ABIM MOC Exam Questions Revealed. Study Guide Leaked Here!

UPDATE 2014: Quite a few folks are finding The Happy Hospitalist searching Google for the ABIM MOC results.   If you're looking for the results and statistics, pass rate and other numbers from the Fall 2012 or Fall 2013 ABIM internal medicine MOC exam , look below.  I have updated this post to include my results and the national results that came with my letter I received late last year and other sources have provided me with Fall 2013 data as well. Make sure you come back  to the top here and read all the questions if you haven't yet taken your boards and want to pass without any problem!

I recently took my ten year Maintenance of Certification (MOC) boards offered by the American Board of Internal Medicine (ABIM).  What I discovered was shocking.  Practicing medicine is not like it used to be.  In my first ABIM certification back in 2003 I remember a bunch of  questions about medications, ICU care, complications and side effects of therapy in addition to a nice assortment of by the book ethical scenarios for new internal medicine graduates to ponder on their way to professional victory.

That's old school man.  That's living in the past.  The ABIM has recognized a titanic shift in patient care responsibilities for internists and hospitalists and has modified their testing methodology accordingly. Happy is risking  his professional certification by coming out on The Happy Hospitalist and detailing these real life test question scenarios that he was sworn to secrecy never to divulge.  He is doing this to help others understand that recertification with the ABIM MOC exam is not what it used to be. DON'T BELIEVE Medstudy!  A new reality in patient care exists and us internists should all be prepared to lead the charge in the name of third party bankers and government deniers.

With that said, I present to you a smattering of questions I memorized from my ABIM  MOC exam.  We want all the board certified internists ObamaCare can handle to take us into the abyss.  So study these questions closely and you'll be sure to get 100% on your MOC exam, or at least a pass.
1)    A blind 94 year old  three legged female with no important medical problems presents to the emergency room with weakness.  She has no complaints that anyone is listening to or believes.  She is too old to go home.  Her vital signs are normal.  A full body MRI, cbc, cmp, cardiac enzyme panel and ekg ordered in the ER are all normal.  A urinalysis obtained by strict ER clean catch methodology shows 1000 squamous cells per high powered field, zero bacteria, negative leukocyte esterase  and over 200 wbc.  You make a determination that the urinalysis is contaminated, because, well, it's always contaminated and you explain to the angry daughter that her old sick and decrepit mother does not have urosepsis, despite what the ER staff told her.  Using advanced AIDET techniques, you explain to the daughter that mom does not have any in-patient hospital criteria that would get her a three midnight inpatient stay so she could get free nursing care at a nursing home under SNF benefits.  However, you tell her to stick with you as there are ways around the rules.  To qualify the patient for in-patient status you should

A.  Order every four hour neuro checks while laughing out loud and saying "Take that Medicare".

B.  Order high dose potassium  to induce severe hyperkalemia with EKG changes that requires  urgent correction.

C.  Ignore basic science and order IV Zosyn for her UTI, making sure to document present on admission.  Documentation trumps physiology.

D.  Write an order for in-patient status anyway just to be funny.

2)    You are a hospitalist at a major tertiary community hospital.  At 3 am on a Sunday morning, while in deep REM sleep,  you receive an urgent and frantic phone call from a moonlighting small town ER physician assistant who's sponsoring physician took off on Friday evening for a mini holiday weekend with  instructions to call the hospitalist to admit all drug seekers.  You are asked to admit an uninsured 19  year old drug seeking frequent flyer with histrionic and borderline personality disorder complaining of severe abdominal pain for the 8th time in 8 months.  You ask for some history and the PA says, "See EHR for details".  After objecting loudly, you review case details with the PA.  Chart documentation indicates that her pain is painful.  It started a long time ago.  It hurts all over.  It is constant.  Her pain is better when she gets that drug that "starts with a d, doo, duh..."   and worse when she runs out of money.  Her ER vitals signs are normal.  No work up was initiated except to call you because that's the order the doctor gave before leaving town.  Your next obvious step should be to

A. Call an air ambulance to life flight  her in the 15 miles to your ICU and perform bedside peritoneal lavage, without ultrasound,  just for practice. 

B.  Bang your head on the table and yell, "What the F***!" after you say thank you to that fine PA for this excellent referral and hanging up.  Because you are all about service. 

C.  Ask the PA to put you on speaker phone and then tell the patient she can come to your hospital but she is only going to get Tylenol for pain.  When the patient starts cussing  and threatens to leave AMA from their ER, explain to the PA that the patient doesn't want to be transferred and her wishes should be observed.

D.  Tell the PA, "No espeaka Englase" and hang up. 

3)     It's Saturday morning at 11:07  am in November.  You are a hospitalist who works hard to leave nurses out of physician to physician communication.  You call all your own consults and speak daily with all your physician consultants, except for a handful of doctors who automatically say, 'What do you want to do about it?' anytime you call them.  You should

A)  Take the high road, be a man, and call them anyway.  You be that model of leadership no matter how much it hurts.

