What Attendings Really Think About Your Shelf Exam Scores

It’s 6:10 a.m. You’ve pre-rounded, scribbled vitals on the back of your sign-out sheet, and you’re standing at the nurse’s station pretending to re-check labs while actually refreshing the portal that just posted your shelf score.

You finally see it.

Not the number you wanted.

Now you’re walking into work rounds with this pit in your stomach: Is my attending going to think I’m dumb? Is this going to tank my eval? Do they even care?

Let me tell you what actually happens on the other side of the workroom door.

Because I’ve been in that residents’ room, listening to attendings talk about students. I’ve watched them open eval forms, seen what they scroll past, what makes them pause, and what they flat-out ignore.

Shelf scores are not what you’ve been told they are. They matter. But not in the way you think—and not to the people you think.

Let’s pull the curtain back.

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Who Actually Sees Your Shelf Scores (And Who Pretends To Care)

First thing: most attendings on your rotation never see your raw shelf score. They see one of three things, if anything at all:

• A vague band: “Below expectations / Meets / Exceeds”
• A converted clerkship grade that secretly bakes in shelf performance
• Or nothing, because your school keeps shelf data at the clerkship director level

What actually happens behind the scenes:

At the end of the rotation, most attendings get an email: “Please complete an evaluation for Student X.” They click a link while half-dictating a note and thinking about their clinic schedule.

They see checkboxes for: medical knowledge, clinical reasoning, professionalism, communication, initiative, etc. Maybe a textbox for comments.

Almost never: a number like “67 raw” or “74 scaled.”

So when you’re spiraling—“My attending is going to think I’m an idiot because I got a 63”—remember: unless they are also the clerkship director, they literally do not see that number.

Who does actually care about the number?

• Clerkship directors
• The MD/PhD or education geeks on the med ed committee
• Your dean’s office compiling MSPE language and honors decisions
• Occasionally, residents if they’re weirdly invested in teaching or competing with other services

Attendings, in general, do not sit there comparing your 78 with another student’s 82. They don’t have time. And they’re not paid to care that much.

But here’s the twist: they do care about what they think your shelf score probably is. Different thing entirely.

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How Attendings Guess Your Shelf Score (And Why They’re Sometimes Right)

They are constantly, subconsciously, doing this math:

“If I gave this student a 20-question mini-shelf right now on my patients, what would they get?”

They’ll never say it like that. But they’re gut-ranking you all the time. And they use five main signals.

1. How you answer questions on rounds

Everyone thinks this is about “knowing the right answer.” That’s amateur hour.

Attendings are listening for how you think:

• Do you organize your answer?
• Do you show you know the why, not just the buzzword?
• Do you know the “next step,” not just the diagnosis?

Example:

Attending: “What’s the first-line treatment for acute COPD exacerbation?”

Student A: “Uhh, nebulizers? And steroids. And maybe antibiotics?”

Student B: “Short-acting bronchodilators with albuterol/ipratropium, systemic steroids—usually IV methylpred—plus antibiotics if there’s change in sputum or signs of infection.”

Both technically “right,” but every attending in the room just mentally gave Student B the higher “probable shelf band” by like 20 percentile points.

They’re not thinking about your NBME scaling. They’re thinking: If this is how you answer cold questions, your shelf score probably reflects that level of structure and depth.

2. What you write in your notes

No one tells you this part.

I’ve watched attendings on medicine, OB, and peds open a student note, skim it for 10 seconds, and say some version of: “Yeah, they’re probably going to do fine on the shelf.”

What do they scan for?

• Is your assessment more than “this is a 65-year-old with pneumonia”?
• Do you actually risk stratify? (CURB-65, Wells, TIMI, BPP, etc.)
• Do you connect pathophysiology to your plan?
• Are your problem lists prioritized and complete?

Shelf exams are “written notes without the note.” Attendings know that.

If your assessment and plan reads like a board vignette answer, they assume your shelf won’t be a train wreck. If your note is a copy-paste of the resident’s template with your name slapped on, they assume the opposite.

3. What you ask about when you have downtime

There are two types of students at 3 p.m. when discharges are done and the list has quieted:

• “Is it okay if I go study for the shelf?”
• “Can I run something by you? I read this but don’t totally get it.”

