Can't seem to do well on shelves. Need help.

[meddit01]

Sorry about the long post. I've included a TLDR at the end.

IM: I went through onlinemeded 2-3 times, did about 1/4th uworld. Got a 73. Thought I was focusing too much on OME and not enough on uworld, and that I needed an actual text to read. So I tried to make those changes for the next rotations.

Surgery: Went through OME 2x, Pestana text 1x, audio 2x, uworld 1x. Got a 67 and became depressed AF. I really felt I tried a lot harder to study but did even worse. But just thought I needed to keep pushing forward and work harder.

Neurology: Went through Case Files, OME 2x, uworld 1x. Got a 73. Again became depressed. Just didn't know what I was doing wrong at this point. Thought maybe I needed to do more questions so I tried that for the next one.

Psychiatry: Did OME 3-4x, read 8/10th of FA for Psychiatry, did uworld 1x and then incorrects, did Rx 1x, did 8/10th of Pretest questions. Felt I really had a strong grasp of the material by the end, as I was getting 80s-90s for the most part on uworld/rx. Took the shelf and got a 74.

At this point, I just don't know what to do anymore. I want to do a primary care specialty but at a competitive location. I did alright in classes during the first two years. First year was P/F, second year got 4 Bs first semester, then all As second semester. Worked hard for Step 1 but still got a ____. Thought I might still be okay for residency apps if I worked harder during M3 and did better on Step 2. But seeing how I'm doing so far, I feel like I'm just doomed for straight B's for the whole year and an average or below average score for Step 2. I'm really worried I won't be competitive at all for the places I want to apply to for residency. I just don't know what to do anymore.

TLDR: I've tried multiple studying strategies for my shelves so far, from reading more, to doing more questions, but nothing seems to help. I always score in low 70s, which seems to be well below the average for my class. Just not sure what to do differently anymore.

I seem to get fairly good evals, which are my only life raft at this point keeping me at high Bs on my rotations. And I did above average during M1/M2, so I don't think (or hope not at least) that it's a knowledge gap. From looking at prior similar threads, may be it's a test taking problem and/or reading comprehension problem? I studied really hard for Step 1 but scored ____. I always had trouble with literature classes in high school/college, and I scored a 6 and 8 on VR on my MCAT attempts. But then again, all of this may have nothing to do with it at all.

Any advice would be really appreciated. Thanks.

---

Members don't see this ad.

 

[Trogdor_The_Burninator]

Sorry about the long post. I've included a TLDR at the end.

IM: I went through onlinemeded 2-3 times, did about 1/4th uworld. Got a 73. Thought I was focusing too much on OME and not enough on uworld, and that I needed an actual text to read. So I tried to make those changes for the next rotations.

Surgery: Went through OME 2x, Pestana text 1x, audio 2x, uworld 1x. Got a 67 and became depressed AF. I really felt I tried a lot harder to study but did even worse. But just thought I needed to keep pushing forward and work harder.

Neurology: Went through Case Files, OME 2x, uworld 1x. Got a 73. Again became depressed. Just didn't know what I was doing wrong at this point. Thought maybe I needed to do more questions so I tried that for the next one.

Psychiatry: Did OME 3-4x, read 8/10th of FA for Psychiatry, did uworld 1x and then incorrects, did Rx 1x, did 8/10th of Pretest questions. Felt I really had a strong grasp of the material by the end, as I was getting 80s-90s for the most part on uworld/rx. Took the shelf and got a 74.

At this point, I just don't know what to do anymore. I want to do a primary care specialty but at a competitive location. I did alright in classes during the first two years. First year was P/F, second year got 4 Bs first semester, then all As second semester. Worked hard for Step 1 but still got a 220. Thought I might still be okay for residency apps if I worked harder during M3 and did better on Step 2. But seeing how I'm doing so far, I feel like I'm just doomed for straight B's for the whole year and an average or below average score for Step 2. I'm really worried I won't be competitive at all for the places I want to apply to for residency. I just don't know what to do anymore.

TLDR: I've tried multiple studying strategies for my shelves so far, from reading more, to doing more questions, but nothing seems to help. I always score in low 70s, which seems to be well below the average for my class. Just not sure what to do differently anymore.

