Dr. M

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Hi everyone,

i am a third year medical student and needless to say, had heard from almost every upperclassman that third year was going to be amazing. I started off my rotation with pediatrics and stupidly took the Step 1 four days before the start of my rotation. So, when i got into peds, i was exhausted. my brain literally could not process any words. I did great on my evaluations because I still remembered stuff from studying step 1, but got a 16% on my shelf. my reasoning was because I sisn't study. Then my next rotation was family medicine. I got at 26% even though I studied from the first day to the last with NMS Family medicine, internal medicine review, ob/gyn review, Boards and Wards (I read every topic except general surgery). because of so much other things going on, I took a leave of absence for a month just to calm myself done. never have i felt so stupid in my life and it didn't help being surrounded by classmates complaining that they only scored a 90% on their shelf. So my next rotation was ob/gyn. this is the career i want to pursue, so I decided to give it my all. I read blueprints Ob/Gyn three times and took notes on the whole book. i read case files for ob/gyn 2 times and did all the questions. i did questions from USMLE world and got 60-70% on them and finally I did the blueprints quiz at the end of the book and got a 85% on it. I felt great. All I wanted was at least a 75% on the shelf. Instead, I got a 24%. In all three of my shelf exams I answered 65/100 questions correctly. Nothing more, nothing less. I am soooooo frustrated. I think I had a nervous breakdown after seeing the results. Is there any advice for why this is happening? And will this hurt me in applying to residency programs. I want to go to more of a community based hospital rather than a university program. It is just frustrtating because I do get great evaluations from my attendings and really can interview patients, write notes, answer questions as much as I can, but i can't do well on the shelf.

Help! please......
 

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Hmmm, don't know what to tell you. Have you always done poorly on standardized exams? If so, then this shouldn't be much of a surprise. How did you step1 score come out.

If you have done well in the past, then this sudden downturn is pretty surprising. Are you getting really nervous during the exams? how do you feel when you walk out of the exams?
 

efex101

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It is not that easy to do well on the shelf exam. It seems unreal that getting a 68/100 can sometimes correlate with very low percentiles...sucks.
 
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First, what's the weight of the shelf grade? I know of places where it's the bulk of the clerkship grade and others where the evaluations take a bigger chunk. Either way, those aren't exactly impressive grades. What do you think was the problem? Was it that you just didn't know the information? (That seems unlikely) Or was it that you had problems interpreting the questions and applying the info? Have you tried talking to your attendings about these problems?
 

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I got a 204 on my Step 1 and I have done goodstandardized tests - SATs I got a 1380 and on my MCATs I got a 30 (10 V, 10 P, 10 B). I am by no means angry that I didn't get a 90%, but I did almost every type of learning strategy whether it was to write notes, or just read and highlight, or read it out loud, and I did questions. I mean I heard USMLE world was a great resource and I did ok on it. The shelf exams are worth 40% of the grade, but eitherway, I still get a pass.

When I walked out of the shelf exam, I felt good. i took the test slowly and went over the exam twice. I wrote in the margins what the question was asking and I was able to finish the exam with 10 minutes to spare. After the exam, i talked to a few students and on certain questions that I had trouble figuring out, we all got the same answer. I felt prepared and confident. I get nervous about exam, but i think everyone gets nervous.

It is hard for me to swallow that i am doing this poorly. I feel like a singer auditioning for american idol, thinking i am good, but in reality i stink.
 
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From the books you list, it seems like you'd likely benefit from doing a lot more practice questions prior to the start of your shelf exam. Pre-test, Appleton and Lange, and even signing up for the year plan of USMLE world would probably help you to become familiar with the types of questions you'll be seeing on the exam.
 

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Hmmm, don't know what to tell you. Have you always done poorly on standardized exams? If so, then this shouldn't be much of a surprise.

Are you mean, dumb, or psychotic?

I don't know any trick to doing better on the exams. If I can offer anything, I would advise trying to protect as much studying time during rotations as possible (ie, be busy when you need to, then just be pagable when you don't.) Good luck. Shelf exams are no fun, but you'll survive.
 

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Instead, I got a 24%. In all three of my shelf exams I answered 65/100 questions correctly. Nothing more, nothing less.

