Bratton's Family Medicine Board Review

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3rd edition, © 2011 by Lippincott Williams & Wilkins, a Wolters Kluwer

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2nd edition, © 2002 by Lippincott Williams & Wilkins
1st edition, © 1998 by Lippincott Williams & Wilkins

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Library of Congress Cataloging-in-Publication Data

Bratton’s family medicine board review / editor, Robert A. Baldor ; section

editors, Margarita C. Castro-Zarraga, Anita Kostecki, Christine ​Runyan,
Felix B. Chang, Frank J. Domino. — Fifth edition.
p. ; cm.

6
Family medicine board review
Includes bibliographical references and index.
eISBN: 978-1-4698-8729-6
I. Baldor, Robert A., editor of compilation. II. Title: Family medicine board
review.
[DNLM: 1. Family Practice—Examination Questions. WB 18.2]
RC58
610.76—dc23
2013051127

Care has been taken to confirm the accuracy of the information presented
and to describe generally accepted practices. However, the authors, editors,
and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no
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or accuracy of the contents of the publication. Application of the
information in a particular situation remains the professional responsibility
of the practitioner.

The authors, editors, and publisher have exerted every effort to ensure that
drug selection and dosage set forth in this text are in accordance with
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Some drugs and medical devices presented in the publication have Food
and Drug Administration (FDA) clearance for limited use in restricted
research settings. It is the responsibility of the health care provider to
ascertain the FDA status of each drug or device planned for use in their
clinical practice.

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 Dedication
I’d like to dedicate this 5th edition to Robert L.
Bratton, MD, the initial author who conceptualized
and developed this board review text. This book has
been an incredibly helpful tool for residents and
practicing physicians to use while preparing for
their ABFM board certification examinations. In
taking over as the editor of this book, I have tried to
match Dr. Bratton’s standard in providing realistic
questions along with insightful answers to help the
readers further their education as they prepare for
the board exams.
I’d also like to recognize my fellow section
editors (Drs. Frank Domino, Tina Runyan, Anita
Kostecki, Felix Chang, and Margarita Castro-
Zarraga), all key members of the University of
Massachusetts family medicine residency faculty,
who have committed their professional careers to
educating the next generation of family physicians. I
applaud their interest in constantly improving the
quality of medical education and sincerely thank
them for their efforts in helping me update this 5th
edition.

9
 Finally, this dedication would not be complete
without my acknowledgment of the incredible
support provided to me by my amazing wife and
devoted partner Rebecca. I could not have
completed this task without her understanding and
tolerance for the many hours spent working on this
book; she is truly deserving of my gratitude and
heartfelt thanks!

Robert A. Baldor, MD

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Mohammad Alhabbal, MD, FHM
Assistant Professor
Department of Family Medicine & Community Health
University of Massachusetts Medical School/UMassMemorial HealthCare
Worcester, Massachusetts

Philip Bolduc, MD
Assistant Professor
Department of Family Medicine & Community Health
University of Massachusetts Medical School
Worcester, Massachusetts

Cassandra Dorvil, DO, MBS

UMass/Fitchburg Family Medicine Residency
University of Massachusetts Medical School/UMassMemorial HealthCare
Worcester, Massachusetts

Rebecca G. Kinney, MD
Partnership Health Center
Clinical Instructor
Family Medicine Residency of Western Montana
University of Washington, School of Medicine
Missoula, Montana

Rocio Nordfeldt, MD
Assistant Professor
UMass/Fitchburg Family Medicine Residency
University of Massachusetts Medical School/UMassMemorial HealthCare

11
Worcester, Massachusetts

Jennifer Smith, MD
UMass/Fitchburg Family Medicine Residency
University of Massachusetts Medical School/UMassMemorial HealthCare
Worcester, Massachusetts

J. Herbert Stevenson, MD
Associate Professor and Director of Sports Medicine
Director of the Sports Medicine Fellowship Program
Department of Family Medicine & Community Health
Department of Orthopedics & Rehabilitation
University of Massachusetts Medical School/UMassMemorial HealthCare
Worcester, Massachusetts

