What Are In-Training Exams?

In-training exams have been designed to assess residents’ progress in training. Two such tests are the American Board of Family Medicine In-Training Examination (ABFM-ITE) and the Internal Medicine In-Training Examination (IM-ITE). The ABFM-ITE is given annually during the last week of October and can be taken by all residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited Family Medicine programs. The IM-ITE is offered each year in late August through mid-September and is designed by the American College of Physicians (ACP) in collaboration with the Alliance for Academic Internal Medicine. These tests can be taken on a yearly basis, and the cost is often paid for by residency programs. Program directors make the final decision about which tests residents should take and when they should take them.

The Questions on the ABFM-ITE exam (240 multiple-choice questions) are written by certified family physicians in private practice or academic medicine and reviewed by a committee comprised mostly of former residency program directors. After the test, you can download the answers and a critique with additional reading suggestions for all questions on the exam. The content outline for this exam is identical to that used for the ABFM Certification Examination, as follows:

ABFM-ITE Content Areas
% of Total Score
Cardiovascular12%
Endocrine8%
Gastrointestinal7%
Hematologic/immune3%
Integumentary
6%
Musculoskeletal12%
Nephrologic3%
Neurologic3%
Nonspecific3%
Psychogenic7%
Reproductivefemale, 4%; male, 1%
Respiratory13%
Special sensory2%
Population-based care5%
Patient-based systems5%

IM-ITE questions (300 items) are written by a committee of expert physician-authors and are meant to test the wide range of knowledge that a second-year resident would be expected to have. Areas tested include acute and chronic care, inpatient and ambulatory problems, and essential clinical skills. Modeled after the initial certification exam of the American Board of Internal Medicine (ABIM), the IM-ITE content areas are as follows:

IM-ITE Content Areas% of Total Score
Cardiovascular13.5%
Endocrine6.5%
Gastroenterology9.5%
General internal medicine (dermatology, ophthalmology, preventive medicine, psychiatry, geriatric medicine, women’s health, nutrition, medical ethics, and biostatistics)
15%
Geriatric medicine
6%
Hematology/oncology11.5%
Infectious diseases9%
Nephrology6%
Neurology4%
Pulmonary and critical care medicine10%
Rheumatology9%

What Are the Stakes?

The in-training exam will provide you with an assessment of your progress in acquiring medical knowledge. Test results will indicate which areas you already know well and which ones will need more study before you take your certification exam. In-training exam results are also helpful to your program director, as they offer him or her the chance to evaluate the residency program in general as well as identify the areas where residents need reinforcement.

For the ABFM-ITE, there is no passing score; this is an assessment-only test. Scoring is similar to that used for the ABFM Certification Examination (in which raters are asked to imagine what a physician who is just barely qualified to be considered board certified would be able to do; each question is scored according to the probability that this abstracted physician will correctly answer it).

For the IM-ITE, the score is determined by the number of correct answers, and there is no penalty for guessing, so you should endeavor to answer all of the questions. The score is reported as a percentage of total questions answered, and there is no passing or failing level in this educational assessment test. After testing, you will be sent a report that shows your total percent correct score and percentile rank as well as the score and rank for each of the 11 major content areas tested, a list of educational objectives for each test question, and a norm table to use in comparing your score with those of various other groups of residents.

What Are the Repercussions if My Test Results Show Inadequate Progress?

All in-training exams are self-assessment tools and are not meant to be used as qualifying or certifying tools. Your program director is prohibited from releasing any scores outside of the residency program. However, because the IM-ITE is part of the ACGME’s Internal Medicine Milestone Project, residency programs are allowed to use residents’ scores to participate in the Next Accreditation System, which uses the scores to determine the overall progress of residents.

According to Dr. Mark T. Nadeau, Senior Reviewer for NEJM Knowledge+ Family Medicine Board Review, residents take the ABFM-ITE every year at his institution, the University of Texas at San Antonio.

“We give the online exam over a period of five workdays or a week, in a dedicated, proctored exam room that has a bank of computers,” says Dr. Nadeau. “The residents sign up and take the exam at various times during this period. Because the ABFM-ITE is a formative evaluation, it is a great way for residents to measure their current knowledge base and prepare or modify their study plan for the certification exam that is given at the end of residency. We discuss individual results at each resident’s review, but we try to use the results in a formative way that will help the resident make a plan of study. If a resident’s exam score is lower than it should be, my approach is to insist that the resident put together a written, explicit study plan.”

What Is the Best Way to Prepare for In-Training Exams?

Because in-training exams are designed to assess your progress in training, you will get a more accurate assessment if you do not cram for this test. Instead, make and stick with a long-term, overall study plan throughout the years of your residency, and regard every day of your residency and your time on the wards as study tools.

Chris Smith, MD, Director of the Internal Medicine Residency Program at Beth Israel Deaconess Medical Center and Deputy Reviewer of NEJM Knowledge+ Internal Medicine Board Review, stressed the importance of reading relevant literature every day, especially while patient interactions are fresh in your mind.

“This means that when you are in the ICU and you have an intubated patient, read about how to help your patient with acute respiratory distress syndrome or best practices to prevent ventilator-associated pneumonia. In a general medicine rotation, when you are caring for a patient with Clostridium difficile, read about the best treatment options and the latest studies to prevent a recurrence,” advises Smith. Dr. Smith also recommends accessing board review question banks for further clinical context and review while a topic is on your mind, as information learned within the context of a real patient scenario will be retained better than information learned during a cram session.

At NEJM Knowledge+, our technology and adaptive learning partner, Area9 Learning, suggests that frequent, short study sessions will give you better results than will infrequent, long sessions. NEJM Knowledge+ has a “My Schedule” feature that allows users to select their exam date or other deadline of their own choosing; the system will recommend how much time to dedicate to board preparation each week. Users can adjust their scheduled study time per week as time goes on and as commitments fluctuate.

Additionally, you can log in to the ABFM website to download a trial In-Training Exam to see where your strengths and weaknesses lie, and then use the results to modify your long-term study plan. The ABFM also offers an online Bayesian Score Predictor that will give you an estimate of the probability of passing the ABFM certification examination on the basis of your scores on the ABFM In-Training Exams.

Lastly, don’t panic if the results of your In-Training Exam show inadequate progress. Instead, figure out exactly what went wrong, assess your strengths and weaknesses, and stick with an adjusted study plan that will address any weak areas.

For more information on exams from NEJM Knowledge+ and the Learning+ blog: