Unbeknownst to many medical students, the NBME publishes an Internal Medicine content
outline of the covered subjects on the Internal Medicine shelf exam. As you review the list of systems, take a few moments to browse through the review book of your choice (more on this
later) and familiarize yourself with the major diagnoses you can expect to see during your
rotation.
As is the case with many medicine exams, Cardiovascular Disease is the basis for more
questions than any other organ system. A large percentage (35% – 50%) of the exam is
comprised of Cardiovascular Disorders, Diseases of the Respiratory System, and Nutritional
& Digestive Disorders.
2. Get a study guide–digital or print–to prepare for the NBME exam and your clerkship
It’s important to have a good study guide that is tailored for the exam while also preparing you
for the patients you’ll encounter on the wards. Some of the more popular and effective guides
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we’ve come across that cover both objectives are: Master the Wards Internal Medicine
Clerkship: Survive Clerkship and Ace the Shelf Exam and Step-Up to Medicine
The former is written by Dr. Conrad Fischer who has decades of experience teaching medicine
at all levels–med school, residency, etc–and it shows in this book. His emphasis on clinical
features, diagnostic workup and management of commonly encountered diseases is fairly
comprehensive and yet easy to follow. Most students seem to find that by reading the relevant
sections/chapters of this book related to their patients, they are able to answer just about any
question an attending or resident asks them on rounds. Over the course of the clerkship, that
serves as a huge confidence boost that can translate into a better performance on the shelf
exam.
Step-Up to Medicine is especially strong because it covers diseases in such detail that even
in the absence of another reference, you should be able to confidently learn the material
needed to take care of your patients in the hospital or clinic and also pass the Shelf Exam.
Easy-to-follow, colorful flow charts are an added bonus. If you’re asked by your attending to
present a diagnosis related to one of your ward patients, don’t be surprised if Step Up is the
first book you find yourself browsing. It’ll systematically cover the signs, symptoms, diagnosis,
treatment and potential complications. While I hesitate to say that any resource is a “must-
have” while you are on a medical rotation since there are so many ways to succeed, this book
is the closest you get to a mandatory reference.
Undoubtedly, however, you will come across many of your medical student colleagues
carrying First Aid for the Medicine Clerkship book. I myself used a previous edition of this book
during my Internal Medicine rotation and felt that it didn’t go into enough details to lead to a
mastery of the material clinically or for the shelf exam. Even if the shelf exam doesn’t ask
minute details, the reference book you choose should provide some context to each disease
rather than concentrating too much on mnemonics, which is what I feel First Aid focused on.
It also wasn’t easily applicable to the patients one might expect to see while on rotation.
Perhaps, folks still gravitate to this title because of the fact that First Aid for the USMLE Step
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1— an absolutely priceless resource–is fresh in the mind of third year medical students on
their IM rotation, having taken the Step 1 exam just months earlier.
Lastly, since 2000, one book has become more recognizable on the Internal Medicine wards
than any other: Pocket Medicine, which proudly states that it is “Prepared by residents and
attending physicians at Massachusetts General Hospital.” From a marketing standpoint, the
book is brilliant. The collective knowledge of the world’s premier institution in the pocket of my
white coat? Who can say no to that?
Like the strategy behind the iPhone, each new edition of Pocket Medicine is easy to identify.
When you discover that the “latest, latest” edition is colored purple, you start to feel that your
green Pocket Medicine book handed down from a recent graduate seems grossly inadequate.
It feels as uncool and antiquated as carrying around a BlackBerry phone. Pocket Medicine
works for some folks; it has to or it wouldn’t still be around after a decade and a half. However,
I found the tiny print to be incredibly difficult to navigate. Because the emphasis is on cramming
information into the limited space, the content does not flow nearly as well as Step Up. While
there are ample citations, given that the study can’t be clicked, it isn’t convenient. To better
view cited material, I would use UpToDate, which your medical center likely offers, at least for
computers on the premises.
3. Thriving on the Internal Medicine rotation doesn’t guarantee success on the NBME
Exam… but it sure helps!
Your weeks-long rotation in inpatient and outpatient Internal Medicine is not designed to
prepare you for the end of the clerkship NBME shelf exam. Plain and simple. It is intended
instead to familiarize you with the common (and some not-so-common) conditions that
internists can expect to see in practice. By knowing those diagnoses like the back of your
hand, you can better spend your study time reviewing the more esoteric diagnoses you
probably won’t come across in the patients on your census.