Hey, sorry to hear about your predicament. I am confused about your story, though. At my school, they only give us 1 grade for the shelf. I'm still not sure whether it's a precentage or percentile. I've asked the various clerkship coordinators and they've all told me that the NBME only reports 1 score and they're not clear whether it's a raw or scaled score.

So, what do you mean by you scored 24% but got 65% correct? Is one of these a precentile? Also, have you failed any clerkship or gotten a conditional d/t your shelf scores? If you haven't failed anything, I think you'll be OK for residency. Maybe consider taking step 2 early to help your residency application.
 

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At some schools they give you a pdf file where your raw score can be seen as a percentile. Depending on when you took the shelf the percentile of the same raw score goes up or down. My school says YOU got X right out of 100 but then clerkship directors use the PERCENTILE to determine who can get H/HP. I for some reason thought this was the norm....guess not.
 

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At some schools they give you a pdf file where your raw score can be seen as a percentile. Depending on when you took the shelf the percentile of the same raw score goes up or down. My school says YOU got X right out of 100 but then clerkship directors use the PERCENTILE to determine who can get H/HP. I for some reason thought this was the norm....guess not.

It's the norm at my school, with the exception that we are never told our raw score, only percentile. The percentile score is also used as a cutoff for pass/fail in the rotation.
 

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In my school, we get the number of questions right and then a percentile on it relating to last year's scores. I have heard that Step 2 is similar to the shelf exams and I don't feel comfortable anymore to take it early. I am thinking about taking it in october to give myself the option of giving it to programs or not. I have not failed anything and pretty much have been consistent, it just sucks to work so hard to get that grade.
 

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I have heard from many students that the shelf questions are harder than those on step 2...
 

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The step II questions and the shelf questions are from the exact same bank. They don't discriminate at all regarding whether the question will appear on a shelf versus step II. This is according to our clinical program director.

He also said that people often perceive step II to be easier because they are usually taking it after all of 3rd year rotations, probably a subI or two and whatever electives they took in between.

I'm in a similar boat, that is my shelf scores are not amazing. I'm just glad that nobody will see them besides me.
 
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I have never heard of the shelf and Step2 questions being part of the same bank of questions. I personally found Step 2 to be much easier than the shelf exams I took. The questions were much less specific. However, the patient vignette style of question what almost all the the Step 2 questions are modeled after. Read the advice in the Step 2 forum here on SDN and you will see most people thought USMLEWorld is the best question bank to use when preparing for Step2....I found it was great. You can start reviewing FirstAid or Crush, whatever books you prefer now start using USMLEworld as you go. Step 2 studying I found to be a longer, but much, much less intense process than studying for Step 1. Review gradually over the next few months and do a ton of questions.
 

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This is what our 3rd/4th year director told us and this was supported by an attending in our Neuro department who has "sat on committees" writing step I, step II and neurology shelf questions. There are several reasons, other than an actual difference between the shelf question content, that could explain why an exam you take after 16 months of clinical experience could be easier than a similar exam that you take in your first 5-10 months of clinicals, a definitely why it may seem more reasonable than step I.
 

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Rumor has it that the shelf questions are actually the step 2 questions from about 2 years ago. I personally sucked it up on my first few shelfs, then started to concentrate on questions with explainations as my major study aid and did much better. They also have some overlap between specialties, so as you go on they tend to seem easier.
 

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I got a 204 on my Step 1 and I have done goodstandardized tests - SATs I got a 1380 and on my MCATs I got a 30 (10 V, 10 P, 10 B). I am by no means angry that I didn't get a 90%, but I did almost every type of learning strategy whether it was to write notes, or just read and highlight, or read it out loud, and I did questions. I mean I heard USMLE world was a great resource and I did ok on it. The shelf exams are worth 40% of the grade, but eitherway, I still get a pass.

When I walked out of the shelf exam, I felt good. i took the test slowly and went over the exam twice. I wrote in the margins what the question was asking and I was able to finish the exam with 10 minutes to spare. After the exam, i talked to a few students and on certain questions that I had trouble figuring out, we all got the same answer. I felt prepared and confident. I get nervous about exam, but i think everyone gets nervous.

