Family Medicine Shelf Exam Tips: To Succeed or Not to Succeed?
Intro
Wow, today was the family medicine shelf and I am glad that it is over. I was told by students who took it earlier than I did that it was difficult. One colleague told me it wasn’t awful but there were some tough questions with easy questions too. Another told me to give up studying because it was impossible regardless. Although we are told varying degrees of difficulty on shelf exams due to how people test differently, I can say that I received consistent feedback that this was a challenging exam due to the broad scope of family practice. I was even informed that if a student was to fail a shelf exam (and was rotating in Atlanta) that they were most likely to have failed family medicine. I knew most of this information (except for the peers that took the exam this week), so I was planning my attack early on this rotation.
Before day one of the rotation my Cramfighter schedule created for the block, I had read all the supporting documents from Ross regarding the rotation, read through message boards and forums from as far back as 2010 to analyze trends from students commenting, and I had created a list of topics I wanted to make sure I read throughout this rotation. Proper planning prevents poor performance, right? Well, I definitely had a game plan formulated and was able to do most of what I intended. The barrier to studying was the rotation’s workload compared to what I had previously experienced in the psych rotation. I am grateful that I was home most evenings by 7 PM and only had to work one Saturday. After the first week, I felt well-adjusted to the schedule but remaining motivated each day to study the discipline after having put in hard work at the clinic was my initial challenge.
The exam: 110 questions followed by an NBME survey for feedback. In terms of timing, I still had 30 minutes at the end of the exam and felt that I maintained a good pace. Some of the questions were easy and some were challenging. None of them were impossible or foreign to me, and the questions I found the most difficult were the ones where I narrowed it down to the two most-likely answers. The reason I had difficulty with settling on an answer when down to two choices was not because of an absence of knowledge but due how similar the answer choices might seem and not being certain on the first next diagnostic step in the workup. Now, there were some questions that really seemed to come from ‘left field’ as they say due to the obscurity of the information but I was exposed to this information solely because I went through the AAFP practice board review questions. When I say obscure information, I mean you would have needed to have practiced with a specialist (say in ophthalmology – which I am thankful that I have) or have done some deeper research into workup methods relating to seemingly random illnesses.
Luckily, I started listening to the Curbsiders podcasts at the beginning of this rotation because it came up as a related podcast for Family Medicine. I have listened to all episodes once and there were several I decided to listen to twice because of how prevalent the conditions seemed to be in clinic…I could also tell that it was helpful on the exam today because the clinical thinking presented in the podcast is what the exam appears to be probing for in order to see if students are developing the paradigm expected for upcoming physicians.
Resources
fmCASES, SIMPLE, and CLIPP cases through MedU that we were assigned cases to read through each week.
Here’s a list of the cases for easy reference:
fmCASES #1 45-year-old female annual exam - Mrs. Payne: Preventive Care
fmCASES #2 55-year-old male annual exam - Mr. Reynolds: Preventive Care
fmCASES #20 28-year-old female with abdominal pain - Ms. Bell: Abdominal pain, contraception, Domestic Violence
fmCASES #17 55-year-old post-menopausal female with vaginal bleeding - Mrs. Parker: Menopause, postmenopausal bleeding
fmCASES #8 54-year-old male with elevated blood pressure - Mr. Martin: Hypertension
fmCASES #6 57-year-old female presents for diabetes care visit - Ms. Sanchez: Diabetes
SIMPLE #16 45-year-old-man with obesity - Mr. James: Obesity, Hyperlipidemia
fmCASES #5 30 year old female with palpitations - Ms. Waters: Hyperthyroidism
fmCASES #4 19-year-old female with sports injury - Christina Martinez: Ankle Sprain
fmCASES #25 38-year-old male with shoulder pain - Mr. Chen: Shoulder pain
fmCASES #10 45-year-old male presenting with low back pain - Mr. Payne: Back Strain, Herniated Disc
fmCASES #11 74-year-old-female with knee pain - Ms. Roman: Osteoarthritis
