Family medicine board examination 2015: One last time.

I’m taking my family medicine board exams one last time. This is not entirely sensible. It’s been 21 years since I did family medicine, and 17 since I last saw a patient. I’m unlikely to practice again. The exam will be difficult; my brain is old and cruddy. (Long ago I did rather well on these, but it does help to actually practice medicine.)

Still, for one reason or another, I’m committed to doing the exam this November. I’ve slogged my way through the ABFM’s intricate preparations, including, for the non-practicing candidate, 6 self-assessment modules (SAMs) and one “alternative” module (which was quite awful and may have been since withdrawn). I even managed to meet the under-documented CME requirements [1]. The expensive Self-Assessment Modules varied from quite good to rather poor; alas the simulations are not worth continued investment [2].

When I’m done I’ll revise this post with what I end up with. By far the best guide I’ve found for someone like me was something written in 2008 (*cough*). I’m basically following my old recommendations (including ignoring audio CME/podcasts). For example:

• ABFM | Exam Preparation: look for the tiny links at bottom to Study Tips and 2-week checklist. Some of this advice is wrong for me - and probably for most people. Still worth a read.
• ABFM | Exam Content: this page hard for me to find - maybe my problem. I focus on topics with 5% and above.
• I have old online medical notes written back when we thought HTML would be a good format for knowledge sharing and documentation. How naive we were! My medical notes started out in pen, moved to Symantec MORE 3.1, then FrontPage/HTML and now they’re back to an outliner (OmniOutliner 3). I have to write to learn. When I’m done I’ll attach a version of my notes here, but they’re really only going to be useful for me.
• SAM Module Review: The SAM modules were a mixed bag, but the question explanations are superb summaries of current/expected knowledge. I’m mining those for my notes.
• ABFM in training exam: The ABFM provides 3 years of teams. I’m studying these in depth, identifying any areas of strength, guiding my study, and generally awakening old memories.
• Online references: this has changed, and not for the better. There’s much less available for “free” online than there was in 2008 [3]. Only Scott Moses’ self-funded hobby/obsession remains - the FP Notebook. So I’m buying selected paper references [4] like the venerable Washington Manual and Sanford Antimicrobial therapy. Some of my old textbooks (EKG interpretation) still work.
• AAFP Board Review prep: skip over the expensive and inefficient modules and find the free (38 credit!) Board Review Questions. I think this is what the ABFM “exam prep” document was warning against. Needless to say, I’ll be sampling these, though Emily recollects they’re less useful than the ABFM in training exam materials.
• Monthly Prescribing Reference (print version): still evil (drug money funded), still remarkably useful. Trick is to know what drugs are actually used vs. what are legacy — would be nice to have a version filtered by popularity.

I’m alternating topical work (reviewing Sanford, relearning EKG interpretation) with review designed to rebuild old memories. My medical knowledge network is frayed and fragmented, but there’s a lot of it. Much of my preparation is really resurrection. I've brute memorization ahead - reading, closing eyes, regurgitating. Then exam-guided note review and expansion.

It will be interesting to see how it all goes. Failure is certainly an option.

- fn - 

[1] Dear ABFM: Please note the current cycle progress tracker omits CME requirements but the future cycle includes CME requirements. Could be fixed.

[2] In the late 80s through early 90s we used to get 360K floppy disks each month with a unique DOS based medical simulation. I cannot, just now, remember what medical publisher did them (something Cardinal?). I remember them as quite excellent, I featured them in our residency computer-based training program.  Several clinicians, likely retired now, did some serious work on those. There really is no modern equivalent. Which is a kind of interesting.

[3] UpToDate is by far the dominant online resource for medical information — and it’s very expensive. (Priced for organizations.)

[4] See [2]. Also the movie Groundhog Day.

Update 11/22/2015

I don’t know my exam results yet, but it went more or less as expected. The test environment worked well — though it took me a while to realize I had to select text then click a secondary highlight icon that floated nearby to get highlighted text for review. My foot pulled a power cord out, but when our proctor fixed it everything worked. For most modules and sections there was ample time. We do get markers and writing material, I didn’t see that mentioned in the ABFM exam descriptions.

The AAFP board review questions and the ABFM provided residency training exam questions were a good guide. The AAFP questions generated CME credit, but I liked going back and forth. Whenever the questions exposed an unfamiliar topic I went off and did guided studying. There’s an AAFP board preparation page that provides USPSTF screening guidelines that’s quite useful.

FP Notebook was, and is, outstanding. I wouldn’t make many changes to my studying, but I’d have stared using FPN intensively sooner than I did. It is a perfect way to bring old knowledge on board, to identify obsolete knowledge, and to extend the sample exam question critiques. It’s also a great way to review medication information. Beyond FPN I mostly used American Family Physician articles and a handful of textbooks.

My key book references were The Washington Manual, Sanford antimicrobial therapy, MPR Prescribing Monthly, Emily’s ACLS “cards” and my venerable med school EKG primer. That’s similar to 2008, but since then my presbyopia has not improved. This year I found the app versions more readable than the paper versions; the Sanford and Washington Manual print text seemed microscopic. The Sanford app is a $40/year subscription, but Emily uses it too (we share same AppleID for purchases). My paper Washington Manual came with a free code for the electronic version, hosted by inkling.app (iOS). I barely looked at the paper manual, but I used the inkling version often.

The ABFM Maintenance of Certification examinations (I had to do 6!) were not particularly useful preparation for the board exam. I don’t think the maintenance exams a useful guide to real world practice either — they are much too esoteric. I regret the time and money I spent on those, but of course we don’t get a choice.

Even though most physicians would have key references like Sanford, Up To Date and drug information at their fingertips our board exams still rely on brute memorization. I suppose they’d be too easy otherwise. Given the years since I’d done family medicine (1994), and the years all by themselves, memorization was not particularly easy. I had to interact with information. I took handwritten notes on exam questions that I knew I’d never look at — but the writing process was important. I created my own spreadsheets of drug information for antimicrobials, antidepressants, anticoagulants, and, above all, oral diabetes meds (mercifully lipid therapy has gotten much simpler!). In each case I created my own groupings (med classifications), frequently reorganizing them. It helped to organize medications but their modern use, rather than by the sequence in which I encountered them. For the oral diabetes meds I would attempt to recreate my classifications by memory, then see where I got them wrong, then repeat… At about 30-40min of painful memory work a day it took 3 days to learn them.

I moved my old notes into OmniOutliner Pro 3 — itself an old piece of software. This was a ‘back to the future’ moment as my notes started out decades ago in a similar product - Symantec’s MORE 3.1. After a couple of weeks of study I could recognize what was worth keeping, what needed to be rewritten, and what should be deleted (much of lipid therapy!). I updated my old references with FP Notebook on a separate screen; this process helped tie old knowledge to new knowledge. 

The old knowledge was important — during the exam I found myself dredging things up from 25 years ago. I was surprised I could get anything from that far back, but really most of my medical base is from that era. For this exam I was largely refreshing and resurfacing it.

I’ll find out some weeks from now whether I need to do it again in a few months, or years, or perhaps never again.

Update 1/25/2015

I passed the exam by a substantial margin. If the maximal score represents percentile I scored about the 75th. That’s much lower than my score when doing academic practice, but it’s not bad for 20 years without patient care.

I did well in all the areas I studied. I didn’t do as well in obstetrics and gynecology, but I strategically omitted them.

My studying approach worked quite well for me.