Jeff Wang, MD, MPH

UMass/Fitchburg Family Medicine Residency
University of Massachusetts Medical School/UMassMemorial HealthCare
Worcester, Massachusetts

Edmund Zaccaria, MD
Assistant Professor
Department of Family Medicine & Community Health
University of Massachusetts Medical School/UMassMemorial HealthCare
Worcester, Massachusetts

12
Bratton’s Family Medicine Board Review, fifth edition, is a directed review
of important topics that typically appear on American Board of Family
Medicine (ABFM) in-training, board certification, and recertification
examinations. This material is not intended to be a comprehensive review
but, instead, should direct the examinee to areas of weakness that may need
further review.
Family medicine is a broad field, and to provide a complete,
comprehensive review of all topics that may be covered is impractical.
Courses are available that attempt to provide this type of review; however,
this book is more abbreviated and focuses on topics that are commonly
found on board examinations.
Adequate preparation for any test is the key to success and rewarding
results. Given this, we all know the importance of practice tests and the
benefits of testing our knowledge base before the actual examination. This
review book is structured for the examinee with an established foundation
of knowledge within the field of family medicine. Its primary purpose is to
identify areas of weakness that can be improved upon, and to that end, each
answer has a suggested “Additional Reading” to assist the reader in further
study on identified topics of weakness as they prepare for the board
examination.
This edition updates the existing content, with revised information to
reflect changes that have occurred in the medical field since the last edition.
The ABFM restructures the examination on a yearly basis, so it is important
to visit its Website, www.theabfm.org, to get updates on the structure of
each examination. I hope that you will find this book enlightening and, most
of all, beneficial in your studies for the ABFM examinations. If you have
any suggestions to help improve this material, please contact me with your
suggestions at [email protected]. Our goal is to help you

13
prepare for and, then, pass your board examination!

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Introduction
To be certified as a diplomat of the American Board of Family Medicine
requires completion of an accredited family medicine residency, obtaining a
full, unrestricted medical license and passing a certification examination.
Below outlines the requirements for taking the ABFM certification
examinations depending on whether you are still in training, seeking initial
certification, or maintaining ABFM certification.

Residency In-Training Examination

The “in-training examination” is for current family medicine residents
enrolled in an accredited training program. Individual registration is not
required as the registration is handled by the residency office. The
Residency Director should have all the necessary details. The test is
administered annually to each resident during the 3 years of residency
training. All residents receive the same test. However, there are no pass or
fail ratings; instead the results are scored and grading is based on the level
of training. The examination is given in the fall, and most residency
programs make any necessary arrangements to relieve residents of clinical
responsibilities for the examination day. The purpose of the “in-training
exam” is to assess resident’s knowledge base as they progress through
training and to objectively evaluate the residency education program.
Scores are reported to each resident with a comparison of the results with
those of the respective peers in training. The in-training exam scores are
also reported to the residency director, so that he or she may track
individual resident’s educational development and look for areas of
weakness across the residency training program.

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The Initial Board Certification Examination
To obtain board certification, not only must candidates successfully
complete the initial board certification examination, but their Program
Director must also verify that the resident has successfully met all of the
ACGME program requirements and the candidate must hold a current valid,
full, and unrestricted license to practice medicine in the United States or
Canada.
The residency program can assist in the process of initial certification;
however, recertification is the responsibility of each physician. The
examination is held in testing centers throughout the country on various
dates twice a year (usually each fall and spring). As stated by the ABFM,
“The American Board of Family Medicine Certification and Recertification
Examinations are tests of cognitive knowledge and problem-solving abilities
relevant to Family Medicine. Appropriate subject areas of the following
disciplines are included: Internal Medicine, Surgery, Obstetrics, Community
Medicine, Pediatrics, Psychiatry and Behavioral Sciences, Geriatrics and
Gynecology. Elements of the examinations include but are not limited to,
diagnosis, management, and prevention of illness.”