fmCASES #15 42-year-old male with right upper quadrant pain – Mr. Keenan: High risk alcohol use, Bililary colic
fmCASES #28 58-year-old male with shortness of breath – Mr. Smith: Chronic Obstructive Pulmonary Disease
CLIPP Case #13 6-year-old with chronic Cough – Sunita: Pediatric Asthma
fmCASES #9 50 yr old female with palpitations – Ms. Yang: Chest pain, Anxiety
fmCASES #16 68-year-old male with skin lesion - Mr. Fitzgerald:Skin Cancer
fmCASES #26 55-year-old male with fatigue - Mr. Cunha: Fatigue, Cancer screening
fmCASES #29 72-year-old male with dementia: Dementia
fmCASES #22 70-year-old male with new-onset unilateral weakness – Mr. Wright: TIA, Atrial fibrillation
fmCASES #7 53-year-old male with leg swelling - Mr. Smith: Deep Vein Thrombosis
fmCASES #18 24-year-old female with headaches - Ms. Payne: Migraine Headache
fmCASES #21 12-year-old female with fever - Marissa Payne: Influenza, Pneumonia, Obesity
fmCASES #33 28-year-old female with dizziness - Mrs. Saleh: URI, Dizziness
These board review questions on the surface seem very easy and are not vignette-style questions as expected from NBME questions. However, the topics tested are so varied and these are the items you would benefit to be exposed to for the random questions you may feel like you’ll see. The questions are focused for clinical practice in family medicine, and if you go through the entire bank you will not regret it. However, it takes almost a week to get access to the qbank and I paid $17 as an IMG student. There are 136 question sets each containing 10 questions, and I made it through 550 of the 1360 questions. For me, it was more beneficial going through the questions almost passively instead of taking my time reviewing explanations in detail as I would with uWorld questions. So just do these questions because you will be exposed to the USPSTF screening guidelines in the ways they’ll likely be tested, and exposed to enough of them to where you will really get down the difference between the scenarios.
So, there is no family medicine section but research helped me find some various recommendations regarding which onlinemeded videos were beneficial to study for this exam with and I will recommend them below. I did watch most of the videos (I skipped the Psych and OB/GYN videos since I watched them during those rotations and the information is still relatively fresh)…but I would have benefited from just watching all of them. I was asked questions that could be answered from every single video listed below:
Cardio – Coronary artery disease, Heart Failure, Syncope, Hypertension.
Pulmonology – Asthma, Lung Cancer, Pulmonary Embolism, COPD
Gastroenterology – GERD
Nephrology – Chronic Kidney Disease, Kidney Stones
Hematology Oncology – Anemia Approach, Macrocytic Anemia, Microcytic Anemia, Normocytic Anemia
Infectious Disease – Antibiotic Ladder, HIV, TB, Skin Infections, Pneumonia, UTI, Genetal Ulcers, Ear Nose Throat
Endocrine – Thyroid, Outpatient Diabetes, Insulin Management, Diabetic Management
Neurology – Stroke, Seizure, Tremor, Headache, Back Pain, Dementia, Dizziness, Coma, Weakness
Rheumatology – Approach to Joint Pain, Lupus, Rheumatoid Arthritis, Other Connective Tissue, Monoarticuloarthropathy
Dermatology – Eczematous Rashes, Hyperpigmentation, Hypopigmentation, Skin Infections
Pediatrics – Well Child, Vaccinations, Preventable Trauma, Child Abuse, Peds Infectious Rashes, Allergies, Ear Nose Throat, Upper Airway, Lower Airway
Psychiatry – Mood Disorders, Mood Life & Death, Eating Disorders, Psych Pharm I, Psych Pharm II, Addiction, Sleep Physiology, Sleep Disorders
Gynecology – Cancer Intro, Gyn Infections, Vaginal Bleeding, Vaginal Bleeding 2, Vaginal Bleeding 3, Puberty, Secondary Amenorrhea, Infertility, Virilization, Menopause
Obstetrics – 3rd trimester labs, Medical Disease, Normal Labor, Eclampsia, 3rd trimester bleeding, Contraception
Surgery: General – Preop Evaluation
Surgery: Subspecialty – Aorta, Ortho Peds, Ortho Hand, Ortho Injuries
Surgery: Trauma – Toxic Ingestion
The Curbsiders Podcast - Knowledge Food for your Brainhole
I’m going to list just the episode numbers that I found useful for this shelf, but you should listen to all of them. I strongly recommend: episode numbers 54**, 53**, 52*, 51, 49**, 48*, 47, 46, 45, 39, 38, 30, 31, 25, 20, 18, 17, 10, 12, 3 -> The starred episodes I listened to twice and highly recommend it…and two stars means listen and try to teach the concept to someone else so you can master it. I listen to these podcasts to and from clinic sites, and I listened to them at 1.5x speed.