It is hard for me to swallow that i am doing this poorly. I feel like a singer auditioning for american idol, thinking i am good, but in reality i stink.


This may be hard to swallow, but your performance sounds concordant. A 204 Step 1 is about 2/3 of a standard deviation below average, which is about 25-th percentile, which sounds to be where you've been overall performing on the shelf exams.

Your 30 MCAT and 1380 SAT probably correspond, respectively, to slightly below average and slightly above average for incoming med student credentials, which means you're underperforming a bit in med school, but then again, med school is very much hard work and rote memorization, whereas the MCAT and SAT do have more of a raw brainpower/reasoning component to them.
 

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You know, your comment is rather hard to swallow. first of all, i am competing with the top 10% of the smartest students in the nation. I by no means am amzingly brilliant. But, what I do have is an emotional intelligence. Although i may not be scoring above average, I have received even in my first rotation excellent evaluations from both attendings and residents. that to me is more important than scoring above average. yes, it may help me get into a better residency, but what I have seen in my school is that the people that have received honors in their clerkships lack social interaction with patients and fellow colleagues. My personality and kindness will take me far. I am a hard worker. I don't slack off. I study every chance that I get. Some people think differently than others. I am just going to keep on trying to work hard. To be told by a stranger that my performance is below average is not going to affect me at all. my goal is to be a compassionate physician. That is something that is not taught in school, that comes from life experience. So, I may not be the top-seated student in my class, but i possess qualities that will get me far in the future.
 

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Hi,

I am also doing poorly on shelf exams. IT's so frustrating because I keep getting outstandings on the clinical portion but do poorly on the shelves which takes my outstandings down to advanced. Also I just got my peds shelf exam score and I did not pass by two points. I feel terrible terrible. Should I drop out of med school? I feel so stupid about this. I never have time to finish these exams and I feel like the dumbest thing on this planet. How can I improve? I really don't know what I'm doing wrong.

I mean I have always had a hard time with standarized testing and because English is not my first language I read very slowly so I have to read a question several times. Can someone please offer me some suggestions? At this point I really feel like dropping out.
 

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Tomorrow is my OB/GYN OSCE exam... it'll be like pulling teeth. I'm going down hard and fast in the first round. I'm sick of being constantly under this kind of pressure. I'd quit if I weren't one year from finishing.

All that to say... you aren't alone.

Well, the thing is that I did badly on my peds shelf. I missed two points so I did not make the pass level so I have to retake it. I don't know how to take these exams apparently. I feel so so so dumb. If I fail it again, I'd have to repeat the rotation and I would get a fail on my transcript. Who would take me up for a residency then? I don't want to get kicked out of med school after making it this far. Can we buy these subject tests from the NBME?
 

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Medquest - As far as not finishing the exam in time, have you tried glimpsing at the last sentence and the answer choices first? Sometimes the massive paragraph is entirely irrelevant and you can skip it. Also, if a question is particularly hard, do you pick something, mark it, move on, and possibly come back to it later? I find that helps, not only time-wise but also with mental energy, which is gone at the end of those things.

Dr. M, first, there are people that are rocking those shelves that aren't complete tools and have excellent people skills. I know many. Second, have you looked at the Case Files series? I was bored to tears with every other book, did questions, etc.; my scores were mediocre. I can't retain much from the disjointed info presented in most of the recommended books. My scores jumped dramatically with far less effort when I started reading case files. Give it a shot...good luck!
 

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Medquest - As far as not finishing the exam in time, have you tried glimpsing at the last sentence and the answer choices first? Sometimes the massive paragraph is entirely irrelevant and you can skip it. Also, if a question is particularly hard, do you pick something, mark it, move on, and possibly come back to it later? I find that helps, not only time-wise but also with mental energy, which is gone at the end of those things.

Dr. M, first, there are people that are rocking those shelves that aren't complete tools and have excellent people skills. I know many. Second, have you looked at the Case Files series? I was bored to tears with every other book, did questions, etc.; my scores were mediocre. I can't retain much from the disjointed info presented in most of the recommended books. My scores jumped dramatically with far less effort when I started reading case files. Give it a shot...good luck!

