PURPOSE: Clerkship directors' practices regarding the National Board of Medical Examiners (NBME) subject exam in medicine are important in enhancing educational evaluation policy. The study's purpose was to determine clerkship directors' use of the subject exam in medicine and related learning activities in the context of curricula and outcomes of the directors' internal medicine clerkships. METHOD: The authors conducted a survey of directors of internal medicine clerkships in 2007. They performed descriptive statistical and multivariate analyses on all responses. RESULTS: Of 110 clerkship directors, 82 responded to the survey, for an overall response rate of 75%. Eighty-eight percent of the clerkship directors required the NBME subject examination in medicine. The mean minimum passing score was 62 (SD = 4.2); this score was not adjusted throughout the academic year, and it contributed 20% to 25% of the final grade. Most (89%) clerkships allowed students a retake after a failed first attempt. Most clerkship directors prepared students for the NBME subject exam in their programs through some combination of lectures, independent self-study, and review sessions with exam-preparation review books. However, 42% of clerkship directors lacked a specific strategy for a retake after a failure. CONCLUSION: Clerkship directors' use of the NBME subject exam in medicine is high. Most allow a retake after a first failure, and a combination of strategies is currently provided to help students prepare. A need exists to develop remediation plans for students who fail the exam. This report may serve as a reference for curricular and programmatic clerkship decisions.