Steps to handle STEP

Tip: Breaks are best when they are limited. Schedule your break and limit their length. For every hour of study take a 10-20-minute break. You can even take 5-10-minute breaks for every thirty minutes of study. Every 3 or 4 hours, take a longer break to recharge and connect with others, or eat a meal.

Tip: Breaks are best spent disconnected for electronics and social media. Electronics and social media tend to be time bandits and before you know it your 15-minute break turned into an hour or more. Ideally, spend your break doing something that is a shift in focus for your brain.

Break Ideas: Take a walk outside, stretch or do yoga (Chair Yoga for Beginners), clean up your work space, connect with a friend, take a shower, do something creative (draw, paint, cook, build), try meditation, or run a short errand.

Studies have shown that when students get optimum sleep (7-8 hours) they perform better academically. Here are some tips on how to get better sleep:

Keep your bedroom quiet and dark: Noise and even dim light may interrupt or shorten your sleep. You can block out unwanted noise by wearing earplugs, running a fan, or using a “white noise” machine.

Keep your bedroom cool: Make sure the temperature in your bedroom is comfortable. Generally speaking, the ideal temperature for sleep is between 62-68 degrees Fahrenheit.

Avoid use of technology: Give yourself at least 30-45 minutes of gadget free transition time before going to bed. This allows your brain the time to process inputs and to transition into sleep mode. It’s surprising how active your phone is during the night, check that your notifications are off. A good policy is to make your bedroom a technology-free zone.

Put the clock under the bed or turn it so that you can’t see it: Clock watching may lead to frustration and worry. Avoid looking at the clock, instead think of the fact that you get to return to sleep or rest for an unknown amount of time!

Develop a Sleep Routine: Consistently having the same bed and wake time will help regulate your Circadian Rhythm and create a good transition to “sleep mode.” Having sleep rituals can help; brushing teeth, preparing your outfit for tomorrow, done on a consistent basis will turn into a signal to your brain that it’s time for sleep. Another good sleep transition technique is to read an entertaining book just before bed each night. Penn State College of Medicine | Office for Professional Mental health Contact us at: Email: PMH@pennstatehealth.psu.edu Phone: 717-531-6858 For urgent need contact: Penn State Crisis line at 877-229-6400 or dial 911

Don’t Force It: If you’re struggling to fall asleep and you’re in bed, get up and go read a book (one that you read for pleasure, not school). When you’re tired again go back to bed.

“I don’t like studying close to bed time because then I can’t shut my brain off.” A.M.

Bonus Tip: If racing thoughts are keeping you from falling asleep try this derivative of Cognitive Shuffling we call the 55 Method for Sleep. Think of a word that is 5 letters in length and has no repeating letters. Next for each letter of the word then find 5 more words that begin with that letter, that you can visualize in your mind’s eye. For each new word take a few seconds to visualize it before moving to the next. Once you’ve visualized 5 things for the first letter, move to the next. Example: primary word is CHAIR now visualize for C: cat, car, cow, can, cap, then visualize for H: horse, house, hammer, harp, hippo, then A, I and R. If you haven’t fallen asleep by the last visualization of the last letter, just start the process over.

“Doing daily activities to improve your wellness is huge during STEP studying. Make sure you are getting 8 hours of sleep a night, drink water throughout the day, eat healthily, see friends at the end of the day, and work out every day. These are the daily drivers that will keep you resilient through the long days.” J.F.

Physical activity can go a long way towards improving your brain health. Even moderate activity releases serotonin and endorphins bringing a sense of calm, accomplishment and improved self-esteem. Engaging in just about any exercise will have positive effect, just do something.

