Board Exam Nightmare

June 27, 2014

By Michael Tanner, MD

The American Board of Internal Medicine compels us internists to take a 6-hour multiple-choice Maintenance of Certification exam every 10 years. I, by an accident of birth year (being old), am one of the few doctors who have had to take “the Boards” three times—in 1994, 2004 & 2014. The exam tests our knowledge of 500 diseases that we haven’t seen in the 10 years since we last had to take the exam. It’s kind of like a college reunion: a chance to catch up with old friends.

I was given a test date of May 5, 2014. My New Year’s resolution to read 10.41 pages per day for 125 days for a total of 1301 pages never really got off the ground, and so with two weeks to go before the test, I opened the first of my eleven Medical Knowledge Self-Effacement Program XVIII books. I thought I’d start off with one of my weaker organ systems, and so I opened “Pulmonary & Critical Care Medicine” and began to read:

Cryptogenic Organizing Pneumonia

Cryptogenic organizing pneumonia (formerly called idiopathic bronchiolitis obliterans organizing pneumonia) is a rare, idiopathic lung disease with the relatively nonspecific histopathologic correlate of organizing pneumonia.

Nonspecific Interstitial Pneumonia

Nonspecific interstitial pneumonia is a rare idiopathic disorder that shares many clinical features with idiopathic pulmonary fibrosis.

Idiopathic Pulmonary Fibrosis

The lung biopsy in idiopathic pulmonary fibrosis shows usual interstitial pneumonia. However, the pattern of usual interstitial pneumonia is not specific for idiopathic pulmonary fibrosis.

Although I could hardly wait to use this knowledge for the benefit of my patients at my next Primary Care Clinic session, I fell into a deep, nonspecific sleep.


I find myself in a darkened gymnasium. There are tables, a mirror ball, a keg of beer, and a band playing cover tunes. One wall is covered with photographs of microscope slides and unfortunate people with hideous, grotesque rashes. A big banner reads…




An ACEAMK worker at the registration desk tells me, “Place your right hand in the Advanced Integrated Cogent Automated Palm Identification System scanner.”

A crowd of 500 is milling around the gym. Everyone is wearing a nametag, but the tags have all flipped over on their clips so that only the blank side is showing. As I wander over to the keg I overhear snippets of conversation.

“Diastolic Dysfunction was my maiden name. Now I go by Heart Failure With Preserved Ejection Fraction.”

“I’ve changed my name, too. I used to be Reiter’s Syndrome, now I’m Reactive Arthritis. I think it has a nicer ring, actually.”

“So what have you been up to?”

“Oh, not too much. Some minor infestations, a little consulting work. Last summer I infected 19 Cub Scouts in a hot tub at a jamboree—that was great! But there’s just not all that much of it. To tell you the truth, I’m pretty much retired.”

A man walks up to me, looks me in the eye, and says, “Well if it isn’t Michael Tanner! How have you been?”

“I’m sorry. I’m terrible at names. You’re a triad, right?”

“Actually, I’m a pentad.”

“Give me a hint.”

“I’m also known as Crow-Fukase syndrome, Takatsuki disease, or PEP syndrome.”

“Sorry, I’m still drawing a blank.”

“Okay, let me spell it out for you: Polyneuropathy, Organomegaly, Endocrinopathy, M-protein, and Skin abnormalities.”


“No, my good man. HELLP would be Hemolysis, Elevated Liver enzymes, and Low Platelet count. She’s over there by the keg. I’m POEMS.”

“Wow, I haven’t seen you since…since I studied for the test 10 years ago.”

“I’m incredibly rare.”

And a bit stuck up, I think to myself, but don’t say it.

I realize that I’m striking out here. I’m a terrible mingler. I recognize no one. After 10 minutes of standing by myself pretending that it’s perfectly fine to be standing by myself, I manage to strike up a conversation with an attractive, slightly familiar young woman. After the requisite pleasantries, however, I am totally at a loss for what to say next.

“So! Are you sexually transmitted?”

“Droplet spread!” she snaps, striding away. Story of my life: open mouth, insert foot.

Suddenly everything goes black. Someone is covering my eyes from behind me.

“Guess who!” says a female voice.

I love “Guess who!” It’s such an aggressive, sexy maneuver. I gently remove the palms from my eyes and turn around to see a slightly crazed young woman wearing a nurse’s uniform, heavy makeup, and a retro hairstyle. She is sweating profusely.

“I know you!” I say for the first time that evening. “You’re the mentally unhinged nurse with severe hypoglycemia who abuses diabetes pills! You never miss a reunion, do you?”

“Nope. But I always do try to switch it up. In ’92 I was into abusing synthetic thyroid hormone—Synthroid® 400 mikes a day.”

“Ballsy dose!”

“My question is designed to test the examinee’s ability to detect factitious disorder, Münchausen syndrome, intentional overdose, all that kooky stuff.”

“It’s so nice to finally see a familiar face. O crazed, glyburide-abusing nurse, will you be my Sybil, my guide through this Underworld of Abstruse Maladies?”

