How to Study for the Surgery Shelf Exam

“How do I study for the surgery shelf exam?” This is a major question all third-year medical students in the US wrestle with as they prepare for the wards and the boards. Studying for this exam can be overwhelming and performing poorly on this exam can seriously impact your surgery clerkship grades and letters of evaluation. Stress no more, because today I will show you how to effectively and efficiently prepare for this shelf exam as well as give you the secrets to help you excel on it!

The surgery clerkship is broad, and by the same token, the surgery shelf exam is broad. As with any other rotation, there is much to learn and a lot of material to cover, but very little time to do so. In 165 minutes, over 110 questions, the NBME surgery shelf exam will test your understanding of numerous areas of surgical management. The official NBME outline (page 129) divides the surgery shelf content by Systems, Physician Task, Site of Care, and Patient Age. While this outline is correct, it has a ton of overlap and it still doesn’t tell you how to best prepare for the surgery shelf. What has helped me in the past, and many students I have mentored, is dividing your surgery preparation into four main pillars/categories:

• Basic principles of surgery
• The medical management of the surgical patient
• Principles of ambulatory surgery
• Trauma

1. Basic Principles of Surgery

This section is fundamental and will cover all the main principles of surgery. The best book to cover this part of the exam is Dr. Pestana’s Surgery Notes. This book is very complete, elaborative, yet concise. Almost all medical students have heard of the effectiveness of this book and how high yield it is while on a surgery rotation. If you compare this back to the official NBME content outline, Dr. Pestana’s book covers many topics tested under Physician Task (i.e., applying foundational science concepts; pharmacotherapy, intervention & management) as well as scattered topics covered in the ambulatory, emergency department, and inpatient settings. 

As you can see, it would be a mistake to think that this book alone will adequately prepare you for the exam or that it covers all the other pillars of the surgery shelf exam. Don’t get me wrong, everything you need to know about the basics of pediatrics, urology, vascular, orthopedic, and neurological surgery will be in Dr. Pestana’s book. As previously mentioned, this book also covers some of the ambulatory topics, which we discuss later in this article, so it is a good companion to have with you as you prepare for the surgery shelf exam. Dr. Pestana’s book will help you tremendously as a medical student on the wards and give you the foundational information that makes up approximately 25% of the surgery shelf. But this book alone does not tell the entire story…

2. The Medical Management of the Surgical Patient

Next, is the section I like to sum up as the medical management of the surgical patient. This is part of the “medicine” that students mention is covered on the surgery shelf exam. This portion will include preoperative management, intraoperative care, postoperative management, and some intensive care management. A challenging part of the surgery shelf exam is distinguishing between a good and a bad operative candidate, as well as knowing the perioperative risks of surgery and common postoperative complications (managing fluids and electrolytes, infections, the 5 W’s, antibiotics and microbiological agents, etc.). Again, these questions make up approximately 25% of the surgery shelf and cannot be ignored. 

It is important to remember that while ALL systems are fair game on the surgery shelf, the official NBME content outline does help in narrowing your focus, and this can come in handy if you become pressed for time. The three most tested systems on the surgery shelf are GI (20-25%), Cardiovascular (10-15%), and Respiratory (8-12%). 

3. Principles of Ambulatory Surgery

This continues the “medicine” arm of the surgery shelf, with a focus on surgical patients in a non-acute setting. When it comes to Site of Care question settings on the exam, the ambulatory setting accounts for 35-40%. Thus, it is important to not only focus on inpatient, perioperative, and trauma scenarios. 

Building on our previous section, all systems are still fair game, with an edge to the aforementioned top three. Working through the GI section of a reputable USMLE Step 2 CK or Shelf question bank (such as TrueLearn’s Surgery Shelf SmartBank) and text (such as Step Up to Medicine) will cover this section thoroughly for you. On the surgery shelf exam, you should expect questions about esophageal diseases, gastric complications, small and large bowel disorders, GI bleeding, hernias, biliary tree, and general GI malignancies. Some questions on the shelf may ask you about the most appropriate next in management, the natural history of a disease, or the current guidelines for intervention (beware, as those cancer guidelines can creep up on you in this section). 

Again, these are detailed concepts you will not find in Dr. Pestana’s Surgery Notes, so that should not be your only resource. The vascular section of Dr. Pestana’s book does help cover some of the ambulatory topics commonly tested on the shelf, such as screening for and managing abdominal aortic aneurysms, peripheral vascular diseases, and aortic dissections. 

These ambulatory questions and medicine-heavy physiology and management questions make up approximately 25% of the surgery shelf exam.