Every attending I know will tell you this: the second student almost always does better clinically and on tests.

Because those questions reveal the depth of your mental model. Whether you care how things connect, or you’re just treating UWorld explanations like flashcards.

When you ask: “Is there a reason we chose ceftriaxone/azithro instead of levofloxacin here?” you’re signaling: I’m actively aligning what I see on the shelf-style questions with what I see in front of me on the floor.

Attendings love that. They infer you’re studying at a higher level, even if they never see your score.

4. How you handle being wrong

This one’s huge.

Students who crush shelves, in the attending’s mind, are not the ones who are never wrong. They’re the ones who do this:

Attending: “No, that’s not quite right.”

Good student: “Okay—so I was thinking X because of Y. What am I missing?”

Bad student: “Oh. Okay.” Silence. Or worse, immediate backpedaling into guesswork.

Shelf exams punish fragile thinkers. Attendings know that students who can take a miss, dissect it, and tighten their logic are the ones who tend to climb from 50th to 75th to 90th percentile as the year goes on.

5. Patterns across rotations

Here’s the dirty secret: attendings talk.

Not formally. But in the workroom, on call, walking to the parking lot.

• “Oh yeah, she was on my surgery rotation. Solid. Read a ton. She’ll do well on your medicine shelf.”
• “He’s nice but really struggles with medical knowledge. Needs things repeated. He might need support for Step 2.”

That reputation? Often more powerful than a single shelf.

Your OB attending isn’t thinking: “Her psych shelf was a 71.” They’re thinking: The medicine attending said she knows her stuff; I’m going to assume that and likely grade accordingly.

Good or bad, those impressions follow you further than one low shelf.

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How Much Shelf Scores Actually Affect Your Evaluation

This is the part schools try to blur, and students wildly misunderstand.

Let’s separate two worlds:

1. What individual attendings think and do
2. How the clerkship and school translate that into grades

From the attending’s chair

Most attendings approach student evaluations like this:

• “Top few I’ve seen this year”
• “Solid, typical student”
• “Concerning in knowledge, or professionalism, or reliability”

They translate that vague sense into checkboxes that essentially group you.

They do not sit there thinking: “I bet this student got a 78 on the shelf, so I’ll give them ‘above expectations’ in medical knowledge.”

They’re thinking: “Would I be comfortable with this person as my intern in a year?”

If yes, you get strong comments and high marks. If they’re really impressed, you get language like “outstanding,” “among the best students I’ve worked with this year,” “functions at or above expected level.”

Those phrases matter far more for residency than, “Scored in the 80th percentile on the shelf,” which almost never appears anywhere official.

From the clerkship director’s office

Whole different game.

Here’s what actually happens when assigning your final grade:

1. They get:

   • Your shelf percentile
   • Your attending/resident evals
   • Maybe an OSCE/mini-CEX score

2. They use a formula you’re sort of told about, but never fully shown.

Here’s a rough sketch of how many schools weight things:

Component	Weight Range
Shelf Exam	30–50%
Clinical Evaluations	40–60%
OSCE/Other	0–20%

Then there’s a hidden layer: politics and grade inflation caps.

I’ve sat next to clerkship directors doing this dance:

• “We can’t have 40% of students getting Honors, the Dean will complain.”
• “This student has glowing evals but a weak shelf; can we bump them to High Pass?”
• “This one has a stellar shelf but mediocre evals; I’m not comfortable giving Honors.”

So your attending might adore you and not care about your 60th percentile shelf. But the clerkship policy might still slam you into “Pass” or “High Pass only.”

That’s how you end up with students feeling: “My attending said I was great, but I got a Pass. Do they secretly hate me?”

No. The director’s hands are often tied by their own rubric and the shelf cutoff.

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When Attendings Actually Care A Lot About Shelf Scores

Most of the time, attendings don’t know or don’t care about the number. But there are three scenarios where they absolutely do pay attention.

1. When you’re clearly struggling across the board

If you’re consistently:

• Lost in the basics
• Missing obvious differentials
• Writing weak notes
• Getting feedback that your knowledge is “below level”

Attendings will start asking the clerkship director: “How are they doing on exams?”

Translation: Is this just a confidence/experience issue, or is there a foundational knowledge gap?

