Developing an Internal Medicine Board Preparation Strategy

Perhaps the most important thing to remember when developing a strategy for preparing for the initial board examination is that the process is a long-term one that should ideally start very early in residency. The sheer breadth and depth of content in internal medicine, coupled with learning theory that shows that progressive knowledge acquisition affirmed by clinical experience and repetition is optimal for most trainees, argues that successful board preparation cannot occur only toward the end of training. Therefore, developing both an “attitude” of ongoing learning and a general plan for preparing for the initial certification exam should start near the beginning of residency.

This doesn’t mean that every second of every day needs to be spent studying for the internal medicine boards, but does suggest that you need to approach your didactic and clinical learning experiences in residency as opportunities to prepare you not only for caring for patients, but also as helping you to be ready for the certification examination. This may be as simple as making sure you don’t miss didactic and other learning experiences (despite being both incredibly busy and tired), and being intentionally mindful of what you know and don’t know about what you are learning. Doing so helps you assess your own areas of strength and those where you need additional work; knowing this information is one of the most challenging aspects of board preparation, and you will be a step ahead if you work on doing this from the time you start residency.

It is also vitally important for you to understand your own learning style when developing a board preparation strategy. Everyone learns differently, and your strategy should incorporate the types of educational activities that fit your learning style as much as possible. Although it may be helpful to ask others what approach has worked for them, avoid the temptation to use a specific study method or resource that you don’t believe will match your own learning style. Attempting to force yourself to study in ways you don’t like or are not comfortable with can make the process of preparing for board certification more painful and less fruitful than it needs to be. That said, there are several general rules-of-thumb that most medical educators agree need to be kept in mind as you develop your own strategy.

  1. Supplement your lectures and clinical experience with reading. It is important to realize that you must do additional reading and study beyond what you learn in your didactic and clinical experiences in residency. Although lectures, case conferences, and patient care activities are essential to being a good internist, no residency program can provide a broad enough range of clinical and teaching experiences of adequate depth to fully optimize your function as a clinician or prepare you adequately for the information covered on the board examination.
  2. Read and study from a variety of sources that match your learning style. Reading broadly in internal medicine provides a comprehensive view of the discipline and allows you to know about important concepts and facts that you may not encounter on your clinical rotations but may be covered on the examination. However, the choice of what you read as part of your studying is important. For example, journal articles are important in expanding your knowledge of specific diseases, and accessing the current literature is an important habit to develop to help you keep current in your future practice. However, articles usually focus on more detailed aspects of disease and are therefore less helpful in studying for the general concepts covered on the board examination. Similarly, point-of-care clinical resources (such as “Up-to-Date” or “DynaMed Plus”) are invaluable sources of information to help care for patients, and their use will also help expand your overall fund of knowledge. However, their clinical focus generally makes them less useful as a primary resource for board examination preparation. Also, programmed reading of traditional textbooks of medicine (such as Cecil’s or Harrison’s) is usually not feasible during the course of residency due to their length and depth. However, they are a valuable source of detailed information for reading about specific topics and for referral as part of studying. A number of “abbreviated” textbooks of medicine are available that are much shorter than traditional full-length medical textbooks. Many of these are focused toward internal medicine clerkship students or acting/subinterns; although they serve as a good review of medicine in general, they usually lack the degree of detail contained on the certification examination. A number of study guides specifically developed for board preparation are available. They vary in structure and length, and it is important to make sure that they provide adequate depth for the level of information sought on the certification exam.
  3. Practice answering questions. Answering multiple choice questions is also considered by most medical educators to be an important method for board exam preparation. Questions may be helpful in a number of ways, by providing self-assessment to guide subsequent areas of focus for study and allowing practice in answering the types of questions that may be encountered on the exam. And some questions are designed specifically to function as a teaching tool by providing detailed explanations of both the correct answer and why the incorrect options are incorrect. Many sources of questions are available, although the quality and cost of these questions may vary markedly, and this needs to be considered in selecting a question source as part of your study strategy.

    There is significant debate about whether answering questions alone is an adequate means of preparing for the certification examination. Although this is the preferred study method for many trainees, most medical educators do not believe that simply answering a large volume of questions without additional reading or study will provide the depth and a more comprehensive view of the subject areas of internal medicine to optimize actual exam performance. This is particularly true for questions not designed with a teaching component or with questions that test only factual knowledge relative to those that require integration and synthesis of information in order to identify the correct answer.

    A combination of "teaching" questions coupled with a source of more in-depth information related to the question content is generally considered the most effective way of approaching board preparation by many medical educators since it provides the advantages of question practice, self-assessment, and more in-depth reading. Because of this, many available internal medicine board preparation materials contain both types of resources that are integrated into a learning "system," although they may approach using these resources differently.

    For example, the Medical Knowledge Self-Assessment Program (MKSAP) is one of the most widely used programs in internal medicine for board exam preparation. It consists of a large number of self-assessment/teaching questions divided by the content areas of internal medicine, accompanied by concise text also covering the content areas of internal medicine. The questions and text are related to allow "bidirectional" study either through answering questions with further study of the text or reading of the text with assessment of comprehension by answering the related questions.

  4. Form a study group. Regardless of the learning resource you choose to use, it is often helpful to participate in a study group, either with one other person or several others. Study groups provide discipline and motivation in studying, support, and a way to affirm your understanding of specific concepts and facts ahead of the examination.
  5. Consider taking a board review course. Some trainees find board review courses to be helpful aids to preparation. Many residency programs provide their own board review course, usually in the last year of residency training, while some other programs may support attendance at an outside board preparation course for their senior residents if they don’t provide one. If your program does not provide a board preparation course, there are many independent courses available. However, the quality of these courses may be highly variable and they tend to be expensive. It is therefore worthwhile discussing specific course offerings with your residency program leadership before committing to a specific course. Learn about ACP's board review course offerings.