I started my third year with my surgery rotation. While I knew it was going to be time consuming, I was excited to interact with patients, work in the hospital, and never have to think about glycolysis again (which isn’t entirely true, but that’s a topic for another time). I knew I had a shelf exam at the end of the rotation, but at that point it was so far away and I was more concerned with succeeding on the wards. I would cross that bridge when I came to it.
While I enjoyed my surgery rotation, the time commitment was as intensive as I had expected – and then some. It got to the point when I came home for the day, I was barely able to greet my roommates, cook myself dinner and change out of my scrubs (which was probably the hardest part, because scrubs are basically doctor pajamas.) The thought of doing any studying was laughable. It didn’t help that I would tell myself I actually WAS studying because of what I saw every day. When the exam was one week away, I finally started to actually study... and quickly came to a tough realization of how woefully underprepared I was.
There were many topics I had never seen before, and even the ones I had seen were never in the context of a multiple choice question. The next week was sleepless and long, but I managed to scrape by. However, I did promise myself I would not be caught in this same predicament for the 6 remaining shelf exams I had. This led me to create a “manifesto” of studying for shelf exams that I hope you find as helpful as I did.
First, some basics:
What is a shelf exam?
The shelf exam is an officially licensed exam by the National Board of Medical Examiners (NBME) that pertains to a particular subject (such as internal medicine, surgery, OB/GYN, neurology, psychology, and pediatrics). Shelf exams are composed of retired USMLE questions that have been “shelved” and are no longer seen on USMLE Step 1 and Step 2 exams. That said, some questions you see on Step 1 & 2 will be INCREDIBLY similar to those you’ve seen on shelves. So pay attention!
Shelf exams are usually given at the end of your rotation, and are available for basic science subjects like Physiology and Pharmacology, as well as clinical science subjects (i.e., rotation-based) like Medicine, Surgery, and Pediatrics.
Here's a complete list of NBME shelf exam subjects:
- Behavioral Sciences
- Gross Anatomy (only Gross Anatomy & Embyology)
- Microbiology (only Microbiology & Immunology)
Health Systems Science Examination
- Health Systems Science
- Comprehensive Basic Science*
- Comprehensive Clinical Science*
- Ambulatory Care
- Clinical Neurology*
- Family Medicine Modular
- Care & Chronic Care
- Care & Chronic Care + Musculoskeletal Medicine*
- Obstetrics & Gynecology*
Advanced Clinical Examinations
- Emergency Medicine*
- Internal Medicine
- Introduction to Clinical Diagnosis
*Available for Administration at Prometric Test Centers
We've included all of above-listed shelf exam topics/NBME Subject Examinations in an infographic below; feel free to download and save it for future reference!
Does my NBME shelf exam score matter?
There is a good chance that your med school will use your shelf exam score in calculating your final grade. Depending on how your school computes your grade, the shelf exam can range anywhere from a big deal to a huge deal! Your grade might be composed of 80% “clinical performance” and 20% shelf score. Or it might be closer to 60% clinical, 40% shelf.
On top of that, the scores you obtain become part of your USMLE record, and while they aren’t the highest on the list of what program directors care about at match time, you might have some explaining to do on your pediatrics interview if you failed your peds shelf. Grades obtained in the clerkship as a whole are relatively important.
Some schools might also necessitate a certain score on the shelf in order to achieve a certain grade in the clerkship. That is, you might need an 80 or better for Honors, or you might need a passing grade to pass the clerkship.
The beautiful thing about the shelf exam is that it provides you (and your institution) with a real perspective on how you match up at the national level. This can help you see what subjects you need improvement in, as well as telling your school what parts of their curriculum might need more attention.
What score do I need to pass my shelf exam?
A shelf exam "passing" score is decided by the medical school. It's kind of like taking the SATs. There's no passing score, but if your math teacher wanted to compute your SAT Math score into your final grade, they could decide if you "passed" it based on whatever arbitrary score they picked.
How do I prepare for the shelf exam?
The usual dogma applies here: let your clinical encounters be the foundation of your knowledge. But, over the course of the clerkship, you likely won’t encounter all the zebras that you are going to be tested on.
Therefore, it is essential that you read frequently, and study outside of your clinical encounters.
As a med student, you won’t be carrying a census of 13+ patients to learn from; it will likely only be 2 or 3, tops. It is only through supplemental materials (like case files, and the old-school textbook) that you will get to an acceptable level of knowledge for shelf success.
We know this isn’t easy. After a 12+ hour shift of being in over your head, there often isn’t a lot of extra fortitude left for hitting the books. Be creative, find a way, and learn as much as you can.
