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


Simple strategies for surviving the board examination

What will work and what won't—like cramming and pulling all-nighters—may surprise you

From the June 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Maureen Glabman

SAN DIEGO—It's the night before the board exam, and the scent of coffee and microwave popcorn fills the room. You're sitting in the middle of a pile of books on the sofa, cramming. You pulled your share of all-nighters as a resident, and you figure that you can do the same to prepare for the two-day exam.

According to test experts, that plan will probably do more harm than good. Instead, they said at an Annual Session presentation on preparing for the boards, residents should rely on tried-and-true studying techniques—and a good understanding of how the board examination is written—to get through the test.

First of all, when it comes to preparing for the American Board of Internal Medicine's (ABIM) certification test, cramming is not a good idea. "Don't study the night before the test or between the two test days," said Joyce E. Wipf, ACP Member, a Seattle internist who regularly teaches board review courses and who spoke on the topic at Annual Session. "Last-minute studying tends to replace longer term knowledge in your short-term memory."

A much better way to prepare is to start studying early—at least four months before the test—and choose the right study tools, said Douglas S. Paauw, FACP, a Seattle internist who regularly conducts board review courses and spoke at the Annual Session presentation. Dr. Paauw said that ACP's "MKSAP 11" is probably the best study aid because it is written in the same style as the board examination. He also recommended "Portable Internist," "Medical Diagnostics," "Diagnostic Strategies for Internal Medicine," "Diagnostic Strategies for Common Medical Problems," "Mayo Clinic Internal Medicine Board Review," "Med Study" and "Scientific American Medicine."

Study techniques

Once you've got the right tools, you should focus on study techniques. Dr. Paauw said that one of the best study strategies is to form a study group in May. The group should divide study materials among the group's members; each member is then responsible for creating mock test questions.

Dr. Paauw emphasized that study groups should include no more than six people. "Any more than six becomes a committee and committees never work," he said. The groups will ideally meet weekly for a few hours, with members taking turns making presentations.

Another technique is to take a board review course. State medical societies, medical schools and other organizations typically offer review courses in May, June and July. ACP also runs four- and six-day classes in eight U.S. locations. Residents can expect to pay between $300 and $500 for these popular courses, which sell out quickly.

John R. Middleton, FACP, who has been directing a four-day board-review course in New Jersey for six years, warned in a telephone interview that residents should not rely just on board review courses. "We don't hold ourselves out as a rescuer to those who haven't put in the time and effort in reading and training," he said.

Dr. Wipf said that practice tests are also a helpful tool, but she warned that they, too, should not be the only study method used. On the plus side, practice tests simulate the time pressures of a long test—the boards span two eight-hour days—and identify your strong and weak areas. However, if you take practice tests too close to the exam, she said, they can frustrate you and increase your anxiety.

The test

When it comes to the actual test, there are several things you can count on. First, Dr. Paauw said, at least 20% of questions will be repeated year after year. Second, roughly 80% of the questions will be case-based. In other words, they present information about a patient and ask, "What would you do next?" Dr. Wipf said that this style of question requires that you think in steps. (See "Case-based questioning: a sample," below.)

Third, many test-takers get tripped up when they forget to consider the ethnicity, geography and occupational history of patients in case studies. For example, if a case study involved a patient of Japanese descent, remember that gastric carcinoma is common among Japanese.

Fourth, focus on knowledge that is fairly established. Anything truly current, such as a new saliva test for HIV, will not be on the test. It takes at least a year for a question to be developed and reviewed before it appears on the exam.

Students who understand the terminology used in questions have a head start, according to Ernest Yoder, FACP, an internist who oversees a board review course at Wayne State University Medical School, Detroit. In a telephone interview, Dr. Yoder said that test questions often feature the words plop (used synonymously for mixoma), tearing (dissection) and paroxysm (meaning theochromocytosis).

ABIM's Web site also offers some help by providing the breakdown of questions in each category. For the 1998 test, for example, 14% of the questions will be on cardiovascular disease, 10% will deal with gastroenterology, 10% will be on pulmonary disease and 9% will be on infectious disease.

Dr. Wipf said that ABIM seems to have a definite philosophy in creating tests. "If an answer seems obvious," she said, "it is probably right. Application of knowledge is emphasized over trivia."

Another tip: If a photograph or image appears on the test, study it carefully. Both Drs. Wipf and Paauw emphasized that pictures and ECGs are so expensive to reproduce on the exam that they are always significant. "If a picture is shown on the test, it is pretty classic or pretty important," Dr. Wipf said.

The questions

Once you're actually taking the test, don't spend too much time focusing on the details of each question, but look for a pattern. If you spend too much time analyzing the details of each question, you will have trouble deciphering exactly what the question is asking.

Also, Drs. Wipf and Paauw suggested trying to answer each question in the following order:

  • Read the directions.
  • Read the stem (the information in the question) to figure out the answer before looking at the choices. The last sentence is the actual question. Often, the bulk of information is superfluous.
  • Be sure you understand what is being asked.
  • Underline a few key words.
  • Circle negatives such as not, negatively, least likely.
  • Absolutes such as always, never and only are usually wrong.
  • Underline one to two words in each answer.
  • Look for clues in the case history.
  • Spend one to two minutes on each question, never allowing yourself to get stuck on one question.

When you come across particularly difficult questions, take your best shot. Change your answer only if you are sure of a mistake or if you suddenly recall some new information.

"Your first answer is your best because while you're reading the question, you're using hypothetical deductive methods," Dr. Yoder said. "When you think too long, you get mixed up."

Finally, pace yourself. Review the entire exam and determine in advance at what time you should have half of the test completed.

The odds

Before you start sweating about how you'll do on the test, however, consider the statistics: Based on data from previous years, roughly 70% of the test's 12,000 registrants pass, which means getting about 65% of the questions right. According to Dr. Yoder from Wayne State in Detroit, individuals who have problems passing tend to have serious problems with test anxiety or are ill prepared.

Maureen Glabman is a Miami-based writer who specializes in health care.

Case-based questioning: a sample

Most questions on the board exam are case-based, requiring you to think in steps about a patient scenario. The following sample question is from Joyce E. Wipf, ACP Member, a Seattle internist who teaches board-review courses. (More sample test questions are available on ABIM's Web site at

A 29-year-old respiratory therapist in your hospital seeks advice regarding a positive PPD. She was negative on her employment PPD screen two years ago. Chest X-ray is negative. You should recommend:

  • (A) Observation for development of pulmonary symptoms;

    (B) Isonaizid therapy for three months;

    (C) Isonaizid therapy for 12 months;

    (D) She must avoid patient contact since she is infectious.


ABIM's schedule of examinations

The American Board of Internal Medicine (ABIM) will hold board examinations Aug. 25-26, 1998, Aug. 24-25, 1999, and Aug. 22-23, 2000. You must register for the test between Sept. 1 and Dec. 1 the year before. The test currently costs $815. For more information, call ABIM at 800-441-2246, or visit its Web site at

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