How to get a 90th percentile score on your Internal Medicine shelf

*The Internal Medicine (IM) Shelf exam is one of the most challenging shelf exams you will take in medical school, primarily because it tests such a broad range of knowledge and clinical reasoning skills. Scoring in the 90th percentile or higher requires a combination of strategic studying, understanding high-yield topics, utilization of the best resources, and intense preparation. This guide will walk you through how to maximize your score and set yourself up for success.

General Study Strategies and Advice

1. Start Early and Be Consistent

Unlike other shelf exams, the IM Shelf covers a vast amount of material – it has the most UWorld or AMBOSS questions out of all of the core clerkships. Additionally, many other clerkships require a fundamental understanding of IM to pass the shelf exam (i.e. many people often say that surgery is a very IM heavy shelf exam). Depending on your clerkship schedule, we highly recommend that you start studying even before day one of your rotation by setting aside dedicated study time each day. When you are on your clerkship, ideally, a minimum of 1-2 hours per day will help you stay on top of the material without last-minute cramming. We recognize how busy your clinical responsibilities can be!

2. Use Active Learning Techniques

Passive review (e.g., reading a textbook) is not as effective as active learning. The classic “see one, do one, teach one” mentality in medicine applies to studying too – it is not just enough to read a textbook (see one). Instead, use multiple resources including

• Practice questions: The best way to reinforce knowledge and improve test-taking skills.
• Flashcards: Use Anki decks focused on IM Shelf topics to reinforce key concepts.
• Teaching others: Explain topics to a friend or colleague to solidify your understanding.

3. Prioritize Clinical Reasoning Over Memorization

The IM Shelf exam emphasizes clinical reasoning rather than rote memorization. Truthfully, most Shelf exams and Step 2 CK relies on clinical reasoning, much more than what is required for Step 1. Understanding the “why” behind diagnostic and treatment decisions is critical. Focus on:

• The natural progression of diseases and their mechanisms
• First-line vs. second-line treatments and their associated side effects/contraindications
• Common pitfalls in clinical decision-making

4. Simulate Exam Conditions

To build endurance and improve timing, take full-length practice exams under timed conditions in the days leading up to your exam. This will help you gauge your readiness and identify weak areas to focus on.

High-Yield IM Shelf Exam Topics

Certain topics appear frequently on the IM Shelf. Here are some of the most high-yield areas to focus on (it is impossible to give an exhaustive list given the breadth of IM!):

1. Cardiology

• Acute Coronary Syndrome (ACS) management
• Heart failure (Preserved vs. Reduced Ejection Fraction) management
• EKGs! Know how to look for common arrhythmias including atrial fibrillation, atrial flutter,  supraventricular tachycardia, heart block, ventricular tachycardia, and ventricular fibrillation
• Valvular heart disease – know how to diagnose this simply based on your physical exam (aortic stenosis is very high yield)
• Hypertension management (both inpatient and outpatient) and complications (both acute and chronic)

2. Pulmonology

• COPD and asthma management (acute flares and maintenance therapy)
• Pneumonia (CAP vs. HAP, treatment guidelines)
  • Know options for antibiotics and indications for hospitalization
• Chest X-Rays! A critical skill for any internist, you should be able to read your own (follow the mnemonic ABCDE)
• Pulmonary embolism (diagnosis, risk stratification, and treatment)
• Pleural Effusion (Light’s Criteria)

3. Gastroenterology

• GI bleeding
  • How to determine upper vs. lower GI bleed
  • Initial diagnostic workup and management
  • How to manage the unstable patient with GI bleeding
• Liver disease: cirrhosis complications (Spontaneous bacterial peritonitis, hepatorenal syndrome)
• Inflammatory Bowel Disease (IBD)
  • Understand the differences between Crohn and Ulcerative Colitis
• Pancreatitis – diagnostic criteria and management (fluids, pain control, and complications)

4. Nephrology

• Acute kidney injury (prerenal, intrinsic, postrenal)
  • Understand how to interpret the BUN/Cr ratio as well as the FeNa and FeUrea
• Chronic kidney disease – know the stages (eGFR cut offs) as well as management (i.e. hemodialysis or peritoneal dialysis)
• Electrolyte disturbances:
  • Hyponatremia – understand how to interpret serum and urine studies
  • Hyperkalemia – when and how to treat
  • Metabolic acidosis/alkalosis – understanding arterial blood gas is a critical skill for any internist