Doing UWorld (or another Qbank like Kaplan) questions also makes for a great supplement to your rotations.
Determine high-yield topics AND make a schedule that covers all of them with at least a couple days before the shelf exam. I thought the Online MedEd video series was very good for providing an outline of the high-yield topics. Your study time is much more valuable for the Shelf exams, as it is harder to come by, which makes your schedule all that more important.
What material will be included on the shelf exams?
Obviously, this will vary based on the subject. You will certainly see the bread and butter diagnosis and management of common pathologies. Some conditions you can certainly expect to see:
1. Medicine: Heart failure, COPD, liver disease, acute kidney injury, diabetes.
2. Surgery: Very “medicine-based.” That is, very little surgical anatomy, much more diagnosis and post-op management. Cholecystitis, appendicitis, post-op fever, any intra-abdominal organ disease, trauma evaluation.
3. OB/GYN: Pre-eclampsia, prenatal management, vaginitis, abnormal uterine bleeding, STIs, physiologic changes of pregnancy.
4. Pediatrics: Dehydration, meningitis, limp, normal development, asthma.
5. Psychiatry: Depression, personality disorders, substance abuse, schizophrenia.
6. Neurology: Movement disorders, multiple sclerosis, nerve injuries, localizing the lesion!
There will also be less common pathologies that are germane to a particular specialty, but that you would be unlikely to encounter in a 4 week rotation. Your knowledge of Creutzfeldt-Jakob disease and meningomyeloceles will probably come from reading and not your day-to-day.
What’s test day like?
Taking the shelf exam is like most exams. It will probably occur on a weekday in your school’s computer lab. There are far fewer hoops to jump through than for your USMLE Step exams. Show up well-rested, calm and collected, and do what you were born to do: answer multiple choice questions over and over…
And now on to shelf exam study tactics!
How to study for NBME shelf exams:
1. Don’t drive yourself crazy with a strict daily study schedule.
There are some days you will joyfully skip out of the hospital at 4:45 PM and others you will be scarfing down cafeteria chicken nuggets at 7:00 PM because you are already late for your next case. If you go home on those late days with the feeling that you also need to read 4 chapters of Pestana’s that night, it will cause you undue stress and make you to try to study when you aren’t retaining anything. I recommend creating weekly “tasks” so that those days when you do get home at 4:45 PM, you can do a little extra that night and when you end up leaving at 9:00 PM, you don’t feel obligated to stay up until 1:00 AM.
2. You will NOT be fully prepared for the shelf exams by only learning from the patients and cases you see during your days on the wards.
These are certainly important and I do believe that seeing a disease first hand is the best way to learn it, but there is no way you are going to see everything you need to know for Urology AND Ophthalmology AND Surgical Oncology in 8 weeks or less. You need to sit down and read about these topics in order to succeed.
3. Like Step 1, don’t overwhelm yourself with the number of exam resources you use for each rotation.
There are so many books, flashcard sets (such as Memorang's IM shelf deck), and videos for every single shelf. No matter which rotation it is, it is better to pick a few quality resources and truly go through them than skim a whole bunch of them.
4. Don’t marry yourself to one “series” of resource for each rotation (such as Blueprints, First Aid, etc.).
“Case-Files for OB/GYN” was by far my most valuable resource for that rotation. “Case Files for Internal Medicine” was insufficient for the shelf exam. Ask your peers or residents if they have any resources that really helped them prepare for the shelf exam you have coming up. You’ll find as you go along that you will prefer a different resource for each rotation.
5. It is okay to give up on a resource.
If it is simply not working for you, you don’t know have to keep using it, even if your bestie loved it. While this holds true for Step 1 as well, it becomes a little more urgent for shelf exams because there is less study time to waste on an ineffective resource.
6. Take the shelf exam seriously.
The shelf exam can be a huge deal, but it doesn’t have to be full of drama and fear. How to turn it from foe to ally? Be prepared. The most important thing you can do to be ready for the shelf is to START READING FROM DAY 1 OF YOUR CLERKSHIP. Build the habit from the get go. Even if it’s just a single condition or a few case files. It is so hard to play catch up when encumbered by your rotation. Read, read, read ...early and often, and the shelf exam will be a satisfying way to demonstrate your dedication and mastery of a subject.
7. You mentioned high-yield shelf exam study. How do I know where to start?
We're glad you asked! Dr. Brian Radvansky has an ongoing series of high-yield shelf exam study guides, many of which are linked here:
Study hard for the shelves but keep in mind that if you survived Step 1 you can survive anything. And lastly, enjoy third year if for no other reason than you sometimes get away with wearing doctor pajamas to work!