Congratulations! You’ve completed Step 1 and you’re ready to get started on wards. But now you have a new challenge to face: the shelf exams you need to complete at the end of each clinical rotation.
These tests are written by the National Board of Medical Examiners (NBME), the creators of the Step exams. Since many schools integrate the score you receive on a shelf exam into your final score for a rotation, they can make the difference between an “honors” score or a “high pass.” In fact, some programs require you to achieve a minimum score on a shelf exam to even be eligible for honors.
So shelf exams matter, and doing well on them is important for your success.
Unfortunately, given how big a milestone Step 1 is, many students focus on it to the exclusion of everything else, and have either not heard of shelf exams or they’ve given them little thought prior to the start of their first rotation. If you’re in this camp, don’t worry—that’s why we’re here!
This blog is a simple guide to answer frequently-asked questions about the shelf exams, such as “How long is a shelf exam?” and “How many questions are on a shelf exam?” We’ll also show you how to develop an effective and systematic approach to NBME shelf questions.
Let’s begin!
Which rotations have a shelf exam?
There are seven core clinical rotations you’ll complete throughout your third year of medical school, including internal medicine, family medicine, general surgery, neurology, pediatrics, OB/GYN, and psychiatry.
These rotations are standardized across the United States and are required to be completed by every medical student. Elective rotations, as they’re not standardized or required, don’t have NBME shelf exams, but they may have other (school specific) tests/assignments.
How long is a shelf exam?
Each shelf exam is 165 minutes long.
How many questions are on a shelf exam?
Each shelf exam has 110 multiple-choice questions.
These are much shorter than the Step exams you’ll take—for comparison, Step 2 is eight blocks of (at most) 40 questions, and there are a total of 318 questions on the exam.
How do I study for shelf exams while also working in the hospital?
Balancing shelf exams with clinical rotations is the most difficult problem third-year students face. You’re expected to be an effective member of a medical team for many hours a week, on top of studying for the shelf exam, as well as Step 2. Then, towards the end of the year, you’ll need to start working on residency applications!
Luckily, you can rest assured that during your rotations, you’ll be learning material that’s relevant for shelf exams and Step 2. But how can this be done when you’re at the hospital?
Well, I recommend making it a goal to learn something new from every patient you see. For example, take note of the lab values of one patient with cholecystitis vs. a patient you see with choledocholithiasis, and try to connect those values with biliary anatomy and where the likely pathology is.
You’ll also need to dedicate time outside of the hospital to preparing as well. You’ve learned the bulk of medical material during the first two years of medical school preparing for Step 1, now is when you start to learn management, next steps, and what medications to give.
A regimen of practice questions with a critical review of the explanations will be an extremely valuable resource that’ll help you get used to shelf exam/Step 2 style questions. Additionally, reviewing flashcards during your few moments of downtime in the hospital is a great way to keep learning and prepare for your tests.
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What’s the best way to approach shelf exam questions?
Something that’ll benefit your entire career is developing a systematic method of reading X-rays, EKGs, and evaluating patients you do every single time so you don’t miss anything.
The same is true for how to approach NBME questions. I’ll summarize my recommended method below, but in the end, you have to decide what you’re most comfortable with.
Here’s the step-by-step approach that I take:
1. Read the questions first.
This will help focus your thoughts. Should you be thinking of the best next step in diagnosis? A treatment? Statistics? These questions will be answered by reading the questions first.
2. Glance at the answers.
This will tell you the genre of the question. Whether the question will be about cardiology, pulmonology, ID, etc., can be seen by looking at the answers.
3. Look at the bottom third of the stem.
Most shelf exam questions have a similar structure, where the pertinent physical exam findings, pathology, and more can be found in the bottom third of the question. It’s convenient when you see that a patient was started on a certain medication, and you already know the question is “What is the mechanism of action of this medication?”
4. Review labs/images.
Now is when it’s a good idea to check any labs or imaging that may be available. At this point, you may have a good idea what the diagnosis is—and possibly the answer.
5. Read from top to bottom.
After you’ve done your initial review of the question, if you don’t know the answer or more information is needed, reading the question from top to bottom will give you the few extra details you need to be fully confident in your answer.
This approach helps guide your thinking to the answer, instead of starting from the beginning without knowing what kind of question you’re dealing with. It’ll help you actively engage with the text and use details as you go to help solidify an answer you already formulated.
I call this the “pre-charting” method, because it’s similar to a physician checking a patient’s chart and gathering information about their medical history, labs, and imaging so they possibly have a good idea of the diagnosis prior to meeting them.
Whichever method you choose, make sure you use it consistently and for every question, so you don’t get lost in difficult questions and miss an important detail that would’ve helped you get to the correct answer.
Final Thoughts
We hope now that you have answers to FAQs such as “How long is a shelf exam?” and “How many questions are on a shelf exam?” your mind is at ease and you’re feeling a bit more confident. Keep the answers to these FAQs in mind during third year, and you’ll not only learn everything you can from your patients, you’ll be a step ahead when it comes to studying for the shelf exams.
Best of luck on your rotations!
