Studying for Third Year NBME Shelf Exams

Chances are, your third year clerkship grades will hinge more on your NBME Shelf exam scores than on your clinical evaluations. The strategy I advocate is to come off of Step 1 strong by immediately shelling out for the USMLE World Step 2 question bank for the entire year. Do the questions for each rotation. Take your shelf exams, nervously wait 1-3 weeks for your scores to come back, and soldier on. Then at the end of third year, reset it so you can start fresh and use it to study for Step 2 CK. If you’ve studied for and done well on your shelf exams, UW and Wikipedia will be sufficient for Step 2 CK.

While UW is, I believe, indispensable for several of the shelf exams, it is not sufficient. Here’s how I would approach each clerkship:

 

Psychiatry

First Aid for the Psychiatry Clerkship is your must read. It’s extremely quick, readable, and hits everything. You can read this book in a day if you want to; it’s that short.

The only book you would need after FA is Case Files Psychiatry. It’s a good volume in the series, and some of the cases do a nice job of distinguishing between adjustment disorder in its many forms (recognizing adjustment disorder versus MDD, GAD, acute stress disorder, and PTSD etc is extremely important for the psychiatry shelf). You don’t need more reading beyond that, just UW. Enjoy the psycation.

More than any other shelf, the psychiatry shelf really stresses adverse effects of its medications. Every important drug has its one or two, and you need to know them cold. All of them.

You also need to pay special attention to medical disorders with psychiatric manifestations (depression and pancreatic cancer, Addison’s disease; pheochromocytoma or carcinoid tumors masquerading as panic disorder; etc).

 

Ob/gyn

Case Files Obstetrics and Gynecology is your first book of the rotation. When in doubt, you can always get through a Case Files book quickly and know that it will hit the highlights (i.e. common board/pimping questions). It’s an excellent foundation for your rotation, and you should read it as fast as possible.

Many people advocate Blueprints Obstetrics and Gynecology, as it is quite readable and nearly exhaustive. I would caution you that unless your rotation has light hours, many many students don’t have enough time or energy to slog through it. Many of my peers who started with Blueprints never finished a single book before taking the exam. They just didn’t have time. Finishing a single book is the most important thing; you need to have one cohesive point of view. Even Case Files alone is better than 3/4 of Blueprints. Don’t get yourself in trouble. Most OBGYN clerkships are exhausting.

If your school pays for the ACOG/APGO question bank, great. Use it. If not, I’d just read Case Files again and do UW. Always focus on things that might seem similar and be able to tell them apart (placenta previa vs vasa previa vs abruption). PreTest is alright if you’re in need of more questions, but I certainly didn’t get through all of it.

 

Pediatrics

Blueprints Pediatrics is the common favorite (and my wife’s personal favorite as well), and though I personally don’t care for the series, it is certainly sufficient. First Aid is overkill. Case Files Pediatrics (my favorite), patient reading, and UW for me was enough, but if you have the time and drive to read a more thorough text, I think BRS Pediatrics is actually the best.

Pediatrics PreTest is one of the better entries in the series, and if you have time for more questions after UW, then it’s a reasonable use of your time.

You probably need two sources. Blueprints or BRS + Case Files is a common combination, if you can stand the cardiology section of BP.

Don’t go overboard on vaccine schedules and developmental milestones. You can sink a lot of time into that for little to no benefit. You should know a couple of big milestones per age group. Know the contraindications for vaccines; don’t learn the actual timelines.

 

Surgery

As always, crank through Case Files Surgery as fast you can so you don’t look like an idiot. Crush Step 2 / Step 2 Secrets (essentially the same book in different formats, one of which you’ll probably want/have anyway) can also help you get a rapid-fire overview of surgery in less than a night (and is also a particularly nice way to quickly learn the very basics of the many surgical subspecialties, which are fair game on the shelf). However, the single best rapid review text is actually the Pestana Surgery Review, written by a now-retired faculty from the University of Texas Health Science Center at San Antonio. This informal packet is actually used by students around the world, is extremely quick, extremely high yield, and an old copy is available for free via Google (or the official version, I suppose).

