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Strategies to pass the internal medicine board exam

From the June 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Ingrid Palmer

PHILADELPHIA—With the American Board of Internal Medicine certification exam just months away, residents everywhere are asking the same question: What's the best way to study for the exam?

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At an Annual Session presentation, "How to Prepare for the ABIM Examination," experts outlined some of the more helpful strategies and identified others that residents should avoid. Here are some of their tips to help you pass the exam.

Study groups

Study groups not only keep you on task, said Douglas S. Paauw, FACP, an associate professor at the Washington School of Medicine, but they allow you to learn from your colleagues' expertise. Dr. Paauw suggested dividing up the material you want to study and meeting with the group once a week. Concentrate on a different clinical area each time.

To make the most of your study group, have members write out practice questions for the others. "When you write questions, you become better at understanding questions," Dr. Paauw said. And because there is a finite number of questions, he added, don't be surprised if some of the questions your study group creates look familiar when you take the exam.

Another approach is to ask study group members to analyze their reasoning out loud when working through a question. Discuss each possible answer in the same way, stating why you think it is or isn't the best answer. Hearing how your peers interpret the information is often useful, said Joyce E. Wipf, ACP—ASIM Member, associate professor and associate director of residency training at the University of Washington School of Medicine.

Remember that emphasis should be on your reasoning, not the correct answer. The test emphasizes overall knowledge rather than trivia, and very few questions can be recalled accurately through basic memorization. "Try to study as if you really want to know the information for clinical practice—not just to pass the exam," she added. After you review a section, rewrite the information in your own words to help you remember key associations.

Courses and tests

Review courses are offered in many parts of the country, but many residents wonder if they are worth the expense. Dr. Paauw gave them a mixed review.

"Board review courses offer a few benefits," he said, "but they're not for everybody." The pros? Review courses can be useful in evaluating areas of knowledge where you need help. The cons? They can be expensive and may not be offered in a location that's convenient. In any event, Dr. Paauw said, review courses should never take the place of consistent, well-paced studying.

Review courses are typically offered by organizations like university medical centers and area hospitals. For information on review courses and audio versions of courses offered by the College, go to ACP—ASIM Online at

In addition to review courses, practice tests are a popular study tool. While these tests can be helpful, they should not be your primary source of study, said Dr. Wipf. "After a while, the information you're learning is only what that question asks, not the overall approach to that category of study."

Practice tests have other uses, though. Because some people run out of time on the exam, simulating the time pressure during a practice test can help residents better gauge how long they should spend on each question. The tests can also help identify areas of strength and weakness. But don't take a practice test shortly before the exam, Dr. Wipf warned, because "it might end up unnecessarily frightening you."

Questions on the exam

Though 75% of exam questions apply to traditional internal medicine and internal medicine subspecialties, a number of questions on the exam don't directly pertain to internal medicine. ABIM believes that internists need to master broad medical knowledge, so you can expect about one-fourth of the questions to cover fields like allergy/immunology, dermatology, ophthalmology and psychiatry.

Most subspecialty questions on the exam will focus on cardiology, gastroenterology and pulmonology. (For a complete breakdown of content areas covered on the exam, visit ABIM online.)

Dr. Paauw said to prepare for questions that cover multiple clinical areas, such as women's health, nutrition and geriatrics. You can also expect to see at least a few questions on ethics.

Three-quarters of exam questions are based on scenarios that take place in offices or emergency rooms. Many require you to look at information from several sources and reach a conclusion using your clinical judgment. "Most of them ask you to pick the right diagnostic test, choose the right therapy or identify risk factors," Dr. Paauw said.

Both short and long clinical stems are on the test. Long stems can be up to three paragraphs and can include a lot of lab information, Dr. Paauw warned. When you're reading through a scenario, remember that the question may not always be about diagnosis.

X-rays or photos of rashes and lesions are fair game on the exam, so be prepared to diagnose problems based on visual as well as written information. Dr. Wipf said that the best way to target this kind of question is to pay attention to how the lesion looks (color, size, clusters, etc.) and where it is located on the body. Charts, graphs and other data may also be presented.

The writers of the exam are not trying to trick you, she added. "If the answer seems obvious, it probably is right." The object is to get residents to think systematically, "to logically use the information to come up with a diagnosis, a plan, and what you're really going to do with a patient," Dr. Wipf said.

Dr. Paauw also recommended looking at the College's Medical Knowledge Self-Assessment Program (MKSAP), which has "the best source of practice questions written in the same style as those on the exam."

Test-taking strategies

After reading through a question, try to come up with the answer on your own before reviewing the choices. For long clinical stems, glance at the last line of the scenario and the question first so you know whether to look for a diagnosis, course of treatment or appropriate testing procedure. On the test, you're not going to have every piece of information that you would want. "Just go with what's given," Dr. Wipf said.

Stay alert for certain "magic words" or phrases (tearing pain, for instance) that can clue you in to key epidemiologic or physical exam data, Dr. Paauw said. Ethnicity, age, geography, gender and occupation can all be magic words. Filipinos, for instance, are more likely to be affected by gout, while northern Europeans have a higher incidence of temporal arteritis.

If you find one of the longer questions difficult, try rewriting it in your own words and then grouping related information to discover patterns. If you still aren't sure, choose the best answer; you are not penalized for guessing.

Dr. Wipf said that your first choice is usually the best one, so if you go back to look over your answers, change something only if "you are sure you made a mistake or misread the question," she suggested.

Studies of people who see themselves as "poor test-takers" show that they often don't understand the question being asked. As you read, circle the negative words (least likely, the following are true except) to highlight key phrases. This reduces your chances of becoming confused by the wording.

Final tips

While Drs. Paauw and Wipf said that the best strategy for passing the boards is to study early and often, they suggested taking the following steps immediately before and during the exam:

  • Get plenty of rest during the days leading up to the exam. "This is going to be a grueling exam and you want to be rested," Dr. Wipf said. If you have a lot going on at home, you might want to stay somewhere else.

  • Don't take a practice test or study the night before the exam. If the test is spread out over two or more days, don't study between the test days or look up answers to the previous day's questions. This kind of cramming and second-guessing can cause retroactive inhibition, a condition in which information learned at the last minute displaces more well-established, long-term knowledge.

  • Wear multiple layers of clothing so that you can easily adapt to the room temperature where you take the exam.
  • Read the directions carefully.

  • When you get the test, compare the number of questions in the section with the time allotment. This will give you an idea of how long to spend on each question. If a question initially stumps you, mark your best answer, put a star in the margin and return to it once you've finished other questions in the section.

  • Stay calm and think positively. The pass rate for last year's ABIM exam was 84% for first-time takers. Pass rates have risen in recent years because programs are better preparing residents and focusing more on education.

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