Nutrition is often overlooked when the conversation is about mental health, however, what we eat can have enduring effects on our mental wellbeing and your academic performance. Literature tells us that with a healthy diet your academic performance can improve. Some suggestions are:

• Prioritize a Balanced Diet: There is a positive association between healthy dietary habits and academic achievement. To improve your academic performance, make sure to include a variety of fruits and vegetables in your diet.
• Avoid Skipping Breakfast: The research highlights that having a regular breakfast can boost academic success. Don’t skip this important meal, as it provides essential nutrients and energy for cognitive function. Penn State College of Medicine | Office for Professional Mental health Contact us at: Email: PMH@pennstatehealth.psu.edu Phone: 717-531-6858 For urgent need contact: Penn State Crisis line at 877-229-6400 or dial 911
• Maintain Regular Meals: Consistency in meal consumption can have a positive impact on your GPA. Try to have regular meals to keep your energy levels stable throughout the day.
• Be Mindful of Unhealthy Food Choices: There is a negative association with consuming certain foods like French fries and soda. Minimize the intake of junk food and sugary beverages to maintain focus during your studies.
• Stay Hydrated: Hydration, it’s essential to support brain function and concentration.

Stay Connected: Your friends and the supports you have created here at the COM are vital toward helping you maintain your self-care during your STEP preparation. Keeping connected to your COM peers helps build accountability, community and a place for you to take care of yourself. This article from the CDC shares that loneliness and isolation can lead to depression and cognitive-decline and that those who make an effort to have abiding social connections have better overall mental and physical health. Here is a summary form another CDC article on Ways to Improve Social Connectedness:

• Establish and maintain social connections: Devote time and attention to develop and maintain relationships. Regular contact with others helps build social connectedness. Schedule time to connect or reach out to others.
• Create a larger and more diverse social network: Having more and different types of people in our lives can potentially provide a greater variety of resources, information, and opportunities to help us with life’s many challenges.
• Connect with others/groups: Being part of a group with shared interests, values, or goals can be rewarding and foster a sense of belonging. Join or create a study group. If you are already part of another social group/network, consider connecting with them after a day of studying.
• Consider the support you give, receive, and have available to you: Reach out to sources of support to help you through the tough times, even though it can be hard to ask for help. Members of your family or community, or health care providers can be sources of support. Providing support to others helps too—it can give them much-needed help, and make you feel good! But don’t forget to take care of yourself when caring for others.
• Strengthen the quality of social connections: Focus on building high-quality, strong, meaningful social connections. Find ways to be responsive, supportive, and grateful to others. Take steps to address conflict or negative feelings when they arise. PMH Tip: Avoid leaving your next get-together to chance. Scheduling something! All too often the “We have to do this again” turns into a never happens again. But, with intentional scheduling your next get-together will already be on the calendar.

In addition, here are some tips to address barriers to social connection:

• Take care of your health. Staying healthy allows you to connect with others socially and enjoy those connections.
• Don’t let technology distract you from engaging with people. Pay attention to ways it might make you feel worse about yourself or others. Try to use it in ways that are positive.
• Busy schedules can prevent us from carving out time to connect with others. Consider sharing things you already do (like exercising or having a meal) with a friend—or doing a new activity with them. Or study with them! Even parallel studying can feel less isolating.

If you are feeling isolated or lonely, or if there are major changes or stresses in your life, consider getting help. We suggest contacting the Office for Professional Mental Health for support.

“I found that the most difficult part of transitioning into my dedicated study period was the loss of a structured schedule that required me to be at a specific place, at a specific time and be held accountable to it. Going from the packed schedule of preclinical courses and requirements to an unstructured period at home was a big change. Try to create your own routine which incorporates going outside for a walk and getting fresh air, as staying inside all day to study during the winter can really negatively impact your motivation and mood. I found that taking a walk after lunch was really helpful for re-energizing myself for the afternoon! Having an accountability buddy or a study group to help co-motivate and commiserate is also highly recommended. Study smarter, not harder. If you’re not sleeping enough or taking care of your basic needs, your brain is not going to work at full capacity.” – V.N.

