How to study for the NBME clinical shelf exams during medical school.

1. NBME Subject Examination
Strategies

2. NBME Subject Exams
 During 3rd year, you will have to successfully pass a
subject exam for completion of each clerkship.
 Exams include Psychiatry, Surgery, Pediatrics,
Medicine, Obstetrics/Gynecology, and Family
Medicine.
 Ob/Gyn requires a score at the 22nd percentile to
pass.
 Family Medicine requires a score at the 4th percentile
to pass.
 The other 4 clerkships require a score at the 11th
percentile to pass.

3. Exam Format
 Exams are paper and pencil format.
 Each exam contains 100 multiple choice questions.
 130 minutes is allotted for each exam.
 That works out to 1.3 minutes per question.
 Clinical vignettes vary in length.
 Common lab values will appear on the front and
back covers of the exam booklet.

4. Exam Strategy
1. Begin each item by reading the question at the end
of the vignette.
2. Scan the answer choices and familiarize yourself
with them.
3. Read the entire vignette looking for clues to answer
the question.
By doing this, it allows you to know what you are
looking for when reading the vignette. If you do
not do it this way, you end up reading the vignette
blindly.

5. Sample
 The following few slides contain a sample item from
the NBME Subject Examination guide.
 These slides will demonstrate the aforementioned
techniques.

6. Read the Question
A 37-year-old woman comes to the physician because of a
3-year history of intermittent, mild, diffuse abdominal
cramps and bloating. Her symptoms occur after meals and
are relieved with bowel movements. She also has
constipation four to six times monthly. She says the
constipation resolves spontaneously, but she sometimes has
diarrhea for 1 to 2 days afterwards. She has not had any
other symptoms. She has no history of serious illness and
takes no medications. Examination shows no abnormalities.
Which of the following is the most likely diagnosis?
(A) Collagenous colitis
(B) Colon cancer
(C) Diverticulosis
(D) Inflammatory bowel disease
(E) Irritable bowel syndrome

7. Answer Choices
A 37-year-old woman comes to the physician because of a
3-year history of intermittent, mild, diffuse abdominal
cramps and bloating. Her symptoms occur after meals and
are relieved with bowel movements. She also has
constipation four to six times monthly. She says the
constipation resolves spontaneously, but she sometimes has
diarrhea for 1 to 2 days afterwards. She has not had any
other symptoms. She has no history of serious illness and
takes no medications. Examination shows no abnormalities.
Which of the following is the most likely diagnosis?
(A) Collagenous colitis
(B) Colon cancer
(C) Diverticulosis
(D) Inflammatory bowel disease
(E) Irritable bowel syndrome

8. Clues in Vignette
A 37-year-old woman comes to the physician because of a
3-year history of intermittent, mild, diffuse abdominal
cramps and bloating. Her symptoms occur after meals and
are relieved with bowel movements. She also has
constipation four to six times monthly. She says the
constipation resolves spontaneously, but she sometimes has
diarrhea for 1 to 2 days afterwards. She has not had any
other symptoms. She has no history of serious illness and
takes no medications. Examination shows no abnormalities.
Which of the following is the most likely diagnosis?
(A) Collagenous colitis
(B) Colon cancer
(C) Diverticulosis
(D) Inflammatory bowel disease
(E) Irritable bowel syndrome

9. Answer the Question
A 37-year-old woman comes to the physician because of a
3-year history of intermittent, mild, diffuse abdominal
cramps and bloating. Her symptoms occur after meals and
are relieved with bowel movements. She also has
constipation four to six times monthly. She says the
constipation resolves spontaneously, but she sometimes has
diarrhea for 1 to 2 days afterwards. She has not had any
other symptoms. She has no history of serious illness and
takes no medications. Examination shows no abnormalities.
Which of the following is the most likely diagnosis?
(A) Collagenous colitis
(B) Colon cancer
(C) Diverticulosis
(D) Inflammatory bowel disease
(E) Irritable bowel syndrome

10. Example
 Reading the question first, answer choices second,
and the remainder of the vignette last, allows the
person taking the exam to know what he or she is
looking for in the vignette.
 This is not the only technique. This was simply the
most common technique when students were polled.