The Maintain of Certification (MC-FP) Process

Following the initial board certification as a family medicine specialist, the
diplomat must participate in the “Maintain of Certification” (MC-FP)
process in order to maintain their certification status. This process has been
required of all specialties (not just for family medicine) by the American
Board of Medical Specialties (ABMS) in order to continuously assess the
competence of physicians and their knowledge base and skill sets. The MC-
FP process emphasizes the importance of ongoing participation in
assessment activities between recertification examinations, rather than just
relying on a periodic recertification examination every several years. The
MC-FP is a requirement that encourages clinical excellence and benefits
both physicians and their patients. The MC-FP assessment process consists
of four parts:

Part I. Professionalism (current, valid license)

16
 Part II. Self-assessment and lifelong learning (SAM educational modules
and CME requirements)
Part III. Cognitive expertise (the recertification examination)
Part IV. Performance in practice (PPM practice quality-​improvement
exercises)

The current guidelines for the MC-FP program require that each certified
diplomat successfully complete a series of these requirements in three
separate (3-year) stages.
The Part II requirement refers to the successful completion of (almost
annual) Self-Assessment Modules (SAMs). These modules include a 60-
question cognitive exam and an interactive simulated patient care exercise
that includes an assessment of the diagnosis and management plan for the
patient scenario. These modules are completed online by the individual
physician, although group learning sessions are often available (such as at
the American Academy of Family Physician [AAFP] Annual Scientific
Assembly). The ABFP runs the examination process, not the AAFP. SAM
topics have included the following:

• Asthma
• Care of the elderly
• Coronary artery disease
• Depression
• Diabetes
• Childhood illness
• Health behavior
• Heart failure
• Hypertension
• Maternity care
• Pain management
• Well child care

A SAM module can take from 2 to 8 hours to complete. CME credits are
awarded for successfully completing each SAM module. The American
Board of Family Medicine (ABFM) Website (https://www.theabfm.org/MC-

17
FP/index.aspx) has the complete details about the SAM modules.
The Part IV requirement refers to completion of Performances in
Practice Modules (PPMs). The ABFM offers Web-based,
quality-improvement modules that generally correspond to the SAMs. To
complete these modules, a physician assesses the care of their patients
using evidence-based quality indicators. Data from 10 patients are entered
into the ABFM Website, and feedback is provided for several quality
indicators. The physician chooses an indicator and designs a quality-
improvement plan, submits the plan, and implements the plan in practice.
After a period of time (at least a week), the physician again assesses the
care provided to 10 patients in the chosen health area and enters the data
into the ABFM Website. The physician is then able to compare their pre-
and postintervention performance and compare the results to those of their
peers. Alternative methods of meeting the Part IV requirement are available
for those physicians who do not currently have a continuity practice (e.g.,
urgent care practice, administration). CME credits are awarded for
successfully completing each PPM.

The Recertification Examination

The recertification examination is held annually in testing centers throughout
the country on various dates twice a year (usually each fall and spring).
Registration for the board recertification examination is done by contacting
the American Board of Family Medicine (ABFM), and a formal application
(www.theabfm.org/cert/index.aspx) must be submitted. However, before
sitting for the recertification examination, family physicians must have
completed the Maintenance of Certification (MC-FP) process as outlined
above. Applicants must have successfully completed Parts I (the applicant
holds a current, valid, full, and unrestricted license to practice medicine in
the United States or Canada), Part II (completed the required number of
SAMs and provide evidence that they have met the required continuing
medical education [CME] hours), and Part IV (completion of the PPM
practice quality-improvement exercises). Successfully passing the
recertification examination is required to complete Part III.