Want to know why deep breathing is an important exercise to learn for reducing anxiety? Watch this short video by Dr. Yewande Pearce: How Does Breathing Impact The Brain? Learn From A Neuroscientist.

Sometimes having someone to guide you through a deep breathing exercise can be helpful. We suggest trying this recorded exercise by Chris Saranchock, Creative Director and Producer at HelpGuide.org. Follow the link to listen, you can download the exercise if you find it helpful.

When studying for an exam we tend to sit in the same position and build tension in our muscles and joints. This tension forms a negative feedback loop (along with the stress of studying) that builds and becomes distracting if not attended to. PMR techniques can help break the cycle and help you refocus.

Additionally, practicing PMR techniques along with guided imagery and deep breathing have been shown to increase one’s overall well-being. To find our more read this article Effectiveness of Progressive Muscle Relaxation, Deep Breathing, and Guided Imagery in Promoting Psychological and Physiological States of Relaxation available from the National Institutes of Health Library.

There are several variations of PMR that you can practice, from the simple self-guided actions described above to more advanced scripted techniques. Additionally, you can find guided audio PMRs on various platforms like Spotify or Pandora. There are also video PMR’s (YouTube link) that are easy to follow.

Here is a PMR for Rejuvenation (Audio-only download) by Dr. Nandini Talwar, Tufts University.

Meditation and Mindfulness exercises are gaining popularity with students due to the academic and mental health benefits. A growing body of research indicates that regular mindful meditation can improve concentration, memory, attention span, reduce stress and anxiety and help with sleep. In their article Brief Mindfulness Meditation Improves Attention in Novices: Evidence From ERPs and Moderation by Neuroticism, Norris, Creem, Hendler, Kober, show that listening to just a 10 minute meditation had a positive effect (better accuracy and reaction times) on participants. With regular mindfulness practices you can develop enhanced mental acuity, recall and focus. Set aside 10-20 minutes each day to practice mindfulness and experience the results for yourself.

Here are some links to some guided meditations:

Audio – 10 Minute Wisdom Meditation – University of California, San Diego

Audio – Mindfulness – 10 Minute Practice Exercise – Professor Mark Williams, Mental Health Foundation

Audio – Performance Meditation – Health Services, University of New Hampshire

Video – Guided Meditation for Positive Energy, Relaxation, Peace

Video – 2-Minute Focus Reset Meditation: Regain Focus to Work, Study, or Get Tasks Done

Video – 10 Minute Meditation for Focused Attention and Concentration (Voice Only)

Remember, setting realistic goals is an important part of achieving success. By breaking your study sessions into a manageable segment with clear objectives, you can stay motivated and focused. Here are some tips to help you accomplish this:

Write down your goals: Writing down your goals helps you to clarify your thoughts and focus on what you want to achieve. It also makes it easier to track your progress and celebrate your successes.

Examples of some goals might be to complete a certain number of practice questions, read a specific number of pages, or rewrite notes from a particular lecture. To help with goal setting consider using SMART goals.

SMART Goals: SMART Goals (Specific, Measurable, Achievable, Relevant, and Time-Bound) are the most often talked about goal setting technique. Because you have heard it everywhere you might be tired of hearing about it. However, the SMART technique is valuable to helping you achieve the result you most desire. Setting SMART goals helps you to be more focused and effective in achieving your objectives.

Check out the Mind Tools website for a tutorial on how to use SMART Goals.

Evaluate and readjust your goals as needed: Regularly evaluate your progress and adjust your goals if necessary. Stopping to examine your goal, progress and current needs is an important part of achieving your ultimate goal. We don’t want to waste energy continuing to pursue a goal that’s been achieved, or if the “goal post” has moved. Adjust your goals according to feedback you receive, such as correct number of questions. Be flexible to your changing needs and be open to new areas to study.

