1. Your #1 priority needs to be not failing out of your Heme/Onc fellowship. So, I agree that you need to focus on Heme/Onc, and postpone the IM boards for now. 2. You need to check to see if passing the IM boards is a requirement for graduation or promotion in your program. This is NOT an ACGME rule, so it will be specific to your program if it exists. For example, I require that everyone pass Step 3 prior to graduation -- if you can't pass, you don't graduate. Hopefully this is on your program's website somewhere, as you certainly don't want to ask your PD. 3. Your ABIM status is public info. Anyone can look it up, including your PD. If your PD looks it up, it will simply say that you are "not certified" -- he or she won't be able to tell whether you failed or didn't take it (unless you took time off from the program to take the boards, at which point it will be obvious what happened) 4. I think from your description above that your program is front loaded -- the 18 months of clinical work come in the first 2 years of fellowship, and then the last 12 months are pure research and clinic. If that's the case, you'd want to consider studying for the exam again during your F2 year, and take it in Aug of your F3 year -- or, you could study during your F3 year and then take the IM exam after you actually finish your fellowship. The former would allow you to take the H/O boards right after you finish your fellowship. The latter would require that you take them a year later, as you can't take the H/O boards until you pass the IM boards. 5. Will this affect your ability to get a job? Interestingly, probably not. When you graduate from your Heme/Onc fellowship, no one will expect you to have passed the H/O boards yet, obviously. They are unlikely to even think about asking about your IM certification status. If you take the exam at the beginning of your F3 year, you'll have your results before you'll be looking for a job anyway -- making this a safer pathway but only if you'll have time during the latter half of your F2 year to study aggressively.