18
Summary
Once you have inquired about the certification/recertification examination
(as noted above), you will receive registration information from the ABFM,
including selection of your preferred testing site location. Prometric is the
computer-based testing vendor that the ABFM has used to administer the
exam with approximately 345 locations in the United States and Canada and
140 international locations. It is important to register early to ensure that
you get your first choice of location. The exam is offered in the spring and
fall, but typically the fall examination has limited seating and is primarily
for those physicians who were unable to take the spring examination and for
off-cycle residents who did not complete training in time to take the spring
examination. Additionally, candidates who are unsuccessful on the spring
administration can apply to retake the examination in the fall. There is no
limit to the number of times a candidate may take the examination, provided
qualifications are met with each reapplication.
Before the test, you will receive additional material that includes your
assigned testing site and a registration number. Make sure you bring the
information including your registration number and photo identification
along with an additional form of identification to the test site on the day of
the test. Failure to do this may prevent you from taking the test, or it may
delay you in the on-site registration process. This is not required for in-
training residency examinations.
More information is available by contacting the ABFM office or
accessing their Website:

The American Board of Family Medicine, Inc.

1648 McGrathiana Parkway Suite 550
Lexington, KY 40511-1247
Phone: 859-269-5626 or 888-995-5700
Fax: 859-335-7501 or 859-335-7509
Email: [email protected]

19
Introduction
Just when we thought that the standardized tests we had to pass in high
school, college, and medical school were behind us, the American Board of
Family Medicine (ABFM) requires an in-training examination (in some
cases referred to as the in-service examination) yearly during residency
training and we must pass a board examination at the end of that residency
training in order to receive board certification. Additionally, ABFM
diplomats must also pass a recertification examination every 10 years to
maintain their board certification. For many, the board examination process
is a stressful time. In addition to using this book to review your family
medicine knowledge, it is always helpful to review some basic test-taking
strategies. The following are some general guidelines for preparing for your
examination.

Examination Formats
The in-training examination consists of 240 multiple-choice questions and
uses a content outline that is identical to the blueprint for the ABFM
certification examination. The examination includes 4 to 8 pictorial items,
which may be radiographs, EKGs, pictures of dermatologic conditions, or
other images. The entire computer-based test is single-best-answer multiple-
choice questions, with each question having four or five answers to choose
from. The study questions and answers that are provided in this book will
help you to study covered topics in a similar format. There is no penalty for
guessing, so if you reach the end of the test and are short of time, make sure
you have answered all the questions.
T he initial certification and recertification examinations are full-day
computer-based exams that contain multiple-choice (one best answer)

20
questions. There are five sections with scheduled (optional) breaks in
between each section. Additionally, all candidates should be prepared to
choose two ‘module topics’ that they will select during the exam application
process. The ‘module topic’ areas include ambulatory family medicine,
child and adolescent care, geriatrics, women’s health, maternity care,
emergent/urgent care, hospital medicine, and sports medicine.
The first 2-hour section of the exam consists of 120 multiple choice
questions. The next 2 sections are 45 minute each, and the content is based
on your selected module topics. There are 15-minute breaks between each
section and a longer break over the lunch hour. The afternoon consists of
two 80-multiple-choice-question sections, each about 90 minutes long with
a 15-minute break in between.
The ABFM Website can be accessed at www.theabfm.org and is an
excellent resource for more detailed information.

The Exam Day

The certification and recertification examinations are given at specific
computer-based testing centers across the United States and may require a
significant amount of traveling to reach the location. Insure that you have
identified the site and are familiar with the surrounding traffic patterns and
parking locations. On arrival, you are photographed and fingerprinted for
access to and from the testing site. You must have two forms of
identification (one with photo) when you check in.
Adequate sleep is imperative as you prepare for any test, and this test is
no exception. It is a good idea to arrange your call schedule to allow plenty
of sleep the week before the test so that you arrive well rested. On the
morning of the test, eat a light breakfast and consider bringing a lunch for
the board and recertification examinations (not necessary for the in-training
examination, because you are usually through with the test at around 1:00
pm). Pack your own lunch and find a quiet place to enjoy your meal and
relax during the scheduled lunch break. Bring along aspirin, ibuprofen, or
acetaminophen if a headache should occur during the test. Cough drops and
allergy medication (nonsedating) should be remembered. Remember that
calculators or watches are not allowed, and beeping electronic devices or