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Treat each and every patient you admit from the emergency room, write a SOAP note on in
the general medicine floors, and see in the exam room of a clinic as an incredible learning
opportunity. Don’t forget that as a student you put in early mornings and late nights to study
human pathophysiology, anatomy, genetics, ethics, etc to be given the privilege of seeing live
patients. This is your chance to not only be a part of an actual patient care team but also finally
correlate the tons of medical lectures to a real patient, not a synthesized problem-based
learning (PBL) case.
As a senior resident, I recall often starting my third year medical students with admissions that
on the surface seemed relatively basic: an alcoholic with acute pancreatitis, an obese middle-
aged man with chest pain after consuming a fatty meal, an 80-year-old female with a 60-pack-
year smoking history presenting with her third COPD exacerbation of the year. But they were
easy admissions only at the superficial level because it was easy to get fooled into thinking
that identifying the diagnosis was the goal of our trade. In fact, these admissions were chock
full of medical knowledge, provided you successfully opened your mind. Even though the
diagnosis is screaming out at you (often the case with the thorough work-up our Emergency
Medicine colleagues perform and the promptness of imaging reads by our Radiology friends),
maintaining a broad enough differential allows you to be prepared for the next patient who
may have an atypical presentation of a common diagnosis. That, of course, is the type of
patient that one finds presented on the NBME exam.
I’ve noticed that with the truncated work-hour schedule in residency, education of residents
and medical students alike has been cut substantially. Even if this means you’re not “getting
pimped” by your attending or senior, read up on each patient’s complaints. In other words,
that patient with pancreatitis should send you on an exploration of the differential diagnosis
based on the location of the abdominal pain. Even within pancreatitis, use the “I GET
SMASHED” mnemonic to branch out and learn about each of those topics separately. For
instance, the G stands for Gallstones, which should lead to a review of the diagnosis,
treatment, and complications of cholelithiasis.
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Rather than trying to serve as an additional intern and take care of as many patients as
possible (remember “medical student” doesn’t equal “workhorse”), use the experience of
taking care of a reasonable number of patient to learn about them and their conditions as well
as you can. Ultimately, that will serve you well for developing a solid fund of knowledge and
experience you’ll be able to apply for years while better preparing you for the NBME exam at
the same time.
4. Join a study group or at least get a study partner
It may seem impossible to find the time on your third-year Internal Medicine clerkship to
coordinate your schedule with other students. Having been in those shoes before, I can tell
you that it can be done. Often, students are given either a Saturday or Sunday off. If you look
around at the beginning of your clerkship orientation, you should be able to find another
student with a similar work schedule.
There’s nothing quite like learning from your colleagues. How do you find a partner who
matches your intelligence? It doesn’t matter what their IQ is relative to yours. You simply need
a partner who shares your passion for learning. Even if you come across questions for which
neither you nor your partner have an answer to, a textbook, reliable website (and most likely
Knowmedge) surely will. And if you find that you actually know more than the person you are
studying with, you’ll be happy to know that nothing reinforces concepts than teaching them to
others. An additional benefit of having a study buddy: A few minutes (not much longer than
that) can be spent debriefing your fellow medical student on the quirkiness of your attending,
idiosyncrasies of your senior attending, and coolness of your intern, etc. Nothing is quite as
soothing as having someone who can relate to your situation.
In the event that you’ve been stationed in some remote location far, far away from your other
class members, don’t despair. Fortunately, we live in a digital age where being part of a study
group is much easier. You can connect with colleagues through Skype, Google Hangout or a
number of other channels. One of our favorite approaches is to remain informed and learn
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through the power of social media – in particular Twitter. In a previous post, we highlighted
excellent Twitter handles to follow for internal medicine board review. If Twitter is not your cup
of tea, you can also connect with colleagues through the High-Yield Internal Medicine
community on Google+. Regardless of what approach you decide to use, studying alongside
others preparing for the same exam is a great motivational tool for success.
5. Get a question bank that fits your personal needs
What is the value of an Internal Medicine question bank? This is a discussion near and dear
to our heart, of course. Question banks have become a popular tool because they bring
together a lot of material in a question format and help create a test taking environment. There
are a lot of question banks to choose from – so what should you look for in an NBME qbank?
High quality NBME-style questions in a format similar to the exam: The exam is
mostly filled with clinical vignettes and has straightforward questions as well. At a
minimum, your NBME exam question bank should have both of these types of
questions. Quantity is important – but the quality of the questions and explanations is
much more important.