“If you’ll be my Aeneas.”

Before you know it, we’re slow dancing to “My Girl.”

I whisper into her ear, “Honey, you’re clammy, confused, and tachycardic. We need to get some calories into you–stat.”

En route to the punch bowl we pass a table of snarky people who smirk as we go by. “Don’t look now,” Sybil says, “but there they are: the Diagnoses of Exclusion.”

I’ve always hated the Diagnoses of Exclusion: Fever of Unknown Origin, Hysterical Syncope, Chronic Fatigue Syndrome, and the worst of the lot, Fibromyalgia. Too cool to have a diagnostic gold standard. At the 2004 reunion they all disappeared into the bathroom together and came out giggling.

We come upon an unfortunate fellow who is coughing his lungs out. Sybil offers him some punch.

“So what do you do for a living?” I ask.

“I print Bibles,” he replies between paroxysms.

“Hey, that’s a clinical entity! Let me just check your nametag.”

As soon as I flip his name tag (which indeed reads “BIBLE PRINTER’S LUNG”), I feel powerful hands gripping my upper arms.

“Doctor Tanner, you need to come with us. The American College of Esoteric & Abstruse Medical Knowledge has a zero tolerance policy for academic dishonesty.”

When they snap my number 2 pencils in half, I lose it. “The ACEAMK is nothing but a bunch of unarmed bandits! How about giving paying members a vote instead of piling on more of those stupid Practice Improvement Modules? This nightmare cost me $1650!


I feel a big needle jab my left buttock. That was the Ativan 2. Then another needle on the right. That was the Haldol 5.

As they pull me from Sybil’s arms and drag me away I cry out to her, “Any study tips for the big test?”

“Forget about reading the text! Just do the questions!”


I awakened. The MKSEP XVIII was lying on my chest. I opened it and read the first sentence on page 894.


Lymphangioleiomyomatosis is a rare progressive cystic lung disease occurring in women in their 20s & 30s as a sporadic disorder or in conjunction with tuberous sclerosis.


Resolving to remain on the lookout in clinic for the lymphangioleiomyomatosis-tuberous sclerosis combo, I got it together, studied really hard for the last two weeks, and passed.

I’ll even reveal my score, esoterically: 10 to the 2.72 power.


To sign the “ABIM Should Recall the Recent Changes to Maintenance of Certification” petition online (now over 16,000 signatures), visit:

Dr. Michael Tanner is the Executive Editor, Clinical Correlations



9 comments on “Board Exam Nightmare

  • Avatar of Despina Siolas, MD PHD
  • Avatar of Paul Kempen, MD, PhD
    Paul Kempen, MD, PhD on

    The issue is BUsiness ethics (he with the gold rules) while a lack of ethics is widespread and increasingly hidden in medical publications and is especially pronounced, whenever any American Board (ABMS) paper is published. This is all about the money and the ability to project politically to create REGULATORY CAPTURE of an industry consuming 18% of the gross national product today. The ABMS has pushed a $400 million industry onto physicians and are forcibly expanding that, increasingly given free publishing in specialty journals for their multitude of nonscientific papers (advertisements), while simultaneously failing to conform to standard ethic guidelines, in ABMS’s own as well as other specialty journals: How does the President, CEO AND Chief editor of a journal (J Am Board Fam Med. 2014 May-Jun;27(3):383-390) earning over $800K in that office, write an article about their recertification products IN their OWN proprietary JOURNAL, stating it is FROM the American Board of Family Practice, openly declare “no conflicts of interest” and “funding: None”???? A new paper in pediatrics (Pediatrics. 2014 Jun 16. pii: peds.2013-2643) was started without IRB approval, found nothing remotely of scientific value, then received IRB approval for a QI project that was turned into a published study used to sell a “MOC Product” without ANY informed consent, while subjecting children to increased testing and treatments, and from Mass General! This violates all ethics, the 1947 Nuremberg laws and Helsinki declarations. It is time to again PROTECT patients and doctors from corporate intrusion using government sanctions permitting intrusion into the sacred physician-patient relationships and put patients first! Ethics are being circumvented daily and the International Committee of Medical Journal Editors is powerless to do anything except attest ethics are being respected. The journals themselves are earning tremendously from the income off the $2.5 billion CME and now “MOC point” industry and have no interest or ability to regulate. There is NO oversight of the ABMS who make CORPORATE decisions from the boardroom and are using this traditional marketing ploy to formulate profits and politics. The problem IS the many non-profit corporations are leveraging political power over medicine and corrupting ethics for $$$$$. This has led to the increasing physician resistance against the ABMS and all Boards products-which are increasingly identified as an archaic and wasteful business with no value in today’s medical care. It is time to follow Nancy Reagan’s recommendation and “just say no” to this addition to worthless “paper gold stars” called certification and MOC!

