The complex questions that appear on medical board exams pose challenges for every test taker, even those who are highly experienced. There are up to 70 questions in each 2-hour segment of an ABIM internal medicine exam, so you need to make the most of your time and knowledge. This post will help you sharpen your approach to do just that.

Most medical certification exams, and all ABIM exams, are made up of multiple-choice questions. The majority are case-based scenarios that require reasoning and decision making. Each question has three distinct parts:

  • The patient vignette or question scenario
  • The lead-in or the question itself
  • The answer options, which include one correct answer and several distractors

Knowing to look for essential cues within each part of the question and applying specific strategies can help lead you to the correct answer.

Read the Lead-In First

When you approach a question, you’ll be tempted to read the case first, but start with the lead-in and pay very close attention to what it asks. Usually it will ask for “the best next step” or “the most likely diagnosis” — and this should be your focal point as you move through the rest of the question. In some questions, more than one answer could be correct, but remember, you are being asked for the best answer, not simply any plausibly correct answer. To reach the best answer, you may need to draw upon both knowledge and higher-order decision making.

Generic advice for multiple-choice tests often suggests covering the answers and mentally forming an answer yourself before looking at the possible choices. This is a good study strategy because the act of retrieving knowledge from your memory may reinforce that knowledge for you and strengthen neural connections, enhancing recall later. But on exam day, the “cover test” is not a good use of your time. Instead, it is best to approach the question in this order:

  1. Read the lead-in first (to see what the focus of the question is).
  2. Scan the answer options (to see what types of answers are being sought).
  3. Read the vignette, slowly and carefully.
  4. Re-read the lead-in and choose your answer.

This sequence sets you up to approach the vignette with a goal in mind. As you read patient characteristics, review laboratory test results, and view images, you can mentally sort the information according to what the question is asking — be it a diagnosis, a treatment, or the best next test.

Consider All the Data in the Patient Scenario

Patient vignettes contain little extraneous data, so anything beyond basic patient characteristics warrants notice. A question writer typically starts with a “testing point,” then builds the question to address it. ABIM explains on its website that its question-writing method is “designed to focus content experts on the viability of the testing point, the appropriateness of the task that the question poses (diagnosis, treatment), an evidence-based single-best answer, and plausible distractors. After these question elements are created, the authors add the key elements that are needed in a patient-based scenario for that question.”

Nearly every vignette includes vital signs, physical exam results, and a few other details to make the case patient realistic. These basic patient characteristics often set the stage rather than offer significant clues to the correct answer.

Good question writers avoid red herrings. Questions typically aim for brevity and include only those lab results or pieces of history and psychosocial information that relate to the answer. New symptoms, recent diagnoses, and the timing of symptom progression should all be taken into account. If family history is mentioned, pay attention to it. Look carefully at all photographs, radiographs, CT scans, and  electrocardiograms — each is included for a reason.

Train Your Mind to Avoid Mental Shortcuts

Certification and recertification exams are not intended to identify the top 10% of test takers or shave off the bottom 10%. Their goal is to test for a base level of competence according to a standard that has been set by the writers and the board. Testing to a standard requires questions that range in difficulty. So, some questions will seem easy. If you’ve read the question carefully and know the topic, your first instinct may indeed be correct. You need not second-guess yourself.

But don’t simply scan an ABIM exam question before answering. A test taker’s biggest mistake is jumping to a conclusion after seeing a buzzword. For example, when you see the term “pill-rolling tremor,” your mind makes the association with Parkinson’s disease, but the correct answer may be about something quite different. Some questions test whether you can recognize the exception rather than the rule.

When preparing for the exam, train your mind to avoid mental shortcuts. And during the exam, pay attention to what is really being asked — rather than to any shortcut your mind might be taking.

It’s easy to make mistakes. Some distractors are designed to test if you know what you’re doing. A good question writer finds distractors that are plausible but incorrect for the particular scenario. A hasty question reader will fall for a good distractor.

If careful reading and reflection causes you to veer from your initial instinct, it’s perfectly fine to change your answer. This advice may run contrary to what you heard decades ago. But evidence has shown that in high-stakes medical exams, changing answers upon reflection can be the correct course.

Take Two Cognitive Steps to Reach the Right Answer

Case-based questions on a board exam call for advanced reasoning and often require more than one cognitive step to reach the correct answer. Typically, a question requires that you first make a correct diagnosis and then go further to infer the best next step.

For example, if a vignette describes a patient with elevated levels of both parathyroid hormone and calcium, it would be too simple to ask only, “What is the most likely diagnosis?” The more likely question is, “What is the most appropriate next step in care for this patient?” Rather than be tempted to do additional laboratory testing, you would be expected to use the existing results to correctly recognize primary hyperparathyroidism and then anticipate that surgery is likely to be needed and that localization imaging should generally precede the surgery.

For the purposes of the test, you are not expected to know the complete range of steps and options progressing into the patient’s future, but the exam will challenge you to infer the best next step in the context of the given scenario. As you prepare for boards, training your mind to make this second cognitive step will help you focus on what the question is asking.

Focus on Resource Utilization and Relevance in Today’s Exams

As you consider the answer to a question, keep in mind the matter of resource utilization. Good test questions now ask about best practices, which can include your use of resources. ABIM’s interest in resource utilization, as evident in its “Choose Wisely” campaign, may be reflected in test questions. This is one example of how the relevance of exams to real-life practice has improved in the past decade. ABIM and other organizations have moved away from testing esoterica and now focus more on situations that a physician is likely to see in practice. But just because a question is relevant, with a familiar scenario, does not mean that it is easy.

Tie All These Strategies Together for Exam Success

There is no single approach to test taking that will guarantee a successful outcome, but the strategies we’ve outlined here — reading the question elements carefully in a certain sequence, being aware of mental shortcuts, and being prepared to make more than one cognitive step — will all help improve your likelihood of success. Try these strategies now with these board review practice questions. For more specifics on how ABIM develops questions and sets standards, see the ABIM website.