Then, before slamming into UWorld with all your might, read the NMS Surgery Casebook. This dense book is your essential read for the clerkship: excellent, organized well, good diagrams, and contains everything you need to know. Note, this is not the NMS Surgery textbook. Don’t bother with that thing. The Casebook is the best resource by far. After that, just do questions. Pay special attention to trauma management, which makes up a lot of the test. Many questions hinge on applying the ABCs properly, often comically obviating the need to know definitive management. If you would do two things simultaneously in real life, never forget that one of them technically comes first based on the ABCs.

Many students use Surgical Recall to help prep for pimping and an overall understanding of the day to day business of surgery. Surgery Recall is a good book for reviewing the common questions you are likely to receive/knowledge you need to succeed in-person and on the wards/in the OR. It’s a good book to carry in your white coat and pull out when you have a few minutes of down time. I would not, however, rely on Recall as a primary studying guide when it comes to the shelf. Details about actual surgeries are not on the exam, but the management of surgical patients is. The portions that do apply to the shelf though are full of rapid fire high yield facts.

 

Internal Medicine

The best way to study for IM is to do all of UW medicine. This will take several weeks but will be worth it. The second most important thing you can do is pay attention on the wards.

The favorite medicine text nationwide is Step-Up to Medicine, which is the best (and the third edition just came out). It’s a bit long, and you may find yourself dropping it in favor of getting through the question bank. Case Files Internal Medicine is decent (helpful mostly if your background is poor and because it’s shorter). First Aid isn’t worth your time. For practical knowledge on the wards, huge swaths of students swear by Pocket Medicine (formerly “the green book,” it’s purple now), though I personally think UpToDate is more interesting and more complete when a computer is nearby.

If you finish UW, do more UW. Nothing else comes close to being what you need.

 

Family Medicine

I leave Family Medicine for last because it’s one of the more irritating tests to study for. Take it later in the year, and it will be mostly straightforward. Taking it toward the beginning of your clerkships can make it the hardest test of the year given its broad scope and the handful of seemingly random questions on every test. If you have the choice, doing it toward the end of third year makes the test far more reasonable.

Medical students can become members of the AAFP for free and then use the AAFP question bank. I thought these questions were more resident-level than the real thing and didn’t care for them all that much. You can slog through a ton of UW and that would work, but that’s a daunting task for a shorter rotation. To prepare via UW, you would ideally get through the OB, Peds, IM, and preventative sections. That’s a lot.

In the beginning of the year, Case Files Family Medicine would help give you the basics. Later in the year, it will likely just remind you of things you already know quite well. Some people use Blueprints FM (breadth but not depth) or Step 2 CK review books (try Crush Step 2, if you must). There just isn’t a great resource geared for the clerkship. That said, some students swear by the use of Swanson’s Family Medicine Review, which is written for the FM boards but has a nice case-based question-heavy format that would likely serve you well. If that seems too daunting, reading the pediatrics and ob/gyn sections of Crush Step 2 will at least help you rapidly hit the highlights.

In the end, family medicine is not a discrete field; it’s a combination of everything else: mostly medicine, a good helping of peds and ob/gyn, and even a bit of psych, surgery, and EM thrown in. My advice is to schedule it for later in the year, especially after medicine, which makes it much more manageable. Questions, questions, questions.

Some thoughts on how to approach irritating/difficult clinical science questions can be found toward the bottom of this page. Step 2 resources are detailed here.

Looking for information on the preclinical shelf exams?
Anatomy, physiology, biochemistry, and microbiology are here.
Pathology is here.

22 Comments

  1. Agree/disagree regarding NMS. I used the text as primary and Casefiles as secondary. There was a ton left out in the NMS case files that the text filled in. I would suggest, however, to read the text and skip any disease processes that has less than a couple paragraphs on as it gets too detailed. But using those two together was hugely synergistic.

  2. Between Pestana, the relevant sections of Crush Step 2, Case Files, the NMS casebook, and UW (in that order), I don’t think I had time for any additional resources during my surgery clerkship. While there may be omissions in the casebook vs the textbook, I had no meaningful gaps in my knowledge for the test with that line-up.

  3. Hello,
    What do you suggest using for the Neurology clerkship? (assuming you had one)
    Great advice otherwise, thank you!

  4. For our neurology clerkship, we actually took an exam written by faculty from our school instead of the shelf. That said, I would make sure to focus foremost on UW.

