Progress, Not Position: Debunking the Myth that Exam Order Drives NBME Clinical Subject Exam Performance

Med Sci Educ. 2026 Oct 8;36(6):2675-2682. doi: 10.1007/s40670-026-02913-2. eCollection 2026 Dec.

ABSTRACT

INTRODUCTION: Finding the “best” clinical clerkship schedule to optimize National Board of Medical Examiners (NBME) subject exam performance is mythologized among students. Regardless of sequence, do students perform better in later clerkships on NBME subject examinations? How does content intersect across subject exams?

METHOD: Three cohorts of student (n = 314) NBME clinical subject exam performance were examined at one medical school. NBME content guides were analyzed using the cosine similarity technique to determine overlapping content between exams.

RESULTS: All clerkship NBME subject exams showed progressively higher means throughout the block sequence. Of 40 failures (< 10th national percentile), 75% occurred during one of the first three blocks, while 45% occurred in the first block. Cosine similarity showed pediatrics (59%), family medicine (59%), and internal medicine (58%) exams each share nearly 60% proportional distribution of content with the other five respective examinations. Surgery shares around 52% proportional distribution of content with the other five examinations. Psychiatry (average 19%) and OBGYN (average 15%) share the least proportional distribution of content with other NBME examinations.

DISCUSSION: Students performed higher on later subject exams in their sequence. Considering early failure rates and the increase in score performance between blocks one-six, specific sequencing may be of minimal consequence. Lower performance in the first blocks shows the need for students to enter clerkships with a consistent study strategy-valuable information for academic advisors. The NBME content outlines show that there are various scheduling permutations that provide degrees of content exposure. Instead, the change between blocks one and two shows the most consistent improvement leap.

SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at https://doi.org/10.1007/s40670-026-02913-2.

PMID:43031797 | PMC:PMC13759948 | DOI:10.1007/s40670-026-02913-2