11. Question Banks
 It is imperative to do practice questions in
preparation for the subject examinations.
 It would be a good idea to buy a 1 year subscription
to USMLEworld’s question bank.
 These questions are very similar to that seen on
subject examinations.
 Practice questions are the most important factor for
subject examination success.

12. The Exams
 Each of the subject examinations has its own
“flavor.”
 Some tend to have longer vignettes(psychiatry,
medicine).
 Others tend to have shorter vignettes(family
medicine, ob/gyn).
 The following slides will focus on each of the 6
exams, including subject material, resources, sample
questions, and tips.

13. Family Medicine Subjects
 General Principles 1%-5%
 Organ Systems 95%-99%
 Immunologic Disorders 5%-10%
 Diseases of the Blood and Blood-forming Organs 5%-10%
 Mental Disorders 5%-10%
 Diseases of the Nervous System and Special Senses 5%-10%
 Cardiovascular Disorders 10%-15%
 Diseases of the Respiratory System 10%-15%
 Nutritional and Digestive Disorders 10%-15%
 Gynecologic Disorders 5%-10%
 Renal, Urinary, and Male Reproductive System 5%-10%
 Disorders of Pregnancy, Childbirth, and the Puerperium 1%-5%
 Disorders of the Skin and Subcutaneous Tissues 1%-5%
 Diseases of the Musculoskeletal System and Connective Tissue 5%-10%
 Endocrine and Metabolic Disorders 5%-10%
 Physician Task
 Promoting Health and Health Maintenance 15%-20%
 Understanding Mechanisms of Disease 20%-25%
 Establishing a Diagnosis 35%-40%
 Applying Principles of Management 20%-25%
 Distribution Across Age Groups
 Childhood 5%-15%
 Adolescence 5%-10%
 Adulthood 65%-75%
 Geriatric 5%-15%

14. Family Medicine Exam Basics
 The family medicine subject examination is like a mini
USMLE Step 2 exam.
 One must be proficient at medicine, pediatrics, surgery,
ob/gyn, and psychiatry to do well on this exam.
 For this reason, a passing score is set at the 4th percentile.
 Clerkship lectures are helpful for the exam, but other
resources must be used.
 If this is one of the last subject exams of 3rd year, less
studying is needed.
 If this is one of the first subject exams of 3rd year, more
studying will be needed.
 Questions are not written by family medicine physicians.
They are written by internists, pediatricians, surgeons, etc…

15. Family Medicine Resources
1. USMLE Step 2 Secrets
2. Boards and Wards
3. Case Files: Family Medicine
4. Current Diagnosis and Treatment in Family
Medicine.

16. USMLE Secrets
Short and too the point, but contains quite a bit of
information.
Question and Answer format.
Chapters separated by medical specialty.
Contains a few black and white photos.
Not a comprehensive resource.
The subject examination could easily be passed if using
only this resource.

17. Boards and Wards
Offers succinct summary of all major topics covered on
the subject exam.
Outline format, similar to the notes distributed during 2nd
year of medical school.
Contains many full color photos of dermatologic
conditions and other photos.
Breadth of information is great, but contains little depth.
May need to reference a larger textbook at times.
Excellent resource for the subject examination and
USMLE Step 2.
Easily reviewed the week before the shelf exam.

18. Case Files
To properly prepare for the family medicine
subject exam, you would need to study from all
case file books.
This book contains a smattering of subjects not
covered in the other case files, such as
prevention.
Not comprehensive enough to be used as a sole
resource for the subject exam.

19. Current Diagnosis and Treatment in Family
Medicine
Very useful for the in-house family medicine
exam.
Not as useful for the subject exam.
Very long, but contains good information.
Would be helpful with the shelf exam only if you
started reading it at the beginning of the
rotation.
Could not be easily review the week before the
subject exam

20. Recommended Strategy
 Start reading and annotating Boards and Wards at
the beginning of the rotation.
 Use a textbook of your choice to annotate if you feel
the information is not deep enough.
 Read Step 2 Secrets if you have time.
 Review the annotated Boards and Wards the week of
the exam.
 Do 50 USMLEworld questions per week. These
should cover all of the subject areas and specialties.

