How to Prepare for Shelf Exams—2024 Guide


The third year of medical school is a very exciting time. After two years in the classroom, you’re finally in the hospital and interacting with patients. That said, it’s also an incredibly challenging year, as in addition to spending upwards of 12-14 hours in the hospital each day, you will also need to find time to study for each of your core rotation shelf exams.

In this post, we’ll break down what shelf exams are, when they take place, and how to best prepare. Note that many of the details around shelf exams vary from school to school. You’ll notice that’s a common theme throughout this guide, but we’ve pointed out when you need to fall back on your school’s specific process as well as how to adapt your own study schedule.


What Are Medical School Shelf Exams?

NBME medicine shelf exams are 165 minute exams that happen at the end of each core rotation, also known as clinical clerkship.

Required rotations include internal medicine, family medicine, surgery, neurology, pediatrics, OB/GYN, and psychiatry. Elective rotations, such as dermatology, do not have shelf exams, as there’s not a nationalized, standardized rotation that every single medical student is required to take.

Shelf exams are designed to evaluate your medical knowledge as well as your ability to practically apply that knowledge. You will be taking the same shelf exam as every other medical student in the country, regardless of the specific medical school you’re studying at—though the weight of the shelf exams is extremely specific to each school, which we’ll touch on later.

Shelf exams are licensed by the National Board of Medical Examiners (NBME), the same organization that designs the USMLE Step exams. Each shelf exam follows the same format as the USMLE Step 1, Step 2 CK, and Step 3 exams. The exams are called “shelf exams” because they consist of “shelved” (expired) USMLE Step 1 and Step 2 CK questions from old exams. You will typically be asked 110 multiple choice questions about a wide range of hypothetical medical and surgical scenarios and situations.

For example, the shelf exam for internal medicine will include questions about the various body systems, so expect to be asked questions about heart failure, diabetes, cancer, liver disease, and so on. In contrast, the shelf exam for neurology will be more narrow in focus, including questions about movement disorders, multiple sclerosis, and other neurological disease processes.

Shelf exams cover a broad range of medical topics, and they’re widely considered difficult due to the massive amount of knowledge students are required to memorize and understand. Plus, you’ll need to apply that knowledge to hypothetical clinical scenarios, which is no small feat.

Not all medical schools take a student’s shelf exam score into account when grading their clerkships, such as in true Pass/Fail programs. That said, the grade may factor into your acceptance at a residency program through communication of your composite rotation performance in your Dean’s Letter. That’s why it’s imperative to do all you can to ace your shelf exams.

There are two main components to your clerkship grade. Learn how your clerkships will be evaluated and much more: 5 Tips to Honor Medical School Clerkships.


When Do Shelf Exams Take Place?

Shelf exams often happen in the third year of medical school, typically between USMLE Step 1 and USMLE Step 2, during the clinical rotations portion of your medical education. Learn more: Medical School Timeline (All 4 Years Explained).

How your shelf exams are spaced out depends on your rotation schedule, which may or may not be up to you, depending on your school’s process. The tests themselves usually occur on the last day of your clerkship, but the exact timing depends on the medical school. Scheduling is straightforward. Unlike Step 1 and Step 2, shelf exams are standardized for you. Everyone takes them on the same day through the same proctoring. Whoever is on your rotation will be taking the exam with you as well.

You also don’t have to worry about finding a date and going to a test center; however, this does depend on your school’s resources. The setting will vary, but shelf exams are often virtual now, so you’ll likely take them at home with a virtual proctor.


How Many Shelf Exams Are There?

There are 7 core clinical rotations: internal medicine, family medicine, general surgery, neurology, pediatrics, OB/GYN, and psychiatry. You will face a shelf exam at the end of each of these rotations, so expect to have at least 7 shelf exams.

Medical School Clerkship icons

While not typical, some schools may require additional core rotations, such as emergency medicine, radiology, or anesthesiology. Depending on your school, it’s possible you will face shelf exams for these rotations as well.


How Do Students Decide the Order of Rotations?

