BOARD EXAMINATION

Stuart B. Mushlin

This chapter is different than the others. Its purpose is to concentrate your mind on the American Board of Internal Medicine (ABIM) examination, its purpose, and its likely test scenarios. The ABIM moved to a written rather than oral test in the 1960s. The testing has been extensively validated and is unlikely to change much in its character. Essentially, the ABIM wants to determine if you have the core knowledge in all the disciplines to be an effective and efficient physician. It further wants to discriminate between you and the other test takers so that you can see how you can compare with others taking the examination. Many candidates, in their increasing anxiety over the subject matter, lose sight of these major objectives. To pass the examination it is not necessary to regurgitate in photographic detail one of the standard textbooks of medicine or the latest MKSAP review. But you should feel that you know the core body of knowledge in all the major medical specialties. For example, you should know, in depth, the diagnosis, rapid assessment, and appropriate management of an acute coronary syndrome. All internal medicine programs that have Residency Review Committee approval have their residents spend time in a coronary care unit, and have exposure to cardiologists. So, too, you should expect to be able to manage an acute respiratory decompensation, determine its etiology, and know how to manage the acute presentation and the intermediate strategies. It is not expected that you be the expert pulmonary specialist, but it is expected you need to know when to call the specialist for the help that only they can provide. And you are expected to have done more than the basics before calling for the further help that you need to successfully and appropriately manage the patient. Furthermore, an economy of testing as well as cost considerations is important. The effective internist/clinician is economically sensitive and efficient in spending the patient’s time and money. Furthermore, they are aware of pretest probabilities, false positive rates, and other such considerations that inform the considered uncertainty surrounding the best patient management.

    These principles should be obvious from your training and not a cause for enhanced study. Where the examination causes more anxiety is material from specialties that require fewer patient hospitalizations. Some of these specialties you may have had less exposure to, but you are required to know the common diseases that appear to the generalist and how to get the basic diagnosis and treatment plan. A concrete example is the “classic” presentation of rheumatoid arthritis. This is an illness with a prevalence of about 1/200 and is mostly managed in the outpatient setting. So by presenting it to you, it allows the board to test both your diagnostic acumen as well as your outpatient management skills. It’s clear that over the ensuing years, more outpatient exposure (be it general or subspecialty based) will be emphasized in training programs, and with this increased emphasis the ABIM will almost certainly increase the outpatient-oriented testing on the examination.

    The ABIM suggests certain examination preparation strategies that are worth noting. The ABIM recommends that you work within a small study group, ensure that you stake out time to prepare and develop a schedule to study. The ABIM also recommends practicing with questions using the board format, such as single best answer. Certain “red flags” hinting at the answer, such as forested area in the Northeast (Lyme disease) or Coca-Cola colored urine (rhabdomyolysis), should be kept in mind.

    The ABIM has a core fund of knowledge that they want to be sure you have mastered (table 106.1). These questions are easily identifiable and sometimes change in format but not core content. They appear over and over to identify that you have mastered the core content. What everyone who takes the examination remembers is the more difficult questions that challenged him or her in areas they had not mastered, and so talking to peers who took the examination can cause misperceptions. The core, or what the ABIM refers to as the Blueprint, is published on the ABIM website (www.abim.org). Remember, the Board wants to test your core knowledge and validate that it is sufficient for you to be certified. But another mission of the test is to provide a discriminatory measure of who demonstrates more knowledge in a standardized environment.