21. Medicine Subjects
 General Principles 1%-5%
 Organ Systems 95%-99%
 Immunologic Disorders 5%-10%
 Diseases of the Blood and Blood-forming Organs 5%-10%
 Diseases of the Nervous System and Special Senses 5%-10%
 Cardiovascular Disorders 15%-20%
 Diseases of the Respiratory System 15%-20%
 Nutritional and Digestive Disorders 10%-15%
 Gynecologic Disorders 1%-5%
 Renal, Urinary, and Male Reproductive System 10%-15%
 Disorders of the Skin and Subcutaneous Tissues 5%-10%
 Diseases of the Musculoskeletal System and Connective Tissue 5%-10%
 Endocrine and Metabolic Disorders 5%-10%
 Physician Tasks
 Promoting Health and Health Maintenance 10%-15%
 Understanding Mechanisms of Disease 20%-25%
 Establishing a Diagnosis 40%-45%
 Applying Principles of Management 20%-25%

22. Medicine Exam Basics
 The medicine subject exam very closely mimics the
material that medical students were taught during
2nd year of medical school.
 It is advantageous to have this rotation towards the
beginning of third year, so the material from year 2 is
still fresh.
 This exam is 2nd in the amount of testable material,
with family medicine being first.
 The exam is not hard to pass, but is fairly difficult to
break the 80th percentile.

23. Medicine Resources
1. Step Up to Medicine
2. Case Files: Internal Medicine
3. Blueprints: Medicine
4. High Yield Internal Medicine

24. Step Up to Medicine
Very thorough.
Outline format.
Separated by body systems.
If it’s not in this book, it will not be on the exam.
Very long and can take a very long time to read.
Need to read more than once in order to really take in all
of the information contained in this book.
Impossible if reading is not started the first week of the
rotation.

25. Case Files
Presents common internal medicine subjects in the
form of clinical vignettes similar to the subject exam.
Relatively complete.
Probably the 2nd best internal medicine subject exam
resource.
Not as much info as Step Up.
Not separated into body systems, just random cases.

26. Blueprints
Presents common internal medicine subject in
paragraph format.
Not as informative to Step Up
Comparable to Case Files, just a different
format.
Contains practice questions at the end of the
book.
Could easily pass the exam using this
resource.

27. High Yield
Not a complete resource by any means.
Contains high yield, useful topics for the exam.
Do not use this as your sole resource unless you
really know your stuff or you are in a serious time
crunch.
Great if used as an adjunct to another book,
especially the week before the exam.

28. Recommended Strategy
 Begin reading Step Up the first day of the rotation,
and read it everyday.
 Try to get through it twice before the subject exam.
 Do USMLEworld questions everyday, to prepare
yourself for the length of the vignettes.
 If you are in a time crunch, read Case Files.
 If you are in a serious time crunch, read High Yield.

29. Ob/Gyn Subjects
 General Principles 1%-5%
 Gynecology 45%-49%
 Promoting Health and Health Maintenance 5%-10%
 Understanding Mechanisms of Disease 15%-20%
 Establishing a Diagnosis 15%-20%
 Applying Principles of Management 5%-10%
 Obstetrics 45%-49%
 Promoting Health and Health Maintenance 5%-10%
 Understanding Mechanisms of Disease 10%-15%
 Establishing a Diagnosis 15%-20%
 Applying Principles of Management 10%-15%

30. Ob/Gyn Exam Basics
 The clerkship lectures are very high yield when it
comes to the Ob/Gyn subject exam.
 Much is expected from students on the Ob/Gyn
rotation, and students know more than they realize
when it comes time to take the subject exam.
 The information tested on this exam is very
specialized, so the material learned during 2nd year
isn’t very useful.

31. Ob/Gyn Resources
1. Blueprints: Obstetrics and Gynecology
2. Case Files: Obstetrics and Gynecology
3. High Yield Obstetrics and Gynecology

32. Blueprints
Contains high yield ob/gyn subject matter in
paragraph format.
Very thorough resource.
Contains practice questions at the end of the
book.
No easily reviewable during the week before
the subject exam.

33. Case Files
Presents common internal medicine subjects in the form of
clinical vignettes similar to the subject exam.
Relatively complete.
Probably the 2nd best ob/gyn subject exam resource.
Good section on STD’s
Slightly less complete than Blueprints.
Not separated logically, just random cases.