4. Trauma

Our last pillar of the surgery shelf exam is the trauma section and it makes up approximately 25% of the exam. This correlates well to the official NBME content outline, which shows the Emergency Department setting making up 25-35% of the “Site of Care” question on the exam. 

Understanding the core principles of acute trauma management is key to this section. Questions under this pillar will range from ABCDE’s (airway, breathing, circulation, disability, exposure), acute evaluations (i.e., primary, secondary, and tertiary trauma surveys), imaging (FAST vs. CT abdomen, non-contrast head CT vs. MRI, etc.), shock (septic shock, SOFA guidelines, stages of hemorrhage shock, etc.), acute resuscitative measures, and intoxication (drug overdose, substance abuse, delirium tremens, etc.). The trauma pillar of the test can be covered by going over test questions from any reputable USMLE Step 2 CK or shelf question bank. Dr. Pestana’s book does cover some trauma, but it will be helpful and higher yield to complete this section from a question bank, as the book alone doesn’t touch on everything.  

The key part to the trauma pillar of the shelf is becoming extremely versed in the guidelines of trauma management. Part of the difficulty of the surgery shelf exam is the shortage of time on the test. You want to become very comfortable with trauma case scenarios so that you are not overthinking the question but predicting the step-wise approach to the patient as you read the vignette. Doing so will score you big points on test day, and you can spend more “brainpower” maneuvering through the medicine-heavy ambulatory and inpatient sections.  

Sample Study Plan

A sample study guide during an 8-week rotation should look something like this:

• Week 1-2: The Basics of Surgery. If possible, you should read through Dr. Pestana’s book within the first two weeks of your rotation. Use a question bank (like TrueLearn’s Surgery Shelf SmartBank) as often as possible. Starting early will help you get into the rhythm, format, and style of the NBME shelf.
• Week 2-3: Trauma. Complete all the trauma-relevant questions of a question bank of your choosing and reread Dr. Pestana’s book.  
• Week 3-6: Principles of Ambulatory Surgery. This section is heavy and you should dedicate a huge chunk of your time to it. If you have already completed a medicine rotation, this section may not be as heavy. However, if you are like me and took surgery before medicine, then this will be an uphill road. This part of the exam is by and large GI-related: biliary tree, liver, pancreas, esophagus, bowel, etc., but there are also a few non-GI topics such as lipomas, breast cancers, and infectious disease treatment. You will also see that this section does correlate quite nicely to what you would see as a student in an ambulatory surgical clinic. During this period, get into the habit of doing practice questions from your question bank for at least 30 minutes every day.
• Week 7: Medical Management of the Surgical Patient. I save this section for last because this section is somewhat the capstone of the surgery shelf. This section helps put together the entire perioperative period together. Topics that are commonly tested in this section include fluids and electrolytes, burns, nutrition, acid-base disturbances, the 5 W’s of postoperative fever, and understanding pertinent lab values such as CBC, LFTs, CMP, lactate, etc. Continue to do practice questions for every topic you complete.  Practice, practice, practice!  
• Week 8: Review and Final. Take your last week to review all the questions you answered incorrectly during your preparation. Review your notes from Dr. Pestana’s book. If you have extra time, incorporate another question bank and purchase some of the NBME practice sessions for surgery. Time management is key during your rotation and it is important to not overstretch yourself as you study. Limit your resources and go through the ones you select several times. 

Conclusion

The mistake most students make as they prepare for the surgery shelf is to focus too much on one aspect of the exam and forget (or lack awareness of) the other part. A tip someone gave me when I was a third-year student was that “Dr. Pestana’s book alone can help you achieve 65% on the test. The rest of the climb is on the wards and the medical management of surgical patients.” That statement, which seems so long ago, remains very true today.

As you prepare for the surgery shelf, be aware of the many subsets of the exam (we have grouped these into four pillars/main sections) and make sure you are studying and dividing your time accordingly. Covering all these parts of the surgery shelf will help you excel on the exam, and even beyond, as a surgery resident, if that is your goal. Medical management is an integral part of a successful surgical practice, just as it is an integral part of the NBME surgery shelf exam. Understanding the four main pillars we outlined here today will make your studying more efficient, targeted, and keep you focused on the high yield content. 

Author: Dr. Eliel Arrey, MD, MBA, is a surgery resident at Grady Memorial Hospital in Atlanta, GA. He is also an experienced board exam question writer and a faculty at various undergraduate universities. He has over twelve years of teaching experience in higher education.