  • Avatar of Divis Khaira
    Divis Khaira on

    I disagree. I felt this way until I recertified in my Hematology twice. The bottom line is if you think of a disease and look for it, you are likely to find something. There are many people admitted to the hospitals where the doctors may not be informed enough to treat. To name a few:
    1. Patient treated for 3 months with Vancomycin for skin lesions on arm that were due to porphyria cutanea tarda.
    2.Multiple admits for staph aureus septicemia, but no workup for source done.(Turned out patient had endocarditis)
    3.Patient with Crohns treated with multiple antibiotics for a nodular lesion on leg…

    The list is endless. Medicine is dynamic and changing.Let us not get a false sense of security. I used to feel the same way the first time I read the MKSAP. I am happy to say after 25 yrs of practice I have seen most everything that has been described and had the opportunity to work with some wonderful doctors who are curious enough to want to get to the bottom of patient’s problems. I think everybody should be required to recertify in some form or another. I am amazed at the the new information that becomes available.Let us remember that medicine changes, so does technology, whether we like it or not…

  • Avatar of respond to Dr Davis Kahira
    respond to Dr Davis Kahira on

    The 2 doctors in my group who are the most superficial and have missed
    endocarditis, storke etc ARE board certified. Most physicians need NOT some corporation to tell them to read and update their knowledge. Most of us learn on a daily basis. Some of us are just not good at multiple guess questions.
    I went through this nightmare and AM certified not because I wanted to (I was forced to). I resisted it for a few yrs but it became impossible as ho$pitals and in$urance companies require it (pushed by ABIM)

  • Avatar of Eric
    Eric on

    To doctor Kahira,

    If someone does not investigate a disease thats not getting better with multiple treatment protocols and does not dig deeper into the problem then it’s because they did not investigate the disease not because they are not board certified.

    Your conclusion does not make sense. We can all site doctors who missed diagnosis and were board certified and some who were not.

    If you personally like being board certified and feel that it helps you in your practice, then do it. But your not the only one on this planet that’s a doctor. And many don’t need it in order to maintain their skills and knowledge.

    In the end, no on should be FORCED to take these crap exams so they can keep making tons of money while the average PCP is struggling to keep their practice open.

    Stop drinking the coolaid.

  • Avatar of Marcel Brysk, MD
    Marcel Brysk, MD on

    Dr. Tanner’s article is nothing short of brilliant!
    Of course, Dr. Kempen’s comment hits the nail on the head.
    In the 45 years since I became an M.D., I have witnessed the progressive usurpation of the profession’s ethical norms by business interests, and their lackies, all for greed.
    Greed for power; greed for money.
    Hypocrisy is the standard of the day with state boards, federal agencies, insurance companies, and legislative bodies.
    They all seem to claim to know what is needed to ensure the appropriate practice of medicine, based on their arrogant ignorance.
    Those of you who worked for years to join a noble profession, need to come to its aid, as it is under siege.

  • Avatar of Jafar Al-Modhiry, MS4
    Jafar Al-Modhiry, MS4 on

    Clever, entertaining, and wildly funny; thank you for this! I enjoy the jester’s jabs at the funny world of medical knowledge we test in frequently–conspicuously distinct from reality. You know, that place where we talk about kids with Maple Syrup Urine Disease as much as we talk about our diabetics with, well, maple syrup urine disease (and maple syrup oral disease??)

  • Avatar of W.Kutteh
    W.Kutteh on

    I read your article with interest. Thanks for the laughs but the joke is on all practicing physicians.
    I was originally certified by ABOG in 1992 for 10 years. Around 1998 ABOG changed the certification expiration to 6 years and suggested that I take an exam. I took my framed certificate, made a copy, and circled the 2002 expiration date and they left me alone for 4 more years. Since that time we have a 4 part MOC process that requires annual chart review of patients with a certain diagnosis, reading a bunch of articles (fortunately our hospital gets them for us – it used to take hours just to get the articles) and answering questions, and now every 6 (six) years a written exam. All to remain board certified. They have made so much money, that they build a nice office and hotel complex in Dallas. The initial exam, which used to be at the Drake in Chicago, is now at the ABOG hotel. Of course, the examiners stay at the same place as the examinees. An now we are expanding those who are eligible for Board Certification. Originally, it was General Ob/Gyn, Oncology, Maternal Fetal Medicine, and Reproductive Endocrinology. Now they have added Urogynecology and others are being discussed.
    The original explanation, was that we must go through this process and make it rigorous, because if we didn’t the NBME was going to implement a very strict examination process every year. So, the NBME lost out on all of the fees to register for and the fees to take the annual exams. Too bad for NBME.
    I think there is no end to the process. If 10,000 internists signed the petition to object to the process, there are 90,000 that did not. It must be a vast majority of practicing internists who object to this process to kill it.

    One more story that really rubs me raw. A Canadian friend of mine, who is two years older, and finished her OB/Gyn training in Canada moved to the US in 2007. I was warning her about the annual process that was required here. I was shocked to learn that she was ‘grandfathered’ in to the old system of permanent certification because of the date of completion of her training. So all she had to do was pay the fee to the ABOG and get certified for life. Unbelievable!.

    Anyway, just wanted to share the Ob/Gyn experience with you. You guys have been able to delay the process for some time but not forever.

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