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Taking the boards? Try these strategies for success

From the May 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Christine Kuehn Kelly

If you're preparing to take the American Board of Internal Medicine (ABIM) certifying board exam, experts say you might need more than traditional study techniques to do well.

Unlike other tests, the internal medicine board exam tests overall knowledge, not just the ability to recite facts and figures. That's why educators say that traditional study techniques may actually hurt your performance on the boards and that you should view the test as different from any other exam you have taken.

Here are some tips to help you prepare for the exam:

Understand the basics. It helps to know how the exam is structured. The ABIM exam is written by practicing internists to make sure the exam is testing participants' overall knowledge about internal medicine and problem-solving skills, and not just asking them to recite facts. As a result, ABIM officials say, nearly 85% of the test questions are presented as clinical scenarios that take place in ambulatory settings.

Twenty-two percent of the questions are repeated from recent tests, which ABIM officials say shows that the test emphasizes general knowledge. And don't worry about keeping up on a study published just last week: Because questions are created a year before the test is given, information from late-breaking clinical studies is not included.

Three-fourths of the multiple-choice questions where you have to pick a single answer test knowledge in the traditional medical subspecialties. (For a breakdown of the percentage of questions from each specialty as well as other general test information, visit ABIM's Web site .)

Don't cram. It turns out that last-minute marathon studying isn't only a daunting venture, but likely to do more harm than good, according to experts. Ideally, you should think about the test all through your training. "It's hard to think of the board exam your first year," acknowledged Herbert S. Waxman, FACP, the College's Senior Vice President for Education, "but if you wait until midway through your third year, it's too late."

For those early in their training, he suggested writing down key bits of information from each morning report and identifying three to five important clinical points from each of your own patients. Collecting this information and using it for review purposes, he said, will go far in helping you prepare for the exam.

Experts emphasize that you shouldn't study the night before the exam or between the first and second day. This may cause retroactive inhibition, in which longer-term knowledge is replaced by short-term memory. And don't look up items during the breaks. Finding out you were wrong may affect your self-confidence.

Assess yourself. Review courses and practice exams can help you prepare by pointing out areas where you need help. "Residents should examine themselves for their strengths and weaknesses," said Douglas S. Paauw, FACP, an associate professor of medicine at the University of Washington School of Medicine who regularly teaches board review courses. "Review course questions can help pinpoint where you need to put in more time."

The in-training exam is another way to pinpoint areas that you need to work on, said Henry J. Schultz, FACP, director of the internal medicine residency training program at the Mayo Medical Center. He noted that many educators have found a strong correlation between residents' performance on the in-training exam and their scores on the boards.

Dr. Schultz said that Mayo residents whose scores fall below the 50th percentile receive help in their first and second years. Frequently, residents need only to change their reading habits. Overall, he said, early remedial efforts have raised some scores from the lower half of national percentiles at the time of the in-training exam to above the 90th percentile in the board exam. That may explain why Mayo residents have an overall board pass rate of 97%.

(For more information on the in-training exam, which will be administered in late October, call Wynne Curry at the College at 800-523-1546, ext. 2568.)

Join a study group. Once you have identified your strengths and weaknesses, study groups can be a good way to get help. Dr. Paauw suggested limiting such groups to three or four members and making sure that they meet consistently, preferably twice a month. The groups can be organized by subspecialty or by organ and can use a study guide or textbook for guidance.

Rowen K. Zetterman, FACP, a professor of medicine at the University of Nebraska Medical Center and codirector of the College's Midwest board review course, said that one way to run study groups is to have each member formulate test questions. "There are only so many questions that can be prepared on a given subject," he said. "When residents finally take the board exam, they may be surprised to learn that they came up with some of the questions."

According to the College's Dr. Waxman, study groups should also practice working with the results of diagnostic studies. "Review collections of characteristic X-rays," he said. "Chances are the board won't expect a newly graduated resident to understand a complicated MRI, but it will expect you to interpret a chest X-ray."

