Introduction

Passing the emergency medicine written certification examination is an important milestone in the process of becoming a board-certified emergency physician. The written exam, formerly called the Written Certification Examination and now referred to by the American Board of Emergency Medicine (ABEM) as the “Qualifying Examination,” is used to identify candidates who are ready to take the oral exam, the final step in becoming board certified. The Qualifying Examination measures core knowledge, and, to many who must take it, it is an intimidating hurdle. Every year approximately 10% of examinees fail the test and must retake it the following year. Given that many test takers are completing their residency and may be moving to start a new job in the months leading up to the test, it is clear that there is a need for a focused, easy-to-use review book to help them prepare.

First Aid for the® Emergency Medicine Boards is such a book. The First Aid series is based on the idea that people who have recently prepared for and taken the test know best how to teach others to study for it. We have drawn on the experience of 26 individual chapter authors and nearly as many senior reviewers, integrating clinical experience, information from existing review books, and the ABEM practice questions to create a book designed to improve your score on the Qualifying Examination. First Aid for the® Emergency Medicine Boards contains dozens of challenging cases (“minicases”) and reinforces important information in highlighted “key facts” and “mnemonics.” Filled with tables and figures, it presents key findings and must-know information in a clear, concise, and highly accessible format that makes it easy to recall both on test day and in the emergency department.

The Qualifying Examination consists of approximately 305 questions. Candidates are given six-and-a-half hours of time to complete the test. All questions are the multiple choice, single-best-answer type. You will be presented with a case scenario and a question, followed by five answer options. Approximately 10% of the questions include a figure (radiograph, photograph, ECG, rhythm strip, or ultrasound image). There are no penalties for wrong answers, so if you find a question unanswerable, make your best guess and move on. Candidates who achieve a score of 75% or higher pass.

The exam is given in the fall of each year at one of 200 PearsonVUE professional computer-based testing centers. Test locations can be found by selecting “Locate a Test Center” on www.pearsonvue.com. Information on registration, fees, and test composition can be obtained from the ABEM website, www.abem.org.

Exam content is defined by ABEM’s Model of the Clinical Practice of Emergency Medicine (EM Model). The table lists the relative weight given to different elements of the exam. A minimum of 8% of the questions involve pediatrics cases, and a minimum of 4% of the questions involve geriatrics cases.

As we have done with other books in the First Aid series, we encourage you to read this book early on and throughout your residency, and to supplement it with margin notes. As with general medicine, mastering emergency medicine does not result from a single reading of a textbook but from many readings and multiple experiences treating patients. For common conditions, such as blunt trauma, CHF, and pneumonia, we focus on the kinds of complicated scenarios that you will find on the test. At this point in your career, you will not be tested on your knowledge of basic information. You will not be asked What is the most common cause of community-acquired pneumonia? for example. Instead, you are tested on your ability to apply that basic knowledge in the far more challenging situations you are likely to encounter in the ED, where the question is more likely to be What is the cause of pneumonia in this patient who has just returned from a rat-infested cabin in New Mexico? For rare conditions, such as an organophosphate overdose, ciguatera toxicity, or high-altitude pulmonary edema, our goal has been to provide simple, clear, memorable explanations. By the time you have read this book two or three times, you should be well prepared to make the right decisions on the exam and in real life.

Some young physicians say that practicing medicine is intuitive and experience based, that once you have done a residency, studying and memorizing are things of the past. For most of us, this is not true. When a patient comes into the emergency department 15 minutes after eating dark-meat fish with flushing and palpitations, you might know that you need to initiate treatment with diphenhydramine for scombroid poisoning. But this knowledge is hardly intuitive. And, unless you had trained in Florida, you would probably never have seen this disease. For most examinees, study and memorization are a necessary part of test preparation.

In preparing for the exam, take an expansive and a reductionist approach. Be expansive by studying with your reference books and internet resources readily at hand. Supplementing your clinical knowledge with pictures and detailed descriptions of illnesses will help you remember how to identify and manage complex and rare diseases. Be reductionist by preparing notes on the subjects you have difficulty remembering. Linking key words together on paper, “dendritic ulcer → herpes keratitis,” for example, and reviewing them regularly is often enough to help you “capture” an important piece of knowledge—and ensure the right answer—on test day.