If they hear “They’ve failed/helped on two shelves,” the mood shifts. Now it’s not about grades. It’s about: Is this person safe? Do we need remediation before we let them loose as an intern?

This is when they start pushing for:

• Learning plans
• Meeting with student affairs
• Extra practice cases
• Sometimes even a leave of absence before Step 2

They are not mad. They are protective. Of patients, yes, but also of you. No one wants to watch a student fail Step 2 and implode their career.

2. When you crush everything

On the other end: if you are the kind of student who:

• Lights up rounds
• Anticipates next steps
• Connects pathophys without flexing
• Asks good questions

And then your shelf score comes back at the 90th+ percentile?

Now attendings suddenly care. Because it confirms their impression.

They’ll say things like:

• “You should seriously think about academic medicine.”
• “You will have your pick of programs.”
• “If you want a letter, I’ll write you a very strong one.”

Not because of the number. Because your performance plus the number fits their “rising star” pattern. And attendings—especially academic ones—love to be right about spotting talent.

3. When you’re applying to their specialty

If you’re on an away or home audition rotation in the specialty you’re trying to match into, the game changes.

Program directors talk directly to clerkship and course directors.

Questions that actually get asked:

• “How did they do on their medicine/peds/surgery shelves?”
• “Were they consistently in the top half/third/quarter of their class?”

Not every specialty cares equally, but the competitive ones absolutely ask this, even in the post–Step 1 pass/fail era.

Attendings in those fields know this. So if you’re applying to, say, Derm or Ortho, and they hear you’re bombing shelves left and right, you will feel the temperature change. They’ll still be polite. But they’ll start framing feedback around “realistic expectations” rather than “you’re in a strong position.”

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How Shelf Scores Really Affect Residency (Not The Myth Version)

You’ve heard all kinds of nonsense:

• “No one cares about shelves.”
• “Residency only sees your clerkship grades.”
• “As long as you pass, you’re fine.”

Some of that comes from older residents who applied in a very different era. Some is just wishful thinking.

Let me outline how this works backstage.

What residency actually sees

Residency programs don’t see a PDF of each shelf. But they see:

• Your clerkship grades
• Your MSPE (Dean’s letter) narrative
• Sometimes, your clinical performance bands (Top 1/3, middle, etc.)

Behind every “Honors in Medicine” or “High Pass in Surgery” is usually a shelf cutoff. So whether or not they see the number, they’re seeing the consequence of the number.

Your MSPE might say:

“Performed in the top 25% of the class on core clinical clerkships, including Medicine and Surgery.”

That phrase is not coming from vibes. It’s coming from the composite: shelves + evals.

The “consistent pattern” thing

Program directors are pattern people. They look for trajectories, not single data points.

A typical quiet conversation in a PD’s office reviewing an applicant:

• “Step 2 is 247, solid.”
• “Mostly Honors and High Pass. One Pass in OB.”
• “Any red flags?”
• “No. Comments are strong. Probably just had a bad shelf or rotation. I’m not worried.”

Versus:

• “Step 2 is 222.”
• “Pass on Medicine, Surgery, OB. High Pass in Psych.”
• “Comments mention ‘needs to continue building medical knowledge base’ on multiple rotations.”
• “Okay, borderline. Maybe okay for our categorical, but I’d be cautious at a high-acuity program.”

They are not dissecting each shelf. They’re reading the story your clerkships tell.

If you tank one shelf but your evals are glowing and the rest of your year is rock solid? Attendings and PDs basically write it off as noise.

If you tank shelves across the board and your evals consistently mention knowledge gaps? Different story.

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How To Look Good To Attendings Even With A Mediocre Shelf

Now the part you actually care about: if your shelf is already done and the score isn’t what you wanted, what can you control?

Here’s the behind-the-scenes truth: a strong clinical impression can blunt a mediocre shelf. A weak clinical impression will not be rescued by a high shelf.

So if your score wasn’t great, attendings will still rate you highly if you:

1. Own it without drama

You don’t need to announce your percentile on rounds. But if you’re close with a resident or attending who asks, saying:

“I passed but was disappointed. Clearly I have some gaps in X and Y—I’ve started focusing there.”