Detailed explanations that review why the incorrect choices were wrong: A
question bank that does not provide you detailed explanations is probably not worth the
money and time spent. As you review questions, you will inevitably get some wrong –
your choice of NBME question bank should detail why your choice is incorrect and the
reasoning behind the correct choice.
Ability to track your personal performance: Your choice of NBME qbank should be
able to tell you your performance overall and by category. Most – not all – question
banks provide you a dashboard broken down by category. The Knowmedge question
bank has gone an additional step to break the categories into subcategories as seen
on the NBME exam blueprint. This allows you to review your strengths and weaknesses
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at a granular level. Knowing you are weak at cardiovascular disease is great – knowing
you are weak at arrhythmia questions is more valuable.
Add-ons – Notes, Lab values, Highlighting: Depending on how you study, these may
be valuable features. NBME exam questions straight talk:
No question bank – not MKSAP for Students, not Knowmedge, not any – knows what will be
on the actual NBME exam. However, the NBME blueprint helps to understand the areas that
are emphasized the most. Granted, you still are going to need to study the whole curriculum,
but it can certainly alleviate some of the anxiety when down the stretch, you are unsure of one
of the topics that forms a smaller percentage of the questions. With limited time to study, you
can better choose which high-yield subject areas to study. During the development of
Knowmedge’s qVault, the entire team focused our energy not on trying to give the exact
questions that will be on the exam. Instead, we look at the sign of an excellent question bank
as teaching important medical concepts that are also useful for the exam.
High-quality NBME exam review questions can be found in many places – question banks are
not the only place. There are study guides, books, and even free sources. So don’t simply
base your decision on a question bank on the questions. In addition to the quality of the
questions, what truly differentiates one NBME exam question bank from another is whether it
will truly help you build a broad base of knowledge and help you retain information for the
exam. If you are not comfortable reading a bunch of text – it won’t matter how great the
questions are. If you are not an audio-visual learner, the MedStudy or Knowmedge videos
won’t do anything for you (As clarity, the Knowmedge qbank contains text and audio-visual
explanations for this exact reason). If you are an “old-fashioned” learner that prefers printouts
– USMLEWorld is definitely not for you – those who have used them are well aware their
software will block you from taking print screens or copying of their content. In short… don’t
follow the herd – each one of us learns differently and you need to pick the best method for
you.
6. Review our suggested NBME test taking strategies
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The NBME exam questions are not intended to trick you – they are intended to challenge your
knowledge and ability to bring together your understanding of many different concepts and
topics. As mentioned above you will see atypical presentations of common diagnoses or
typical presentations of the uncommon diagnoses. Below are some of the tactics you can use
as you are practicing questions and/or taking the actual NBME exam:
For clinical vignettes, read the question (last line) first and then go back and read the
scenario. This way you’ll know what to look for as you are reading the scenario.
Try to answer the question even before peeking at the answer choices.
Watch for key demographic information – geography, ethnicity, gender, age,
occupation.
The NBME test is not intended to be tricky but we are all human so we miss keywords
sometimes – such as “least likely” – pay attention to these. Fortunately, exams have
cut down on including these but you may still come across them.
If you are challenged by a longer clinical vignette, note the key items and develop your
own scenario – this may trigger an answer.
Most medical students I’ve spoken with say time is generally not an issue – 100 questions in
2 ½ hours means 90 seconds per question–but be sure to maintain the pace recognizing that
it’s not uncommon to find yourself slowing down towards the end. Get off to a steady start to
save time for the home stretch. We cannot stress enough the mantra “study early and study
often.” The exam is challenging due to the breadth of Internal Medicine topics but it can be
conquered with diligence and proper preparation.
7. Understand and be prepared for Shelf exam day
Be prepared and confident. No matter how you have chosen to study, on test day – confidence
is critical! Get a good night’s rest – last minute cramming and staying up late is only going to
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stress you out more. Get there early – don’t risk getting caught in traffic. It’s much better to be
a little early than be aggravated in traffic.
Take an extra layer of clothing. The last thing you want to do is be uncomfortable and cold
because someone decided to turn on the air conditioner too high.
That’s a basic overview of how to study for and pass the NBME Internal Medicine Board Exam.
As mentioned, there is no secret sauce or method to this – you simply need to have a broad
base of knowledge. There is no substitute for studying early and studying often! If you are in
the middle of your Internal Medicine rotation or about to start, we wish you well – we’re here
to help so let us know if you have any questions! Happy learning!
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