Most cases you see in an emergency department will require more complex thinking than can be presented in a multiple choice question. We encourage you to accept that the test simplifies complexities in order to provide an objective measure of your knowledge. For evolving and complex situations, such as evaluating the source of chest pain, we describe the current, generally accepted approaches. Please be aware that medicine continually changes, and there are many situations for which we still do not know the best approach.

When you work in the emergency department, knowledge and experience are your friends. The greater your experience with and understanding of a given complaint, the faster you will be able to help your patient. And while it may seem that the amount of information that could be included on an emergency medicine certification exam is unlimited, it is not. Like most of the exams you have taken in the past, this one tests a finite body of knowledge. The material on the exam is readily identifiable and studying can greatly improve your competency with it. In short, you can master the content of this exam. What’s more, preparing for the exam should make you a more confident and capable emergency physician. You are no longer simply studying for an organic chemistry test; you are preparing for a career as an emergency physician.

How much time you allow for test preparation will depend on your interest in the formal study of the material and how likely you are to pass the exam with minimal preparation. If you consistently score above 85% on in-service or practice examinations and are currently practicing emergency medicine and reading regularly, you probably won’t need to study too much. Most people, however, need two to three months to study for the exam. Giving yourself adequate time makes the experience richer and more enjoyable, and enables you to integrate your clinical experience with what you are studying. We recommend that you read this book in its entirety at least two months before the exam date. Use this initial read to identify the gaps in your knowledge and facts that you want to memorize. Use practice test questions, such as those found in PEER VIII, to improve your test-taking skills, to further identify knowledge gaps, and to add to your list of facts to memorize. Two weeks before the test, review the book again, focusing on areas of weakness. Avoid trying to cover new ground, and instead spend your time reviewing core knowledge and memorizing your list of facts.

Knowing the right answers is the most obvious way to pass the test, but studying is not the only way to prepare. Knowing how to take a multiple choice test can also help. There are five key components.

First, anticipate the answer as you read the question. With most questions, you should already have an answer in mind before you look at the choices. For example, a question might describe a young lady who presents with odd neurologic complaints. She is not obviously sick, and she reports that she had a different neurologic problem two months ago. Just as when you listen to real patients describe their symptoms, a differential should form in your mind. At the top of the list for the test patient should be multiple sclerosis. If you are confident in your answer, you can avoid wasting the time it takes to carefully consider the merits of each answer choice. Instead, you can scan for the one you know is right, check the alternatives to make sure they don’t compete with your anticipated answer, and move on.

Second, when you cannot anticipate the answer, use the following guidelines to help you make your choice:

1. Opposites attract. If two of the answers are the opposites of each other, one of them is usually the right answer.

2. Similars attract. If two answers are similar, one of them is usually the right answer. Test writers don’t usually create two similar wrong answers.

3. Grammar is a guide. Sometimes wrong answers can be identified through minor grammatical inconsistencies between the question and the answer choice. The right answer should link to the question without grammatical errors, as if it is part of a sentence that was cut neatly in half.

4. Avoid “always” and “never.” Answers that include always and never are almost never correct. This fact has become so well known that you will probably not see these words on the test. If you do, be wary.

5. Worst-case answers are often right. One of the goals of emergency medicine training is to teach you to consider life-threatening illnesses first. Be always on the look out for the pulmonary embolus or the ectopic pregnancy, and anticipate the need for immediate surgical consultation and early intubation. The diagnoses of GERD, gastroenteritis, or musculoskeletal low-back pain should be made only after you have ruled out more serious diseases with similar presentations.

Third, don’t be flustered if you have difficulty interpreting a figure on the test. Like diagnostic tests in the emergency department, images on the written exam should be used to confirm or refute a clinical suspicion. The question will often guide you to the answer without the image. Use the picture to strengthen your confidence in your answer choice. For example, a 72-year-old man presents with hip pain and difficulty walking after a ground-level fall at home. What is his diagnosis? If you were seeing this patient in the emergency department, you would put hip fracture at the top of the differential. The purpose of the radiograph would be to exclude a hip dislocation (although your exam will usually do this) and to identify the location of the fracture. If the radiograph is negative and the patient really cannot walk without a lot of pain, you will probably proceed to a CT or an MRI to find the fracture that you cannot see on radiograph. Take the same approach to this patient on the test as you would in the emergency department. Determine the answer from the story, and look to the image to confirm your diagnosis. If you can’t interpret the image, answer the question without it.

