Get Expert Shelf Exam Tutoring from Top NBME Tutors

Each shelf exam tests comprehensive knowledge specific to that clinical rotation. The exams consist of 110 multiple-choice questions drawn from retired USMLE Step 1 and Step 2 CK questions. Content areas vary by specialty — for example, the Internal Medicine exam covers 17 different organ systems with cardiovascular (10-15%) and multisystem processes (10-15%) being the largest portions. The Surgery exam focuses heavily on gastrointestinal system (20-25%), while Psychiatry concentrates on behavioral health (65-70%).

Questions test diagnosis (45-70% of most exams), pharmacotherapy and management (20-35%), and applying foundational science concepts (8-20%). The distribution between ambulatory, inpatient, and emergency department settings varies significantly. Family Medicine is 100% ambulatory while Surgery is more evenly distributed across all settings.

Shelf exams are computer-based assessments administered either at your medical school's testing center or at Prometric test centers nationwide. Most schools schedule them during the final week of each rotation. The exam interface mirrors the USMLE format with questions presented one at a time on a locked-down computer that prevents access to other applications.

You have 165 minutes (2 hours and 45 minutes) to complete all 110 questions in one continuous block without scheduled breaks. You can flag questions for review and navigate back if time permits. Schools must order exams in advance through the NBME portal, and some institutions use Prometric centers for students on away rotations or at distributed clinical sites. You'll receive specific instructions about location, timing, and any required check-in procedures from your clerkship coordinator.

Shelf exams use an equated percent correct scoring system that allows fair comparison across different exam forms and test dates. Your raw score (number of questions answered correctly) is converted to both a scaled score and a national percentile rank. The NBME provides detailed score reports showing your overall performance and breakdown by content area compared to national averages.

Most schools set passing at the 5th-10th percentile nationally, though this varies by institution. For honors consideration, schools typically require 70th-90th percentile performance. Your school receives multiple reports including roster reports with all student scores, content area performance analysis, and item-level performance data. Students can access their individual results through INSIGHTS, an interactive dashboard that tracks performance across all NBME assessments. The percentile rankings are based on national data from all LCME-accredited medical schools.

Yes, shelf exams are mandatory for core clinical rotations at virtually all U.S. medical schools. The seven core rotations — Internal Medicine, Surgery, Pediatrics, OB/GYN, Psychiatry, Neurology, and Family Medicine — require passing their respective NBME Clinical Science Subject Examination to complete the clerkship. These exams typically account for 20-30% of your final clerkship grade, with some schools weighing them up to 40%.

Failing to pass the shelf exam usually results in failing the entire rotation regardless of clinical performance, requiring remediation and potentially delaying graduation. While Advanced Clinical Science exams exist for fourth-year electives like Emergency Medicine, these are less commonly required. Schools have specific policies about retakes, with most allowing one retake opportunity after a period of dedicated study. The mandatory nature reflects their importance in standardized assessment and preparation for Step 2 CK.

Most medical schools allow students some flexibility in scheduling their clinical rotations, though the process varies significantly. Typically, around the middle of second year, students submit their preferred rotation order through a ranking system, lottery, or selective scheduling process.

Common strategies include: starting with Family Medicine or Internal Medicine to build broad clinical foundations; scheduling Surgery later after gaining experience in Medicine and procedural skills in OB/GYN; placing your specialty of interest strategically — early if you're uncertain (to help decide), or later if you're committed (to excel and secure strong letters); avoiding back-to-back demanding rotations like Surgery and OB/GYN; and considering that shelf exam performance often improves throughout the year as test-taking skills develop. Some schools offer more flexibility than others, with options ranging from complete student choice to predetermined tracks with minimal customization. Students should also factor in Step 2 CK timing and away rotation scheduling when planning their clinical year.

A "good" score depends on your goals and your school's grading criteria. For passing, you typically need to score above the 5th-10th percentile nationally. For a competitive performance that contributes positively to your residency application, aim for above the 50th percentile. To achieve honors on most rotations, you'll need to score at or above the 70th percentile, with many schools requiring 80th-90th percentile for honors eligibility.

Some competitive specialties pay particular attention to relevant rotation scores. For example, dermatology programs may scrutinize Internal Medicine scores. Raw scores vary significantly by exam; achieving 70th percentile might require 90% correct on Psychiatry but only 80% on Pediatrics. Since Step 1 became pass/fail, strong shelf performance (consistently above 70th percentile) has become increasingly important for demonstrating academic excellence. Remember that percentile requirements can vary by school and that clinical evaluations also factor into final grades.

Shelf exam performance strongly predicts Step 2 CK success, as students who consistently score above the 70th percentile on shelf exams typically score 250+ on Step 2 CK. The Medicine and Surgery shelves alone represent up to 90% of Step 2 CK content, making them particularly crucial for board preparation.

With Step 1 now pass/fail, clerkship grades (heavily influenced by shelf scores) have become critical differentiators for residency applications. While most schools don't directly report shelf scores to residency programs, these scores significantly impact your clerkship grades that appear on your Medical Student Performance Evaluation (MSPE). Many residency programs scrutinize clerkship performance in relevant rotations. Surgical programs focus on Surgery grades, while Internal Medicine programs examine Medicine performance. Strong shelf scores demonstrate consistent clinical knowledge throughout training rather than performance on a single exam. Additionally, excelling on shelf exams reduces Step 2 CK study burden, allowing more time for research, away rotations, and application preparation.

The number of tutoring hours varies significantly based on your baseline knowledge, target score, and specific challenges. For students aiming to improve from passing to honors level, 10-15 hours per rotation spread throughout the clerkship typically suffices. Those at risk of failing or recovering from a failed shelf exam often benefit from 20-30 hours of intensive support with frequent sessions. Students seeking comprehensive support across all seven core rotations often invest in 50-75 total hours throughout their clinical year.

For targeted intervention before a specific exam, 5-10 hours of focused preparation can address knowledge gaps. We recommend starting with a diagnostic assessment where your tutor evaluates your current performance, reviews practice exam scores, and creates a personalized plan. Regular weekly sessions throughout rotations typically yield better results than last-minute cramming. The key is consistent support that adapts to your evolving needs rather than a one-size-fits-all approach.

Failing a shelf exam has serious academic consequences that vary by institution. Most schools require immediate remediation, which may include additional clinical time, mandatory tutoring, focused study periods, or in some cases, repeating the entire rotation. You'll need to retake the exam after remediation, usually requiring a minimum passing score to progress. Many schools cap your maximum achievable grade at "Pass" after remediation, regardless of retake performance.

Some institutions require students to drop subsequent rotations until passing the failed exam, potentially delaying graduation and disrupting residency application timelines. The failure appears on your transcript and Medical Student Performance Evaluation (MSPE), which residency programs review. After failing two shelf exams, students may face academic probation or dismissal proceedings. However, with proper support and dedicated preparation, most students successfully remediate. Early intervention when struggling can prevent failure entirely. If you're scoring below the 25th percentile on practice exams, seek help immediately.