The ABR Core Exam: Study Strategy and Tips

Forty-seven months into this marathon we call residency and somebody has set a fairly substantial hurdle in your path. You’re tired, you’re preoccupied, and your eyes are set on the finish line. So how can you focus on the task at hand and leap this hurdle without falling flat on your face? In this post, I hope that I can give some of my own insight into what turned out to be a successful study plan with regards to the ABR Core Exam. I will try and establish a little bit of context, lay out my study strategy, and hopefully toss in helpful tidbits along the way.

Prelude

So, who am I? I’m the father of two girls (2.5 years and 5.5 months) and a husband to my amazing wife. I was raised in rural Iowa, went to two years of community college as part of undergraduate training, and received my medical degree in Colorado as a D.O. I am a current resident at University of Illinois COM in Peoria, IL, where I will be completing my ESIR and Independent IR training. I am fortunate to be at an incredible residency which continues to prepare me well for the real world (and apparently standardized exams). I am neither afraid of hard work, nor a stranger to it. With that being said, I had no expectation or interest in doing anything more than passing the Core Exam when I set out on my study path. After what seemed like an eternity, I was pleased and relieved to learn I had passed. It pretty much ended there.

A couple of weeks after score reports came out, as my three co-residents and I were sharing our exam experiences and congratulating one another on passing, they recommended that I submit my score to the Prometheus Lionhart Master of Sport contest. He eventually awarded me the Master of Sport award for achieving the highest overall score on the June 2019 Core Exam. The spoils included $2,500 and a pretty sweet statue of a lion.

Your ACR RFS Secretary reached out shortly thereafter and graciously asked me to share my experience in the blogosphere. Initially, I had no interest in becoming a “blogger,” but here I am sharing experiences. My motivation is simply to engage and assist my peers. Even if this meager attempt at a blog submission will help two or three people, that is incentive enough for me.

For those of you who might be reading this in your first or second years of training, the best piece of advice I can give you is to read textbooks/articles and do RadPrimer questions while you are on each rotation. Keep up with your reading early in training and this test will seem reasonably easy. Don’t start studying for the Core Exam until mid-to-late R3 year. Worry about establishing a rock-solid foundation. Be really good at clinical radiology, not at passing a multiple choice exam.

The Nuts and Bolts

What you are reading is my opinion and what worked for me. Everybody requires different strategies to succeed. There is no secret formula, concoction, diet, sleep plan, or essential oil that will result in the passing or failing of this exam. This is about hard work, perseverance, confidence, and delayed gratification. There is nothing, absolutely nothing, that will take the place of putting in the work. Value your time. Study hard when you’re studying. Study to be a good radiologist rather than just to pass the test. Despite what a lot of people would have you believe, you can study to pass this test and become a better radiologist simultaneously. Find your weaknesses and be aware of them, make sure they don’t remain weaknesses for long. Don’t make excuses for yourself. Nobody wants to sit with their head in a book for 12 hours at a time while their post-gravid wife is trying to pacify a screaming baby who blew out her diaper for the second time that day, all while trying to get a two-year-old to go to bed. Nobody wants that, but there is no other option. Remember why you are doing this, whether it be for your patients, your family, your ego, a paycheck, whatever. Set aside time for the people and things you love, but pick up the hammer and get to work when it is time to study. Refuse to fail and make no excuses. Rant over.

The Resources I Used

Nobody paid me to say what I’m about to say regarding the resources I used. This is strictly an opinion and is not meant to try and sell something or to devalue somebody else’s hard work.

Core Radiology: I really like this book as a foundation builder. I read this book maybe two or three times throughout the course of R1/R2. Our program uses this text in place of Brant and Helms now, for what it’s worth. You could probably use this as your primary text for board studying, but I did not. If you haven’t read it by 6-8 months out, it may not be worth starting unless you’re using it as your primary review text. I treated it more like a true textbook and less like a review book, though often referred to certain sections as I was studying.

Crack the Core: I would consider this to be my primary review text, and I would use it again in hindsight. Use the text as an outline for your studies, not the only source. This should be treated a lot like you treated First Aid for Step 1, but it’s more entertaining. Don’t read this book to try and guess what’s going to be on the exam, you’ll be disappointed in the result. Learn the material and develop a deeper understanding when you run across a high yield topic. Write a ton of notes in the margins while you are doing questions, casebooks, or YouTube-ing/Radiopaedia-ing. Read these books cover-to-cover a couple of times, then use them as reference/review. I don’t know that I looked through many of his high yield points/tables at the end of Volume 2, but some may find it helpful.
War Machine: Highly recommended and the one book I feel strongly that everybody should use. You can most likely get away with using this as your only physics book review, as long as you supplement it with questions. I also read Huda (very early on and before I realized how good War Machine was), did select RSNA modules, and watched lots of YouTube to gain a deeper understanding. For our test, the Non-Interpretive Skills (NIS) Section of this book was essentially a waste of time. I expect that will be true on future tests unless the ABR says otherwise. The rapid review at the end of the book is worthwhile.