B)  Ask the consult to be called in,  as a verbal order, as you're walking down the hall, in a hurry, to pick up your JimmyJohns delivery that just arrived in your call room.

C)   Call the floor from your office and ask the RN to contact the physician consultant, but  make sure you turn  down the volume on the big game that just started.

D)  Wait until Monday when another doctor is on call to request consultation or just ignore the problem until your partner takes over in a couple of days.

4)     A 42 year old chronic schizophrenic with polypharmacy and 20 medical problems presents at 11 pm to the ER for the third time in 3 days with mental status changes, nausea, vomiting, abdominal pain and diarrhea for two weeks.  In this time, the primary care doctor has tried everything, which is nothing except to tell her to "go to the ER".   The ER has given her 13 total scripts over the last 3 visits with a total pill count of 27 tablets to treat her nausea, vomiting, abdominal pain and diarrhea. But she forgot to fill them.    Her exam is benign.   Labs show show only severe hypokalemia at 2.1.  Her EKG shows diffuse t wave changes with QT prolongation.  There are no other relavant findings except that she doesn't know any of her medications, including the lithium she has been on for 15 years, which you figured out the next morning by checking a random level.   Your partner had admitted her for a big work up including CT and ultrasound of abdomen, GI consultation and a whole bunch of other stuff.  You end up canceling all that and treating her  symptomatic lithium toxicity (defined as severe by text book definitions)  with IV hydration for 24 hours, resulting in excellent clinical recovery to allow for early discharge.  The next day you get a call from the physician reviewer at UnitedHealthcare Managed Medicaid saying the patient is only appropriate for observation because they were there only about 24 hours.  You should

A)  Tell him that the patient met criteria for severe lithium toxicity by all objective criteria and tell him you were treating it and not observing it to determine whether it needed to be treated.  Scold him for believing that simply observing critical hypokalemia and QT prolongation constitutes malpractice and he should know better.

B)  Initiate a class action lawsuit against your Managed Medicaid company  for a systemic pattern of abuse for  denying appropriate inpatient stays because patients are given such great care that they leave less than 24 hours later for life threatening conditions.

C)  Tell them he is correct and that you are going to contact the patient directly and have them readmitted for severe lithium toxicity with a standing order to call the physician reviewer to let you know when they meet inpatient criteria, then discharge the patient.

5)  You are called to the ER to admit an 89 year old former marathon runner, but now in an Alzheimers lock down unit,  with no medical problems who presented with acute bilateral hip pain consistent with bilateral hip fractures.   After arriving at the seen of tragedy you notice a few abnormalities, including, but not limited to, hypercalcemia, rouleaux formation, anemia, acute renal failure, an increased globulin gap,  a sed rate greater than 140, severe sepsis with hypotension, bilateral pneumonia, bilateral cellulitis, acute non ST elevation MI and weight loss of 50 pounds in the last year.  Mom is full code because, as daughter says, "Why wouldn't she be?"  You diagnose the patient with obvious imminent death syndrome. You should

A)  Order a palliative care consult to be called in by the ER clerk.  Move on to your next tragedy.

B)  Call the palliative care doctor personally to tell them you have an unusual situation that they've probably never seen before.

C)  Rush the patient to bilateral hip fracture surgery and have the other stuff dealt with later, when someone else is on call.

D)  Play  the "This is what CPR looks and sounds like in a dying 89 year old" app on your iPad  for the daughter and hope she changes her mind about being full code.

6)  You are a hospitalist working the night shift when a chronically debilitated 82 year old DNR patient on dialysis with severe sepsis and shock arrives as a direct admission to your ICU on bunch of  Dopamine and  Levophed being dripped through  two 25 gauge peripheral  IVs, one in the foot and one in the thenar eminence of the left hand.  The patient is in extremis and is about to stop breathing.   You learn the patient was started on these drips one hour before leaving the small town ER, but after receiving a 100 cc fluid bolus and ice some chips for comfort.  The patient has a rigid abdomen and a lack of bowel sounds.  Additional aggressive resuscitative measures prior to transfer  included calling the ambulance and getting them the heck out of their ER as the sponsoring doctor was sleeping 40 miles away and the moonlighting psychiatric nurse practitioner had never seen a case of sepsis before.   The next appropriate step in management is

A)   Call a surgeon stat, intubate the patient, place a central line, initiate aggressive fluid resuscitation and broad spectrum antibiotics and finally consult palliative care to see in the morning, if the patient is still alive.

B)   Order a PICC line and ask the nurse to call the intensivist and surgeon to see stat and go back to bed.  It's too late for this crap.