5. Endocrinology

• Diabetes management and complications
  • It is critical to know the different types of insulin that we use in the hospital and as an outpatient
  • GLP-1s
• Thyroid disorders (hyperthyroidism, hypothyroidism)
• Adrenal insufficiency and Cushing’s syndrome

6. Infectious Diseases

• CAP vs. HAP (as above)
• Viral Respiratory Infections
  • When and who to treat with influenza and COVID-19
• Sepsis management
  • Diagnostics: two sets of blood cultures, urinalysis, chest X-ray, sputum culture (searching for a source)
  • Treatment: fluids, antibiotics
• HIV/AIDS
  • You do not need to be an expert at antiretroviral therapy
  • Rather, knowing the opportunistic infections is high yield
• Bacterial meningitis: empiric treatment
• Endocarditis: diagnostic criteria (Duke criteria) and management (which antibiotics and duration)
• Osteomyelitis
• C. difficile Infections
• Tuberculosis
  • How to differentiate Latent and Active TB
  • Treatment for both conditions

7. Hematology/Oncology

• Anemia (Very high yield!)
  • Develop a framework for your patients with anemia (both inpatient and outpatient)
  • Common causes include, iron deficiency, B12/folate deficiency, hemolytic, bleeding, chronic disease, etc.
• Leukemia and lymphoma basics (and liquid tumor emergencies)
• Complications of solid tumors (bowel obstruction, pleural effusions, etc.)
• Tumor Lysis Syndrome
• Febrile Neutropenia
• Anticoagulation management and Coagulopathies

The Best Resources for the IM Shelf Exam

1. UWorld/AMBOSS QBank (Essential)

• This should be your #1 resource. Aim to complete all IM questions, ideally, two weeks prior to your shelf examination to provide you ample time to complete practice tests and work on your weaknesses.
• We recommend working through the question bank prior to the start of your rotation given the large number of questions
• Mark difficult questions and revisit them before the exam.

2. NBME Practice Exams

• Take at least two NBME self-assessments to gauge your readiness (ideally you would take all of the available tests).
• These exams mimic the real test’s style and highlight knowledge gaps.
• Complete these in the two weeks prior to your shelf exam.

3. Step Up to Medicine

• A great reference for in-depth learning, particularly for weak areas.
• Use this as a supplement rather than a primary study tool (however, it is an easy read and you could read it cover to cover, but we do not recommend this).

4. OnlineMedEd (OME)

• OME videos provide excellent high-yield summaries for core IM topics.
• Best used in the first half of, or even before, your rotation to build foundational knowledge.
• There are many videos and this will take time to get through all of them

5. Anki Decks

• If you like spaced repetition, there are premade Anki decks which can help reinforce high-yield facts.
• Be consistent with reviews to maximize retention.

6. Cheat Sheets (Highly Recommended)

• Concise, high-yield notes that prioritize how to succeed on your IM rotation.
• Access them here: Cheat Sheets

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7. Divine Intervention Podcast (Selective Use)

• For our students who are audiophiles!
• Excellent high-yield podcast episodes on specific topics.
• Best for reinforcing weak areas or reviewing on the go (do NOT listen to all of them, this is not an efficient way to learn)

Final Study Plan (6-Week Strategy for Success)

Week 1-2: Build a Strong Foundation

• Begin working on UWorld/AMBOSS questions (ideally, even before your clerkship starts).
• Watch OME videos or read relevant sections from Step Up to Medicine on weaker topics.
• Begin using Anki daily (if you like this resource).
• Commit yourself to patient care (be present and help the team! You are here to treat patients!)

Week 3-4: Solidify Knowledge & Identify Weak Areas

• Complete remaining QBank questions.
• Take your first NBME practice exam near the end of Week 4 and review your mistakes.
• Focus on reviewing weak topics using Step Up to Medicine or OME
• Continue Anki and targeted review.

Week 5-6: Final Review & Exam Readiness

• Take multiple NBME practice exams.
• Re-review missed UWorld/AMBOSS questions and high-yield topics.

Final Takeaways

• Prioritize your Question Banks: This is the best predictor of success and serves as the most comprehensive resource in your arsenal
• Master high-yield topics: Focus on the topics we listed above (these are both clinically useful and high yield for the shelf)
• Use practice exams: NBME assessments help gauge readiness.
• Leverage your resources wisely: OnlineMedEd, Step Up To Medicine, and Anki are great supplementary tools.

In conclusion, by following these strategies consistently, you’ll strengthen your clinical reasoning over time. Therefore, you’ll be well on your way to acing the IM Shelf. Best of luck!