    For books, PreTest is a good entry in the series. I would focus on the subjects you feel least comfortable about (e.g. movement disorders), since it’s often difficult to churn through a whole PreTest book. Case Files Neurology is also not bad, but not the best in the series. So Case Files + PreTest is a common combination. The neuro section of Step up to Medicine will also serve you well if you have that volume already. Localizing the lesion is oddly more of a focus on the preclinical neuroscience exams, but for help with that I’ve been a fan of Clinical Neuroanatomy Made Ridiculously Simple.

  5. thanks for your great advice. If I wanted to purchase some of the study guides you have recommended, Where could I find them? Did not have luck at Barnes and Noble. Would really appreciate your advice.

    Thanks,
    Ann

  6. No brick and mortar store that I know of has a meaningful selection of medical resources (even the school bookstore is typically overpriced and understocked). The above links are all to Amazon.com, which I use to buy all of my texts. The B&N online store has most as well. A good number of non-Kindle digital versions can be found on iBooks and B&N.

  7. 1) This question is regarding surgery rotation prep. When you did Uworld, did you do only Uworld surgery questions? Or did you do select Medicine topics as well?

    2) I’ve been getting mixed reviews of Pretest and Casefiles. Why did you choose to go with Case files(an additional text to pestana and NMS) and not with pretest?

    3) I noticed that you recommended step 2 secrets/crush step 2 Surgery reading for the surgery rotation only. You didn’t mention to review either of these books for the other rotations. Is there a specific reason why you’d recommend we do it for surgery?

    Thanks!

  8. 1) Just surgery questions. Most of the “medicine” on surgery is not actually medicine, and it is not really necessary to do the medicine questions in preparation.

    2) I read Pestana first, followed by Case Files, followed by NMS. While NMS is excellent, it takes a while to get through. Pestana is great but is less of a book, and I felt Case Files is a good starting book to get the highest yield basics down. NMS then reinforces and supplements. I’m not generally a fan of the PreTest series, and I rarely used them myself as a third year. I found that in order to hit 500 questions per volume there was generally a bit of fluff, a decent number of questions that are not reflective of the exam, and it was a sort’ve numbing experience that sapped my energy. That said, other people like them.

    3) I mention Crush 2 specifically for surgery because the other resources don’t really cover surgical subspecialty knowledge very well, which is also fair game on the shelf. Crush’s brief chapters are a nice introduction to the most very basic of ENT, urology, neurosurgery, orthopedics, vascular, ophthalmology, etc. You could read the relevant portions of Crush in 1-2 days easily. ENT, for example, takes up a whopping 6 pages.

    In hindsight, I would have actually probably read the relevant portions of Crush before each rotation, just to familiarize myself with the absolute essentials (which is all it contains, really). There is no book faster than Crush for giving yourself a very superficial knowledge of a topic during third year.

  9. Hi Ben, Thanks for writing all of these suggestions out!
    Our medical school doesn’t have shelf exams and I am preparing for Step 2CK in the next 3 months. I saw that you mentioned a few review books for Step 2CK (e.g. Master Boards, First Aid, Step up to Medicine). Would it be beneficial to read all of the case-files series for this exam + Usmleworld questions? Or do all the question from the list you made above + Usmleworld? I took a NBME and am somewhat below the passing mark. I passed Step 1 with a 210. Thank you for everything!

  10. I think in terms it books it would depend on your foundation in the various core fields how necessary a complete walk-through would be. In this situation, I would say that for Step 2 CK I wouldn’t necessarily pursue an additional question source outside of UW (At least for me, I didn’t think PreTest taught me as well as other sources). My gut is that it might not be time inefficient to do all Case Files either (but likely helpful if there are fields for which you have less of a foundation). I would leave 4 weeks for UW at the minimum. Since this will be your first go through, you may need 6 weeks to give yourself time to do all questions once and then go through the incorrects/marked questions a second time (my personal favorite strategy).

    I think book-wise, I would probably read Crush Step 2 in a few days to jog your memory. Then follow it up with MTB or First Aid as is your preference (MTB probably); when you hit topics you feel less comfortable with, you might supplement with further reading then. That would give you 6 weeks of books, not bad in the context of no shelf exams, and then 6 weeks of questions.

