Prepping for the ABIM Exam: an Internist’s Candid Perspective (Part III)

I’ve always wondered who actually writes the questions that end up on the ABIM exam. In my mind, I picture a Voldemort-like character leading a group of similarly dark souls, cackling each time they come up with a particularly tricky question sure to trip up some poor test-taking sap. More likely—and this is also pure speculation—there is a group of senior academic internal medicine physicians, fellows or even masters of the ACP (you know, FACPs and the vaunted MACPs that are listed on CVs) who are trying to devise a way of objectively evaluate future colleagues. But I still like the Voldemort characterization better.


On that fateful August day, test day, I felt like Harry Potter about to battle the forces of evil. After the alarm sounded on my iPhone at 6 am, I leapt out of bed, the adrenaline coursing through my veins.


The night before, I grudgingly put the books and questions away. Instead, I watched Game of Thrones clips on YouTube. In between clips, I got everything ready that, on a normal work day, would’ve been done in a mad-dash scramble in the morning. I packed my backpack with pens, a notepad, a watch, a hooded sweatshirt, and snacks including potato chips and chocolate chip cookies. My mom thought I was back in high school.


Lunch, which I also packed the night before, was one ham and cheese sandwich, one salami sandwich with mayo, crackers, a can of orange soda, and two bottles of water. Certainly I am a hypocrite, given that I normally advocate a low-sodium, low-sugar diet. But today, I wanted, and deserved, all my comfort foods.


On the way to the testing site, I blasted my motivational playlist: Eminem, Jay-Z, and Rocky movie theme music. I finally arrived at the site at 7:30 am. The employees were inside, but wouldn’t let us in. The only people waiting outside were, by the looks on their faces and the books they were flipping through, also ABIM exam takers. I asked a woman with MKSAP cardiology, “You ready for the test?” She did not respond. She must’ve thought I was hitting on her. Whatever. She wasn’t that cute anyway.


After loitering outside for half-an-hour more, the employees let us through the door. I was fingerprinted and had my photo taken, and I put my backpack in a storage locker. An employee said we would be videotaped at all times. I felt like I was getting registered for prison, but as I understand it, this is necessary to ensure the integrity of the test. Later on, some non-ABIM test-takers rolled in late. They complained that their 3-hour tests were draining. I had no sympathy for them.


When I sat down in my cubicle, there was a black felt-tip marker and a plastic-laminated pink sheet where I could scrawl some notes. A pair of noise-cancelling headphones hung off the edge of the cubicle.


I clicked on “start” and began going through the questions.


Unlike previous tests we’ve taken, the ABIM test consists of “only” 240 questions. They are divided into four blocks of 60 questions each, with two hours for each section. This gives a total testing time of 8 hours, including one hour for breaks that you can use at your discretion. For each question, I read the question stem and the answers before I would go back and read the paragraph(s) of text. This helped me put each question in context.


I had the greatest difficulties with the first block of questions. I was pressed for time, and had marked at least 10 questions with little red flags, because although I could narrow the correct answer down to two choices, I often couldn’t decide between the two. Worse still, I let my ego get in the way, and spent ten minutes agonizing over a question about eosinophilic esophagitis.


If you do the math, you have two minutes to answer each question. Given that all of the questions are equally weighted, and there is no penalty for a wrong answer, the right thing to do when stuck is to make an educated guess and move on. You should go back to the question only if you have extra time at the end.


Fortunately the other 3 sections were far more manageable. The questions varied from multiple paragraphs to one sentence in length. If I knew the answer to a short question, it was like an oasis in the desert. True to form, the questions also ranged over the entirety of internal medicine. My test, for instance, was especially heavy on rheumatology concepts.


Other people I spoke with, however, felt that block 2 or block 4 was the most difficult, or that their exams emphasized gastroenterology or nephrology. Thus, each test-taker probably has a different order of questions, or more likely a different set of questions altogether. According to the ABIM, some of the questions are also experimental and don’t count towards the final score (hopefully ones I got wrong). I wish I could figure out the exam’s exact methodology, but I fear that the punishment from the ABIM would be severe.


If I finished a section early, I would leave the clock running to take a restroom break, so that I wouldn’t eat into my one hour of break time, which I used for an extended lunch. After completing blocks 1 and 2, I decided it was time for lunch. Given that it was a hot California summer day, I ate outside, afterwards resting my eyes for 15 minutes in the hopes that I could recharge my brain.


Midway through block 3, I was in a state of flow. The clock and other distractions melted away, and I tunneled in on answering the questions like I was Michael Jordan preparing to hit the game-winning shot. At the same time, my number of bathroom breaks increased—there must be a study linking stress with increased urination.


Finally, I sped through the last 10 questions of block 4, and walked out of the testing site feeling good. I knew I got some questions wrong, and I wished I had studied certain sections with greater depth, but this was not a moment for second-guessing. I felt good enough to know that I had passed the test: At the end of the day, that was all that mattered.


The evening was a time for drunken celebrations.


You can find Part IV of Dr.Feng’s prepping for the ABIM board exam and other posts by Dr.Feng on the Knowmedge Blog. You can find also additional topics and questions directly from the Knowmedge Internal Medicine ABIM Board Exam Review Questions QVault. __________________________________________________________________

Charles Feng is an internal medicine physician at Kaiser Permanente. He will be starting an allergy / immunology fellowship at UC Davis in the summer.

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