Third year and shelf struggles

[KnightofBaldMt]

---

Members don't see this ad.

My third year track record has been less than stunning. I feel like I've been hit with wave after wave of either anxiety/depression/imposter syndrome over this year. I got my Step 1 score back (pretty terrible, 1 SD below my practice tests) and then turned around and failed the subsequent Neurology shelf. I've failed a total of two shelves this year, while passing two others around 45-50th%. One of these shelves happened to be the field I think I want to go into. I scored 80th%+ on the four NBME practice exams then scored 47th% on the real deal. Another kicker is the fact that all my evals are good and generally receive very positive comments and would honor most if not for my shelves. I've never been cited on my evals for lack of knowledge. I'm supposed to be re-taking the Neuro shelf over break, but I'm didn't pass my last NBME practice. I'm at a loss.

Education counselors suggested I have test anxiety, but my meeting with a psychologist about it wasn't helpful. She didn't have much to tell me except for diaphragmatic breathing. While that is helpful, not exactly new or groundbreaking for me.

I am getting married the summer between MS3/MS4. If I fail either of my two make-up shelves again, I will end up having a rotation during my month off for wedding and part of my Step 2 study period. While I know Step 2 doesn't take as much time for others, my track record and needing to make up for Step 1 indicates I need that time. I also feel like I need to have my Step 2 CK back before Sept 15 since I'm probably facing an uphill battle anyway. Only thing I have going for me is good research, but I know that only adds and doesn't make up for your shortcomings on apps.

I'm not sure what I can or should be doing differently to improve.

TL;DR- I'm systematically performing lower than benchmarks and I have failed two shelves. I don't know how to salvage my performance and I'm pretty discouraged.

 

[NYCdude]

Seems like your preparation isn't an issue if you're hitting >80% on the NBME's. It probably is test anxiety or something during the real deal that causes you to simply not think how you usually do when taking practice exams.

My advice for relaxing is to simply not give a **** about what happens and just take the test wanting to destroy it with a vengeance. Focus on the questions, reason out what the best answer is, click that **** and move on to the next one until you're done. Thinking about what happens if you fail and all that other negative stuff will make you spend way too much time second guessing stuff during the exams and cause you to lose your natural thinking flow.

Be confident in the fact that you adequately (or more than adequately) prepared and trust your reasoning and stomp those shelves.

 

[Redpancreas]

My third year track record has been less than stunning. I feel like I've been hit with wave after wave of either anxiety/depression/imposter syndrome over this year. I got my Step 1 score back (pretty terrible, 1 SD below my practice tests) and then turned around and failed the subsequent Neurology shelf. I've failed a total of two shelves this year, while passing two others around 45-50th%. One of these shelves happened to be the field I think I want to go into. I scored 80th%+ on the four NBME practice exams then scored 47th% on the real deal. Another kicker is the fact that all my evals are good and generally receive very positive comments and would honor most if not for my shelves. I've never been cited on my evals for lack of knowledge. I'm supposed to be re-taking the Neuro shelf over break, but I'm didn't pass my last NBME practice. I'm at a loss.

Education counselors suggested I have test anxiety, but my meeting with a psychologist about it wasn't helpful. She didn't have much to tell me except for diaphragmatic breathing. While that is helpful, not exactly new or groundbreaking for me.

I am getting married the summer between MS3/MS4. If I fail either of my two make-up shelves again, I will end up having a rotation during my month off for wedding and part of my Step 2 study period. While I know Step 2 doesn't take as much time for others, my track record and needing to make up for Step 1 indicates I need that time. I also feel like I need to have my Step 2 CK back before Sept 15 since I'm probably facing an uphill battle anyway. Only thing I have going for me is good research, but I know that only adds and doesn't make up for your shortcomings on apps.

I'm not sure what I can or should be doing differently to improve.

TL;DR- I'm systematically performing lower than benchmarks and I have failed two shelves. I don't know how to salvage my performance and I'm pretty discouraged.

First thing I’d say is accept who you are completely and still love yourself for whatever other strengths you possess. You do not objectively have the combinedknowledge base+application skills as others in your class have. Stop looking for that one reason to explain it.

1.) Test anxiety is a thing but it’s never going to go away completely regardless and most people suffer from it are on a spectrum. (Exercising directly before the exam and avoiding caffeine a week prior helped me but it’s not a panacea obviously.)
2.) You have a pattern of poor testing performance despite the one practice NBME where you scored 80th.
3.) Clinical rotations which are half people skills, half execution aren’t really the place where knowledge gaps are identified. Attendings either ask impossibly tough questions if they’re intense (in which case everyone gets them wrong) or they ask things they remember being high yield after 5+ years out of Step 1 so they’re not too challenging.