A word regarding “Enough” and “Should” Language: Be mindful of your use of “enough” and “should” in your talk about your studies. Statements like “I didn’t study enough today” will lead to anxious thoughts later. The word “enough” has no definable meaning. What is enough? Is it 1 more hour, 5 more or 27 more? The word “should” can also be dangerous. Thoughts like “I should study more tomorrow” will generate anxiety later. What is a “should” and how do you define it? A better thought might be “I wish I studied more today. So, tomorrow I am going to set aside another two hours to study this topic.” This statement gives your brain a clearly defined path and plan to manage the problem. With a plan in place your brain will be settled and allow you to concentrate on the task at hand, or allow you to sleep without the racing thoughts on how to fix the problem. Pro Tip: After turning your “should” or “enough” into an actionable plan, write it down. By writing it down your brain will be more trusting of the plan and will leave you at peace so you can sleep.

Other useful Time management techniques are:

• The Pomodoro Method: this method is effective when you struggle with keeping focus or starting your study. The method consists of 25-minute work intervals alternating with 5-minute breaks (you can adjust the interval times to your needs i.e. 20 minutes/5 minutes, 15/2, 50/10). This method can help you gain motivation by rewarding your study with short breaks. It is also a good method for building study momentum. Once you go a few rounds, you may feel more settled into your studies and just continue without taking breaks.
• Saying “No”: One of the best ways to protect and manage your time may be to say “No,” to distractions and time wasters. While we encourage you to stay socially connected and to take time out of your study for self-care, you may also need to decline some events that will take up quite a bit of time. If an invitation to a friend or relative’s birthday will take you away for a weekend, maybe your polite “No, I can’t make it this time, but I’d like to connect after my exam,” is the best way to manage your study-time.
• Scheduling: Making a schedule of your study times is another effective time management tool. Planned study times tend to be more productive and less stressful than trying to “fit time in.” Blocking out times on your calendar will encourage you to keep that time available to study. Scheduling will help prevent overbooking your time and will help you to say “no” when necessary (see above). Having scheduled time to study can also help you to engage in more self- care activities, because you will know when and where you can fit them in.
• Bonus Tip: Schedule study time for when you are most alert and focused. Are you a morning person? If so, consider scheduling early study time to maximize your natural state.
• Multi-tasking/task switching: Resist trying to multi-task or switching between two or more tasks. Trying to study while watching a movie or listening to a podcast isn’t an effective use of your time. Neither is trying to study while working out, doing laundry, scrolling through social media or answering emails. Research (here is a great review of the research provided by Psychology Today: Multitasking: Switching Costs) has consistently shown that when we attempt to do more than one task at a time, we become less proficient at both, and it costs more mental energy than had we focused on one task.
• Turn off notifications: Phone and computer notifications can cause unwanted distractions and anxiety. Turning off notifications will help you maintain concentration when you need it most. You can schedule a specific time to take a break to check and respond to emails, texts and voicemails.

“Working out daily was really key for helping me stay focused. I also ended my study day by 8 pm every night to have at least two hours before bed to relax which helped prevent some burn out. — Create a study schedule/calendar and try your best to stick to it.” Z.C.

A comfortable and dedicated study space will create the best environment for your brain to concentrate and be open to learning. Avoid studying where you eat, entertain yourself or sleep. Our brains associate the space/environment with the task it most often does there. For example: when you sit at your kitchen table your brain associates that space and posture with eating so, you will most likely get hungry seated there. Similarly, if you study in bed, your brain is going to want to sleep, and if you study in front of the TV, your brain will want to be entertained. So, if you study on the entertainment couch or in bed you’re going to have the fight the urge to watch TV or sleep. To take advantage of this we encourage you to designate a place for studying and to keep that area a “Study Zone.” With time, when you enter the zone your brain will default to study mode. In addition to your Study Zone, you will be more comfortable and successful if you have access to some common items. Have tissues, water, and maybe a healthy snack available so you don’t have to get up to get them. Have extra paper, highlighters, sticky notes and other consumable study aids readily available. Good lighting is also helpful. Poor lighting will strain your eyes and tire you more quickly.