Thanks for your response. I have tried reading questions quickly and I'm glad I did because there were several questions that I happened to quickly glance at the end and I think I was able to put the right answer. But for both this peds and even for my psychiatry shelf exam, I was unable to answer about 15-18 questions because I ran out of time. I was able to pass my psych shelf though. I'm just so terrified of being kicked out for this after all these years in med school. What resource can I use? Can I buy samples of these tests? Im feeling kinda desperate and frustrated at this point.
 
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how long do you guys have to take shelf exams? i thought the norm was 2 hrs and 10min, but have heard from students at other schools they sometimes get up to 3 hours! for me, timing is one of the hardest parts about these exams.
 

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Yes, we get 2 hours 10 mins. But I am a very slow reader. I am able to answer about 80 questions in the time frame that they give us, which I think is part of what hurts me the most. I don't know how to fix this. I have worked so hard to get dismissed now. I am a few shelf exams away from being a doctor, but if I fail, I'm done. I have no idea how to fix this though. The question books like Pretest or Appleton and Lange seem to be entirely different from the questions they ask, especially the length. I have no idea how to get through this.
 
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Yes, we get 2 hours 10 mins. But I am a very slow reader. I am able to answer about 80 questions in the time frame that they give us, which I think is part of what hurts me the most. I don't know how to fix this. I have worked so hard to get dismissed now. I am a few shelf exams away from being a doctor, but if I fail, I'm done. I have no idea how to fix this though. The question books like Pretest or Appleton and Lange seem to be entirely different from the questions they ask, especially the length. I have no idea how to get through this.


Those question books are different from the shelf exams. I always found both A & L and Pre-Test pretty far from anything on USMLE Step II or the shelf exams. The shelf exams are more detailed than Step II.

My best prep for the shelfs was to read. I read about the conditions that my patients had and then covered all of the entities in First Aid for the Wards for each rotation.

In terms of difficulty I would rank the shelf exams in order of difficulty:

Most difficult: Peds, Internal Medicine, Family Medicine
Somewhat difficult: Surgery, OB-Gyn
Not at all difficult: Psychiatry

Many of my classmates put Surgery in the Most Difficult category and some put OB-Gyn into the "Not at all difficult" category.

My USMLE Step II had long scenarios but the test was definitly easier in many ways that USMLE Step I. Since Internal Medicine was my last 3rd year rotation, I took Step II in August (at the beginning) of my fourth year. Step II was mostly Internal Medicine and after that hard shelf, I really focused on Medicine. After Match Day, I went on vacation and showed up only to pick up my degree.

As opposed to doing tons and tons of questions, try focusing on clinical entities. Do some questions if you like but really get a good reveiw book and master those clinical entities for each rotation. For example: On Internal Medicine, I would focus on Emphysema, it pathology, it's clinical signs and symptoms and it's clinical course/treatment. I would then focus on Asthma and do the same thing.

I made concept maps of each disease entity and studied those. This worked far better for me than doing questions. I was able to focus on what was being asked and get right to the anwer faster.

I hope this helps.
 

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Hi and thank you for your suggestions. I think I face two major problems: The first is lack of time to study. For example, I only had about 1 week to study for peds shelf. I also went to a site that was really slow and was unable to learn much. What book should I read for peds shelf? I tend to do some questions but try to much more heavily read but i find myself very tired when I get home and with no time to read. Also again because of how slow I am in reading, it takes forever. Second, lack of time in the exam kills me. Again, I missed the pass level by 2 points, and I didn't get to answer really about 20 questions. I would like to find a way to fix this because had I gotten only even half of those questions right I may have even gotten a high pass on the exam. Could you possibly suggest a way for this? I know my director at my current rotation commented that she knew a brilliant student who kept failing Step 3 but he found a way to pass after trying certain techniques but she didn't really elaborate. If you could provide with any suggestions in regards to that, I'd be very grateful.
 