I seem to get fairly good evals, which are my only life raft at this point keeping me at high Bs on my rotations. And I did above average during M1/M2, so I don't think (or hope not at least) that it's a knowledge gap. From looking at prior similar threads, may be it's a test taking problem and/or reading comprehension problem? I studied really hard for Step 1 but scored 220. I always had trouble with literature classes in high school/college, and I scored a 6 and 8 on VR on my MCAT attempts. But then again, all of this may have nothing to do with it at all.

Any advice would be really appreciated. Thanks.

Hello meddit!

Please don't be depressed! I know, easier said than done, right? I assume you have a few more shelf exams to go before step 2 to really figure out a strategy that works for you to perform at a level that you think is consistent with your proficiency in each of these subjects (to maximize your potential). So, all is not lost! MS3 is a long haul, and you have to stay positive!

Just for clarification: Are the shelf scores you posted percentiles or raw scores? (You don't have to answer that if you don't want to...I understand).

I would suggest considering a few different things, though I feel like I can only give any sort of (maybe?) helpful advice on one of them.

- First are factors that affect actual test-taking. Do you think you have test anxiety that may cause you difficulties when you take the shelf exam? Can you get through the exam in the alotted time? etc.

- Second, how early or late in the clerkship are you starting to study? Also, when you study, are you being efficient? Are you having issues with building a fund of knowledge or with the actual structure of the exam (please see above). Do you study everyday? most days? occasionally? Do you constantly revisit what you have studied? Do you feel pressed for time to study during your clerkships, to the point where you can't get through the material?

- Third, have you considered using sources other than OME? I know the selection of texts and question banks is often a very personal choice, but are you willing to consider researching some sources, finding things that have worked for others and giving them a try? For example, most all of the students in my IM clerkship used step up to medicine; most all of the students in my surgery clerkship used the NMS casebook +/- NMS text or step up to surgery + pestana's. Ultimately, the sources you use are only helpful if you can get through them entirely, and then go through multiple (preferably) passes to get the stuff down cold as you're doing practice questions. More is not always better, but a change could be beneficial...?

I hope my post is helpful. Please PM me if you'd like to talk further. Personally, I find that starting studying as early as possible in a clerkship, going through my few select sources as many times as possible, and taking (short) notes on practice questions and making multiple passes at my notes/questions to very successful strategies in tackling the shelf.

Best of luck!

 

[Señor S]

I feel you on this. Tough to know exactly what the problem is but I would recommend:

-Picking one good book and trying to get through it at least 2x. For example, I'd recommend BluePrints Ob/Gyn and BRS Pediatrics.
-Making sure you get all the way through your question banks and do all the incorrects. Maybe consider adding another question bank (I've had pretty good luck with Kaplan)
-Doing all the NBME practice tests and reviewing the answers (I recommend doing this the day before the shelf if possible, as they usually like to take a couple questions almost verbatim from these things)
-Save OnlineMedEd for the day/morning before the test

The curve for the shelves has changed recently and I wonder if it hasn't gotten harsher due to score creep ala Step 1.

 

[meddit01]

Hello meddit!

Please don't be depressed! I know, easier said than done, right? I assume you have a few more shelf exams to go before step 2 to really figure out a strategy that works for you to perform at a level that you think is consistent with your proficiency in each of these subjects (to maximize your potential). So, all is not lost! MS3 is a long haul, and you have to stay positive!

Just for clarification: Are the shelf scores you posted percentiles or raw scores? (You don't have to answer that if you don't want to...I understand).

I would suggest considering a few different things, though I feel like I can only give any sort of (maybe?) helpful advice on one of them.

- First are factors that affect actual test-taking. Do you think you have test anxiety that may cause you difficulties when you take the shelf exam? Can you get through the exam in the alotted time? etc.

- Second, how early or late in the clerkship are you starting to study? Also, when you study, are you being efficient? Are you having issues with building a fund of knowledge or with the actual structure of the exam (please see above). Do you study everyday? most days? occasionally? Do you constantly revisit what you have studied? Do you feel pressed for time to study during your clerkships, to the point where you can't get through the material?