C)   Call the nurse practitioner and ask her how she would like it if that patient was her mother, her grandmother or even herself.  Do this BEFORE stabilizing the patient so you can get your anger off your chest and THEN concentrate on the dying, under resuscitate patient they sent you.

D)  Tell the family it's time, give a bunch of morphine for comfort and let the poor woman die in peace because that's what the family actually wanted in their small town ER but the medical team wouldn't allow it.  The moonlighting psychiatric nurse practitioner diagnosed the family with homicidal thoughts.  

7)    You are a hospitalist called at 6:50 am by the preoperative nurse with an order by the ophthalmologist  to "see for H&P" for an elective cataract surgery scheduled at 7 am  on a healthy 65 year old female "Dancing with  the Oldies" aerobics instructor.  Your next step should be

A)  Decline the consult as there is no ICD code for H&P

B)  Give a verbal order for "no further work up necessary" and sign off the case, by phone, and bill the ophthalmologist $50 for waking you up with this nonsense.

C)  Tell the nurse that the surgeon has an obligation to evaluate the patient prior to surgery and that includes performing a history and physical and tell her to have the surgeon call you if they have any questions.

D)  Tell her that doing H&Ps are outside your scope of practice and and give an order for the  ophthalmologist to hire an NP or PA to do their busy work for them.

8)  You are a hospitalist at a busy community hospitalist and you have 18 people to round on today.  You realize there is no way you will complete your rounds before the end of your shift and you have no interest in staying late because that's not what you signed up for.  The most efficient way to complete rounds on time and get out to enjoy a nice beautiful sunny afternoon with your family is to

A)  Start rounds really early before patients are awake and before any family members have arrived.

B)  Start rounding with an iPad and never log into the slower than mollasses centralized desk top EHR.

C)  Consult another specialist for every tiny, unimportant and irrelevant issue.

D)  Forget to wear your pager until the end of rounds.

E)  All of the above.

9)  You are an outpatient internist who always sees your own hospital patients. Always.   If you want to improve the quality of your life and the efficiency of your practice you should consider a policy of using the hospitalist to admit a select subset of your patients when

A)  The patient has lots of personality disorders that makes daily evaluation emotionally exhausting and you'd rather not deal with it.  Or if they are a drug seeker or if they smoke chronic or if they have chronic dizziness or chronic headaches or chronic abdominal pain or are chronically unhappy.  Or anything beyond simple pneumonia for that matter.  Then consult the hospitalist.  Definitely use the hospitalist in these situations.

B)  You're going out of town, it's a holiday or a it's weekend or after 10 pm or if your daughter has a soccer game that morning.

C)  They don't have insurance.

D)  They have Medicaid.

E)  All of the above.

10)  Medicare is accusing everyone of fraud these days.  Hospitals and physicians should assume they are fraudulent until proven innocent.   That means hospitals are being vigilant in documenting observation status instead of inpatient admission for many weak admissions.  Unfortunately, Medicare does not pay for home medications under observation status and patients may get stuck with big bills for hospital administration of home medications under observation status.  As a hospitalist you should

A)  Inform the patient on admission of their observation status and allow them the opportunity to use their own home medications or to hold them while they are in the hospital.

B)  If the hospital won't allow this (as if they have an option), tell the patient to take their own medications or have their spouse give them and not to tell anyone.

C)  Not give a crap because you are too busy or you just don't care about it and let them get a bill for $20 Tylenol once they get home like everyone else does.  What do you care?  As an observation status patient, they aren't included in the HCAHPS patient satisfaction survey for value based purchasing so who cares if they're upset or not.  No skin off your back.

11)  You are a hospitalist who was called with a positive wound culture by the night nurse, RN.  This critical lab finding was called to you at 2 am while you were admitting two critically ill ER patients.   You explain to the RN in the most gentlest and kindest and heart felt terms so as not to be considered a disruptive physician that you do not routinely order wound cultures since you are not a surgeon.  You kindly ask the nurse who ordered the test and you are told it was requested by the surgeon.  When you ask the nurse if she has contacted the surgeon, she says no.  When you kindly indicate that good medical practice and professional courtesy warrants notification of the ordering physician, she says, "But you're a hospitalist and you're already here.  Do you want me to call the surgeon now  or wait until the morning when they are awake".  Your next response should be 

A)  "You called me.  Why would you wait until the morning to call the surgeon?"

B)  "I am not being paid by the surgeon to field their calls. You need to call the ordering physician."

C)  "Are you really a nurse?"

D)  "Is this a joke?"

E)   "I'd like to fire you as my patient's nurse.  Can I pretty please talk to your charge nurse?"

F)  "Is this a joke?  Are you really a nurse?  You called me.  Why would you wait until the morning to call the surgeon?  I am not being paid by the surgeon to field their calls.  You need to call the ordering physician with critical lab results.  Also, I'd like to fire you as my patient's nurse.  Can I pretty please talk to your charge nurse?"

