American College of Physicians: Internal Medicine — Doctors for Adults ®

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Are you ready to take the internal medicine boards?

Experts advise self-assessment tests, study groups and other ways to best prepare—and pass

From the May 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Jennifer Fisher Wilson

When Angela L. Brown, ACP Associate, sat for the boards last summer, she found it to be a daunting experience. "I wished I had longer to prepare," recalled Dr. Brown, who now works at Barnes-Jewish Hospital in St. Louis. "I found that there was a lot I hadn't gone through. Plus, some of the things I had studied earlier didn't stick."

And while the exam's content was intimidating, Dr. Brown said, so was spending two days in an exam room. "Taking the test was very painful," she recalled. "Not the first day, necessarily, but then you go home, try to sleep, and the next day you're right back in it. By the afternoon session I was just exhausted."

The thought of preparing for—and taking—the internal medicine board certification exam makes many residents nervous. This test is usually the last—and most difficult—stop in training. But from choosing the right study tools and techniques to knowing when to get help in the form of board preparation courses, education experts say there are ways residents can not only survive the process, but also learn from it.

Assess yourself

Experts emphasize that continual preparation is a critical first step. "Learn throughout the residency, patient by patient," said Herbert S. Waxman, FACP, the College's Senior Vice President for Education. "If you learn something new, read something new every time, you'll be ready to pass the test when the time comes." Experts also suggest doing extra reading about each patient's problems to supplement the learning process—and better prepare for the boards.

No matter how complete your residency training may be, though, you should plan on setting aside some study time to review areas in which you have minimal experience. Many residents, for example, feel shaky about reading X-rays or examining blood smears.

To pinpoint your areas of weakness, take a self-assessment test during your second year or in the early part of the third year of training. Douglas S. Paauw, FACP, director of the board preparation course at the University of Washington School of Medicine, explained that self-assessment exams can help residents focus their studying on areas where they really need it. He recommended using the College's Medical Knowledge Self-Assessment Program (MKSAP) or similar self-assessment tools that not only comprehensively measure knowledge, but also use case-based questions similar to those on the board exam.

You also can get an idea of just how much you need to study by taking the internal medicine in-training exam, which was developed by ACP, the Association of Professors in Medicine and the Association of Program Directors in Internal Medicine. The voluntary test, which residents usually take in January of their second year of training, measures residents' knowledge of internal medicine. More than 10,000 residents, including those in the first and third year, take the exam annually. According to ACP's Dr. Waxman, research has shown that residents who score high on the in-training exam have a good chance of doing well on the boards. (For more information on the in-training exam, talk to your program director.)

The best study groups

Once you know the areas in which you need the most review, set a timeline for studying—and plan on getting an early start. Dr. Paauw recommends starting six to nine months in advance.

Because time is the one thing that you're most likely lacking, try participating in a study group. These groups typically consist of members of the same residency class and offer a no-excuses way to schedule study time.

According to Dr. Paauw, study groups, which usually form in the summer or fall before the boards, should follow these guidelines:

  • Meet each week for a few hours. A more frequent schedule makes it harder to coordinate schedules.
  • Be composed of three to four people. This size keeps the group tight and supportive. Larger groups tend to break down more easily.
  • Create a schedule to cover major topic areas each week and then assign individual topics. At each study meeting, members of the study group make a presentation about their topic.

    This form of studying can help the entire group—both the presenter and the listeners-learn, primarily because interaction helps the learning process. "Individuals in groups can take turns writing questions, and both the question-takers and writers learn a lot this way," Dr. Paauw said.

  • Work on case-based questions as well as exercises in memorization. ACP's Dr. Waxman emphasized that the ability to evaluate a case and manage it—not just memorize facts—is the key to passing the boards.

    It is advice that veterans of the exam like Dr. Brown endorse. "The practice questions were the best thing," she said. "Actually doing the questions and even finding out why the other answers were wrong really helped."