Obviously not the entire book, but these chapters should be reviewed at least once:
Diseases of the Cardiovascular System
Diseases of the Pulmonary System
Endocrine & Metabolic Diseases
Infectious Diseases
Diseases of the Skin & Hypersensitivity Disorders
Ambulatory Medicine.
The last three are the most high yield along with Endocrine & Metabolic Diseases if you need to triage the listed chapters and are short on time.
Topic List
This list is what I first entered the rotation with and wanted to make sure I was at least familiar with the topics. This information was found in our Ross recommended weekly assignments, EPEs, EPPs, and my own meandering experience. Think of things that people would commonly present to their primary care physician to address. A PCP may not be the person to remove renal cell carcinoma, but should be able to work-up gross hematuria with differentials and logical diagnostic progression.
Screening Guidelines:
Asthma – NHLBI: know this cold.
COPD – GOLD
Chronic Kidney Disease - KDOQI
Heart Failure - ACC/NYHA
Systems and concepts:
Abdominal Pain: including Appendicitis, Cholecystitis, Constipation, Diverticulitis, Dyspepsia, Ectopic Pregnancy, Gastritis, Gastroenteritis, **GERD/PUD, **Inflammatory Bowel Diseases, and **IBS.
Abnormal vaginal bleeding: Including recognition of dysfunctional uterine bleeding and menstrual disorders
**Arthritis: including Osteoarthritis, Rheumatoid Arthritis, setting goals for managing pain and maximizing function.
***Asthma/COPD: Including staging criteria, interpretation of spirometry and step wise approach to care.
Back pain: Including muscle strain, nerve root compression and spinal cord compromise, fracture, infection and metastatic disease as well as managing pain and risks of narcotic adverse outcomes.
Chest pain: Including GERD, Costochondritis, Angina and MI, Pulmonary Embolism and Pneumothorax and identifying and counseling to reduce risk factors for cardiovascular disease.
Chronic Pain: Including different etiologies of chronic pain syndromes and medication management, role of physical therapy, psychosocial support.
***Cough: Including infections – pneumonia, bronchitis, URI, lung cancer, GERD, allergic rhinitis.
Depression/Anxiety: Including common presentations (fatigue, insomnia), assessment of suicide risk and effect on managing other medical conditions.
Diabetes: Including diagnostic criteria, medication and lifestyle management, performing a foot examination, managing quality indicators/flow sheets.
Diarrhea: Including Gluten-related, Infectious, Irritable Bowel Syndrome, Inflammatory Bowel Disease.
*Dizziness: Including BPPV, Labrynthitis, Orthostasis, Cerebral Vascular Disease, Meniere’s disease; differentiation of disequilibrium, central and peripheral vertigo; and use of Dix-Hallpike and Epley maneuvers.
Dysuria: Including urethritis, bacterial cystitis, interstitial cystitis, prostatitis, pyelonephritis and vulvovaginal candidiasis.
Eyes: look up most common occular complaints a patient would bring to their family physician. This would include things like presbyopia, retinal detachment, macular degeneration, macular edema secondary to diabetes, cataracts...to name a few.