Each shelf exam is one to one with the rotation itself, so scheduling is super specific to the medical school. Depending on your school, you may be able to decide the order of rotations, or you may not. Some schools allow students to pick their rotation order, some schools try to accommodate requests but aren’t always able to, and other schools randomly assign rotation order.

Core rotations typically last 6-12 weeks. Unlike Step 1 and Step 2, where you can choose the day, you can’t necessarily choose the date of your shelf exam, as if you’re on the rotation, you will be expected to complete the exam at the end of it.

This poses a challenge to students who do not plan ahead or adequately prepare, as you can’t delay your test. That said, some schools operate on a pass/fail system, so your exact grade may not matter so much. Some schools implement a non-grading system to encourage students to focus on the hands-on elements of the rotation itself, rather than being distracted by a strict and strenuous study schedule.

In either case, you do not want to do poorly or fail any of your shelf exams. Next, we’ll cover preparation and study strategies.


How to Prepare for Shelf Exams

Know that internal medicine, family medicine, general surgery, and pediatrics are the most intense shelf exams because they cover so much ground.

Neurology, as you would expect, is all about the brain, so shelf questions about the subject will be extremely narrow compared to internal or family medicine, where you could face questions about neurology but also those about cancer, GI bleeds, and other family medicine-esque things. It’s the breadth of the shelf exam’s content that often determines its difficulty.

Establish a Schedule Early On and Stick to It

Although MS3 means you’re about to spend most of your time in a clinical setting, keeping effective and consistent study habits is still essential to your success. This is true not only for your shelf exams but also USMLE Step 2, which covers a lot of the clinical knowledge you will acquire during your core rotations.

Save our USMLE Step 2 CK Guide.

You will need to continue to refine your study strategies, as you will be under even more extreme time constraints. Some of the rotations, especially the big ones like internal medicine, are extremely time-consuming. You’ll likely be working 12 to 14 hour days with little time off. You may have call, random shifts, six days on, one day off, and so on.

That said, you will likely know your schedule at least a couple of weeks ahead of time, so start early and be proactive. Plan ahead. Design a consistent study routine and stick to it. Cramming for the shelf exams right before your clerkship ends won’t help you.

Success on your shelf exams is about consistency rather than cramming.

For best results, begin studying for your upcoming shelf before your rotation begins. This will give you the foundational knowledge needed to succeed in your rotation and impress your superiors. Continue studying a little bit each day, and try to relate what you’re studying to the real-life practice you’re gaining in the hospital.

Studying can either be in the morning before you start or at night when you get back, and will depend on your current rotation schedule. Remember: it’s easy to tell yourself you’ll study when you get home, but after an impossibly long and difficult day, studying will likely be the last thing you want to do. Getting the majority of your studying done before your shift starts and during your breaks will cut down on what you have to do at the end of the day, and it will ensure your studying never gets skipped.

Your time will be very limited during your rotations, so it’s imperative you utilize every spare moment. Anki has shelf-specific flashcards, so pull up the app and go through some flashcards during downtime between cases or while you’re waiting for the attending physician. And don’t save it just for the hospital. If you’re on a bus or waiting in line at the grocery store, use that time to run through a few flashcards. While it may not sound like a lot, every little bit counts, and a few minutes here and there add up quickly over the course of a few weeks.

Focus on High-Yield Information and Study Strategies

We can’t emphasize this enough—your time will be very limited, so you’ll have to use it wisely. To succeed, you’ll have to go all in on a study smarter, not harder approach. What study methods and resources will produce the most results with the smallest amount of effort?

Focus on high-yield information. For example, if you recently completed USMLE Step 1, there’s a good chance you put in a whole lot of study hours learning the material you needed to pass. The material you covered for that exam has a lot of crossover for your shelf exams, so it might be more prudent to jump into testing what you know than starting to memorize the basics all over again.

In this case, practice questions (especially from question banks that come with explanations) are higher yield, as you’ll be able to evaluate your current knowledge and find out where the gaps are. You don’t need to keep studying what you already know. While it may be satisfying to continually get the answer right over and over again, this isn’t a good use of your time. To get the most out of your effort, invest your energy in strengthening your weak areas.