34. High Yield
Excellent, succinct summary.
Great tables and graphs to demonstrate key
concepts.
Should be used in conjuction with another
resource.
Only use as a sole resource if you are
extremely confident in you ob/gyn
knowledge.

35. Recommended Strategy
 Start reading Blueprints or Case Files at the
beginning of the rotation.
 Read before each lecture, the corresponding section
in your chosen book.
 Begin reading High Yield two weeks before the
subject exam, and get through it twice.
 Do USMLEworld questions throughout the rotation.
 The required text for the rotation isn’t very useful
for the subject exam.

36. Pediatrics Subjects
 Normal Development 5%-10%
 Organ Systems 90%-95%
 Immunologic Disorders 5%-10%
 Diseases of the Blood and Blood-forming Organs 5%-10%
 Mental Disorders 1%-5%
 Diseases of the Nervous System and Special Senses 5%-10%
 Cardiovascular Disorders 10%-15%
 Diseases of the Respiratory System 10%-15%
 Nutritional and Digestive Disorders 10%-15%
 Gynecologic Disorders 1%-5%
 Renal, Urinary, and Male Reproductive System 10%-15%
 Disorders of Pregnancy, Childbirth, and the Puerperium 1%-5%
 Disorders of the Skin and Subcutaneous Tissues 1%-5%
 Diseases of the Musculoskeletal System and Connective Tissue 5%-10%
 Endocrine and Metabolic Disorders 5%-10%
 Physician Tasks
 Promoting Health and Health Maintenance 5%-10%
 Understanding Mechanisms of Disease 25%-30%
 Establishing a Diagnosis 40%-45%
 Applying Principles of Management 10%-15%

37. Pediatrics Exam Basics
 Clerkship lectures are pretty useful resources,
especially when it comes to developmental
milestones and vaccination schedules.
 Dr. Pino does an excellent review the week before the
subject examination.
 This test tends to be heavy in microbiology and
infectious diseases.

38. Pediatrics Resources
1. BRS Pediatrics
2. Blueprints: Pediatrics
3. Case Files: Pediatrics
4. Dr. Pino’s Mega Review

39. BRS
Very complete resource in outline format.
Very cumbersome book.
Has everything that could ever be tested on the subject
exam, but would be difficult to use unless you are very
dedicated.
Excellent tables and charts.
If ambitious, you could obtain >90th percentile using this
book.

40. Blueprints
Contains high yield peds subject matter in
paragraph format.
Very thorough resource.
Contains practice questions at the end of the
book.
No easily reviewable during the week before
the subject exam.

41. Case Files
Presents common pediatric subjects in the form of
clinical vignettes similar to the subject exam.
Relatively complete.
Probably the 2nd best subject exam resource.
Not as much info as Blueprints.
Not separated into body systems, just random cases

42. Dr. Pino Review
Dr. Pino does a “mega review” towards the end of the
rotation.
Contains very high yield subject material.
Almost word for word the same material that Dr. Pino
teaches during the USMLE Step 2 Kaplan course.
Not complete, but very high yield.

43. Recommended Strategy
 Begin reading Blueprints at the beginning of the
rotation.
 Do USMLEworld questions throughout the rotation.
 Attend Dr. Pino’s review and cram that material in
the last few days leading up to the subject exam.

44. Psychiatry Subjects
 General Principles 5%-10%
 Organ Systems 90%-95%
 Mental Disorders 75%-85%
 Mental disorders usually first diagnosed in infancy, childhood, or adolescence
 Substance-related disorders
 Schizophrenia and other psychotic disorders
 Mood disorders
 Anxiety disorders
 Somatoform disorders
 Other disorders/conditions
 Diseases of the Nervous System and Special Senses 10%-20%
 Physician Tasks
 Promoting Health and Health Maintenance 1%-5%
 Understanding Mechanisms of Disease 10%-15%
 Establishing a Diagnosis 55%-65%
 Applying Principles of Management 15%-20%

45. Psychiatry Exam Basics
 The clerkship lectures are very useful for this subject
examination.
 This exam focuses on diagnosis of mental illness and
less on treatment.
 Know the DSM criteria for diagnosis of mood
disorders, personality disorders, etc…
 Watch out for mental illness caused by a general
medical condition. This almost always appears a
couple of times on the exam.
 Know all of the psych drugs.

