‑1, Quarter 3 (January–March): First In‑Training Exam Prep

This is where most programs start talking about your specialty in‑training exam.

Residency Exam Milestone Timeline

Period	Event
PGY-1 - Jul-Sep	Build habits and choose resources
PGY-1 - Jan-Mar	Prepare for first in-training exam
PGY-2 - Jul-Sep	Ramp up volume and depth
PGY-2 - Oct-Dec	Intensive prep for second in-training
PGY-3 - Jan-Mar	Final in-training and gap targeting
PGY-3 - Apr-Aug	Focused board exam preparation and sitting

At this point you should:

1. Know the ITE date. Put it on your calendar.
   Back up 6 weeks. That is your “ITE ramp period.”

2. During the 6 weeks pre‑ITE:

   • Aim for 20–25 questions/day, 5 days per week, focused on your weaker systems
   • One 40–60 question timed block per week to practice test stamina
   • Review explanations thoroughly; do not chase more volume at the expense of review.

3. Do one brief pass through a rapid review resource

   • Example: reading high-yield chapter summaries or flashcards for:
     • Cardiology
     • Pulm
     • ID
       Pick your top 3 most common inpatient systems to keep it realistic.

If you are crushed with nights/ICU during this period, scale the numbers but keep the structure. The ramp matters more than the exact total count.

PGY‑1, Quarter 4 (April–June): Post-ITE Debrief and Adjustment

When ITE scores landed in my inbox, the smartest interns did something simple that most skipped: they booked a 15‑minute meeting with their program director or APD.

At this point you should:

• Get your ITE breakdown (by system, topic, or domain)
• Identify your bottom 2–3 areas (e.g., endocrine, rheum, psychiatry)
• Design a 3‑month “repair plan”:
  • One focused topic per week from your weak areas
  • 20–30 questions/week specifically from those sections
  • Quick read of 1–2 key review chapters for each weak system over the quarter

Your PGY‑1 year closes not with “I survived,” but with a clear map of where you are weak and what you will attack in PGY‑2.

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PGY‑2: Depth, Volume, and Serious In‑Training Strategy

PGY‑2 is the engine year. You are no longer just trying to not get yelled at on rounds. This is when board prep becomes deliberate.

PGY‑2, Quarter 1 (July–September): Scale Up

At this point you should:

1. Commit to a real weekly question volume

   • Target: 150–200 questions/week
   • Structure:
     • 3–4 days of 20–30 questions (untimed, learning mode)
     • 1–2 days of 40–60 questions (timed blocks)

2. Begin your first full pass of a major Qbank

   • Internal medicine example: full UWorld IM pass this year
   • Track completion: aim for ~25–30% done by end of September

3. Integrate learning into work

   • Pick 1 patient each day and tie them to a question block that night
   • If you admitted GI bleed, your questions that evening hit GI bleeding, transfusion thresholds, anticoagulation.

PGY‑2, Quarter 2 (October–December): Structured Content Review

This is where many residents stall. Do not.

At this point you should:

• Set up a 12‑week system‑based plan
  Example for IM (adjust to your specialty):

  • Week 1–2: Cardiology
  • Week 3–4: Pulmonary
  • Week 5: Nephrology
  • Week 6: GI
  • Week 7: Endocrine
  • Week 8: Rheum/MSK
  • Week 9: Heme/Onc
  • Week 10: ID
  • Week 11: Neuro
  • Week 12: Misc / catch‑up

For each week:

• Read high-yield summaries or core review chapters (2–3 evenings)
• Do 60–100 questions focused on that system
• Write 5–10 “must remember” pearls in your notebook or digital notes

This gives you your first true content sweep of residency.

PGY‑2, Quarter 3 (January–March): Second In‑Training – This One Counts

This ITE drives a lot of PD anxiety. It is closer to your boards and seen as a predictor.

At this point you should (8 weeks before ITE):

1. Increase to 250–300 questions/week

   • At least two 60-question timed blocks per week
   • One of those in “random mixed” mode to simulate exam conditions

2. Finish your first major Qbank pass

   • If you are not on track, accelerate:
     • 40–60 questions per day on lighter rotations
     • Use post-call mornings for review (not for new blocks).

3. Use practice exams if your specialty offers them

   • Internal medicine: NBME-style practice exams or vendor “mock” boards
   • Surgery: SCORE exams, SESAP practice sets
     Take one 4–6 weeks pre‑ITE, one 1–2 weeks pre‑ITE.

After the ITE:

• Compare PGY‑1 → PGY‑2 scores
• If your percentile dropped or stayed low:
  • You are now on a structured remediation track. Good. That is better than denial.

PGY‑2, Quarter 4 (April–June): Second Pass and Weakness Targeting

This is where you begin your second pass through questions and high-yield concepts.

At this point you should:

• Identify bottom 3–4 domains from your ITE report

• Set a 3‑month weakness boot camp:

  • For each weak area:
    • Re‑do all missed questions from that topic
    • Add 40–60 new questions from a second Qbank or unused sections
    • Review 1–2 focused chapters or guidelines (e.g., 2017 ACC/AHA HTN guideline)

• Begin a “spaced recall” habit

  • One evening per week:
    • Rapidly scan your notes from prior months (10–15 minutes per topic)
    • Close notes and force yourself to recite key facts / algorithms from memory

By the end of PGY‑2, you should not just know that you are weak in, say, rheumatology. You should have already attacked it once and know precisely which subtopics (e.g., vasculitis, SLE criteria, inflammatory myopathies) still give you trouble.

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PGY‑3: Board Alignment and Execution

PGY‑3 is not the time to “start” board prep. It is the time to convert your prep into a passing board performance.