That sounds mature and focused. What they hate is denial or blaming: “The test was unfair,” “NBME is trash,” etc. Everyone knows the exams are flawed. Complaining just makes you sound like someone who externalizes everything.

2. Tighten what they actually see

You cannot retroactively change your shelf score. You can absolutely change:

• How you present on rounds
• How you write your assessment and plan
• Whether you anticipate next steps
• How often you offer to follow up on questions

Attendings primarily grade what they experience with you at the bedside and on the team. Double down there.

3. Turn your “meh shelf” into a specific plan

Attendings trust students who can say, specifically:

“I realized I’m weak on chronic kidney disease management and interpretation of ABGs. I’m doing one UWorld block a day just on those and trying to connect it to our patients.”

That is exactly the kind of student who later has comments like “responded well to feedback” in their MSPE. Program directors eat that up.

4. Don’t let one score infect your attitude

Every attending I know can spot the student who spiraled after a bad shelf and mentally checked out. The ones who start disappearing at 3 p.m., stop asking questions, act like third year is a punishment.

Those students get bland evals, no matter how their exams shake out.

The students who take a hit, recalibrate, and keep showing up engaged? Those are the ones attendings quietly root for and sometimes help behind the scenes—extra calls, quiet advocacy in ranking meetings, strong letters.

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Visualizing What Actually Drives Final Clerkship Grades

To make this concrete, here’s how three hypothetical students end up graded, and how attendings think about them:

Student	Shelf Percentile	Clinical Eval Quality	Final Grade	Attending’s Impression
A	90th	Strong	Honors	“Star, would love as an intern.”
B	45th	Very Strong	High Pass	“Excellent clinically, test okay.”
C	75th	Weak	Pass/HP	“Knows facts but not a team player.”

Every attending I know would rather vouch for Student B than Student C for residency. Even though C had the “better” test story.

That’s what you’re up against.

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A Quick Reality Check: What Actually Moves The Needle Over M3

To close the loop, let me map this out in a way you can picture over the whole year.

Impact of Shelf Scores vs Clinical Performance Over M3

Step	Description
Step 1	Start of M3
Step 2	Your behavior on the wards
Step 3	Your notes and presentations
Step 4	Your attitude and growth
Step 5	NBME Shelf Exams
Step 6	Clerkship Directors
Step 7	Final Clerkship Grades
Step 8	MSPE & Class Rank
Step 9	Residency Applications
Step 10	What do attendings see?

The attendings mostly live on the left side of that diagram. The people who care about your raw shelf lives on the right.

Your job is to not confuse the two.

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FAQ: What Attendings Really Think About Your Shelf Scores

1. Do attendings actually see my exact shelf exam score?
   Usually, no. Most attendings only see your performance through your clinical work and the final grade (Pass/High Pass/Honors). The exact shelf percentile typically stays with the clerkship director and dean’s office, not the day-to-day attending.

2. Will one bad shelf exam ruin how attendings think of me?
   Not if your clinical performance is strong. Attendings weigh what they see on rounds, in notes, and in your behavior far more than a single test. A pattern of poor knowledge and weak engagement is what shifts their impression, not one rough exam.

3. If I do really well on shelves, will attendings treat me differently?
   Only if it matches how you show up clinically. If you’re already impressive on the wards and they later hear you did great on shelves, it reinforces their “rising star” view. But a high shelf with mediocre clinical performance won’t magically upgrade their impression of you.

4. Should I tell my attending my shelf score?
   Not routinely. If they ask, or you’re discussing performance honestly with a mentor, you can share it in the context of what you learned and how you’re adjusting. Dropping your percentile unsolicited usually comes off as insecure or braggy, depending on the number.

5. What matters more for residency: shelves or how attendings evaluate me?
   For individual attendings and letters, your clinical behavior and evaluations matter more. For your transcript and MSPE, shelves indirectly matter a lot because they influence final clerkship grades. Residency programs see the grades and narrative, not the raw shelf scores—so both layers matter, but for different audiences.

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If you remember nothing else:

1. Attendings mostly judge you by how you show up, not by a number they never see.
2. Shelf scores quietly shape your grades and MSPE, but they’re just one part of a larger pattern.
3. A strong clinical reputation can soften a mediocre test; a great test will not rescue a weak reputation.