Modulate your studying based on your objectives. What you should focus on will be different for everyone, and again, it depends on your school’s process. Balance content review with questions. Carefully examine the question explanations to better understand why you got something right or wrong.

Additionally, how you study can have a huge impact on your results. It’s not about the amount of time you put in; it’s about how well you perform in the end. Some study methods are simply more effective than others. Match the way you choose to study with the type of material you’re learning. Learn more from our guide: 7 Evidence-Based Study Strategies (And How to Use Each).

Adjust for Your School’s Process

Just like the order of your rotations, the weight of your shelf exams are specific to each school. For some schools, up to 80% of your clerkship grade is based on the shelf exam, whereas 20% is based on your evaluations. For others, only 40% of your grade will be based on your shelf exam, and 60% will be based on your evaluations.

Each school also determines cutoffs. For some schools, 80% is a pass, and 90% is a high pass. For others, a C is a pass, and so on. At Stanford, for example, everything is now either pass/fail, which enables students to put more of their energy into the experience of their clerkships over studying.

This means you will need to adjust your study strategies based on the medical school you’re attending. Every school is different. If the results of your shelf exams will play a significant role in your grade, you will need to prioritize your studying. If your shelf exams won’t play as much of a role in your final grade, dedicate more of your energy to your rotations and securing excellent evaluations.

That said, be sure to honor each of your rotations, as your performance will ultimately be factored into your Dean’s letter as well as your Medical Student Performance Evaluation (MSPE).

The key to your success is understanding exactly how you will be evaluated, and the best place to start is the syllabus or medical student handbook. The syllabus will break down how you will be graded, what’s expected of you, and other details specific to the rotation. Read these details carefully as soon as possible so that you can begin to design an effective study schedule and routine catered to your medical school’s process.

Don’t Over Resource

There are a plethora of resources at your fingertips—so many that it can be confusing to know where to begin or which ones are the most effective. Plus, the best study tools can vary from rotation to rotation. But when it comes to study resources, more isn’t better. Commit to something, and stick to it. Using too many resources leads to diminishing returns, and it will only make your studying more complicated.

For primary resources, we recommend the latest AnKing Anki Deck with its shelf-specific tags or Step-Up to Medicine, depending on if you prefer flashcards or books. If you prefer videos, the Boards & Beyond videos + White Coat Companion study aid or OnlineMedEd are both great resources as well. Finally, for on-the-go studiers and auditory learners, the Divine Intervention Podcasts specific to your shelf exam are a great comprehensive rapid review option to listen to in transit, while cooking, or exercising.

One of these resources should provide you with enough information. Pre-read some of these resources quickly to understand the general concepts, then dive into the most important element of your studying: questions. After completing and reviewing a UWorld block, go back and fill in any gaps with your primary resource to improve for next time.

Some of the best resources for shelf exams are the question banks from either UWorld or AMBOSS. Schedule at least one block of questions each day. Treat the block like an exam by timing yourself and keeping the questions random. This will help you familiarize yourself with the exam’s time pressure and enhance your retention of the material.

You do not need to complete the entire set of shelf questions from either resource. However, you should strive to do as many as you can. Of course, do not forget the NBME Clinical Mastery Series practice shelf exams. While oftentimes not full length, these tests provide the most realistic sense of what exam day will look and feel like. As with the USMLE exams, strategically and regularly (weekly or more frequently) position your practice shelf tests beginning approximately halfway through your study period to gear up for the real thing.

Endeavor to understand why you got a question incorrect, and if you answered a question correctly, explain out loud why you didn’t select the other answers. This active recall method forces you to assess other areas of your knowledge; plus, it enhances your ability to eliminate answers during the exam. The latter will come in handy when you need to make an educated guess.

Use a good reference book, such as Step-Up to Medicine or the Boards & Beyond videos + White Coat Companion, as a secondary resource. If you encounter a case pathology you didn’t master, these will help to fill in any gaps in your knowledge. After the UWorld block and review, reading a bit about your patients will go a long way during your rotations, and real-life examples are more likely to stick in your mind.

