Strategies to help pass the internal medicine boards
From the June ACP Observer, copyright © 2003 by the American College of Physicians.
By Jason Van Steenburgh
SAN DIEGO—With only about two months left until the American Board of Internal Medicine (ABIM) certification exam is given, time to prepare is quickly running out. But residents and young physicians about to take the test still have time to sharpen their test-taking skills.
At an Annual Session presentation, two veteran board-preparation instructors—Douglas S. Paauw, FACP, and Joyce E. Wipf, FACP, both from the University of Washington School of Medicine in Seattle—shared many of the tips and tactics they have developed over years of helping young physicians prepare for the test.
While both stressed that there is no substitute for knowledge, they agreed that physicians will have an easier—and less stressful—experience taking the boards if they know what to expect. Here is an overview of some of the test-taking strategies they outlined.
Because the board exam is designed to test the depth and breadth of your knowledge of internal medicine, you cannot cram for it. That said, there are several ways to optimize the time you have left to prepare.
Dr. Paauw, who is ACP's Governor for the Washington Chapter and professor of medicine and coordinator for student teaching at the University of Washington, said one option is to take a board review course.
On the plus side, he said, these courses can help identify areas where you need more study, provide a good source of questions and boost your confidence. The down side? These courses are usually expensive, and you'll have to give up a week or so of your time.
Your best bet, Dr. Paauw said, may be to form a study group that meets regularly to review topics that will likely appear on the test. A study group with four people, he said, is usually ideal. It's just big enough for everyone to learn from each other, but not so big that scheduling becomes a problem. He recommended creating a syllabus and planning regular meeting times to give your group some discipline.
Dr. Paauw suggested that group members write test questions for the others. "There are only 2,000 to 2,500 questions in the question universe," he said. "If you get five people in a room who have gone through an internal medicine residency and say, 'Write a congestive heart failure question,' you will be shocked at how similar the questions will look."
When working together to answer questions, he added, don't focus only on the specifics of the question. Focus as well on helping each other develop the analytical skills needed to formulate the correct response.
Dr. Wipf, who is associate director of the University of Washington's internal medicine residency program, added that practice tests are a good way to identify knowledge gaps and get a feel for the exam's scope and pace.
She offered one important caveat, however: Don't take a practice test right before your actual exam. If you don't do well, she said, you may become too upset to do well on the actual test.
And while many residents say the questions in the College's various MKSAP programs are excellent, Dr. Wipf advised residents not to get too discouraged if they have trouble answering some of the questions. Those questions, she said, are harder than most items on the exam.
What to look for
The board exam is comprehensive and focuses on all major areas of internal medicine. Cardiovascular disease is covered in 14% of the questions, while gastroenterology and pulmonary disease each make up 10% of the test content. (A full breakdown of the primary content areas of the boards is online.)
The test is designed to present the same complex cases most internists see in practice. All the questions are case-based and ask you to pick the single best answer from a multiple-choice list. For many questions, you'll need to both make a diagnosis and suggest the best treatment.
If a question's history section says that a patient's parent committed suicide, it could be a big clue that the patient may be suffering from depression.
Dr. Paauw said that while the ABIM isn't out to trick test-takers, the answers will not always be obvious—even if you have learned everything you need to answer the question. He suggested paying close attention to the history that accompanies each question.
If the history mentions that a patient's parent committed suicide, for instance, that could be a big clue for a family history of depression. At the same time, don't assume that all of the details given are absolutely correct. Just as in actual practice, he pointed out, some bits of information in the questions might not be completely reliable.
In one sample question he presented, for instance, a patient says that his father dropped dead of a heart attack—information that turned out to be slightly off base because the father probably had a dissecting aneurysm. Dr. Paauw added that the patient's father had not been autopsied, pointing out that physicians need to remember that family lore is not always accurate.
Because of mounting concern about medical errors, you may even be expected to catch the mistake of another physician in the case report. You will receive enough information with these questions to determine that some part of the report is incorrect.
Because most questions focus on stable information and established best practices, make sure your knowledge is reasonably up to date. The ABIM won't expect you to have memorized journal articles published the week of the test, but new developments may be covered.
The test might ask you, for example, about important new data from studies on atrial fibrillation that compared rate and rhythm control. Other recent tests asked about a work up for anemia, fixed splitting of second heart sound and the diagnosis of atrial septal defect, genital ulcers and the physical exam. Dr. Wipf suggested that residents familiarize themselves with major laws that bear on ethics decisions in their state.
She pointed out that the ABIM usually includes a few "test" questions asking about very recent findings. If you are struggling with an answer where new data seem particularly relevant, she said, you may be answering a "test" question that won't even count toward your final score.
Drs. Paauw and Wipf offered the following tips to help you boost your performance on the test:
Work questions systematically. Once you have read the question and analyzed the data, try to devise a solution in your head before looking at the choices. With a pre-emptive response, you'll spend less time considering incorrect answers when you are on target.
Read the entire question. Don't spend time trying to figure out the diagnosis until you have read the question completely. You could be given a lot of information before you come to this last line: "How would you treat this patient's syphilis?" Don't waste time making a diagnosis when the condition may end up being given to you.
Look for "magic" words. Questions will frequently include a key clue—such as the patient's ethnicity, geography or occupational history—that can help you crystallize a diagnosis. Certain facts or words tend to be associated with specific conditions, Dr. Paauw pointed out.
The fact that a patient is from Cambodia might confirm a suspicion of rheumatic heart disease. A Japanese patient, on the other hand, might be more susceptible to gastric carcinoma. And "tearing" chest pain could cue you to think of aortic dissection. He suggested that you underline any words that jump out at you.
You should also underline all negatives such as "except" and "not" to make sure you read the question correctly. And pay particular attention to pictures, said Dr. Paauw. They are expensive to print and are generally included only because they contain relevant information—even if that information is sometimes subtle.
When questions become complicated, try to summarize them with a few key words. And always circle abnormal study results.
Go with likely answers. Because the ABIM is emphasizing knowledge over trivia, Dr. Wipf said, don't concentrate on exceptions or anecdotal knowledge.
Even if you once saw a case to prove your point, you will not be able to argue with the question writer. When picking a response, don't ask what answer could be correct, but which one is most likely to be correct.
Beacuse the boards emphasize knowledge over trivia, Dr. Wipf says test takers shouldn't concentrate on exceptions or anecdotal knowledge, but on the most likely answer.
Always make sure there is an epidemiological fit. The patient with lupus will probably be a young female, not an 80-year-old man. Choose the most realistic answer over a finding that could be reportable.
When answering geriatrics questions, Dr. Paauw recommended looking for a chance to stop a medication. "The smoking gun is often on the med list," he said. In these cases, thinking about the black box warnings on drug package inserts can be helpful.
While most of the questions will focus on the "bread and butter" of clinical practice, the ABIM wants you to be able to recognize rare diseases. When considering an unusual diagnosis or disease, make sure you have key information to confirm your suspicions, such as a patient's travel history.
And when asked what to do next, take that as a clue that the case is an emergency. Nonemergency diagnoses can probably be discarded when the question focuses on choosing which treatment comes first.
Pace yourself. During the test, take an occasional break to check the clock and make sure you are on pace to finish the exam. Along those same lines, move on from questions that are taking too much time, and guess when you're completely stumped.
Also, occasionally double-check that your answers are in synch with the questions on your answer key. An error there could be disastrous.
Finally, if you have time to review your answers at the end of a section, Dr. Wipf warned against changing your first answer unless you realize that you read the question wrong or missed something.
And "if the answer seems obvious, don't second guess yourself," Dr. Wipf said. "It is probably right."
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