Dr. Paauw added that it's a good idea to know abdominal X-rays and common skin findings and suggested that residents review a general dermatology atlas. Other important areas include peripheral blood smears and microscopic examination of urine sediment.

Rely on study guides, not textbooks. Instead of trying to glean information for the test from medical textbooks, try using supplemental study guides, particularly those that simulate the experience of taking the board exam. Look for ones that offer a large number of multiple choice questions and study questions with cases that force you to identify salient features for correct diagnosis or treatment. Educators say that the really good study guides won't make it too easy to identify the correct answer.

Review sample questions. Scrutinizing sample test questions can help you become a better test-taker. "You won't see the same question on the board exam," Dr. Paauw said, "so your goal should be more than to simply find the right answer." He suggested trying to determine why the answer was correct and the other responses wrong. "You can get five times as much information from a question when you use this technique," he said.

About 80% of residents sitting for the boards have used the College's Medical Knowledge and Self-Assessment Program (MKSAP). The product is divided into multiple booklets that cover different subspecialties and presents the past three years of key advances in internal medicine. (For more information, call ACP-ASIM's Customer Service at 800-523-1546, ext. 2600, or 215-351-2600, 9 a.m. to 5 p.m., EST.)

MedStudy is another widely used study guide that includes a handbook and a simulation exam. (For more information, call 800-841-0547.) Expect to pay from $200 to $335 for each guide.

Use review courses to fill in the gaps. Review courses can be useful at the end of the study period, but Dr. Paauw pointed out that they won't make up for three to four months of reasonably paced study. These courses, which are organized by university medical centers, local hospitals and ACP-ASIM (see "ACP-ASIM board review courses," this page), range from workshops to textbook reviews. Since you should know your strengths and weaknesses by this point, choose a review course that will fit your learning style and fill in the gaps. The courses range from $500 to $1,200 and tend to fill up quickly.

Here are some other tips on what to do when you finally sit down to take the exam:

  • First, spend a few minutes organizing yourself. Determine how many questions you should have answered at the midpoint of the exam.
  • The majority of questions are based on information about the patient in the question, known as the stem. First, read the stem without looking at the answers. The trick is to pick out the pertinent bits of information that will lead you to diagnosis or treatment decisions. Only after you've tried to figure out the answer on your own should you refer to those provided.
  • If an answer seems obvious, it probably is. "There are absolutely no trick questions," said Harry R. Kimball, MACP, president of the ABIM.
  • If two or more incorrect answers are similar, both will be wrong. If two appear to be correct, choose the one that causes the other to occur.
  • Consider ethnicity, race, gender, geography and occupation when you read case studies. For example, African-Americans are at higher risk for sarcoid; young women have a higher incidence of lupus erythematosus compared with men.
  • Don't agonize over a question you don't know the answer to. Your goal should be to answer one question every one or two minutes. At the end of the test, return to the questions you skipped. Writing out the question in your own words may help you focus. Or you may want to pick out several words to underline, and do the same with the responses. Don't return to change a response unless you are positive you misread the question the first time or have remembered pertinent information.
  • Be optimistic. Thanks to the use of better preparation by residents and an effort by the board to make questions more relevant to the practitioner, exam pass rates have been inching up over the past few years. In 1998, the pass rate was 84%, a slight increase over the previous year. Overall, 75% of the questions were answered correctly.

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

Test yourself: a sample question from the ABIM's board exam

The following type of question appears on the American Board of Internal Medicine's (ABIM) board certification exam. It is one of 20 questions available on the ABIM Web site:

A 35-year-old white woman comes to your office because of difficulty reading, which has become noticeable during the past two weeks. She has never required glasses. She takes no medications or other drugs.

The pupils are of normal size and react sluggishly to light. Both optic discs appear sharp, and there are no hemorrhages or exudates. Visual acuity is strikingly impaired and remains so when the patient uses a pinhole card. Five-beat nystagmus and double vision are noted on left lateral gaze.

Which of the following is the most likely diagnosis?

A. Diabetes mellitus
B. Multiple sclerosis
C. Myopia
D. Pseudotumor cerebri
E. Drug toxicity

Answer: B

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