    Importantly, the concept of managing a patient involves not just the physician but also the entire healthcare system. It is a mistake to see a case and rapidly go to the answer or diagnosis that seems self-evident. Pause to consider the ethics of the situation, the cost of the testing or therapy you are considering, and the healthcare systems involved. You will be expected to be respectful of the patient in your answers, have appropriate concern for their families, understand their social situation and home environment, and have an appropriate respect for the other members of the healthcare team. You may well be challenged with ethical choices. You will be expected to understand the cultural context of your patient’s lifestyle. You will need to be attuned to things that the patient might not tell you that will give you the correct diagnostic direction to pursue (e.g., telltale signs of physical abuse). These aspects of appropriate care by an internist are not available in textbooks but must be absorbed in the training environment by appropriate mentoring, role modeling, and constructive feedback. As the Board no longer interviews the candidate, they need to get some measure of the humane essence of the candidate and their humane and holistic consideration for the patient in the patient’s milieu. Additionally, examination of the candidate’s knowledge of medical systems will be tested. Although this will manifest itself mostly in the option to readily use expensive or unnecessary tests and therapies, it may also be tested by such matters as cultural competency, sensitivity to literacy, and financial constraints that a patient might have. Other systemic structures, such as HIPAA compliance and collaboration with other disciplines or colleagues, are most often interspersed within the various cases.

    The recipe for the examination is as follows. The examination is held over one day with four modules. Each of the modules is of 2 hours duration and comprises 60 questions. The questions reflect primary content areas (77%)—these are the traditional medicine subspecialties—and “non-core specialties” (23%) comprising questions in allergy/immunology, dermatology, gynecology, neurology, ophthalmology, and psychiatry. Additionally, the Board tests “cross-content areas” (critical care, geriatrics, prevention, women’s’ health, clinical epidemiology, ethics, nutrition, palliative/end of life care, adolescent medicine, occupational medicine, patient safety, substance abuse).

    Each question is formatted with a clinical “stem” (patient) followed by “lead-in” (last sentence), question, and then choices. The ABIM is looking to test analytic skills not simple memorization. There are no so-called “trick” questions. The material will not be controversial and will likely be dated at 2 years or older. So, an article you read 4 months ago will not be tested. Since the questions are generally written by practicing internists they will reflect current widely accepted practice.

    Some strategies for answering questions are worth bearing in mind. The most important is to answer all questions. It is better to not get stuck on one question but rather to go back and tackle the difficult question if there is time later. You should aim to take approximately 2 minutes per question. While there are many different ways to answer questions, one popular strategy is to try to answer before looking at the choices and not change the answer unless you remember new information.

    The discussion so far has addressed applicants taking the examination for the first time. But many taking Board Review Courses are doing Maintenance of Certification (MOC) testing preparation. For these candidates the Board has announced an important new initiative regarding Maintenance of Certification (MOC). Prior to 2014, there were some examinees that were “grandfathered” into never having to recertify. Both the Institute of Medicine and the ABIM have recognized that this is not an appropriate standard any longer. Consequently all diplomates will be expected to engage in ongoing MOC activities. For all diplomates the nature of MOC will change (with the exception of the first year after passing the Internal Medicine examination). Going forward, diplomates will be expected to maintain 20 hours of MOC every year and every other year their MOC status will be publicly available. All diplomates (including those now “grandfathered”) will still be expected to take a recertification examination at least once every 10 years. This significant initiative is an effort to ensure as well as monitor ongoing educational activities for diplomates and overtly acknowledges that the practice of internal medicine or its subspecialties requires a commitment to lifelong learning.

    The ABIM website is very helpful in describing these new MOC standards as well as an overview of the examination. See the additional reading list at the end of the chapter.

    Below is a representative case that illustrates these points with a discussion at the end of the “best choice” for each of the questions.

    An 84-year-old Caucasian male presents to your Emergency Room complaining of shortness of breath.

    He has a long history of rate-controlled atrial fibrillation and a 10-year-old mitral valve repair. He has been on warfarin therapy for 15 years with no difficulty in maintaining an International Normalized Ratio (INR) of 2.5 to 3.0. He has never had any bleeding complications.

    His wife of 56 years died 8 months ago. You had seen him about a month after her death and he was independent and eating and well groomed. He has two supportive children who live in the community. At the time you saw him he was normotensive, heart rate was 68 beats per minute, and his weight was 154 pounds (he is 65 inches tall). His lungs were clear. He had a longstanding 1/6 apical midsystolic murmur that radiated slightly to the axilla and was unchanged for years. There was no organomegaly and no edema. Jugular venous pulse was <4 cm of water.

