My story, how I passed on the 3rd try (in year 4 post-residency), and life as a fellow -> subspecialty attending without certification... quite long-winded but I hope that this post is of help to someone. I feel like I am in somewhat of a unique situation, but perhaps someone else out there is struggling with the burden of not being ABIM certified while progressing along the career path of a subspecialist. Perhaps that person or those people think like me and have similar strong and weak suits. This post will detail my residency, fellowship, and attending experience while working to pass the boards and include some commentary on what worked for me.
As a point of reference/relevance, I went through all steps of this process on the west coast/pacific northwest, including now.
After doing very well in college I went to a nationally respected (though not top tier) residency after going to a middle-of-the-road medical school. Though I had little difficulty in testing prior to medical school (I didn't even study for the MCAT and blew it away), in medical school I got the lowest score in my biochem class that they had seen in 5 years - a 43% - on our first test, and did not fare much better in anatomy. I ended up withdrawing from anatomy and retaking it the next summer. This trend continued with most every test I took through medical school. I was in the bottom third of my class, easily, in all testable metrics, but always gathered high clinical scores when actually seeing patients. I passed step 1, 2 CK, 2 CS, and 3 on the first try, though they admittedly required ridiculously high amounts of study time, on the order of 35-40 hours a week of dedicated study time for 4-5 months. I used USMLE World as my exclusive study material for each - no more, no less. Every single question, whether I got it right or wrong, I studied the explanation and learned from it; otherwise I never would have passed. Between medical school tests themselves and the steps, I discovered that I do not at ALL do well with or benefit from a) studying with partners/groups, b) so called high yield lectures/programs, c) flash cards, or d) audio study guides. I also discovered I am much more efficient studying in long blocks rather than short spurts.
I did get into my first choice of residency, likely because I am a halfway normal dude who kills it in interview settings and also because I am a US born, US medical grad from an MD program (which unfortunately but really seems to give you a little leg up in every step along the way). This residency itself - everyone there agreed on this - makes very good physicians and problem solvers but not the best test takers. My in service exams put me in the 13th-18th percentile range nationally each time. I went through the hem/onc match process and ended up matching at my first choice of fellowship. Based on how I was treated during this process and where I was granted interviews for fellowship slots, it seems to me that step scores really don’t matter at this point anymore. It did help that I hooked up with a world-renowned expert in cancer, a physician who is a household name in those circles, and published one article with him which was on my CV. To this date, this is the only research I have published.
Onto my first board attempt and study method… I got the full set of MKSAP books to use as my study material. I started studying in June 2010 for my August 2011 exam. I painstakingly read through each section, reviewing each subject in detail along the way. After finishing each subject I went through each question within that subject in sets of 5, reviewing my answers – right or wrong – and studying the heck out of the explanation for each. I scored consistently around 60% on these sets. I did this for each subject and then did a quick review of book content prior to taking mixed/random samples of questions from MKSAP across all subjects, first in sets of 10 and then 50 at a time. I was scoring around 75% on these sets by the end, but also realized that I have a very good recall memory when it comes to test questions I have seen before – so perhaps this score was a bit inflated due to my recognizing some questions rather than having gotten them correct after conceptual learning. I also used this time to learn how to pace myself by doing the questions in timed sets. It appeared I would have plenty of time and would finish each real set of questions with time to spare.
I took 3 days off before the exam from studying and then showed up; no books in my car, no notes. I have never had any issues with nerves and again did not on this day. I went in confident that I would pass. Compared with MKSAP, the questions were surprisingly very very much longer and more involved. They were also higher order and quite a bit more difficult. I did finish each section, though I was somewhat hurried toward the end of two of them. When I left the test center, I knew for a fact that I had failed the test. My standardized score was 330 which put me near the top of the first decile of test takers.
This was devastating for me, but I brushed off my shoulders and moved on. I knew taking the exam at the beginning of my second fellowship year would be a disaster due to scheduling so I opted to wait until the beginning of my third year of fellowship to retake it (2013). This time, after realizing my yearlong study routine was actually too long, I opted to start studying in January for an August test. As poorly as MKSAP performed for me, I decided to use MedStudy for this time. I used virtually the same study method beyond this as the year before, and after going through the books once and the MedStudy qbank a second time with random sets, I very quickly reread each subject and then retested myself on a bunch of the MKSAP questions (without rereading MKSAP). I started scoring 70% on MedStudy (after reading each section once) which turned into 85% by the time I was done. I was in a pretty high percentile on these sets. I took 2 days off before and showed to the test with my books in the car. I did each section and brushed up on stuff between sections. I felt better about how I did this time, but again knew I had failed. Medstudy questions were far easier than the MKSAP questions and were only slightly more representative of them formatwise than MKSAP was to me. My Standardized Score actually went DOWN as compared with my first try; I posted a 304, putting me way down deep into the first decile.
What made this point in my journey most interesting was that I had been applying for jobs and contacting practices (did not use any recruiters or job list sites; just cold called (well, e-mailed)) in my geographic preferred areas since I was a third year fellow. All were non-academic hem/onc practices. I decided that I would only apply for IM jobs if hem/onc fell through at this point. My job search started in January, right around when board review started. I was most surprised that 75% of the places I put an application in offered an in-person interview. Mind you, these are practices in desirable locations that are not hurting or desperate for business. Every one of the places asked for clarity on my not being IM board certified. By the time all was said and done at all of the practices (a total of 8 out of the 10 I contacted I did interviews at), 2 of the 8 specifically said that not being IM certified was the reason they would not take me, due to their hospital affiliation and the hospital not giving privileges to non-certified folks who have failed even once. Interviews moved forward with other places where there was mutual interest – a total of 4 practices. This was cut down to 2 practices once they found out I had failed a second time during 2013, amidst the time they would otherwise have given contract offers. The two practices still considering me were in different metro areas and very different practices altogether. One was a true private practice with two partners, a truly rare scene these days, at least in hem/onc. The other was a hospital-affiliated practice with 14 partners across multiple locations in a large metro area. The physicians at both were very happy, appropriately worked, and very well compensated; I say this only to illustrate that they were both very desirable positions.
