Tips for Taking the Initial Certification Examination

Understanding the internal medicine certification exam

Because of its importance, it is essential to be prepared both physically and mentally for the examination. Getting adequate rest prior to the certification exam is critical, and beyond studying, knowing what to expect on exam day is important.  

The American Board of Internal Medicine (ABIM) has multiple resources that explain the specific details involved in taking the examination that should be reviewed well in advance of your scheduled testing day. This includes information about signing-in to the testing center, the schedule for a typical testing day, and information about breaks and lunch. 

Two resources that may be particularly helpful are a tutorial about taking the internal medicine certification examination and a practice test. The tutorial provides an overview of the functional features of computerized testing used for the exam, including how to navigate through the exam and use additional features such as note-taking, highlighting, strike-through, and the calculator. Although you will be able to review this information on the day of the examination, it is highly recommended that it be reviewed sometime before the scheduled test to gain familiarity with the testing program and features. The other resource is a practice test which enables you to see and answer sample questions as they will appear the day of the test, which may help develop some comfort with the testing process.  

Internal medicine exam question structure

The examination is made up primarily of clinically-based, single best answer multiple choice questions. Although there are some questions that are more fact-based, the majority of questions require integration and analysis of clinical information to determine the correct answer. The typical question structure is as follows:

Many questions also contain additional clinical data (such as laboratory results, imaging, electrocardiography, urinalysis, or skin findings) that must be interpreted to answer the question.  

The tasks to be answered in most questions are usually clinically-based: diagnosis, therapy, management, screening, or preventive medicine. Questions asking about normal physiology, the pathophysiology associated with specific diseases, and pathology or histology are not typically included on the examination. Also, most questions do not ask about specific drug dosages except in specific cases in which it is important to understand the differences between drug dosing levels (such as dosing for prophylaxis vs. therapy).

Although the question content follows the examination blueprint, the clinical vignettes and topics covered will be based in both inpatient and outpatient settings as well as the emergency department. Because the examination is intended to focus on medical issues faced in actual practice, approximately 75% of questions will be based in outpatient settings. 

Taking the exam

It is important to remember that your performance on the examination is based on the total number of questions answered correctly. There is a minimum passing score for all examinees as determined by the ABIM; there is no grading “on the curve,” and it is theoretically possible for all examinees to pass the exam.

It is also important to know that any unanswered questions are scored as “incorrect.” Therefore, all questions should be answered even if you are unsure of the correct answer. Use the provided test-taking tools (such as the ability to mark questions for later review) if they will help you ultimately answer all of the questions.

Based on the number of questions relative to the allotted testing time, an average of 2 minutes is provided to answer each question. This time is usually more than sufficient for most test takers, recognizing that some questions will likely be answered more rapidly than others, and that some questions are longer and may take more time to process. However, you need to be cognizant of possibly spending excessive time on a smaller number of questions about which you are unsure. A timer is provided on the screen during the exam so you can track your progress relative to the allotted testing time.

You will be provided the opportunity for break times between testing sessions. These are not mandatory and it is possible to skip these breaks and continue working on the exam. However, most testing experts recommend taking these breaks to avoid testing fatigue and maintain your performance over the course of the exam. You are also able to take unscheduled breaks during the testing sessions. However, it is important to note that the testing timer will continue to run through any unscheduled breaks.

Here are several tips to keep in mind when taking the certification exam:

  • Read the entire question carefully and avoid jumping to a conclusion about what the question is asking based on a superficial review of the clinical vignette.
  • Pay close attention to the context of the question which may provide a clue to the correct option.  Factors such as ethnicity, occupation, travel, or medications (especially if recently initiated) may give important information needed to answer the question. 
  • Pay attention to the exactly how the question is posed.  For example, questions that ask for the “immediate next step,” “initial therapy,” or “most likely” may help guide selection of the correct option.  
  • Remember that clinical images (such as radiographs or skin findings) are typically “classic” for the condition being questioned, and abnormal findings, when present, are not usually subtle.  Over-interpretation of images is a common test-taking error.
  • Attempting to answer a question without looking at the option list is a potentially helpful way of suggesting that the correct answer has been chosen.  If the answer you determined based on the provided clinical information is in option list, that answer is likely to be correct, and this also tends to avoid distraction by other potential options.  If your answer is not in the option list, then re-read the question carefully. 
  • Be comfortable recognizing classic word cues that may help direct you to a likely correct answer.  For example, the following word cues suggest the associated diagnoses: 
    • Plop - atrial myxoma
    • Tearing sensation - aortic dissection
    • Travel to the American southwest - coccidiomycosis
    • Health care worker - surreptitious administration of medication
    • “Worse headache of my life” - subarachnoid hemorrhage
    • Patient is adopted - sex-linked or autosomal dominant genetic disorder
    • Patient is an immigrant - congenital heart disease, tuberculosis
    • Dies playing sports - hypertrophic cardiomyopathy
  • If you are unable to determine the correct answer to a question:
    • Eliminate options that are obviously wrong
      • Each eliminated option increases chance of guessing the correct answer by 20-25% 
    • Don’t go back and change initial answers
      • First selections are more likely to be correct