Radiology Core: Physics Plus App: This is a must have for physics review. The questions are short and to the point, much like many of the physics questions on the actual test. The interface is surprisingly irritating, but power through. These questions will force you to think about physics topics from various angles, also providing a necessary amount of redundancy. I often used this when I only had 5 or 10 minutes, or when I couldn’t muster the strength to do anything else. Available in iTunes and Google Play Store for about the price of a Big Mac.

RadPrimer: My primary question bank. Question style is NOT at all similar to the exam, but this resource will help you make some serious gains by repetition. It will also bring to light some topics that are missing in the books. Some of the sections are better than others, so don’t get caught up in a few bad questions. At first, I only did the questions specific to the rotation I was on and/or the topic I was studying that week. Later on (maybe 1-2 months out from the exam), I randomized. I did most of the 7000+ questions, but spared some sections like Physics, NIS, and MSK towards the end of studying (I just didn’t find those questions to be all that helpful, even in hindsight). Initially, I preferred to use tutor mode but moved towards test mode closer to the exam.

Seriously, if you’re going to spend your time doing these questions, review the answers. Read both the right and wrong answer explanations. Even if it’s an easy question, I guarantee you will learn something by reading the explanations (especially from some of the neuro writers whose explanations are superb and very high yield).

Board Vitals: In comparison to RadPrimer, the question stems are shorter and to the point. This is more in line with questions on the actual exam. Most of these questions are pretty easy, but (believe it or not) it is similar to the exam. If you can do well on BoardVitals, my opinion is that you will do fine on the exam. However, don’t let that be an excuse to get complacent if you are doing well. Their website will give you an estimated percentage of questions you should be getting right to pass the exam. My colleagues and I agree that this was surprisingly reliable as long as your sample size is large and you are seeing the questions for the first time. I paid for the three month subscription and used it mostly within the last two months of study. My opinion is that it is worth the money. Again, read both the correct and incorrect answer explanations to maximize your repetitions. They often have discount codes available.

Titan Radiology Board Buster: These videos are aligned with the Crack the Core books and serve as a very nice supplement. There was quite a bit of high-yield information included in the videos that was not found within the books. Given the time crunch that most of us are on while studying, it was useful to have a study resource with audio rather than text. I utilized these videos while I was working out, mowing the lawn, driving, etc. High quality physics videos are also included. I was less impressed with the question bank which is a work in progress regarding the user interface, as well as content. I suspect the questions will continue to improve. I would use this resource again, though I didn’t realize the cost was so high until today ($139/month). Our program is humane enough to provide these videos for three months, so it was a no-brainer for me.

IMAIOS e-Anatomy: If you haven’t been using this in residency, you are missing out. I had this app open as I was studying as a means to review anatomy. There are plenty of anatomy questions on this test, usually shown in a plane you have never thought about. I used the app to review various anatomy in multiple planes and modalities, which helped immensely. At a minimum, you should do this for Neuro and MSK. The anatomy questions tend to be easy points, so don’t overlook the basics. The American College of Nuclear Medicine (membership free to residents) offers a yearly subscription for $29, so take advantage. I also frequently had a Netter atlas handy, strangely enough.

ABR Core Practice Exam: You must do this at least once. It is 100 questions, 5-10 of those will be reused on your test. I did this once in January and once about a week before the test.
ABR Non-Interpretive Skills Study Guide: For our exam, this is all you needed for NIS. Whether you like it or not, you have to know this material. Read the guide 2-3 times, highlighting important topics for last minute rapid fire review before the exam. These are easy points that you can’t neglect.

“A Core Review” Series: I think going through case books is nearly equivalent to doing questions as far as getting bang for your buck. I’m sure any case book is good, but I really found A Core Review to be high yield and a great review source. Use these (or something similar) to supplement your question banks.

My Timeline

The fall before the exam (November, December and January), I intensively studied for the rotations which I was currently on (Nucs/PET, IR and Mamms). For those three months, I studied the respective topics like never before. Typically 2-4 hours per night after work and more on Saturdays. I read select sections of the associated textbooks such as Mettler for Nucs. I read the sections in Crack the Core at least twice each during the respective four-week rotation, and did almost all of the RadPrimer questions for each topic while I was reading the books. I found it helpful to kick off board studying by limiting myself to those topics which immediately pertained to my training. I think you may burn out early if you start trying to learn the whole breadth of radiology from 6-8 months out.

In December, in addition to my IR studies, I read the Huda physics book one time. This only takes a weekend. I found it somewhat helpful, though not mandatory. I also mixed in RadPrimer physics questions, RSNA modules, and watched some physics videos during the fall of 2018 as I had neglected physics as much as possible during early training.