- Third, have you considered using sources other than OME? I know the selection of texts and question banks is often a very personal choice, but are you willing to consider researching some sources, finding things that have worked for others and giving them a try? For example, most all of the students in my IM clerkship used step up to medicine; most all of the students in my surgery clerkship used the NMS casebook +/- NMS text or step up to surgery + pestana's. Ultimately, the sources you use are only helpful if you can get through them entirely, and then go through multiple (preferably) passes to get the stuff down cold as you're doing practice questions. More is not always better, but a change could be beneficial...?

I hope my post is helpful. Please PM me if you'd like to talk further. Personally, I find that starting studying as early as possible in a clerkship, going through my few select sources as many times as possible, and taking (short) notes on practice questions and making multiple passes at my notes/questions to very successful strategies in tackling the shelf.

Best of luck!

The scores I posted are raw scores. I don't feel anxious whenever I'm taking shelf exams. I actually feel pretty calm and am able to get through all the tests with 20-30 min to recheck/go back to ones I skipped earlier. I start studying the weekend before the clerkship even begins. It's usually when I start going over OME, which I try to finish up in the first 1-2 weeks. And then just questions till the shelf. I know I'm not the most efficient studier, but that's moreso when I'm doing OME. I dread doing lectures, but they're what I use to build my baseline knowledge. But I do 10 uworld questions at a time, which takes me about 45 min or so, after which I take a break and start again. I try to study everyday, but there are certainly some days where I just feel too tired and use that day to catch up on sleep. I feel like my fund of knowledge does lack a lot at first, but the more questions I do and notes I review, the more I feel I start to understand the material. I don't get a chance to constantly revisit what I study, but I review my notes from incorrects at least once a week. I do feel pressed for time during the rotations, but not anymore so than the average student I think. Though I am baffled at those who somehow have time to read Blueprints x2, do uworld x3, pretest x1, etc, all within 4-6 weeks. The most I ever got to do was OMEx3, rx x1, uworld x1, first aid x1, and pretest x1, and that was only cause it was psychiatry.

I'm not sure if part of it is my inability to pick up/retain pertinent info from vignettes. For example, just yesterday I missed 2 questions on Sheehan syndrome. I could rattle off details about it at the top of my head, yet I wasn't able to pick it up from vignettes twice in the same day. And both of those vignettes had the same presentation too.

I feel you on this. Tough to know exactly what the problem is but I would recommend:

-Picking one good book and trying to get through it at least 2x. For example, I'd recommend BluePrints Ob/Gyn and BRS Pediatrics.
-Making sure you get all the way through your question banks and do all the incorrects. Maybe consider adding another question bank (I've had pretty good luck with Kaplan)
-Doing all the NBME practice tests and reviewing the answers (I recommend doing this the day before the shelf if possible, as they usually like to take a couple questions almost verbatim from these things)
-Save OnlineMedEd for the day/morning before the test

The curve for the shelves has changed recently and I wonder if it hasn't gotten harsher due to score creep ala Step 1.

Honestly, I never really considered myself a book reader since I have a hard time retaining the info. I was able to do it in high school and college cause I had more time then. But I'm a fairly slow reader and often have to reread sentences multiple times to understand/retain what they're saying. But even then, I tried it for both neurology and psychiatry, and that too, different types of text–Case Files for neuro, and FA for psych. Even then, I did just as bad on the shelves. So I've kinda given up on the idea of trying a dedicated text again. But I'll try doing rx again for my next shelf, on top of uworld. Hopefully that will help.

 

[EmergDoc2B]

Im no stud but Id suggest what other have suggested. Use 2 qbanks and go through all subject questions timed and then review incorrects. I start doing questions the first day of the rotation usually 25 a sitting unless there just arent that many questions then adjust accordingly. If I need to read I usually defer to the standard books everyone else has mentioned and just pick 1 and uptodate for any ambiguity. By starting early I alleviate most of my test anxiety. As for qbanks I use U world and combank (school purchased). I wish you the very best.

 

[J ROD]

It really is hard. Some folks are not great at standardized tests. I am not either. Just do your best and as long as you are not shooting for super competitive stuff you will be fine.

 

[twospadz]

I really don't like the woe is me attutide. Based off your step 1, you were expected to perform this way. To honor the shelf, you need to get in the 75th percentile which is one standard deviation above the curve. The average step 1 is 230 std 20. Which means those indiviuals that are consistently honoring have most likely scored in the 250s or above or close to it. I know people who scored 240s who havent honored one rotation. This path gets harder in on out so suck it up for real or residency is gonna hit you like a ton of bricks.

