What Makes the Surgery Shelf Exam so Difficult?

If you’re a US Allopathic medical student, your surgery rotation was probably a lot like mine. Long, mind-numbingly boring operating room (OR) days sprinkled in with a bit of panic when you’re asked an esoteric question about human anatomy. I was lucky enough to have attending physicians who asked me about relevant surgical anatomy and management while letting me help with drains and chest tubes. But, not all students are so lucky. I had classmates who trained themselves to dissociate at a moment’s notice, spacing out for hours at a time in an OR. So, how in the world is anyone supposed to learn surgical management in this kind of learning environment? Why is the surgery shelf exam so difficult if the rotation is so inconsistent? Well, somehow, I pulled it all together, getting 97% of the questions correct on the exam and scoring in the 99th percentile. 

What makes the surgery shelf exam so difficult? Let’s talk about it.

The sheer amount of material

Many students – myself included – found the amount of testable material on the surgery shelf exam overwhelming. There’s an elephantine amount of information you need to know to do well on the exam. How do you eat an elephant, you might ask? One bite at a time. The surgery shelf covers a lot of information, but with a solid knowledge-base gleaned from UWorld (or another equivalent question bank) and consistent review (see: Spaced repetition and Anki), many students end up learning the material for the shelf exam. 

In addition to UWorld and Anki, I used a few other resources to study for my surgery shelf.

• AMBOSS – UWorld only has about 500 surgery-specific questions in their question bank. If you’re looking for more practice questions, AMBOSS is a great resource for extra practice. It’s side-by-side interlinked explanations and content guides are great for reviewing high-yield points during a practice block or in the hallway outside the OR minutes before a procedure.
• Divine Intervention Podcasts – Divine Intervention is a podcast series that covers almost all of the high-yield content on USMLE Step 1, USMLE Step 2 CK, and your shelf exams. He presents the information in easy-to-digest vignettes with explanations that I found incredibly helpful on test day (hint hint). 
• Surgery: A Case Based Clinical Review by Christian de Virgilio, Paul N. Frank, Areg Grigorian – If you’re only going to read one book for your surgery shelf, read this one. I felt like my exam was written based on this book. It’s great for surgical pearls, scoring, and indications (e.g., when to operate with a zone 2 abdominal trauma). 

Surgery is internal medicine with extra steps

It’s not a secret that the internal medicine and surgery shelf exams are very similar. This is for good reason! The best surgeons are also great internists. Your surgery shelf exam will test you on your surgical management, your understanding of surgical situations, and your understanding of internal medicine. Your score on the surgery shelf exam will be largely dependent on your understanding of internal medicine. 

All the criteria/scores

So. Many. Criteria. 

Surgeons love their criteria/scores for good reason. Scores like the Alvarado score for acute appendicitis can help them assess the likelihood of particular diagnoses and whether or not to operate on a patient. 

These scores and grades can be helpful for you, too. But why memorize them when they’re all organized on useful applications like MD+Calc? As readily available these apps are on your rotation, we unfortunately can’t use them on our shelf exam. Some of these grades and scores are particularly high yield for surgery shelf. For example, you need to know how to calculate a patient’s Glasgow Coma Scale and identify brain death criteria for your surgery shelf exam. These aren’t as high yield as some other topics, but there were a lot of questions about criteria and scores on my surgery shelf exam and they add up quickly if you don’t know a lot of them. 

Medical vs. Surgical decision making… When do you operate?

A good rule of thumb for the surgery shelf is when deciding between conservative or medical management, choose conservative management. Yes, you read that correctly. The mark of a good surgeon (and good medical student taking their surgery shelf) is knowing when to operate and when not to operate. 

In the same way, a critical part of answering any surgery shelf exam question is correctly assessing the clinical situation. Before you pick an answer, ask yourself some basic questions about the status of the patient in the vignette. Choose your answer based on how invasive you think the management should be. 

1. Is the patient stable or unstable? 
2. Is the setting acute (e.g., ED) or non-acute (e.g., clinic)? 
3. What does your gut tell you? Sometimes, picking the right answer comes down to choosing between two similar management options, one of them for the acute, unstable patient and another for the stable patient. 

Choose wisely!