About the Internal Medicine End-of-Clerkship Examination

All third-year internal medicine clerkships have a system of assessment as part of the rotation to evaluate your acquisition of medical knowledge and clinical skills. These assessments may include subjective or structured evaluations of your clinical performance by your attendings and residents, one or more objective structured clinical examinations (OSCEs) to evaluate your clinical skills, and usually some form of test to assess your grasp of core internal medicine knowledge.

NBME Medicine Subject Examination

For assessing internal medicine knowledge, some institutions develop their own examinations for use in the clerkship. However, the majority of clerkships in the U.S. use the National Board of Medical Examiners (NBME) Medicine Subject Examination as an end-of-clerkship examination. Because this exam is not developed locally and is obtained from the NBME “off-the-shelf,” it is commonly referred to as the “shelf” exam. The NBME produces a series of subject examinations across different disciplines, so you will likely encounter similar style exams in use in your other third-year clinical rotations.

If your clerkship uses the NBME Medicine Subject Examination, you can learn more about it at the NBME website. The exam is a web-based test consisting of 110 questions, the majority of which are single-best answer multiple choice questions, administered over 2 hours and 45 minutes. The content of the NBME exam covers basic internal medicine knowledge as determined by a committee of content experts, most of whom are internal medicine medical educators. You can view the content outline of the Medicine Subject Examination at the NBME website; sample items similar to those on the exam are also available at that site. The questions on the examination are develop and reviewed similarly to those used on the United States Medical Licensure Examination (USMLE) Step 1 and Step 2 Clinical Knowledge examinations. However, it is important to remember that despite the similar content and development process, the Medicine Subject Examination questions are different from those used on the USMLE examinations, and performance on the Medicine Subject Examination is independent from the Step examination scoring process.   

Scores from the Medicine Subject Examination are reported to your clerkship director. Both individual student scores and summary scoring information for all of the students taking the exam at your school are provided. Scores on the Medicine Subject Examination are statistically equated, meaning that the reported scores will have the same meaning for all students even though they may have been given different versions of the same examination at different locations. Equating makes scores comparable across schools, and also allows your clerkship director to see how you and your classmates performed relative to other schools and with different classes over time. Information from the shelf examination can also help your clerkship director ensure that what is being tested on the exam is being covered in the clerkship curriculum.

How schools report your exam results to you and how they are used in the clerkship evaluation and grading process vary significantly by institution. This information will almost always be provided to you at the clerkship orientation session at the beginning of the rotation.

There are several important things to remember about the end-of-clerkship examination:

  • It is important to understand how the examination is used in your clerkship. Although most clerkships use the exam as a component of your overall performance assessment and grade, it is helpful to know its role in this process. Similarly to the USMLE Step examinations, some students overly focus on achieving a high score on this aspect of assessment at the expense of learning clinical medicine, which is the ultimate goal of the clerkship. Make sure that you keep a healthy perspective about the exam while in the context of a clinical rotation. 
  • Clerkship directors are aware of the topics covered by the examination and will make every effort to ensure that you will be exposed to this content as much as possible, or otherwise indicate what information you need to study and know. However, even in the most rigorous clinical rotation you are not likely to see every condition covered on the exam or learn everything about it you may need to know about specific diagnoses and treatments. It is therefore imperative that you do additional study beyond your clinical activities to make sure that you have covered key internal medicine topics to an appropriate level. Many study resources are available, and your clerkship director may make specific recommendations about which study resources to use.
  • Because the exam covers the broad range of internal medicine knowledge, it is most helpful to prepare for the examination over the course of the rotation. Although your clinical duties will keep you very busy, studying is most effective if done over the course of the rotation instead of attempting to intensively study over the several days just before the exam. Having a plan and developing a system and habits for ongoing study is important for learning internal medicine, doing well on the exam, and helping you keep up with changes in medicine as you progress through your training and into practice.

If you have additional questions about the end-of-clerkship exam and how best to prepare for it, you should talk to your clerkship director for further advice and guidance.