Lastly, Anki decks are an invaluable on-the-go resource. Create your own Anki flashcards based on any questions you miss in UWorld or AMBOSS, and pull out this resource whenever you have a few minutes to spare. When you’re as busy as you will be during your rotations, every little bit counts.

To summarize, select a primary resource for content review, preferably an interactive one with active recall built-in, and pair it with regular question blocks from either UWorld or AMBOSS. Whichever you choose, stick to it. For additional reference material, use the resources at your disposal, whether that be the Boards & Beyond videos or the AMBOSS database. Finally, as test day approaches, begin working on NBME practice shelf exams to get you in the right mindset.

Remember, the intensity of your studying should match that of the grade weight your school attributes to the shelf.


Executing Exam Day

While shelf exams may not be as extensive as other high-stakes medical school exams like the MCAT or USMLE, many of the same exam day preparation tips apply.

Before your exam:

  • Prioritize a good night’s sleep. The quality of your sleep is just as important as the quantity, and getting adequate sleep will do much more for you than staying up to cram last minute information.
  • Stick to what you know. Exam day is not the time to try something new. This goes for your routines, sleep habits, the food you eat, stimulants, what you wear, exercise, etc. If you want to build a healthy habit, start doing so weeks in advance of your exam to ensure you are comfortable with it by the time exam day hits.
  • If you consume caffeine, do so strategically and in moderation. Don’t try coffee or any other stimulants you haven’t tried before on an exam day.
  • Eat a brain healthy breakfast/lunch, and stick to foods you are familiar with. Don’t forget to hydrate!
  • Give yourself much more time than you think you need. If you need to take the exam in person, leave much earlier than you normally would to account for any emergencies or roadblocks you may encounter on your way. Arriving early will give you a few extra moments to find your focus by utilizing breathing exercises.
  • If you’re taking your test online, follow the same principles. Set up and double check your technology well in advance and sit down at your at-home exam station early to acclimatize and find your focus.
  • If you take the test at home, ensure you let everyone you live with know when you are taking your exam and that you can’t be disturbed.
  • Everyone is going to be taking the same exam on the same day at the same time under the same conditions. Do not allow others’ uncertainty, nervousness, or use of other resources deflate your confidence, especially as exam day gets closer. Stay committed to your own study plan.

During your exam:

  • When waiting for your exam to begin, refrain from engaging with the nervous energy of others. Stay cool, calm, and collected, knowing that you prepared the way that was best for you.
  • Don’t let yourself get stuck on a question early on. Build momentum by taking a quick first pass through the questions. Answer the ones you know, mark the ones you’re unsure of, and leave the questions you don’t know the answer to.
  • For any questions you don’t know the answer to and left blank, choose the most probable choice, or choose the answer you believe the test makers want you to.
  • Don’t move through the questions too fast. Avoid silly errors by taking some mental breaks during the exam.
  • Keep water handy and remember to take some deep breaths. If you get stuck, sometimes the best thing you can do is take a moment to breathe, recenter, and get your focus back on track. Move on to another question if you have to. The question you’re stuck on is only one question.

Learn more: Test Day Strategies – Step 1 and Step 2CK.


Go Into Your Shelf Exam With Confidence

Do you want to honor each of your clinical rotations, ace your shelf exams, match into the best residency programs, and become the best doctor you can be? Check out our admissions and tutoring services, including tutoring services tailored to shelf exams. Our one-on-one tutoring pairs you with a physician advisor who can answer all of your burning questions about applications, how to transition into each year of medical school, what to do with time between your studies, and so much more.

If you are approaching or currently in your rotations, check out our comprehensive Clerkship series, which covers everything you need to know for your core rotations. These guides highlight how to make the most of your rotations, what resources to use, advice for the shelf exam, and the pros and cons of pursuing the specialty.

We have a wealth of medical school and residency resources on the Med School Insiders blog. We add content every week and continue to update our guides to reflect the most up-to-date information. Sign up for our weekly newsletter to get our latest advice, guides, and videos sent straight to your email.

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