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Dang, this is a tough problem, and if you're studying like you say, then I, like you would intuitively expect higher percentiles. It's a bit difficult for me to relate because with relatively little studying I come out of standardized tests like the shelf examines looking like a superstar, which was convenient for me because I did NOT have superstar in-house grades. It seems that perhaps some people are better at these tests than others. Which brings me to the thought about your anxiety level during tests. You sound anxious about this and it can at times become a self-fufilling prophecy. Ever tried some propranolol prior to testing? Or perhaps treating the anxiety with either CBT (CBT is the therapy of chocie for like everything, so just in case you're stumped on the psych self - guess CBT) or and an SSRI? I have a colleague who uses propranolol before tests and his scores went up. One last thought any drinking or other recrational drug use. You do not have to answer, but this can affect the memory, especially the marijane. Sleep enough, get exercise, eat nutritous? I wish you luck.
 

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Hi, well I unfortunately do very well clinically and with patients, and attendings love me in general. But again the whole shelf exam thing is killing me. Can I ask how you study for shelf exams? Like, for how long do you study, what do you read/how many times, do you do questions? If you could offer some info on that, that would be great. also, no, no drug/alcohol use of any kind. I am normally anxious and a bit OCDish, which makes me a perfectionist and I believe I certainly have ADD since I cannot concentrate at all! Not to mention English is not my first language. I also don't know who to talk to. I feel so embarassed about this. :(
 

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Hi, well I unfortunately do very well clinically and with patients, and attendings love me in general. But again the whole shelf exam thing is killing me. Can I ask how you study for shelf exams? Like, for how long do you study, what do you read/how many times, do you do questions? If you could offer some info on that, that would be great. also, no, no drug/alcohol use of any kind. I am normally anxious and a bit OCDish, which makes me a perfectionist and I believe I certainly have ADD since I cannot concentrate at all! Not to mention English is not my first language. I also don't know who to talk to. I feel so embarassed about this. :(

I personally pick up a lot by osmosis, but for actually studying: questions, lots and lots of questions. Remember the test is asking you mostly to differentiate the possible diagnosis. If the question tells you something it is important and not random filler for the differential - I mean a normal set of vitals tell you so much for instance - like if you're given an ALOC case, and there is no fever, are you going to look for bacterial meningitis? Study for the test getting used to moving through differentials with practice questions and remember the right answer in the "most likely" answer.

As far as medication. Go to student health. Ask to be tested for ADD and request anxiety medication for the test. If you're not sold on trying an SSRI, try a low dose of propranolol (10mg) prior to testing. I'm no expert, but you wont be the first student the docs at student health have seen with this problem.
 

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I just wanted to add my 2 cents. I struggled with my shelf exams too. But did well on Step II. The difference? Practice questions. I noticed by the end of third year that the time I spent doing questions correlated with my grade more than reading in general.
 

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For medstudentquest,

I really understand exactly what you are going through. I also think I have ADD because I will read something over and over again and still need to read it one more time. My problem is is that I need like a hint during my pimping from residents and then I can explain the answer. Unfortunately, you don't get hints during the shelf exam. Surgery is my last rotation and I am trying yet another endeavor. I am reading Lawrence to get a good foundation and supplementing it with First Aid. I have Appleton and Lange questions that I do after every chapter, and i do USMLE world questions. Also, I have Case Files in Surgery that I read and Clinical Vignettes Surgery that I read before I go to sleep (it hopefully will help me for my oral exam) and I am planning on doing question after question for the last couple of weeks of my rotation.

And to those that I may have offended by my comment - I never meant to say that people who do get the 99% on the shelf or honors on their rotation are tools or complete *****s when it comes to bedside manners. I was more upset with a few of my classmates that actually do well on their exams AND are tools. When we are in a group of students and we talk about exams and performance, it is always those students that say something negative or look at you as if you were stupid. That just bugged me and unfortunately, I took it out on a reply to WatchingWaiting and I apologize.

I have to say that I feel okay more as I read messages from fellow students who are also in the same boat. I have learned that there is so much more to medicine that just grades and I think that if you understand the material, but are not getting those amazing scores, you can prove your intelligence in another area, like during pimping or during patient presentation.
 

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Thank you everyone for your answers. I think I will try to get some meds to control the anxiety and possibly try to get something for the lack of concentration. I'd really like to do well on my current rotation. I'll try to do more practice questions and see if more practice can possibly help me with the speed and reading comprehension issues. Thanks again!
 
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