21
cellular phones should be left at home. Earplugs may help mute unwanted
noises that distract you.
The examinations require you to sit for extended periods of time. Bring
a lightweight jacket or sweater in case it gets cold and loose-fitting clothing
with comfortable shoes. Also, don’t forget your glasses. You are not
allowed to take any additional materials, into the testing room for the
certification/recertification examination. Personal items are to be left in a
secure locker provided by the testing site. The testing site does offer hard
candy or mints and you are given a small white erasable board with a magic
marker for making notes or doing calculations.
Make sure you use the bathroom before entering the testing room;
having to leave requires you to raise your hand and the proctor must log
you out from your computer and allow you to leave the room and then
fingerprint you when you return; needless to say, this can waste a lot of
valuable test-taking time. While in the examination room, you are seated at
a small, isolated cubicle with fellow test-takers (who might even be high
school students taking their SATs!) at your left and right. A proctor is
seated behind a glass enclosure and observes all who are taking the test.
Additionally, you are monitored by video cameras during the examination.

22
Anxiety is a natural response when faced with a test situation. The
important thing is to not let anxiety affect your performance deleteriously.
Relaxation techniques, such as stretching or deep breathing exercises can be
used. However, a little anxiety can be good for you and may improve your
performance.
Answer the easiest questions first. Start with the first question of each
section and answer all the questions you can with reasonable certainty. If
there is a difficult question, skip over it and return when you have finished
the section. The computerized examination format allows you to flag
questions that you are unsure about, so that you can return to them later.
Check your pace and be mindful of the time. On the computer, you
should see the time in a small box at the bottom of the screen. Pay attention
to these reminders and adjust your pace as necessary. A good rule of thumb
is to plan for a minute per question. Don’t spend an excessive amount of
time on any one question, which could put you at risk for not being able to
answer easy questions at the end of the test because you ran out of time.
A strategy that can be helpful when taking examinations is to read the
answers first. If you don’t have a good understanding of the test question,
you can’t answer it correctly based on your knowledge. Reading the
answers can activate your knowledge about the question, and when you then
read the question, the ‘activated knowledge’ impacts on your understanding
of the question.
A common test-taking error is failing to read ALL of the question and/or
ALL of the choices before actually marking your response. General
skimming of the question can lead to premature closure and result in a
wrong answer. Self-assessment is important as you may not even realize
that you tend to skim the question or fail to read all the choices. Be mindful
of making such errors when you answer the questions in this book and mark

23
any such errors on your “Study Grid.”
Being “lured by a distractor” is another common error. One strategy to
address this is to read the actual question to be answered first, before
reading through the background information/vignette. For example, there
may be a sentence or two leading up to the question, “What is the best
treatment?” If you read the question first you become aware that the
question is about treatment, so that you begin to think about treatment
decisions as you read the question, rather than being distracted by other
information presented in the question. Avoid reading extra meaning into the
questions. The ABFM does not structure questions to try to outsmart the
test-taker. Questions are designed to be fair and not have hidden agendas.
Therefore, take questions literally and do not imply hidden meanings.
As you read questions, try to identify “keywords.” Typical keywords to
look for include the specific symptoms that are present, the duration of the
symptoms, and current treatments. Be mindful of other keywords that are
sometimes ignored such as age and diagnoses other than those related to
chief complaint. Other “nonmedical” terms (e.g., season, social issues, and
miscellaneous adjectives) can also be important to consider.
Guess if you do not know the answer, but use what you know (partial
knowledge) to narrow down the choices and resist: being lured by an
unknown distracter; choosing on the basis of “technical words” that must be
right; or using “tricks” rather than actual knowledge (i.e., two are same, one
of those must be right). Consider similarities and differences between
answers—use these to either serve as a memory trigger to help recall the
forgotten information or to make a guess by choosing the outlier. However,
this is a last ditch effort because there may be more similarities and
differences between options other than that which discriminates the correct
answer.
You are penalized only for an incorrect or unanswered question;
therefore, all questions should be answered even if they require a guess.
Also, it is important to remember that if the answer uses absolute
terminology, such as always, never, all, or none, it usually is a false
response. Very little in the world of medicine is absolute.
If time allows, review your work. Sometimes you will want to consider
changing a previously answered question. If this is based on being cued

24