  • Focus on learning the common diseases of the field. While rare diseases might be the most challenging, in actual practice "the rare diseases you would refer to a subspecialist," said Michael J. Lichtenstein, ACP Member, director of the board preparation course at the University of Texas Southwestern at San Antonio.

    Another tip: When studying cases, focus on the symptoms and not just the disease to better prepare for the board exam, suggested John R. Middleton, FACP, director of a boards preparation course at Robert Wood Johnson Medical School in Piscataway, N.J.

Preparation courses

Board preparation courses, taken towards the end of the study process, give residents a way to tie up their studying efforts and boost confidence. (Warning: These courses can be a waste of time if residents have not studied.) While preparation courses are not a necessary part of the training process, Dr. Middleton views them "as an attempt to crystallize all the information residents have learned through their own studying."

Most courses are offered in late spring—May and June—leaving plenty of time afterward to fill any gaps in knowledge. Be sure to choose one that is case-based, not lecture-based.

The cost for three- or four-day ACP-sponsored courses runs from $410-$500 for ACP Associates to $750 for residents who don't belong to the College.

Dr. Middleton's four-day preparation class emphasizes interactive participation between faculty and residents. Besides attending lectures, residents review "boards of knowledge," 20 case-oriented posters that depict disease processes through pictures. Attendees determine what each case presents; they receive the correct answers the next day.

The course also offers residents a chance to interact in workshops that focus on clinical images. During evenings, faculty present case studies accompanied by an EKG, X-ray or pathology report in areas such as hematology, radiology, cardiology, ethics and laboratory medicine. Group discussions follow the presentations as residents try to determine how to best manage the situations presented to them.

Final advice

When the time for taking the boards arrives, experts say, don't cram. Last-minute studying may serve more as a confidence buster than as a confidence builder. And it can also be overly tiring. Dr. Paauw instead suggested that residents try to get a good night's sleep.

When taking the test, "take it one question at a time," Dr. Waxman said. "Read the whole section; identify important information; take time to understand the question; narrow your choices," he explained. Once the test has started, don't try studying during breaks. "Test-takers will sometimes look things up that they missed," Dr. Paauw said, "but it's unlikely that these things will come up again, and this can even be detrimental."

If you start to panic, remember that the odds of passing are in your favor. Eight out of every 10 first-time residents who sit for the boards pass, according to John Norcini, PhD, executive vice president for evaluation and research at the ABIM.

All the preparation and anxiety that goes into taking the boards may be frustrating for busy, already stressed-out residents, but the work can pay off, as it did for Dr. Brown. After months of studying, self-assessment, and reading, Dr. Brown passed the boards.


Exam registration

Registration begins in September for the August 1998 exam. It coasts $790. Late registration, starting in December and closing in February, costs and additional $300, according to the American Board of Internal Medicine (ABIM), which administers the exam. Information: ABIM, 800-441-2246.


A sample question

Beyond simple memorization: case-based testing

Memorization is not everything. Here is an example of a case-based question taken from the College's MKSAP 10 cardiovascular medicine section. An educational objective plus a bibliography follow that explain the condition in depth and how it relates to this patient.

A 50-year-old male business executive with a history of mild hypertension is referred by an oral surgeon before a gingivectomy. On physical examination the patient's blood pressure is 160/90 mm Hg in the right arm and 120/84 mm Hg in the right leg. On auscultation there is an aortic ejection sound, a 2/6 basal mid-systolic murmur, and a grade 1/6 high-pitched early diastolic murmur at the left sternal border. Chest roentgenogram and electrocardiogram are normal.

Which of the following conditions is most likely to be present in this patient?
(A) Essential hypertension with secondary aortic regurgitation
(B) Coarctation of the aorta and a bicuspid aortic valve
(C) Supravalvular aortic stenosis plus pulmonary branch stenosis
(D) Isolated aortic regurgitation
(E) Patent ductus arteriosus


Answer: B

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