  11. Hey Ben
    1) for all your rotations, in particular your surgery rotation, did you do Uworld once or multiple times? Right now I am thinking I should do Uworld at least once during 3rd year and a second time a month or two before my ck. So minimally 2 rounds of world before my step 2 ck.

    2) I did poorly on Step 1, although I passed on my first attempt. I really need to do well on Step 2 ck to make up for my poor performance. I know nothing is for certain but based on feedback from other students, as well as your own experience, do you think that following your study plan for each rotation/shelf exam can help me get a 240+ on step 2 ck?

    Thanks a lot

  12. 1) I typically did the questions for each section once, marking questions I got wrong or guessed on, and then did only those questions a second time. At the end of the year, when it came time to sit down and study for Step 2 CK, I reset the q-bank and started fresh with the same approach.

    2) Focusing on high yield resources and tailoring your time to maximize the benefit from questions/UW is a sensible approach that I’ve frequently advocated for myself, colleagues, and my former students. I’ve certainly seen jumps of 20-30 points from Step 1 to Step 2 CK. Absolute numbers are difficult to say. The magnitude of the change itself would depend a large part on how much one underperforms on Step 1 due to inefficient studying, fixable poor test-taking approaches, and test-day anxiety/personal distractors/etc. I do believe that this sort of preparation is sufficient to maximize one’s individual performance, and I do doubt that adding many more resources, etc would meaningfully change most peoples’ scores. There is definitely a point of diminishing returns.

    3) Significant portions (3+ years ago), but not cover to cover.

  13. Hey Ben I would like to begin using my Crush Step 2 book for rotations. I’m trying to figure out how to best divide the different chapters of Crush among my core rotations. Is the goal to finish the entire book during rotations or only complete pertinent sections?The chapters in this book are 1)Cardio Medicine 2)Dermatology 3)Ear, Nose, and Throat 4)Emergency Medicine 5)Endocrinology 6)Ethics and Patient Encounters 7)Gastroenterology 8)General Surgery 9)Genetics 10)Geriatrics 11)Gynecology 12)Hematology 13)Immunology 14)Infectious Disease 15)Internal Medicine 16)Laboratory Medicine 17)Nephrology 18)Neurology 19)Neurosurgery 20)Obstetrics 21)Oncology 22)Ophthalmology 23)Orthopedic Surgery 24)Pediatrics 25)Pharmacology 26)Preventative Medicine, Epidemiology, and Biostatistics 27)Psychiatry 28)Pulmonology 29)Radiology 30)Rheumatology 31)Urology 32)Vascular Surgery

    I’ve categorized the obvious ones but I am unsure about the rest of the chapters(marked by a ?) Would you be able to please help me out? Thanks.

    Surgery rotation: General surgery, Neurosurgery, Orthopedic Surgery, Vascular surgery, Ear nose throat?, Opthalmology?,

    OBGYN rotation: Gynecology, Obstetrics,

    Psychiatry rotation: Psychiatry, Ethics and patient encounters?,

    Family Medicine rotation: Genetics?, Geriatrics?, Pharmacology?, Preventative Medicine, Epidemiology, biostatistics?,

    Internal Medicine rotation: Internal medicine, Infectious diseases?, Cardio medicine?, Dermatology?, Emergency medicine?, Endocrinology?, Gastroenterology?, Hematology?, Immunology?, Nephrology?, Neurology?, Oncology?, Pulmonology?, Radiology?, Rheumatology?, Urology?, Laboratory medicine?

    Pediatrics rotation: Pediatrics,

  14. ENT, Urology, and ophthalmology fit best in surgery, although there are components that fit into medicine as well.

    Ethics is broad. While it’s most at home psychiatry, it can also just be squeezed into the beginning of the year. Radiology is also general.

    Preventative medicine fits in FM. Genetics, geriatrics, pharm, etc would go either with FM or IM, whichever you do first. These chapters are short, so it’s not too difficult to move them around (i.e. doing ob/gyn during FM is advisable, particularly if you do FM first). If you do FM before IM, the IM chapters in general all apply to FM.

  15. I’ve addressed that question previously in the comments (which are getting somewhat long). You can either scroll up the comments or search for “neurology” to get at the relevant text.

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