Now that that’s clear, what are you going to do about it? As much as people champion hard work and hitting the books for shelves, it’ll take time to develop a knowledge base and learn how to apply it. You’ll have to work harder and do more questions than your peers. You’re going to have to look back more and google things more often. Other priorities will take hits. Also, as contradictory as this sounds to the whole tone I’ve set, you have to relax. Sounds like mental health is becoming a contributing factor. You have to be ready to at some point accept your performance is where it’s at after you put in “X” amount of work or else you’re work will start backfiring . That’s the essence of keeping anxiety at bay. If improving your knowledge base is that important to you for future exams, then take a serious, broad approach and commit to it. Otherwise, clinical honors/HP is still a relatively competitive mark.

 

[operaman]

Sorry to hear you're having some struggles with this. A few thoughts/suggestions:

1) Are your practice NBMEs taken under actual test conditions? If not, try taking them under more test-like conditions so you have a more accurate predictor.
2) I would consider seeing another professional such as a psychiatrist. If your educational specialists and the psychologist have both suggested this may be playing a role yet have nothing helpful to offer, then it might be worth seeing someone who may have additional options.
3) What other preparation are you doing? Are you getting enough practice questions in during your practice time?

Overall it's hard to figure out what you're doing without seeing you take a test or do some practice questions. I'll tell you my secret for shelves and Steps 2 and 3. Basically it comes down to this: for every single question, before you even think about answering it, ask yourself this question: what is my diagnosis?

It amazes me how often this step gets overlooked, but it's absolutely critical in answering clinical test questions. If you read the NBME's publications in the academic literature, you will see them talk endlessly about creating questions that require this kind of clinical thinking, for this is a crucial aspect of real life clinical medicine.

So what is your diagnosis? How specific a diagnosis can you make? Spend a little time thinking about this because it's the key to doing well on these exams. If the question stem is asking for a diagnosis, then your work is done at this stage and you know they will have given you enough information to make a diagnosis or create a differential diagnosis with one choice that's clearly more likely than the others. Where this method really shines is in "next step" sort of questions.

Here's a simple example I've posted a few times before but I think illustrates the point. Consider these similar questions:
1) 43yoM presents to the emergency department with weakness and shortness of breath and cough for 5 days. Has tried OTC cold medicines without improvement. Denies chest pain. No significant past medical history. Non-smoker, non-drinker. Febrile to 101.9 Pulse 101, RR 18. Coarse breath sounds, left sided ronchi. Which of the following is the best next step in diagnosis and management?
1) Chest CT scan
2) Complete blood count
3) Chest xray
4) Blood cultures
5) EKG

2) 65yoM presents to his PCP with weakness and shortness of breath. This began 4-6 weeks ago and has been slowly progressive. Associated symptoms include cough, night sweats, a 20 pound weight loss over the last 2 months. He has a 50 pack-year smoking history. Afebrile, pulse 85, RR 16. No clubbing or LE edema. Which of the following is the best test for making the diagnosis?
1) Chest CT scan
2) Complete blood count
3) Chest xray
4) BNP
5) EKG

3) 65yoM presents to the ED with weakness and shortness of breath. This has worsened over the last 3 weeks and now he gets short of breath just from moving around his house. Associated symptoms include weight gain and cough. Denies chest pain. He is afebrile, pulse 95, RR 24, SpO2 89% on room air. Exam notable for bibasilar crackles, bilateral LE pitting edema. Which of the following is the next most appropriate test to order?
1) Chest CT scan
2) Complete blood count
3) Chest Xray
4) Echocardiogram
5) Arterial blood gas

Ok so three similar presentations with some little tweaks here and there. All the answer choices are reasonable choices, but only one is the clearly correct answer. These questions can throw you off if you're not thinking of your diagnosis. So for question 1, the patient is presenting with what is likely a community acquired pneumonia, and a chest xray will allow you to make your diagnosis. Question 2 is basically screaming cancer for which a chest CT scan would be the appropriate test for making the diagnosis. Why not the xray? Because you will still order the CT regardless of the xray findings. Number 3 looks a lot like a CHF exacerbation for which the best test would be an echo. Would you order the others? Probably, but the echo is the most important one. Steps and shelves probably won't be that tricky or will give you enough other information to make the correct answer completely unimpeachable.

It's easy to imagine how I could have altered those vignettes to give you a COPD exacerbation or A-fib with RVR or PE or some restrictive lung disease, a child with CHF, or a dozen other things. It's important that you actually make a diagnosis or else you'll fall into the NBME trap of picking tests for symptoms rather than a diagnosis.

 

[Gingi]

sent you a message. check please.