We understand that space can be at a premium and finding a dedicated space might be difficult. If this is your case, you can use an area that you commonly use for other activities, but consider rearranging the area for when you study. Try sitting at the opposite end of the table from where you normally eat, or

use the chair that doesn’t face the TV directly. If you must study in bed, try sitting on the opposite end from where you rest your head. Look outside your home as well. Great study spaces can be found at the local library. Alternatives might be a restaurant (like Starbucks or Panera Bread) during the hours between meals when distractions are low.

Bonus Tip: when doing a practice exam try to do it in an environment and posture that will best mimic the way you will take the test. Sit at a table, use good posture, lighting and with few distractions. This process will help you feel more comfortable when you are in the actual testing environment.

“I recommend that everyone set scheduled study periods with built-in time for breaks…. Also take one day off each week … to not study at all – instead use the time to engage in hobbies, interests, and social activities!” – A.C.

Studying in a group can be effective. However, if poorly structured your study group can turn into a stressor or a distraction. Groups that aren’t focused or have a clear goal will quickly breakdown and turn into a socialization or complaint group.

Here are some strategies to ensure that your group study sessions are productive and contribute to successful exam preparation:

• Set Clear Goals and Objectives: Clearly outline the purpose of your study group—is it dissecting complex cases, mastering anatomy, or delving into pharmacology? Establish specific learning objectives for each session to ensure focused and efficient study.
• Establish a Schedule: Time management is vital to the group’s success. Establish a regular meeting time and length of time together. Consistent study sessions will help synchronize your group’s efforts, ensuring that vital topics are covered. Honoring the schedule by being on time and finishing as scheduled will help build commitment among group members.
• Select a Suitable Location: A conducive study environment is essential as it can create an atmosphere of collaboration or distraction. Look for a quiet space with access to Wi-Fi, books, and other reference materials. Avoid choosing someone’s home, coffee shop, or other public places, as distractions may be difficult to escape.
• Limit Group Size: Precision often thrives in smaller settings. Keep your study group intimate to encourage meaningful discussions. A focused, small group fosters an environment where everyone can actively contribute to your collective expertise.
• Assign Roles and Responsibilities: Every good team has designated roles, and assigning responsibilities within your study group can aid in its success. Consider designating a group coordinator, a lead researcher, a timekeeper, a quizmaster, a case presenter, a motivator, and a note-taker. This approach mimics the teamwork essential in the medical field, ensuring everyone plays a crucial and active role in success. Members can take on multiple roles and consider rotating roles so all can display their talents and develop skills.
• Preparation Before Group Study: Preparation is the foundation of success. Come prepared for each session with knowledge, questions, and a willingness to share insights. Preparedness is your prescription for effective study group synergy.
• Focus on Active Learning: Medical education is a participation sport; it’s a hands-on, active endeavor. Engage in problem-solving discussions, teach and challenge each other, and simulate the types of content you will encounter on the test. Active learning helps ensure that the knowledge you gain is absorbed and deeply understood.
• Stay on Topic: You study a vast field, and it’s easy to veer off course. During your sessions, maintain focus on the exam-relevant content. Resist the temptation to delve into tangential discussions. Precision is key—stick to the script.
• Use Technology Wisely: Embrace technology; utilize collaborative tools like Google Docs for shared note-taking or other online resource-sharing platforms. Technological integration enhances the efficiency and effectiveness of your study group. Remember, you are not the first to take this exam; others have built reliable guides and resources. With a bit of searching, you may find study guides, flashcards, and other resources that others have found helpful.
• Encourage Open Communication: Effective communication is the bedrock of any successful team, and the same applies to your study group. Cultivate an environment where questions are welcomed, and uncertainties are clarified and treated with kindness. Open communication ensures that everyone benefits from the collective knowledge pool.
• Include Breaks: Preparing for medical exams demands mental stamina, but even the sharpest minds need breaks. Schedule short intermissions during study sessions. These breaks aren’t just for relaxation; they’re opportunities to recharge, exchange thoughts, and reinforce the camaraderie within your medical study team. Groups can also benefit from scheduling activities outside of the study that will foster team cohesion and trust.
• Regularly Review Progress – Evaluate and Adjust: Just as you would reassess a patient’s condition, periodically review your group’s progress. Reflect on what was covered, identify areas of strength and weakness, and adjust goals as necessary. If a strategy doesn’t yield the expected results, be agile and ready to adapt. Flexibility is a hallmark of successful exam preparation. If the group isn’t working for you, you may need to consider alternate methods.
• Simulate Exam Conditions: Just as you simulate procedures before performing them, consider replicating exam conditions during some group sessions. Set time limits, mimic the stress, and navigate through questions as if in the exam room. This practical approach prepares you for the environment you’ll encounter taking the exam and will help you build comfort for the day of experience.