46. Psychiatry Resources
1. First Aid for the Psychiatry Rotation
2. Case Files: Psychiatry

47. First Aid
Succinct summary which is relatively complete.
Outline format.
Contains high yield facts in all areas of
psychiatry.

48. Case Files
Presents common psychiatry subjects in the form of
clinical vignettes similar to the subject exam.
Relatively complete.
Rivals First Aid as best resource
More info than First Aid, but may be overkill.
Not separated logically, just random cases

49. Recommended Strategy
 Pay attention to the clerkship lectures.
 Begin reading Case Files at the beginning of the
rotation.
 Do USMLEworld questions throughout the rotation.
 Begin reading First Aid two weeks before the subject
exam.
 Get through First Aid two times before the exam.

50. Surgery Subjects
 General Principles 1%-5%
 Organ Systems 95%-99%
 Immunologic Disorders 1%-5%
 Diseases of the Blood and Blood-forming Organs 5%-10%
 Diseases of the Nervous System and Special Senses 5%-10%
 Cardiovascular Disorders 10%-15%
 Diseases of the Respiratory System 10%-15%
 Nutritional and Digestive Disorders 25%-30%
 Gynecologic Disorders 5%-10%
 Renal, Urinary, and Male Reproductive System 5%-10%
 Disorders of Pregnancy, Childbirth, and the Puerperium 1%-5%
 Disorders of the Skin and Subcutaneous Tissues 1%-5%
 Diseases of the Musculoskeletal System and Connective Tissue 5%-10%
 Endocrine and Metabolic Disorders 5%-10%
 Physician Tasks
 Promoting Health and Health Maintenance 1%-5%
 Understanding Mechanisms of Disease 20%-25%
 Establishing a Diagnosis 45%-50%
 Applying Principles of Management 25%-30%

51. Surgery Exam Basics
 This test contains far more internal medicine than
one might expect, therefore it is advantageous to
have completed internal medicine before taking this
exam.
 Know IV fluid management, diagnosis of acute
abdomen, trauma survey.
 Be able to tell when a patient is truly in danger of
dying (vital signs, etc…)
 There are a few questions on orthopaedics, vascular
surgery, urology, etc…

52. Surgery Resources
1. Case Files: Surgery
2. NMS: Surgery
3. PreTest Surgery
4. Pestana Review Notes
It should be noted that Surgery Recall is an
excellent resource for case preparation, but it is not
a good tool for the subject examination.

53. Case Files
Presents common surgery subjects in the form of
clinical vignettes similar to the subject exam.
Relatively complete.
Probably the 2nd best surgery subject exam resource.
Not as much info as NMS.
Not separated into body systems, just random cases

54. NMS
Large resource in outline format.
Very complete, but could be somewhat
cumbersome to complete.
Contains general surgery as well as subspecialty
chapters.
This could be used as a sole resource.

55. PreTest
Excellent question book that mimics the questions
on the subject exam.
Far more useful than USMLEworld for the surgery
subject exam.
Read the question and the explanation.
Absolutely not intended to be a sole resource.

56. Pestana
Dr. Carlos Pestana’s Kaplan notes for surgery are
extremely high yield.
This is regarded as the Holy Grail of surgery
resources.
It is hard to come by, because it is supposedly illegal
to sell these.
They are available on eBay and other websites, it
just requires some searching.

57. Recommended Strategy
 Begin reading NMS at the beginning of the rotation if
you wish to do extremely well.
 Use Case Files if you just want to pass.
 If you can get obtain the Pestana notes, use them as
well.
 Do questions from PreTest, because the
USMLEworld surgery questions focus too much on
subspecialty surgery and not enough on general
surgery.

58. Final Remarks
 The common theme for subject exam preparation is
doing timed practice questions.
 This is the only way to accurately simulate the actual
exam.
 In addition to questions, you must find a resource
you like.
 Most resources are good, you just have to find one or
two for each exam that fits your study style.

59.  And most importantly…

60. RELAX!!!!!!!!!!!