At this point, both of these practices knew they would be taking me on as someone not IM certified and therefore not hem/onc board eligible. Both were very clear that I would have a timeline during which I would have to pass not just IM but my specialty boards. Both were also clear that I would be acting as an attending hem/onc and not a medicine guy from day 1 with their practices. Seeing as I did not know that both would offer a contract, I continued to speak with both and did a THIRD in person interview with one. I actually received contract offers from both. Neither practice restricted any part of my contract due to the fact that I was not board certified aside from what follows here. One said I had to pass IM within 2 years and hem and onc within 4; the other said I had to pass IM within the first year, onc the second, and heme the third. Both clearly stated I would be terminated without cause if I did not meet these deadlines. I chose one over the other just due to practice dynamics, i.e. without putting any weight into how/when they expected me to pass boards.
In the meantime, my studying for the third attempt began in earnest in January of 2014. Though I had read through the ABIM thread at SDN long before attempt #2, I re-read in more detail through the ABIM exam thread this time around. Based on what I had read at SDN, I purchased USMLE World, which had last worked for me for my steps and seemed to make sense. This time, I used a similar method to before, reading through one subject entirely in MedStudy only (skipped MKSAP altogether this time aside from a very small sampling of questions), then doing that block’s MedStudy questions, then doing sets of 10 of USMLE World questions until finishing that subject. I did that for each subject. I did not have a set amount of time to complete any given subject but did watch the calendar to make sure I was going at a reasonable pace. Like before, I studied in detail explanations for every answer choice for every question, whether I got them correct or not. Once I had done this for every subject, I retested every question in MedStudy in sets of 10 randomly chosen from different subjects. I followed this with all of the USMLE World questions in sets of 10 randomly chosen from different subjects. Then, I did the USMLE World questions again in sets of 50. My MedStudy performance was similar to my second attempt. My USMLE World performance put me in the 60th percentile to start, then to the 80th percentile by my third time through all of the questions. At this point, I tried to do questions again, but practically every question in these sets were etched into my mind and I knew the questions themselves too well. I decided to purchase Knowmedge and got through about 1/3 to 1/2 of these questions before it was time for boards. This time, I studied until even the night before the exam.
Needless to say I had crossed into and through July and most of August before taking the boards. I had accepted one of the two job offers I had been given and had already been seeing hem/onc patients in earnest for nearly two months prior to my exam. My studying at this point was reserved for nights after I got home from work and on and administrative time I had at work, and between patients. As an aside, most insurance companies will allow you to see patients, bill, and be reimbursed so long as you become board certified in whatever you are doing within 5 years of finishing training, at least in the state I am practicing in.
I went to take my exam for the third time, knowing that if I failed there would be no going back and I would truly be out of a job with little if any chance of even picking up an IM position. I had plenty of time on each section and left the test feeling very, very good about how I did on a test for the first time since I took my MCAT. Again, to me the MedStudy questions seemed WAY, WAY too basic. USMLE World were highly representative of the actual test, but a good bit harder and more involved than the real exam. Knowmedge seemed to be reverse of World – not representative questions at all, but instead teaching and really hammering home individual points about specific topics. I felt that MedStudy was a good first superficial layer to study with and that World especially and Knowmedge to a lesser degree were supremely helpful in learning how to approach the test and store knowledge. In short, I felt like the test was easy mode USMLE World.
I found out I’d passed in early October and got my score report today. I got a Standardized Score of 438, putting me into the 4th decile, probably around the 35th.
To put things into perspective, I will say that I have done just fine at my job. My heme knowledge and practice is actually superior to most of my colleagues in the practice, but interestingly I was only in the third decile for heme on the boards. My onc knowledge is less than anyone else at the practice (though still easily adequate), but I scored in the seventh decile in onc on the boards. Just goes to show you that what is on the boards is not necessarily practical. I will post here the entirety of my score history by subject just to show you what improved and what didn’t with each study method.
Deciles, by subject and year
2011 2013 2014
Cardiovascular Disease 5 2 1
Endocrinology, Diabetes, and Metabolism 2 2 4
Gastroenterology 1 2 5
Hematology 1 1 3
Infectious Disease 1 1 3
Medical Oncology 3 3 7
Nephrology/Urology 1 1 1
Pulmonary Disease 2 5 6
Rheumatology/Orthopedics 2 1 5
Other Medical Specialty Areas/Miscellaneous 2 3 7
Standardized Score 330 304 438
Standardized Score Decile 1 1 4
Board Prep Used:
2011: MKSAP
2013: Mainly MedStudy(some MKSAP)
2014: MedStudy+USMLEWorld+(briefly and incompletely)Knowmedge
So, in terms of how each study material worked per subject for me, World was far and away the best as it had the most representative questions (by a long shot). It was much better for me for GI, rheum/ortho, pulm, and other/misc. It was weak in cardiology compared with MKSAP, though. Knowmedge was a good supplement but I would never have passed using only it.
Now, onto the next test… onc in a year or so. I hope this story has helped encourage those of you who may have failed twice or are working toward a subspecialty position and are still not certified. Let me know if you have any particular questions for me that might provide any other help or insight for you…
, overall is 79 