*Fatigue: Including Thyroid Disease, Rheumatoid Arthritis, Lupus, Anemia, Fibromyalgia and symptom of Depression. THYROID, THROID, THYROID: I underestimated how many endocrine questions could be asked and thyroid was definitely high yield…
Headache: Including Tension, Migraine, Sinus Pressure, Meningitis, Subarachnoid Hemorrhage and Temporal Arteritis
Heart Failure: Including systolic, diastolic, staging both functional and structural, medication management, and strategies for prevention
Hypertension: Including Essential, Secondary and Refractory hypertension; ability to take accurate blood pressure, knowledge and application of JNC-8, recognition of end organ disease.
*****Joint pain/MSK: including septic arthritis, fractures, tendinitis, bursitis, overuse, injury – for example: ankle sprains, knee pain- ligamentous and meniscal injuries, patella-femoral syndrome, shoulder pain – rotator cuff injuries, hip pain, carpal tunnel syndrome. Tinel, Phalen, Empty Can and correlate with anatomy. Seriously, know every joint injury possible à this is the topic I was assigned for my didactics presentation and it seriously won me some major points today because of how high-yield MSK injuries are to Family Practice.
Obesity: Including obtaining a diet history and setting goals with patients for appropriate weight loss
*****Rashes and skin lesions: Including Acne, Atopic, Contact and Seborrheic dermatitis, Urticaria and Scabies; Characteristics of skin cancers including Basal Cell, Melanoma and Squamous Cell (esp. ABCDE mneumonic)
Substance Use: Including tobacco, alcohol, illegal and prescription drugs
***Upper respiratory symptoms: Including Allergic Rhinitis, Infections-viral and bacterial including URI, Sinusitis, Pharyngitis, Otitis Media, Mononucleosis; and the benefits/harms of medications
Vaginal Discharge: Including bacterial vaginosis, candida, chlamydia, gonorrhea, trichimonas, and physiological
Testicles/Male GU: understand the ddx for testicular swelling/pain in a young male (teenage to adolescent) along with the work up. Also know the ddx/workup for a geriatric male with urinary symptoms.
Wrap up
This is an overwhelming list which is why I cannot emphasize how important it is for you to plan before the beginning of the rotation to create a study schedule so you can spend one-two hours each night studying to make the volume much more manageable than those of you who live life on the edge via procrastination and cramming.
Also, I tried the hokey “create a strengths and goals list” as recommended in one of the preparatory documents for Family Medicine and I must admit that I am better for it. This will not be something I do before my other rotations and electives because I appreciate the direction it gives me when I am in clinic and keeping an eye out for opportunities.
This is what I listed before starting the rotation:
Strengths and goals -
I am confident with my ability to build rapport and write a H&P. I am also confident that I want to pursue OB/GYN.
My goals include: being able to read an EKG, have a better grasp of nephrology cases, and be better at oral presentations.
I am glad that I wrote this out when I did because I definitely got to work on all of these goals as the opportunity presented. I even took my opportunity of asking questions of the Residency Director of Family Medicine what advice he would give to a student seeking to be better at giving oral presentations.
Again, the shelf is doable and I did NOT feel prepared in the slightest because I worked up so much angst regarding how difficult it was reported to be. I think having that mindset was great for me because this was the first NBME exam I have left where I didn’t feel like my grade could be polarized for the better or for the worse and I would have no clue. The exam today made me feel more confident with my Family Medicine knowledge, and even validated that I am in the makings of being a well-rounded physician.
And part of being well-rounded includes crazy experiences, so please enjoy this flashback video to a time where I thought it would be smart to ingest food so spicy that it causes a chemical burn all along the GI track and requires gloves to perform. I never again will attempt a Man Vs. Food Challenge that requires a waiver or the possibility of having an MI, but I am glad that I tried such an interesting experience (and kudos to my then fiancé for trying to cheer me on, allowing me to say “shut up” without taking it personally so I could focus, and for still marrying my crazy self anyway).
25 Minutes to eat the burger
Allowed to eat/drink anything execpt for remedies
No restroom breaks, sharing, spitting or double tasting
If the burger is eaten within the 25 minutes, then a 5 minute waiting period begins.
Good Luck to any brave soul willing to take on the 4 Horsemen!!!
***Notice*** A chuck bucket is provided, but use of it is an automatic disqualification. If the bucket is missed a $20 clean-up fee is added to the price of the burger. ☺