ABIM Certification Exam Format: Everything You Need to Know

Completing the American Board of Internal Medicine certifying examination (ABIM-CE) is a rite of passage for residents completing internal medicine training and it designates successful mastery of its core curriculum. This blog describes what you need to know about the ABIM exam format, question types, and content. Familiarity with these aspects in advance helps prepare for the exam.

How Long is the ABIM Exam

From registration to the optional survey at the end, your day will be 8-10 hours long. The ABIM-CE is computer-based and administered in a dedicated testing center. Up to two hours is allotted to complete each module (8 hours in total for the entire exam). A timer is provided on the computer screen during the exam so you can track your progress relative to the allotted testing time. An opportunity for break times is provided between modules.

These are not mandatory and it is possible to skip them 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. The allocated 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.

How Many ABIM Questions

The ABIM examination consists of four modules of 60 questions each (240 questions in the entire examination).

ABIM Exam Format

The exam consists of single-best-answer, multiple choice, questions comprising:

• A brief statement, case history, graph or picture (over 75% are based on patient presentations – most take place in an outpatient or emergency department; others are primarily in inpatient settings such as the intensive care unit or a nursing home)
• The question 
• List of possible answers (five choices)

You must choose the one answer that is better than the others; the answer options include one correct answer and several distractors. Here’s an example of a question from the ABIM web site:

Sample ABIM Question

A 72-year-old woman has had increasing fatigue and limb weakness for one year. One month ago, she was treated for pneumonia, and since that time the weakness has become much worse. She cannot rise from a chair or lift her arms to comb her hair. Physical examination reveals weakness and hypotonia of all four limbs, with more weakness proximally than distally. There is weakness of neck flexors and extensors. No fasciculations or atrophy is noted. The muscles are not tender, and reflexes are preserved. Babinski’s sign is absent. Sensory examination is normal.

Laboratory studies: Leukocyte count 4500/1; normal differential Erythrocyte sedimentation rate 77 mm/hr. Serum creatine kinase: Total 3200 U/L MB isoenzymes 21

Which of the following is the most likely diagnosis? 

• (A) Amyotrophic lateral sclerosis
• (B) Polyneuropathy
• (C) Limb-girdle syndrome  
• (D) Polymyositis 
• (E) Polymyalgia rheumatica 

ABIM Exam Content and Breakdown

According to the American Board of Internal Medicine (ABIM), “the exam is designed to evaluate the knowledge, diagnostic reasoning, and clinical judgment skills expected of the certified internist in the broad domain of the discipline.” The exam requires recognition of common as well as rare clinical problems for which patients consult an internist. The ABIM publishes a “blueprint” showing what portion of the exam will be on various topics (Allergy and Immunology, Cardiovascular Disease, Dermatology, Endocrinology, Diabetes, and Metabolism, etc.).

The focus during exam preparation should be based on the proportional to what’s covered on the exam itself. Because the examination is intended to focus on medical issues faced in actual practice, approximately 75% of questions will be based in outpatient or Emergency Department settings, and the remaining 25% on the inpatient setting.

The blueprint includes 18 primary categories:

How to Use the Exam Breakdown in Your Study Plan

Each primary category is characterized by subsections and further in disease specific items. For example, Cardiovascular Disease comprises 15 subsection topics and 48 disease specific items. Every question in the exam will fall into one of the primary medical content categories. 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. Be prepared for and expect to interpret some pictorial information such as electrocardiograms, radiographs, and photomicrographs (e.g., blood films, Gram stains, urine sediments). Clinical images (such radiographs, CTs or cutaneous rashes) are typically “classic” for the condition being questioned, and abnormal findings, when present, are NOT usually subtle. Over-interpretation of pictorial information is a common test-taking error.

Remember it is inevitable that certain concepts and facts covered on the examination may not have been encountered on your clinical rotations during residency. Therefore, your study preparation needs to provide adequate depth for the level of information sought on the certification exam. Although it is not possible to predict the questions in an upcoming ABIM-CE, several generalizations do apply to question content:

• Memorizing clinical equations is unnecessary, only the most general  equations (e.g. anion gap) would figure in a selecting the correct answer
• Questions rarely require learning about specific drug dosages or chemotherapy regimens
• Questions about adverse drug effects are common
• New or emerging information published in journals 6 to 9 months in advance of the ABIM-CE would unlikely be the basis of questions
• Be sure to select an internal medicine question bank that uses ABIM-style practice questions.

Abilities Tested by the Questions

In the development of questions for the ABIM-CE, the skills required of a competent internist are the ones tested. Therefore, the questions test the ability to: 

• Integrate information presented in the case to come up with most likely diagnosis
• Recall and understand from the case, the clinical manifestations of disease described
• Settle on the best diagnostic testing dictated by the case information
• Natural history/epidemiology of the disease outline in the case
• Use the case to make the appropriate management decision:
• Pathophysiology/basic science
• Interpretation of literature/statistical methods

Recall Knowledge Questions

Recall knowledge questions require only the recall of facts; for example (from ABIM website): 

Which of the following malignant conditions is most likely to be cured if the patient remains disease free for 30 months? 

• (A) Acute myelogenous leukemia (B) Carcinoma of the breast
• (C) Ovarian carcinoma * 
• (D) Embryonal cell carcinoma of the testis 
• (E) Small cell carcinoma of the lung

*correct answer

Synthesis Questions 

Synthesis questions require the integration and interpretation of facts to reach a conclusion; for example (from ABIM website): 

A 72-year-old woman has had increasing fatigue and limb weakness for one year. One month ago, she was treated for pneumonia, and since that time the weakness has become much worse. She cannot rise from a chair or lift her arms to comb her hair. Physical examination reveals weakness and hypotonia of all four limbs, with more weakness proximally than distally. There is weakness of neck flexors and extensors. No fasciculations or atrophy is noted. The muscles are not tender, and reflexes are preserved. Babinski’s sign is absent. Sensory examination is normal. Laboratory studies: Leukocyte count 4500/1; normal differential Erythrocyte sedimentation rate 77 mm/hr. Serum creatine kinase: Total 3200 U/L MB isoenzymes 21. 

Which of the following is the most likely diagnosis? 

• (A) Amyotrophic lateral sclerosis 
• (B) Polyneuropathy 
• (C) Limb-girdle syndrome * 
• (D) Polymyositis 
• (E) Polymyalgia rheumatica 

*correct answer

Judgment Questions

Judgment questions require knowledge, interpretation, synthesis, and then the application of judgment to take the appropriate action; for example (from ABIM website): 

You are asked to see a 73-year-old woman who has had epigastric pain for several months. The pain is relieved by sucralfate. Her illness has not interfered with her activities. Findings of physical examination are normal. Upper gastrointestinal series with small bowel follow-through, obtained by the referring physician, was normal. Serum gastrin was 789 pg/mL four weeks ago and 830 pg/mL two weeks ago. 

Which of the following tests should you order next? 

• (A) Serum calcium level*
• (B) Measurement of gastric pH 
• (C) Secretin stimulation test 
• (D) Upper gastrointestinal endoscopy 
• (E) Computed tomography of the abdomen

*correct answer

Summary

Understand the Structure of the Exam:

• The American Board of Internal Medicine (ABIM) publishes an exam blueprint detailing what material is represented on the examination, with the percentage assigned per content category. 
• The exam is composed of multiple-choice questions with one correct answer, most of which describe clinical scenarios. These types of case-based questions require making a diagnosis, identifying necessary tests and interpreting test results, recommending treatment, and understanding the underlying pathophysiology of disease.