 

[operaman]

Number one test taking error I see people making on shelves and steps: not thinking clinically.

Per the nbme 's published materials, they write questions that reward students who think clinically and penalize those who don't.

For every single question, you must verbalized to yourself your diagnosis or your top 4-5 differential. Too many people skip this step and start trying to treat lab values or symptoms or vitals, etc.

For example, pt with cough and sob. If the rest of the vignette puts PNA or ptx at the top of your ddx, then a cxr would be your test of choice. If the vignette made lung cancer or a PE your primary concern, then a chest ct scan is what you want, or a v/q scan if you're thinking PE but the SCr is too high. If the vignette pointed to something like a tension pneumo then obviously you'd want to do an intervention rather than a test. The important thing is to think clinically, make your diagnosis or ddx, and then treat that or work it up. Too many people see the cough and sob and reflexively pick cxr (or something the high SCr) instead of thinking it through and making a diagnosis or ddx first.

 

[pbnmac]

Number one test taking error I see people making on shelves and steps: not thinking clinically.

Per the nbme 's published materials, they write questions that reward students who think clinically and penalize those who don't.

For every single question, you must verbalized to yourself your diagnosis or your top 4-5 differential. Too many people skip this step and start trying to treat lab values or symptoms or vitals, etc.

For example, pt with cough and sob. If the rest of the vignette puts PNA or ptx at the top of your ddx, then a cxr would be your test of choice. If the vignette made lung cancer or a PE your primary concern, then a chest ct scan is what you want, or a v/q scan if you're thinking PE but the SCr is too high. If the vignette pointed to something like a tension pneumo then obviously you'd want to do an intervention rather than a test. The important thing is to think clinically, make your diagnosis or ddx, and then treat that or work it up. Too many people see the cough and sob and reflexively pick cxr (or something the high SCr) instead of thinking it through and making a diagnosis or ddx first.

That's an interesting spin operaman! You raised some major errors of way that I'm equally guilty of in how you might skip over the diagnosis and rolling differentials. Clinicals and Step 2ck seem to be widely different than how we may have prepped for step 1 and basic science years (less rote memorizatoin and fact recall).

What I've noticed at least with many of the popular text and review books mentioned in these rotations threads that I've tried previewing, is that it's somewhat challenging to apply what you have read into a frantic 1-minute or less mental grind when doing that test question... and then, we're not talking about just one question under such timed constraints but many hundreds thereafter and for like the step 2ck, 300+. I'm sure that also puts a potential dampener on performance in the psychological sense.

What kind of resources for each of the rotations did you use for your to apply yourself to "verbalize" and approach shelf exam questions that way you were describing? Does this methodology also apply to when you're on the wards and during rounds? Or is that where textbooks or up to date learning come into play? I've seen a mix of posts where some learn much more through doing questions but not sure how that aids whens you're not being examined (e.g. shelf exams, step 2ck) but are now caring for a patient.

 

[Medpub2018]

Here are my SHELF scores:

FM - 75 (64th percentile)
OB/GYN - 73 (~40th percentile)
Psychiatry - 75 (45th percentile)

I still have a couple more to go.

Tbh, I worked my tail off for my FM SHELF. I over-think questions pretty hard and I am sub-standard test-taker. No matter how hard I try, I fall right at the average for the nation.

For instance, for FM, I did 1600 AAFP questions along with Case Files. I am fairly certain that if I hadn't missed the 4 questions that I over thought, I would have probably gotten an 80, resulting in a higher percentile. It's just the nature of the game. There's so little difference between each of the scores. So little.

So, don't kick yourself. Just try as best as you can. And tbh, average for the country for Step 2 is a 240. If you are scoring right at average or a little below, that means you are right around 240. That's a really decent score. And nothing to be ashamed of.

 

[meddit01]

Im no stud but Id suggest what other have suggested. Use 2 qbanks and go through all subject questions timed and then review incorrects. I start doing questions the first day of the rotation usually 25 a sitting unless there just arent that many questions then adjust accordingly. If I need to read I usually defer to the standard books everyone else has mentioned and just pick 1 and uptodate for any ambiguity. By starting early I alleviate most of my test anxiety. As for qbanks I use U world and combank (school purchased). I wish you the very best.

I generally have been using 2 qbanks–uworld and pretest/rx/etc. I've been reviewing incorrects this entire time. I've tried using books as well but they don't seem to be helping. I also use uptodate to double check any ambiguity. Thanks for the input.

It really is hard. Some folks are not great at standardized tests. I am not either. Just do your best and as long as you are not shooting for super competitive stuff you will be fine.

Yea, I guess that's all I can do at this point. Unfortunately, I'm shooting for a competitive location for an uncompetitive specialty, so numbers still matter quite a bit. Thank you though.

I really don't like the woe is me attutide. Based off your step 1, you were expected to perform this way. To honor the shelf, you need to get in the 75th percentile which is one standard deviation above the curve. The average step 1 is 230 std 20. Which means those indiviuals that are consistently honoring have most likely scored in the 250s or above or close to it. I know people who scored 240s who havent honored one rotation. This path gets harder in on out so suck it up for real or residency is gonna hit you like a ton of bricks.

I'm not asking you to have pity on me. I was just laying out what all I've tried and am just asking for input about what I'm doing wrong / what I should be doing differently. Yea, I didn't do well on Step 2, and I'm sure it was in part for the same reasons that I'm doing poorly now. But I know of several of my classmates who scored 220-230 who are all scoring 80+ on the shelves. I never even cared to honor. I was just shooting for the A cutoff. But I'm always off by 7-10 questions every time.

Number one test taking error I see people making on shelves and steps: not thinking clinically.

Per the nbme 's published materials, they write questions that reward students who think clinically and penalize those who don't.

For every single question, you must verbalized to yourself your diagnosis or your top 4-5 differential. Too many people skip this step and start trying to treat lab values or symptoms or vitals, etc.

For example, pt with cough and sob. If the rest of the vignette puts PNA or ptx at the top of your ddx, then a cxr would be your test of choice. If the vignette made lung cancer or a PE your primary concern, then a chest ct scan is what you want, or a v/q scan if you're thinking PE but the SCr is too high. If the vignette pointed to something like a tension pneumo then obviously you'd want to do an intervention rather than a test. The important thing is to think clinically, make your diagnosis or ddx, and then treat that or work it up. Too many people see the cough and sob and reflexively pick cxr (or something the high SCr) instead of thinking it through and making a diagnosis or ddx first.

This is a very good point and something I never really thought of. When I'm doing questions, I don't pause and form a differential before I look at the question. But I do find myself eliminating diagnoses as I'm reading through the vignettes. Not sure if that's the same thing or not. If not, then I'll have to try what you're suggesting. Thank you.

Here are my SHELF scores:

FM - 75 (64th percentile)
OB/GYN - 73 (~40th percentile)
Psychiatry - 75 (45th percentile)

I still have a couple more to go.

Tbh, I worked my tail off for my FM SHELF. I over-think questions pretty hard and I am sub-standard test-taker. No matter how hard I try, I fall right at the average for the nation.

For instance, for FM, I did 1600 AAFP questions along with Case Files. I am fairly certain that if I hadn't missed the 4 questions that I over thought, I would have probably gotten an 80, resulting in a higher percentile. It's just the nature of the game. There's so little difference between each of the scores. So little.

So, don't kick yourself. Just try as best as you can. And tbh, average for the country for Step 2 is a 240. If you are scoring right at average or a little below, that means you are right around 240. That's a really decent score. And nothing to be ashamed of.

Really appreciate your thoughts. I'm sorry you're in a similar situation. But you're right, just doing as best I can now. Hope your situation improves as you progress along the year.

 

[Planes2Doc]

Number one test taking error I see people making on shelves and steps: not thinking clinically.

Per the nbme 's published materials, they write questions that reward students who think clinically and penalize those who don't.

For every single question, you must verbalized to yourself your diagnosis or your top 4-5 differential. Too many people skip this step and start trying to treat lab values or symptoms or vitals, etc.