    In the emergency room he was dyspneic at rest at 45°, with a respiratory rate of 22. He was afebrile. There was dullness at the right base one-third of the way up the hemithorax. There were moist rales halfway up on both lungs. There was an S3 gallop and his murmur was now 3/6 at the apex. Jugular venous pressure (JVP) was 7 cm at 45°. The liver was not distended and not pulsatile, but there was a suggestion of a fluid wave in the abdomen. There was 3+ edema of the legs.

    He was taking his medications, namely verapamil 240 extended release, lanoxin 0.25 mg a day, warfarin 4 mg a day, and lisinopril 5 mg daily.

    An electrocardiogram (EKG) showed atrial fibrillation and no acute ST-T changes and no interval q waves or loss of r waves. A standing chest posterior-anterior and lateral x-ray showed a large pleural effusion on the right and cardiomegaly. There was prominent vascular redistribution to the upper and middle lobes. There were no Kerley B lines noted.

    Laboratory results showed a hemoglobin of 13.9 g/dL, hematocrit (Hct) of 40%, a white blood cell (WBC) count of 7500/mm³ with a normal distribution, sodium 132 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L CO₂ 25 mEq/L, blood urea nitrogen (BUN) 46 mg/dL, and creatinine 1.6 mg/dL. AST and ALT were each twice normal. INR was 3.3.

    He was admitted to the hospital.

QUESTION 1. What is the most likely diagnosis?

    A. Congestive heart failure

    B. Chronic renal emboli with renal failure

    C. Noncompliance

    D. Salt overload

    E. Endocarditis

    He was managed with bed rest and intravenous furosemide and his other medications were continued. His weight on admission was 175 lb (up from 153 lb when last seen). He started to diurese about 1.5 kg a day, however his murmur remained unchanged and his liver tests remained moderately elevated as did his INR.

QUESTION 2. Which test do you want now?

    A. Computed tomography (CT) urogram

    B. Transthoracic echocardiogram

    C. Agitated saline microbubble echocardiogram

    D. Transesophageal echocardiogram

    E. GI consult with evaluation for liver biopsy

    F. Magnetic resonance imaging (MRI) of the abdomen and pelvis, with special attention to the prostate

    The echocardiogram shows a flail mitral valve with nearly complete mitral regurgitation. The left atrium is only moderately enlarged. No clots or vegetations are seen.

QUESTION 3. The next step in your management should be:

    A. Transesophageal echocardiogram to rule out vegetations

    B. Peritoneal dialysis to more rapidly remove fluid

    C. Cardiothoracic surgery consultation

    D. Six blood cultures

    The patient was seen by cardiology and cardiothoracic surgery. As his congestive failure was very significant, and because he had had previous mitral valve surgery, it was felt he should undergo semiurgent mitral valve repair. He was taken to the OR and the mitral valve was repaired without untoward difficulty. He remained in atrial fibrillation. He was given intraoperative and postoperative second-generation cephalosporin coverage.

    After the surgery he had trouble eating. Speech and swallow studies showed recurrent aspiration. Although his congestive failure improved daily, he had failure to thrive and a week after the surgery a percutaneous endogastric (PEG) tube was placed. He was transferred to a local rehabilitation facility 3 days after PEG tube placement. Discharge medications were: digoxin 0.25 mg a day, verapamil 120 mg extended-release daily, warfarin 3 mg a day, furosemide 40 mg twice daily, and K⁺ supplementation.

    You had contact with him by phone in the rehabilitation facility. His spirits were good, but he still was on PEG feedings. Because of some diarrhea he was placed on “an antibiotic.” Touching base with him a week later revealed that he had developed worsening diarrhea and was now on oral vancomycin. You called the covering physician at the rehabilitation facility and found out that the patient had a positive C. difficile toxin assay. At the time of your call the patient was passing 10–12 stools a day. One week later he was sent into the emergency room with abdominal pain and distention.

    His CT from the emergency room is shown in Figure 106.1.

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