You Passed!

The year 2007 marked the first time that the certifying exam in sleep medicine for physicians was given under the aegis of the American Board of Medical Specialties (ABMS), having been previously given by the American Board of Sleep Medicine (ABSM). The new exam, offered on a biennial basis, is accessible through the American Board of Internal Medicine, the American Board of Pediatrics, the American Board of Otolaryngology, the American Board of Psychiatry and Neurology, and the American Board of Family Medicine. During the first three cycles (2007, 2009, 2011), it has been and will be possible to sit it through both fellowship and clinical experience pathways; from 2013 onward, one will need to have completed a formal sleep medicine fellowship in order to do so.

Because sleep medicine is such an integrative field, encompassing so many different areas of medicine as well as psychology, child development, and pharmacology, preparation for this exam, especially for those who have not gone through a formal fellowship, can be very stressful. This can be understood when reviewing the pass rates for the 2007 exam, the only one for which there are data available at the time of this writing. An analysis of the results of the 2007 certifying exam1 showed that while 93% of those previously certified by the ABSM successfully passed the new ABMS exam, only 82% of those who had completed a formal sleep medicine fellowship and 59% of those sitting through the clinical experience pathway passed it. While there are a number of board preparation courses offered through the American Academy of Sleep Medicine and other organizations, it remains an intimidating exam, even for those who have completed a fellowship in sleep medicine. Therefore, those gearing up for the exam need to perform a comprehensive review of a large amount of material in order to be properly prepared for it. One way of preparing for the exam is to make use of one or more review books, especially those containing multiple choice questions and answers presented in the same format as the examination itself. I successfully sat the most recent sleep medicine board examination in November 2009, and in preparing for it made good use of three such books (in addition to other resources), all of which had relative advantages and disadvantages, and utility.


Review of Sleep Medicine, second edition (Barkoukis T, Avidan A. Philadelphia: Butterworth Heinemann Elsevier; 2007),2 has 208 pages of concise review divided into 11 chapters, followed by an additional 16 chapters (312 pages) of more than 500 multiple choice questions similar to those found on the board exam. The review chapters are well written and replete with charts, diagrams, and illustrations.

Sitting the exam through the clinical experience pathway with a background in pediatric pulmonology, I was especially concerned about neuroanatomy, neurotransmitters, and sleep. The questions testing knowledge in these areas seemed to be the most difficult, sometimes to the point of being frustrating, as the information necessary to correctly answer them, while extensively explained in the answer sections, was often not mentioned in the relevant review chapter(s). Some of the questions were harder than those that appeared on the actual exam. Still, as appreciated after using all three books, learning through questions is no less important than reading through lists of facts, and served to underscore what the authors, all experts in the field, felt was important to know.

The review chapter on pharmacology and sleep was extensive, and full of lists of the effects of different medications on sleep, but there were only 40 questions in the question section, which somehow felt insufficient given the sheer volume of facts that need to be internalized about how different medications affect sleep. The chapter on artifacts, while having only 25 questions, was excellent, in that full montage screen snapshots were given, many times without the artifact being pointed out, requiring meticulous review of all channels displayed. The chapter on pediatrics was excellent as well (full disclosure: it was cowritten by a colleague of mine) and included 46 questions. It is important to point out that while pediatric content is supposed to comprise just 2% of the content of the exam, according to the ABIM blueprint, it seemed that the actual percentage of pediatrics was much higher in the 2009 exam, and so this is a big plus, especially for those without a pediatric background. The last two chapters were devoted to practice parameters and a literature review (albeit for the years 2005-2006), and were followed by appendices devoted to scoring (per R&K, not the 2007 AASM scoring manual) and to cardiac arrhythmias.


Sleep Medicine: Essentials and Review (Lee-Chiong T Jr. New York: Oxford University Press; 2008)3 is similar in format to Review of Sleep Medicine in that it has 16 chapters of review followed by 600 review questions. It differs significantly, however, in that the review section extends more than 491 pages, followed by appendices on scoring and staging sleep (in accordance with the 2007 scoring manual), whereas the answers to the 600 questions are significantly briefer, filling only 83 pages. The format of the review section was user friendly, in that the content was spread out widely on the pages, and did not feel “dense” and intimidating; it contained lots of shaded text boxes containing charts for easy reference. The chapters also began with a very nice outline as to what was covered in them.

This book lives up to its name, and successfully presents the essentials of sleep medicine and facilitates their review in a way that can help the reader pass the exam. The questions are diverse and very representative of those that appeared on the 2009 examination, with one important difference—the examination itself had a large number of questions accompanied by graphic images of polysomnograms, actigraphy, and sleep logs, whereas the review questions in this book did not. There were also a number of questions in which the answer was not immediately clear, leaving one to guess at the author’s intention, and a few in which the answer indicated appeared to contradict authoritative information found elsewhere. For example, according to the answer to question 181, K complexes first appear in children after 6 months postconceptual age, whereas the AASM scoring manual states that they first appear between 4 and 6 months or later; likewise, the timing of the emergence of sleep spindles is given in the answer to question 558 as being between 4 weeks and 3 months, whereas the scoring manual states that they emerge 2 to 3 months post-term or later.

These really are trivial differences, unimportant in the grand scheme of things, though when preparing for the exam, one does need to know the “correct” answers. That being said, these were only minor detractions from an otherwise excellent study aid.


Focus on Sleep Medicine: A Self-Assessment (Lee-Chiong T Jr, Brown WD, Harrington J, et al. Philadelphia: Lippincott Williams & Wilkins; 2010),4 with contributions by nine authors, is similar to the question and answer section of Sleep Medicine: Essentials and Review in that it has 278 well-written and diverse multiple choice questions followed by answers averaging a paragraph long.

Two important features, however, distinguish it from its predecessor—the presence of more visual aids (polysomnography screen shots, sleep logs), which, as mentioned previously, is more reflective of the format of the exam itself; and the ability to access an online version of the book. The online version allows one to simulate actually sitting the exam. While this feature is very helpful, it is unfortunate that one is not able to start the questions online, exit as needed, and later resume from the point of interruption.

I found that using all three books was extremely helpful, both as study tools as well as in instilling confidence prior to the exam itself. Indeed, after answering the more than 1,400 questions found in the three, the exam felt very familiar and often easier than expected. All three books are well worth the investment of time and money, and should, alongside the scoring manual, ICSD-2, practice parameters, and a good atlas, be used in order to obtain not only a broad understanding of the principles of sleep medicine, but to maximize one’s likelihood of successfully passing the boards.

Dennis Rosen, MD, is a pediatric pulmonologist and sleep specialist at Children’s Hospital Boston, where he is a member of the Division of Respiratory Diseases and associate medical director of the Sleep Disorders Program. He is also an instructor in pediatrics at Harvard Medical School. The author can be reached at


  1. Quan SF, Berry RB, Buysse D, et al. Development and results of the first ABMS subspecialty Certification Examination in Sleep Medicine. J Clin Sleep Med. 2008;4:505–508.
  2. Barkoukis T, Avidan A. Review of Sleep Medicine. 2nd ed. Philadelphia: Butterworth Heinemann Elsevier; 2007.
  3. Lee-Chiong T Jr. Sleep Medicine: Essentials and Review. New York: Oxford University Press; 2008.
  4. Lee-Chiong T, Brown WD, Harrington J, et al. Focus on Sleep Medicine: A Self-Assessment. Philadelphia: Lippincott Williams & Wilkins; 2010.