Why Is the Medicine Shelf So Hard and What Can You Do to Be Ready?

With internal medicine having the most applicants for residency positions every year (nearly 27,000 from a total of 51,000 applicants in 2021), it makes sense that clerkship students want to excel on their medicine shelf exam. Additionally, many specialties require an internal medicine intern year before starting the field’s core residency (fields like Dermatology, Radiology, Ophthalmology), making an even bigger pool of applicants into this already crowded application pool. 

When it comes to applying for internal medicine residency spots, one of the best ways to showcase your skills as a superb resident-to-be to your potential program director is by honoring your medicine clerkship. From my experience as a third-year student, the biggest barrier to honoring your clerkship is not the highly complex patients you’ll have to take care of or the pre-rounding followed by hours of morning rounds on the wards, it’s the medicine shelf exam itself. So whether you’re planning on applying for an internal medicine residency, or just looking to impress with a stellar internal medicine shelf exam score, this blog post is for you! We’ll discuss the internal medicine shelf, why it’s so hard, and how you can prepare!

This exam is unlike any other that medical students will take throughout their clerkship year. The sheer amount of content needed for the internal medicine shelf exam dwarfs any other topic by two-fold or more in terms of dedicated content questions in test banks like UWorld. Not only does UWorld dedicate a whopping 1,100+ questions to the field “Medicine” alone, but there are also an additional 400+ questions in the “Ambulatory Medicine” subject field, which covers aspects of internal medicine from the outpatient population. Combined, the 1,500+ questions in the field of internal medicine make up over 40% of the UWorld Step 2 CK question bank. In comparison, neither neurology nor psychiatry has more than 400 questions each and the next biggest field is surgery with just over 600 questions. 

On the medicine shelf exam, students are required to go above and beyond the expectations of preclinical board questions, shifting focus from the foundational medical science concepts that make up 60%-70% of USMLE Step 1’s question content to now understand the proper diagnostic workup and management plans that makeup over 80% of the medicine shelf exam’s content. Foundational science still makes up the remaining 20% of the shelf exam, so make sure to continue your spaced repetition learning so you can recall the facts you may have crammed during pre-clerkship. (See SUBJECT EXAMINATIONS for a complete breakdown of the medicine shelf exam content and example questions, which will be helpful as you start your studying.) 

Another tricky part about the medicine shelf exam is that there may be more than one right answer for a situation, but you must choose the BEST answer, or the best option to begin right away. USMLE Step 1 questions tended to have blatantly incorrect answers; drug options that would often do nothing or even worsen a patient’s condition if given. For shelf exams, however, you might see a list of answers with drugs you know would have some beneficial effect, but you can’t quite parse out the right answer. To ace your medicine shelf exam, you’re expected to know not only the first-line treatments, but also the second-line and even third-line treatments for broad conditions like hypertension, diabetes, heart failure, COPD, and cirrhosis. For example, a beta-blocker is a great idea for any patient with hypertension and a past coronary artery disease history, but if they’re also dealing with COPD, you might think twice about giving them any sort of non-selective beta-blocker for fear of worsening bronchoconstriction. These types of tricky questions are very commonplace throughout your medicine shelf exam, so studying and knowing the fine details becomes vital. 

Additionally, the internal medicine shelf exam requires that you understand common drug combinations used as guideline-directed therapy for conditions like Heart Failure. You can no longer rely on knowing that diuretics help relieve fluid overload. Instead, you’ll need to know that clinical trials have proven beta-blockers, ACEs/ARBs, Mineralocorticoid receptor antagonists, and recently SGLT2 inhibitors to be linked to reductions in morbidity and mortality while classic Step 1-testable drugs like Digoxin have not been linked to any study-proven benefit in morbidity/mortality in heart failure populations over time. 

Lastly, Patients on the medicine shelf exam often have multiple co-morbidities like the above example that complicate management plans. Type 2 diabetes, hypertension, dyslipidemia, coronary artery disease, stroke, HIV, injection drug use, DVT history, and significant alcohol/tobacco use can all be expected to be common aspects of your patient’s past medical history both on the wards and on your shelf exam. Question writers expect that you know how these conditions relate to one another and how they can serve as risk factors for the development of further co-morbidities later in time. 

Now that you know why the internal medicine shelf exam can be so hard, here’s what you can do to make up for the difficulties of this exam. 

1. Start studying early! This is my biggest recommendation. Having all Medicine and Ambulatory Medicine questions completed in UWorld prior to your shelf exam will make sure that you have the knowledge base to tackle the wide array of patient presentations you’ll see on test day. Better yet, you’ll be ready to apply that knowledge to the difficult questions that the medicine shelf will showcase.
2. Know everything you can about your patients. Every tutor will tell you that some of the best learning from a clerkship year comes from the patients you take care of. Seeing these patients and presenting their labs and updated exam findings on rounds every morning acts as spaced repetition that will hammer in the exam findings and management plans you need to know about the wide array of presentations you’ll see on your shelf exam. 
3. Know everything about your team’s patients. Medical students generally care for 1-2 inpatients at a time, while an entire medicine team may have 12-20 patients at any given time. Becoming familiar with the workup and main management plan points for each patient will make sure that even when you didn’t see every type of medical patient, you’re familiar with the general workup and management plan for the most common admissions to the hospital. These common admissions to the hospital also tend to be the most common patient presentations in medicine shelf questions. 
4. When you don’t know something about your patient or your team’s patients, ask questions during rounds. Focused questions like: “How can we estimate this patient’s insulin needs?” tend to fare a lot better than “What’s the plan for this patient’s hyperglycemia?”. Additionally, “Is the patient’s hyponatremia failing to correct because of their congestive heart failure?” shows that you recognize an abnormal lab value and can apply reasoning to its origins while “Why is this patient’s sodium low?” simply shows that you can recognize an abnormal lab value. Not only will these focused questions impress your team by showing you’re consistently thinking about your patients’ care, but you may also occasionally bring up questions that your entire team might learn from (and that will almost certainly become great feedback for your rotation evaluation).
5. Take advantage of the NBME practice exams! These questions closely replicate what you’ll be tested on for the real shelf exam. Taking these in a timed setting will make sure that you’re ready for the real deal.
6. Consider enlisting the help of a shelf exam tutor! EMP is here to help you with all your shelf exams, USMLE, board exams, etc. tutoring needs! Schedule a free consultation call here.