Treatment Algorithms on Internal Medicine Board Exams

The primary purpose of internal medicine board exams is to test clinical knowledge. Questions that evaluate the knowledge of treatment options are therefore commonly seen on these exams. The following aspects of treatment may be tested:

• Treatment options in specific populations
• Variation of treatments according to disease variants
• Details about particular treatment interventions
• Treatment algorithms

This post focuses on treatment algorithms. Treatment algorithms can be defined as a rank order of treatment options that begin with first-line treatments and end at the last-line treatment option.

Some internal medicine board exam questions are based on a case vignette that involves a patient who should receive the first-line treatment for his/her condition, and the response options of the question include the correct first-line treatment option.

This type of question tests only the knowledge regarding first-line treatment interventions and is, therefore, relatively more straightforward. This question type is usually appropriate for testing the knowledge about rare diseases for which only a basic knowledge of treatment is expected. Alternatively, the disorder may be common but a physician belonging to a different specialty usually treats such a disorder, and therefore, only a basic knowledge of that condition is expected from an internal medicine physician. A question testing the clinical knowledge regarding an ophthalmologic condition in the internal medicine board exams would be one such example.

Another type of question that may appear in the board exams involves a case vignette that tests the knowledge of the second, third or even lower steps of the treatment algorithms. There are two ways to structure these types of questions.

The first way is to include information in the case vignette which clearly indicates that the first-line treatment can NOT be used in the patient. For example, the patient may be described as having an allergy to the medications used as first-line treatment for a particular condition or the patient may have a history of having a severe adverse reaction to the first-line treatment medication. Another example would be of a patient who has had a poor response to a trial of first-line treatment. Hence, a reason has been provided to considered treatment options other than the first-line treatments in the list of response options.

Another approach that can be used to force one to select a second-line or third-line treatment option is by not providing a first-line treatment in the question’s response options. The vignette describes a straightforward case that requires a first-line treatment intervention to be selected; however, the first-line treatment is not included in the answer options. Therefore, the next most appropriate option has to be chosen from the response options that are available.

Example Exam Question from Internal Medicine

Question: A 45-year old man, who has obesity and a sedentary lifestyle, is diagnosed with pre-diabetes during a routine medical check-up. The patient is educated regarding his condition, and lifestyle changes are advised. Three months after the initial diagnosis, he is found to have an HbA1c of 6.8%. A diagnosis of type II diabetes is made, and metformin is initiated, but it fails to lower the HbA1c even at its maximum tolerated dose. The HbA1c reaches 7.1% after six more months. Which of the following treatment options is now most likely to be recommended to this patient?

1. Add tolbutamide
2. Add glimepiride
3. Continue metformin alone
4. Add insulin
5. Replace metformin with insulin

Question Explanation

Patient education, as well as lifestyle interventions to treat obesity and to manage body weight are essential for all diabetes and pre-diabetes patients. Pharmacotherapy should be started in case of failure to achieve good glycemic control or if the HbA1c reaches 6.5% following 2-3 months of lifestyle changes. Metformin is considered to be the first-line oral hypoglycemic for the management of type II diabetes. However, metformin monotherapy has failed to achieve the target HbA1c levels in the patient described in the case vignette. A second oral agent may, therefore, be added to metformin. The addition of insulin therapy may be considered if the HbA1c reaches 7.5% despite being on oral medication. Currently, sulfonylureas are prescribed as an add-on or second-line treatment options for type II diabetes. Tolbutamide is a first-generation sulfonylurea, whereas, glimepiride belongs to the second-generation of sulfonylureas. Second-generation agents are preferred over first-generation sulfonylureas in clinical practice as they have been found to be more potent, i.e., lower doses with a lesser frequency of administration are required. Therefore, adding glimepiride to metformin is the most likely treatment option to be recommended to the patient.

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