For example, pt with cough and sob. If the rest of the vignette puts PNA or ptx at the top of your ddx, then a cxr would be your test of choice. If the vignette made lung cancer or a PE your primary concern, then a chest ct scan is what you want, or a v/q scan if you're thinking PE but the SCr is too high. If the vignette pointed to something like a tension pneumo then obviously you'd want to do an intervention rather than a test. The important thing is to think clinically, make your diagnosis or ddx, and then treat that or work it up. Too many people see the cough and sob and reflexively pick cxr (or something the high SCr) instead of thinking it through and making a diagnosis or ddx first.

You're amazing!

 

[operaman]

That's an interesting spin operaman! You raised some major errors of way that I'm equally guilty of in how you might skip over the diagnosis and rolling differentials. Clinicals and Step 2ck seem to be widely different than how we may have prepped for step 1 and basic science years (less rote memorizatoin and fact recall).

What I've noticed at least with many of the popular text and review books mentioned in these rotations threads that I've tried previewing, is that it's somewhat challenging to apply what you have read into a frantic 1-minute or less mental grind when doing that test question... and then, we're not talking about just one question under such timed constraints but many hundreds thereafter and for like the step 2ck, 300+. I'm sure that also puts a potential dampener on performance in the psychological sense.

What kind of resources for each of the rotations did you use for your to apply yourself to "verbalize" and approach shelf exam questions that way you were describing? Does this methodology also apply to when you're on the wards and during rounds? Or is that where textbooks or up to date learning come into play? I've seen a mix of posts where some learn much more through doing questions but not sure how that aids whens you're not being examined (e.g. shelf exams, step 2ck) but are now caring for a patient.

For resources, I made a point to get through 2 question sources for each rotation. I used pretest and Lange q and a; in retrospect j think case files may be better. In reality it doesn't matter - all the resources cover the same material more or less. UWorld is far and away the best and I would also use it, but the other resources have shorter questions that were easier to get through quickly. The key is actually completing a couple of them so you get a look at the full scope of what you'll be asked.

Clinical thinking definitely comes into play on the wards as it's the very thing one does there. Make a diagnosis and then treat, or make a differential and work up - roughly the framework of clinical medicine. It's why shelves and steps (not counting step 1 of course) respond so well to this approach. It's hard to do it on a test because it's so condensed into a vignette and it's easy to get distracted but buzz words and abnormal values and symptoms. Make the mistake of latching on to a tiny piece and you'll surely pick the wrong answer that was placed there to capitalize on just such an error. Sometimes the distracting things are images and ekgs- imagine an ekg sowing some tachycardia and possible ST depression - easy to think the question is about management of an nstemi and miss the PE entirely because you overlooked the rest of the vignette and all the things pointing to the actual diagnosis.

 

[pbnmac]

Impressive mindset to have and learn from! Thank you! I think we're onto something and hopefully the original poster and others get a chance to see your comments. The emphasis here is the multitangentional exposure to a variety of stylized questions!

How were you able to pull and create a rolling list of differential diagnosis from just questions?

What I meant was, rarely do the explanations themselves list a series of differentials to consider if questions become the primary source. Some question sources are sectioned off by system or chapters and I guess that's one way to begin compartmentalizing differentials to continually think about. Some practice questions from what I've seen depending on their quality, might also list related diseases to rule in/out and I guess that's one way of building a list of differentials when reading through their corresponding explanations. Uworld has some scattered tables listing a set of related diseases that you could learn to compare and contrast from. It would be awesome if they had something like that for every question being that they're mega millionaires now and can probably hire people to do that

I've seen others mention the I-VINDICATE or VITAMIN C mnemonic but haven't explored how one could build that from just questions unless I'm missing something when interpreting the explanations and written clinical question. It's probably one of the biggest sticking points during the wards when your resident or attending asks, "Here's our patient presenting with... what's the differential diagnosis?" and you stare back blankly

• Vascular
• Infectious
• Traumatic
• Autoimmune
• Metabolic
• Idiopathic/iatrogenic
• Neoplastic
• Congenital

I haven't seen differentials listed as such in any review book like first aid for Step 2ck but have seen them sometimes listed in the bigger textbooks like Blueprints and Case-Files. There's a popular free mobile app called diagnosaurus that has a list for a lot of conditions and presentations but quite intimidating to learn from unless you look up every point listed separately in another resource.