Third year rotations are inherently subjective. What even goes into the clinical component of your evaluation on the wards for a given rotation? In theory, some combination of your fund of knowledge, interviewing prowess, physical exam technique, presentation fluidity, and overall enthusiasm. The devil is in the details, however, because you will encounter tremendous variability among your attendings and residents with regard to how they attempt to measure these variables, which they emphasize more than others, or if they even bother to measure certain variables at all. Some will reward you for knowing even the tiniest tidbit about their field, while others will penalize you for not knowing an obscure factoid typically not learned until residency.
All this arbitrariness can feel unfair and frustrating to medical students, which is what makes shelf exams so important.
As a standardized multiple choice test examining everyone on the same material, the shelf exam is the only truly objective tool for evaluating students on their clinical clerkships. The shelf exam is also more predictable than your human evaluators on the wards, which makes studying for it more efficient and dependable. Lastly, while hands-on experience with real patients is of course indispensable, any post-3rd year medical student will readily admit that, in the course of only a 1-2 month rotation, one encounters only a fraction of the material covered by that rotation’s corresponding shelf exam. The implications of this are two-fold: (1) one cannot rely just on “hands-on” wards experiences to prepare for the shelf exam, and (2) studying systematically and strategically (see below) for the shelf exams can help you not only with the shelves themselves but also with your performance on the wards.
Tips for Success
What Resources to Use
With your study time limited both by rotation length and competing priorities (e.g., daytime wards responsibilities), it is important not to spread yourself too thin. Choose 2-3 resources that have worked well for you in the past, or have worked well for trusted friends or colleagues that have already finished the rotation(s) in question, and focus on those. Here are some general guidelines from my experience, although I will list rotation-specific details below: realistic practice questions with thorough answer explanations should be the core of your study material. The USMLE World Step 2 CK question bank is usually your best option for this, although for some specialties (e.g., surgery, OBGYN), UWorld does not provide very many questions, so it is prudent to use a second resource for additional practice questions (e.g., Pretest, MKSAP, UWise, Pestana). To supplement practice questions, I found it helpful to have a print resource of some kind for each rotation—ideally one that organized knowledge into mock clinical cases (e.g., Case Files or NMS Casebook). Despite my warning not to spread yourself too thin, in some cases you may find it helpful to have more than one book (for example) to supplement your practice questions. In these cases, it’s OK if you don’t necessarily finish each book cover to cover; for instance, for psychiatry, I ended up doing all the UWorld psych questions, finishing First Aid Psychiatry, and making it about 50% of the way through Case Files Psychiatry. Since there is substantial overlap between resources, this was not a problem. Although this list of resources may sound financially daunting, remember that your institution may lend you some of them, and others you can share with classmates on a rotation-by-rotation basis.
Case Files or Blueprints
First Aid Psychiatry
Pestana's Surgery Notes (this is a surprisingly high-yield book for the shelf, with both content and practice questions!)
Case Files or NMS Casebook
UWise (question bank authored by the Association of Professors of Gynecology & Obstetrics [APGO])
Short online APGO videos
How to Pace Yourself
Make a schedule! This may seem obvious, but it is not uncommon for students to get caught up in their wards responsibilities, lose track of the time, and find themselves a week before the shelf having studied only a fraction of the material that they originally intended. Tally up how many days you have before the shelf exam, and how many practice questions and/or book chapters you intend to get through during that time. In your calculation, be sure to omit days that you will not have time to study: maybe you are on call until late at night, traveling to a friend’s wedding, or simply need some time off (as we all do!). Ideally, also budget enough time to repeat practice questions that you got wrong the first time around; one approach would be to multiply the number of practice questions on your to-do list by 1.3-1.5 before determining your daily schedule. Finally, calculate how many questions and chapters per day you need to tackle. This may vary somewhat based on the rotation in question, and may also vary from week to week within the same rotation (for instance, you may reasonably schedule more intense studying during an outpatient month than during your inpatient months on a medicine rotation). On average, though, you will be busy on the wards, and should not expect your daily study schedule to be nearly as rigorous as that of a 6-week devoted Step 1 study period. It may come out to something like 20 practice questions and 1 book chapter per day. Lastly, if/when you have taken an NBME practice test or a timed chunk of UWorld questions and determined that you are not having problems with finishing the tests on time, I would recommend doing your UWorld practice questions on Tutor mode (untimed), thus allowing you to focus on the content and take your time reading each answer explanation thoroughly.
In Summary, shelf exams should be seen not as a threat but as a unique opportunity to shine on your rotations under an objective lens of evaluation. Focus on a few key resources for each rotation, incorporating both practice questions and written material, and make a study schedule for yourself at the beginning of each rotation such that you can pace yourself effectively. Don’t forget to have fun with it, and good luck!
Ben Freedman is an internal medicine resident at Beth Israel Deaconess Medical Center this July. He tutors for the USMLE Step 1, Step 2 CK, and shelf exams with USMLE Pro Tutors.