John Rickard and Benico Barzilai
GENERAL INFORMATION
The American Board of Internal Medicine (ABIM) Certifying Examination in Cardiovascular Disease takes place each year in the fall. Applicants with special conditions who require longer testing durations generally take the exam over a 4-day period starting approximately 2 weeks after the general exam. Registration for the board examination begins in early March and lasts until early May. There is a late registration period, which incurs a late fee (generally around $400), which lasts from early May until early June. After the late registration fee deadline has passed, registration is no longer possible. Once registered, the opportunity to cancel registration (for an 85% refund) lasts until early September. After this deadline, cancellation is still possible up until 1 day prior to the exam at a 50% refund. At the Web site, www. abim.org, applicants can register for the exam online. Other valuable information such as coding sheets and a simulated computer question format for the exam are also found at this site. As registration test centers often fill up rapidly, early registration is key to assure the ability to take the exam at a nearby test center. Test results are typically first available on the ABIM Web site in early February.
For those recertifying, the test is offered twice annually, once in early April and again in early November. The deadlines to register for each test administration are in mid-February and mid-August, respectively. Board certification in internal medicine is not needed to recertify for the cardiology boards. In addition to passing the board exam, those seeking recertification must also have a valid and unrestricted license to practice medicine and obtain 100 points of self-evaluation via modules available on the ABIM Web site.
FORMAT
The cardiovascular diseases board exam is taken over the course of 2 days for first-time takers and 1 day for those taking it to recertify (those recertifying are exempt from the ECG and imaging sections). The first day is a full day consisting of four 2-hour blocks consisting of 200 multiple choice questions. The second day is a half-day consisting of an ECG section of 35 to 40 tracings lasting 2 hours 15 minutes and an imaging section lasting 2 hours consisting of 35 to 40 video images that include echocardiograms, ventriculograms, aortograms, and angiograms. Table 1.1 delineates the weighted subject content for the exam. Many cardiology trainees do not have sufficient exposure to peripheral vascular disease, pharmacology, and congenital heart disease during their training and must overcome this deficiency during their preparation for the examination. For the ECG section, a brief one- or two-line clinical vignette is provided with each ECG tracing. The test taker then must code relevant findings using a coding sheet, available in advance for review at the ABIM Web site. Similarly, for the imaging section, coding sheets are provided to capture the various findings. Of note, the coding sheet for the imaging section was updated for the 2011 exam. Test takers must make sure they review the updated coding sheet prior to the test. For the 2011 exam, coding sheets could be found at http://www.abim.org/pdf/cert-related/cvd_sample_cases.pdf.
TABLE
1.1 Breakdown in Content of the Cardiology Board Exam
HOW YOU ARE SCORED
For scoring, traditionally the multiple choice section and the imaging section have been combined. Starting in 2011, the imaging section was joined with the ECG section to form one component, while the multiple choice section comprises a separate component. For a passing score, both components need to be passed. While the imaging section can be challenging, due to the combination of scoring with the ECG section, a poor performance on the imaging section can be balanced out by a stronger score on the ECG section. While there is no penalty for guessing on the multiple choice section, there is on the ECG and imaging sections such that overcoding leads to point deductions. First-time taker numbers and pass rates for the exam from 2006 to 2010 are listed in Table 1.2.
TABLE
1.2 First-Time Taker Pass Rates
TIPS
A 3-month study period prior to the test is a reasonable amount of time to prepare for the exam. Reviewing information in a scheduled way over this time period is important. The examination encompasses a large quantity of information making a last-minute approach ill advised. Fellows who are enrolled in busy advanced fellowship programs such as electrophysiology and interventional must be realistic about the need to study for the examination. Too often, these trainees do not allow themselves sufficient time to prepare. They may consider signing up for a dedicated course, which would force them to focus on the material covered on the examination.
The multiple choice section of the boards is structured such that a clinical vignette is presented with up to five answer choices provided. While the clinical vignettes are often long, each block of 50 questions is allotted 2 hours of time (2.4 minutes/question). Very few questions on the boards simply ask a question on a medical fact. The large majority of questions make the test taker read through a patient scenario complete with a past medical history, current symptomatology, in-depth physical examination findings, and imaging and laboratory data prior to asking how to proceed with the patient’s management. In addition, the exam will often challenge the test taker to determine the most likely condition from the physical examination and then determine the treatment options based on other information given. Therefore, knowing the physical examination findings of common cardiovascular conditions is imperative.
The board exam will not ask questions on any areas that are controversial or not supported by evidence. The majority of questions will focus on information obtained from guidelines—most notably class I and III recommendations. In preparing, it is important to focus on common therapeutic and diagnostic conditions rather than rare conditions. Anticipate questions regarding common conditions structured in complex ways. In addition, the results of major, practice-changing clinical trials are favorite board topics. Some board questions may strike the test taker as strange or potentially even unfair. It is important not to get stressed out by such questions as the board pilots new questions every year. These new questions will not be included in the final score. Lastly, the imaging section of the boards can be difficult due to variable image quality. One should ensure not to waste time overcoding but simply code the major findings that are clearly identifiable. It is also critical to make sure that all the available images have been viewed.
It is vitally important not to underestimate the ECG section. The majority of patients who failed the boards in the past have done so by failing this section. Knowing the coding sheet cold prior to sitting for the test is vital (the coding sheet is available online from the ABIM). Many test takers run into time issues with this section. Searching for the correct codes on the sheet can waste a significant amount of time and may cause some examinees not to finish. Secondly, the board exam commonly tests clinical syndromes on the ECG section. The test taker should be very familiar with the clinical syndromes on the code sheet and be able to identify such conditions rapidly. While electronic calipers are provided, they are rarely required to obtain the correct answer. Overuse of calipers can waste valuable time. It is also important not to overcode the ECG portion of the test. The board examiners want to ensure that the examinee can identify the major findings on each tracing. Taking time to code small, somewhat questionable ECG findings will waste time and possibly cause point deductions.
Lastly, it is important to get a good night sleep prior to the exam as the test is lengthy and can be very fatiguing, especially toward the end of the examination session. Taking the exam at the first opportunity after completion of your fellowship is strongly advised as the material learned in training will be the freshest at that time. Finally, and as mentioned previously, early registration is important to secure a nearby test location. Having to travel large distances or staying in a hotel prior to the test will only cause unneeded stress and distraction.
TEN PITFALLS TO AVOID
1. Underestimating the ECG and imaging sections
2. Not being familiar with the coding sheets for the ECG and imaging sections prior to the test
3. Not being able to identify common cardiovascular conditions based on physical exam findings
4. Overcoding the ECG and imaging sections
5. Spending a disproportionate time on one or two questions at the expense of other easier questions
6. Getting upset by what appears to be very strange, “out of left field”-type questions that are probably pilot questions that are not factored into the final score
7. Wasting too much time with the electronic calipers on the ECG section
8. Cramming for the test at the last minute
9. Registering late forcing the test to be administered a distance away from home
10. Not reviewing the sample questions on the ABIM Web site