Treat yourself with the same kindness and understanding you would offer a friend facing a similar challenge. If you find yourself frustrated take a step back, take a deep breath and ask yourself: “If my friend were in this situation, what would I suggest to them?” Chances are the answer to the question will reveal your next step.

If you would like to develop more self-compassion we suggested exploring self-compassion.org a website by Kristin Neff, PhD, devoted to helping you build appropriate compassion for self and others. Kristin shares that “self-compassion means you are kind and understanding when confronted with personal failings – after all, who ever said you were supposed to be perfect?” The site provides guided practices and exercises to practice building self-compassion.

Resilience is the ability to cope with and bounce back from the difficulties of life. It can mean the difference between handling pressure and losing your cool. Resilience is not something that you’re born with—it’s something that you learn and develop over time. Kendra Cherry, MSEd, provides 10 Ways to Build Resilience, in her linked article. A summary is provided here:

1. Find a sense of purpose: Building a support system of loved ones, giving a voice to the underserved, leading a healthy lifestyle, learning, or serving your community can help you find meaning in life’s
2. Believe in your abilities: Having confidence in your ability to cope with the stresses of life plays an important part in resilience. Listen for negative comments in your head. When you hear them, practice immediately replacing them with positive ones, such as, “I can do this,” “I’m a great student/learner/test taker,” or “I’m good at what I do.”
3. Develop a strong social network: Having caring, supportive people around you acts as a protective factor during difficult times. While simply talking about a situation with a friend or loved one won’t make your troubles go away, it allows you to share your feelings, get support, receive positive feedback, and come up with possible
4. Embrace change: Flexibility is essential to resilience. By being adaptable, you’ll be better equipped to respond when faced with a new Resilient people often utilize these events as an opportunity to branch out in new directions.
5. Be optimistic: Resilient people tend to maintain a positive Look for the “silver lining” or the thing that was learn and that you can build on.
6. Nurture yourself: Taking care of yourself is essential to building resilience. Make time for activities that you enjoy, such as reading, watching movies, or spending time with Eat a healthy diet, exercise regularly, and get enough sleep. See Prioritizing Self-Care above.
7. Develop problem-solving skills: Rather than avoiding problems, resilient people typically face them head on. Identify the problem, brainstorming possible solutions, weighing the pros and cons of each, and then act.
8. Establish goals: Setting goals can help you focus on what you want to achieve and give you a sense of Establishing goals can also help you feel more in control.
9. Take action: Resilient people are action-oriented. They take decisive actions rather than dwelling on problems and negative Take action on the things that you can change, and try not to worry about the things that are outside of your control.
10. Commit to building skills over time: Building resilience takes time and With time, your skills will improve.

“Be kind and gentle with yourself during this stressful time. Eat well. Sleep well. Study with trusted peers. Ask for help if your struggling. WE ARE here for you as you navigate these challenging junctures!” – Alison Smolinski, MA, Administrator, MD/PhD Program, Penn State College of Medicine