In January 2019, I formulated a written plan and took the Core Practice Exam. You need to make a plan and adhere to it as strictly as possible. If you’re like me, you should put it in writing so you don’t have an opportunity to procrastinate. If you’re not a procrastinator, you’ll likely do this before January.

January and a good part of February were spent reading Crack the Core Vol. 1 & 2 cover-to-cover twice. While I was reading the book, I created a PowerPoint slideshow with an image of almost every topic in the books. This forced me to view the information in a different light, reinforce knowledge, add missing information, and create a rapid fire review resource. The Crack the Core books are image-poor, and you need to see actual images of disease processes for the image-rich Core Exam. Use Dr. Google, Radiographics, AJR, etc., to gather your images. The process of creating slides, although somewhat time consuming, will reinforce those weak neuronal synapses.

The rest of February was spent reading War Machine and learning as much physics as I could tolerate. When I didn’t understand a concept, I used supplemental resources such as RSNA modules, YouTube, SUNY videos, etc. Pay special attention to imaging artifacts, as they seem to be incredibly high yield. There are quality Radiographics articles on imaging artifacts that will help you to gain understanding.

From March to June, write a week-to-week study plan on a calendar. For the topics you know are difficult or high yield, allow two weeks. For straightforward topics (Breast Imaging comes to mind) or those you know well, a week (or less) will do. The topics I wrote on my calendar were: Breast, GI, MSK, Neuro, Nucs/RISE, Peds, Thoracic/Cardiac, GU/Repro, Endo, Physics, Vascular/IR. I would try and go through each corresponding section in Crack the Core two times. I read slowly the first time through and quickly reviewed the second time through, adding/editing my PowerPoint as I went. Typically, I focused on questions on Friday and Saturday of the week. I also did questions or looked through case books when I lost interest in reading, no matter what day of the week. Sunday was my day of rest. I would recommend building in planned days off to avoid fatigue and maintain your sanity.

I reserved the last 2.5 weeks before the exam for general review. I went full blown nerd on randomized questions. Do as many as you can feasibly do while still reviewing the answers and referring to the topic in Crack the Core. I still wrote notes in the margins of the book to solidify my knowledge. Continue to do the physics questions in the app during this time. Repeat the ABR Core Practice Exam and review the answers again.

As far as the last few days before the exam, continue to do questions. Make sure you don’t overdo it, as you will need to reserve energy for the test. You will inevitably feel a sense of panic. Know that this is normal human behavior and all ~1199 other people are experiencing the same anxiety. Overcome it and trust your preparation. Go ahead and review the pure trivia at this point. I had kept an 8.5x11 sheet of paper with things like half-lives, photopeaks, Nucs QA, syndromic associations, and so on. Try to review this a few times while you’re traveling or sitting in a hotel room. Refer to the ABR website and other blogs such as Ben White’s “ABR Core Exam Experience” in regards to the actual test day. You don’t have to stay at the recommended hotel, but it will make your test days less stressful. Get rest and don’t stay up cramming until 4 a.m. the morning of the exam.

Random Thoughts

• I would recommend starting your study session with some sort of self-reflection, meditation, or prayer. To be clear, I have never been all that much for meditation or time within my own head outside of prayer, but I found this incredibly helpful. If you desire silent meditation, I have heard the Headspace app is pretty good. In any manner, give yourself 5-10 minutes to breathe, find your focus, and reflect on what is motivating you. After that, I took Prometheus’ advice and jammed out to one song as loud as it would go. It’s akin to an athlete getting in the zone, I suppose. Then it was go-time. 
• In our program, we try to place residents in less demanding rotations in the final 2-3 months before boards. I made sure to take full advantage of that time, and hopefully your program director or chief residents have set up a similar system. If not, it’s up to you to plan accordingly.
• The week before the test, I made sure I had no work obligations. I studied for 12-14+ hours per day. Take vacation if needed.
• When we took the exam, they allowed hard candies in the testing center. I found LifeSavers Mints to be pretty good at getting me back in the zone. Just don’t be the guy/girl crunching candies like a psycho, your neighbors will probably slap you. 
• Study with earplugs in, not earbuds. No matter what you believe, listening to music or watching TV while studying is distracting. The testing center will provide foam ear plugs, which I think you should take advantage of. Start using your own earplugs while studying so you become accustom to them. 
• Look at the ABR Website and plan your studies accordingly. They provide a lot of valuable information, so don’t wait until the last month of studying to find out what the people writing the test want you to know.
  
  

Hopefully you will find my opinions to be valuable. If you gathered nothing else from my verbose attempt at a blog, just stay focused and put in the work. Your study plan will be different from mine, as it should be. Make your plan and stick to it. Whatever has worked on previous exams will work for you this time. You’ve got this.