Fourth, read the question carefully. As in the emergency department, there is a danger in being overly confident in a diagnosis. It is good to anticipate an answer as you read, but be sure to read the entire question. Don’t be so certain about your diagnosis of glaucoma that you miss the sulfa allergy, the history of sickle cell disease, or COPD. Paying attention to such details can mean the difference between choosing the right answer and a wrong one.

Fifth, be aware that test writers like to mislead test takers. It has been said that writing good test questions is easy—it is writing good test answers that is difficult. A good test answer choice captures the imagination of unprepared test takers, and lures them down the wrong path. Here, again, knowledge is your friend. In this book, we include information about unusual problems to help you hone in on the correct diagnosis and alert you when you are being led astray. For example, strychnine causes muscle convulsions leading to asphyxia two hours after ingestion and is therefore unlikely to be the right answer to any question, but if you don’t know that, you might end up choosing it. Of course, good foils sometimes are right answers; knowing the key information covered by each question should help you tell the difference.

Finally, good luck and enjoy your time studying. There are few careers that offer as much opportunity to positively impact the lives of others as that of the emergency physician. The investment you make in yourself by studying will make you a stronger test taker and a more competent emergency physician.

There are a number of excellent books that will help you prepare for the written exam. They are listed below, along with sources of practice questions and review courses you can take.

Books for Review

Harwood-Nuss A, Wolfson AB, Linden CH, et al (Eds). Harwood-Nuss’ Clinical Practice of Emergency Medicine, 4th ed. New York: Lippincott Williams & Wilkins; 2005.

Marx JA, Hockberger RS, Walls RM (Eds). Rosen’s Emergency Medicine Concepts and Clinical Practice, 6th ed. St Louis, MO: Mosby; 2006.

Rivers C (Ed). Preparing for the Written Board Exam in Emergency Medicine, 5th ed. Milford, OH: EMEE, Inc.; 2006.

Tintinalli JE, Galen DK, Stapcyzinski JS. Emergency Medicine: A Comprehensive Study Guide, 6th ed. New York: McGraw-Hill; 2004.

Practice Questions

PEER VIII: Physician’s Evaluation and Educational Review in Emergency Medicine, 8th ed. Dallas, TX: American College of Emergency Physicians; 2006.

Pennsylvania Chapter, American College of Emergency Physicians Written Board Practice Examination. www.paacep.org.

Promes S. Emergency Medicine Examination and Board Review, 3rd ed. New York: McGraw-Hill; 2005.

Written Exam Review Courses

American Physician Institute

Emergency Medicine Qualifying Exam Course

www.thepassmachine.com

1-877-225-8384

Emergency Medicine Review: The Comprehensive CORE CONTENT

Board Review Course. Education Medical Services, Inc.

P.O. Box 510222

St. Louis, MO 63151

1-800-MED-TEST

Illinois College of Emergency Physicians, Written Board Review Course

1 S 280 Summit Avenue, Court B-2

Oakbrook Terrace, IL 60181

1-630-495-6400

www.icep.org

LSU Emergency Medicine Written Board Review Course and Clinical Update

Department of Medicine, Section of Emergency Medicine

Louisiana State University School of Medicine

LSUHSC Institute of Professional Education

1600 Canal Street, Suite 1034

New Orleans, LA 70112

1-504-568-5272

Medical University of South Carolina Intensive Review in Emergency Medicine

Office of Continuing Medical Education

261 Calhoun St., Ste. 301

P.O. Box 250189

Charleston, SC 29425

(843) 876-1925

National Emergency Medicine Board Review

4535 Dressler Road NW

Canton, OH 44718

1-800-651-CEME

www.emboards.com

Ohio Chapter American College of Emergency Physicians, Emergency

Medicine Review Course

3510 Snouffer Road, Suite 100

Columbus, OH 43235

1-888-OHA-CEP4

www.ohacep.org

Pennsylvania Chapter American College of Emergency Physicians, PaACEPs

Emergency Medicine Written Board Review Course

777 East Park Drive, P.O. Box 8820

Harrisburg, PA 17105-8820

1-888-633-5784

www.paacep.org

Preparing for the Written Board Exam in Emergency Medicine

Emergency Medicine Educational Enterprises

200 TechneCenter Drive, #103

Milford, OH 45150

1-800-878-5667

www.emeeinc.com