These are just a few of the questions I was able to memorize word for word on the American Board of Internal Medicine Maintenance of Certification exam for 2012.  There were 170 others just like this.  Other topics touched on included medical management consults, managing difficult families, lazy and or undertrained staff, unnecessary busy work, evaluation and management billing and coding, chart audits, RAC audits and a whole lot more.  As you can clearly see, the focus has dramatically shifted from patient care issues to relationship management and how to succeed in a team based approach of ObamaCare.  Good luck internists and hospitalists.  I hope this helps and I hope you all pass.  God Speed ahead!


 I received a letter on November 30, 2012 telling me I passed my 180 question  MOC ABIM internal medicine boards.  I knew several weeks prior that I had passed from communication I received on the ABIM physician log in website.  The letter contained my results and statistics about how I compared nationally.  I could find nowhere on the letter that this information was copy write protected, so I publish it here for information purposes.  I cannot guarantee its accuracy, except to say, it is the results I got in my letter from the ABIM.  Here is the letter I received:

Dear Dr Happy: 
Scoring and analysis of your performance on the Fall 2012 Maintenance of Certification Examination indicates the following: 
Internal Medicine         Pass 
Congratulations!  The enclosed score report provides feedback on your performance on the examination, along with a description for interpreting your scores. 
Log in to your Home Page at www.abim.org to update your contact information and to view your Maintenance of Certification Status Report.  If you hold more than one certification, any applicable expiration dates will be noted.  If you have questions, please call 1-800-441-ABIM (2246).

So, here is a picture of my results and how I compare with the national numbers.

As you can see, I scored a 604, well above the standardized passing score of 366.  The letter I received had an explanation of how to interpret these numbers.  As they said in the letter:

"The purpose of the Score Report is to provide feedback about your performance on the fall 2012 Internal Medicine Maintenance of Certification Examination.  The Score Report summarizes your performance on the examination as a whole and provides feedback in several medical content areas to aid you in identifying areas of relative strength and weakness.  Your examination was offered on multiple dates and different forms of the test were administered.  These forms were constructed to be equivalent in content and difficulty so that, regardless of the form taken, examinees faced the same challenge."

The overall performance decision is based on the entire exam.  The scale is from 200-800.  The mean score for first time test takers is 500 with a standard deviation of 100.  So a score of 600 is one standard deviation above the mean.  The passing score was 366.  For my test in Fall 2012, 5,047 candidates took the test and 78% passed.  Of the 5,047 candidates who took the test, 3,850 took the test for the first time and 84% of them passed.

For the medical content areas, the number of questions in each content area are reported along with my percent correct score.  Pass-fail standards have not been established for content scores.  The reported decile score ranges from 1-10.  A decile score of 10 ranks with the highest scoring first time takers (top 10%) while a decile of 1 indicates the score ranks in the bottom 10%.  My strongest areas where cardiology and gastroenterology although I did fairly well in all areas.  My weakest area was oncology. I figure that's why God made oncologists.

While not reported on my Score Report, the letter I received contained a decile rank for overall performance score.  According to this overall score range, I completed the exam in the top 15%.  Not bad since I only made it through half my Medstudy books (and light skimming at that) and I figured if I didn't pass the test, I could take it again the following year.  I guess I passed the test.   No, I take that back.  I rocked the test with almost no studying.  I even sold my Medstudy books for $200 to a partner with a bunch of  kids under seven years old.    Something tells me there ain't gonna be a lot of studying going on there.



Here is an update of the Fall 2013 ABIM MOC results.  The exam is pass-fail with a score range of 200-800.  The mean standardized score for first-time text takers was 500 with a standard deviation of 100.  The passing score was 366.  For this Maintenance of Certification exam, 5,634 candidates took the test with a pass rate of 71%.  First-time test takers (4001 of them) passed at a rate of 78%.  I'm shocked at the declining pass rate.

The chart below displays the ten deciles of scores.

Fall 2013 Internal Medicine MOC Score Report Deciles

My advice for first time test takers.  If you finished your residency from a decent program, have practiced continuous internal medicine for the last ten years and consider yourself to be of average intelligence, don't waste your time studying for it.  Take it a year early.  Definitely don't waste your money on board preparation exams that will send you junk mail by the hundreds after the ABIM or someone else with access to the fact you signed up for the test sold your name for profit to hundreds of board prep organizations.  They feed on your fear.  You have nothing to fear.  You'll do fine.  Don't, I repeat, don't waste your money on these folks.

If you happen to fail the test,  then waste your time and money to study for it.  But you'll probably do fine.  And if you don't, please let me know so I can stay as far away from you as possible.  Because where I'm sitting, no internist with half a brain has any business failing the test I sat for and I want to avoid you like the plague.

This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk. 

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