Quarter	Primary Focus	Weekly Question Target
Q1 (Jul–Sep)	Second-pass Qbank, integrate with work	200–250
Q2 (Oct–Dec)	Third-pass on weak areas, practice exams	250–300
Q3 (Jan–Mar)	Final ITE, refine gaps	200–250
Q4 (Apr–Jun/Jul–Aug)*	Board-specific boot camp	150–250

*Exact Q4 timing depends on your specialty board exam window.

PGY‑3, Quarter 1 (July–September): Controlled Aggression

At this point you should:

1. Begin (or continue) your second full Qbank pass

   • Now in random, mixed, timed mode most of the time
   • 200–250 questions/week is a solid target if rotations allow

2. Lean into pattern recognition

   • While reviewing, explicitly ask:
     • “What are they really testing here?”
     • “What is the single key word or lab that gave away the answer?”

3. Start building a one‑document “Boards Playbook”

   • 10–20 pages max
   • Sections: Cardio, Pulm, Renal, etc.
   • Only ultra high-yield:
     • Diagnostic criteria
     • First‑line vs second‑line therapies
     • Classic “board‑style” presentations

By the end of September, you want a concise, personal reference that you trust more than random PDFs people email around.

PGY‑3, Quarter 2 (October–December): Serious Simulations

If your board exam is spring/summer after graduation, this is the last true “build” phase before you enter execution mode.

At this point you should:

• Schedule 2–3 full practice exams

  • One early in the quarter
  • One mid‑quarter
  • One near end of quarter or early next
    Simulate test day: same length, timed, no interruptions beyond what the real exam allows.

• Analyze practice exam performance ruthlessly

  • For each exam:
    • List top 3 weakest systems
    • List top 3 types of errors:
      • Rushing, misreading
      • Getting tricked by distractors
      • Knowledge gaps in core pathophysiology

• Tighten time‑management

  • Practice keeping a steady pace (e.g., 1–1.2 minutes per question)
  • If you are habitually finishing with <10 minutes left, you are probably rushing and making avoidable mistakes.

This quarter is about making the exam feel boringly familiar.

PGY‑3, Quarter 3 (January–March): Final In‑Training + Micro-Targeting

Your last ITE is a free board practice test with consequences but no immediate license on the line. Use it aggressively.

At this point you should (6–8 weeks pre‑ITE):

1. Hold 200–250 questions/week steady

   • Mixed-mode blocks, heavy focus on speed + accuracy

2. Do at least one full‑length simulation under strict exam conditions

3. Polish your Boards Playbook

   • Fill gaps exposed by practice tests
   • Trim clutter—this is not a textbook.

After the ITE:

• Compare your performance trajectory PGY‑1 → PGY‑2 → PGY‑3
• If you are above your board pass threshold and trending up: maintain and refine
• If your score is borderline:
  • Schedule a meeting with PD/faculty now
  • Arrange lighter rotations or elective time ahead of the board window if possible
  • Consider formal remediation: extra review course, tutor, or structured faculty mentoring

PGY‑3, Quarter 4 (April–Board Exam): Final Four to Eight Weeks

This is the sprint. Not the entire race.

Final 6-Week Board Prep Allocation

Category	Value
Qbank questions	40
Practice exams review	25
Reading/notes	25
Rest & logistics	10

Assuming a June/July exam, here is how to structure the last ~6 weeks.

At this point you should:

1. Set realistic weekly goals (example for IM):

   • 150–200 questions/week
   • 1 full or half‑length practice exam every 1–2 weeks
   • 5–7 hours/week dedicated to reading your Boards Playbook and key chapters

2. Shift from “learning new” to “sealing known”

   • Prioritize:
     • Frequently tested bread‑and‑butter (CHF, COPD, DM, sepsis, AFib)
     • Common management algorithms and guidelines
   • De‑prioritize:
     • Ultra‑rare zebras you have seen once in 3 years

3. Lock down exam‑day logistics at least 2 weeks ahead:

   • Confirm:
     • Test site location and parking
     • Start time
     • Required IDs and confirmation emails
   • Plan:
     • How you will get there
     • What you will eat before and during breaks
     • Sleep schedule in the 3–4 nights prior

4. Final 7–10 days:

   • No massive new Qbank binge
   • Focused review of:
     • Your Boards Playbook
     • All the questions you repeatedly missed (flagged list)
   • Short daily timed blocks (10–20 questions) just to keep the engine warm

5. Final 24–48 hours:

   • Light reading only
   • No full exams. No staying up late.
   • Maybe 10–15 easy questions just to keep confidence intact.

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Red Flags and Course Corrections by Year

You will not follow this perfectly. Nobody does. Here is when you absolutely must course-correct:

• PGY‑1 ITE < 20th percentile

  • Response: Early conversation with PD, increase structured study by 30–50%, possibly pair with a senior mentor.

• PGY‑2 ITE not improved from PGY‑1 or still borderline

  • Response: You are now in a “board risk” category. You need:
    • Formal plan
    • Scheduled weekly study blocks protected as much as possible
    • Possibly a review course during PGY‑3.

• PGY‑3 practice exams consistently below passing (within 6 months of real boards)

  • Response: This is not a “wait and hope” situation.
    • Aggressive 6–8 week remediation
    • Re‑distribution of rotation intensity if your program can accommodate it
    • Maybe delay boards if your specialty allows and PD agrees (rare, but better than a fail on record in some cases).

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You do not need to study like a full‑time student throughout residency. You do need to treat board prep like a long, controlled campaign instead of a last‑minute rescue.

Here is your concrete next step:

Open your calendar for the next four weeks and block three specific 30–45 minute study sessions per week. Label each with the exact task (e.g., “20 cardio questions,” “review endocrine notes”). If you cannot defend those three tiny blocks from chaos now, you will not magically defend six weeks of board prep later.