Know Thy Shelf: Surgery Edition (Part I)

  • /Reviewed by: Amy Rontal, MD
  • There are two things in the world that everyone loves. And I’m not talking about ice cream, nor puppies. They are (A) asking about the surgery shelf exam, and (B) telling people about the surgery shelf exam.

    I’m going to go with column B here, and drop some knowledge regarding perhaps the most feared shelf exam in the NBME’s armament.

    What You Need to Know About Studying for the NBME Surgery Shelf Exam:

    1. First things first: You will have to study a lot.

    This can be a difficult prospect if you are spending a legitimate amount of time in the operating room and following your postoperative patient(s) on the floor. It is imperative to study at just about every given moment at the hospital without impeding patient care or missing opportunities to scrub into surgeries. Remember, you will never learn something as well as when you actually see and experience it. That acute cholecystitis patient that you saw in the ED will burn a much more indelible mark into your brain than words on a page. But, over the course of just a few months, you certainly won’t see it all, and will have to read, read, and read some more. Although expansive, the volume of material is finite, and as long as you keep up from Day 1 of your rotation, you should be good to go. One of the biggest mistakes you can make is to put off studying. Given the time commitment that this rotation requires, it is increasingly difficult to get appreciable study time in at home. Do your best to find the time inside the hospital and get a jump on this early.

    2. Another tenet of the NBME surgery shelf exam that bears repeating is that it has incredibly little to do with what you will see inside the OR.

    Most of your questions will focus on presentation, diagnosis & workup, and treatment/management. There is significant overlap with the conditions you will see on the surgery and internal medicine shelves. Therefore, consulting non-surgical texts is a very valuable strategy. Our favorite happens to be Step Up to Medicine. Pay special attention to the Acid/Base/Electrolyte and GI chapters, as they are the most relevant to surgery questions.

    3. Get your hands on some proper surgical resources.

    The NMS casebook has a nice combination of both shelf-worthy information and/or guidance, making it a nice all-purpose reference. The sine qua non of your rotation will likely be Pestana’s surgery notes. Dr. Pestana has built a very simple and comprehensive framework that delivers an incredible amount of high-yield information with a small volume of text. There are associated audio-recordings of his that can be used as well. Another highly recommended resource is the OnlineMedEd videos and question bank. Many MST team members prefer this resource to the more narrow-in-scope UWorld Step 2 CK Surgery questions.

    4. What topics will be heavily tested on the surgery shelf exam? 

    There is little value in asking friends who have previously taken it. Our memories of the test are often skewed toward the questions that gave us the most difficulty. Look no further than the boring (but incredibly useful) NBME website. It provides an objective system-by-system breakdown of the test, and is certainly worth the 2 minutes it takes to read.

    Like most 3rd year shelf exams, you will only have 2 hours and 30 minutes to complete 100 difficult questions, many with infuriatingly long stems. At 90 seconds per question, you will have no choice but to move fast. One of my personal findings from the exam was that you will be moving so quickly that there isn’t time to do that much deliberation on any one question; rather, you will be forced to use the framework of knowledge in your head, and answer many questions by feel rather than algorithmically. After all, when we internalize diagnoses and algorithms deeply enough, and combine them with our own clinical experience and intuition, the result is just that: feel.

    5. My last piece of general advice is to keep common sense in mind in all situations.

    That is, think back to what you would actually do and what you’ve actually seen. It is so easy to get bogged down by esoteric questions that we forget the basics. No need to figure out if a patient’s condition needs an ERCP or an MRCP when they have a BP of 70/40 and evidence of hemorrhage. This dude needs fluid resuscitation! Read ALL of the answer choices, keeping in mind the order that things proceed. This is especially important in the trauma scenarios, where we return to the ABCs (airway, breathing, circulation). Get in the habit of asking yourself, “How, if at all, will ordering this test affect my management?” If a laboratory or imaging study won’t change what you would do anyway, then skip it. Another classic: If a patient is bleeding post-operatively, what is more likely? A rare coagulation factor deficiency? Or the much more common failure to achieve good hemostasis with sutures, staples, and clips. Use your head, and don’t let your advanced training get the better of you.

    In this next surgery shelf post, we talk about some specific high-yield topics that you will almost be assured to see on the test.