It’s 4 am, and it’s the third time I’ve woken up in my room at the Chicago Palmer House Hilton Hotel. I’m deciding whether to get up now, or try to get a little more sleep before my ABOS Part II examination. In the end, I decide to get out of bed, shower, and do some last minute case reviews before the 6:30 ‘briefing session.’ In my mind, I have spent months preparing for this exam, but in actuality, I have spent years in preparation for this day.
Board certification in medicine provides a trusted credential to the public and demonstrates that physicians have met certain standards of education, training, and practice. The purpose of the American Board of Orthopaedic Surgery (ABOS) Part II examination is to evaluate the knowledge, skills, and practice patterns of individual surgeons for the ultimate well-being of patients. Because it is a voluntary process, it demonstrates a commitment to the highest quality care, ensures safety of thought processes and techniques, and sets physicians apart as specialists for hospitals, employers, insurers, and patients.
The Part II oral examination is the second of the two parts of the certifying examination process for orthopaedic surgeons. To begin the procedure of board certification, a surgeon must be a graduate of an accredited four-year medical school, have successfully completed a five-year accredited orthopaedic residency program in the U.S. or Canada, and have successfully passed Part I. The final 24 months of training must be obtained in a single program. After passing Part I, there is a period of five years to apply for and pass the Part II oral examination. If Part II is not taken within that time frame, Part I must be taken again (and passed) to quality for admission for the oral examination. Finally, candidates must have a full and unrestricted medical license, and have been in practice for 20 months in one location.
As part of the application process, evaluations from the hospital chief of staff, the chiefs of orthopaedics, general surgery, and anesthesia, and nursing staff in the operating room as well as the orthopaedic wards must be submitted. Furthermore, peer reviews of the candidate from certified orthopaedic surgeons familiar with his or her work must be obtained. The credentials committee of the ABOS reviews all the above information and determines whether applicants should be admitted to sit for Part II.
Once admitted to take the oral examination, there is a six month board collection period (from April 1 until September 30). Every case that is performed in the operating room during this timeframe must be included. By October 31 after the case collection, the completed application, application fee, scribe list, and names of peer reviewers must be submitted. The following April, the letters of notification for the exam are sent along with the case selection, which now includes ten total cases. In the past, examinees were permitted to “throw out” one to two cases. Currently (as of 2017), however, all ten cases will be examined with no opportunity to eliminate questionable cases.
Once the case list has been provided, the lengthy process of uploading all of the required files (including consent forms, operative reports, office notes, radiographs or advanced imaging, and arthroscopy and clinical images) begins. This is the time to review the relevant literature, anatomy, alternatives, and indications for each case. It is extremely helpful to go through the cases with partners and/or mentors. There are also formalized board review courses, where cases can be presented in preparation for the exam.
The scoring system is based on six items:
- Data gathering
- Diagnosis and interpretive skill
- Treatment plan
- Technical skill
- Outcomes
- Applied knowledge
The examinee is judged on each of the ten cases, record-keeping, case mix, organization, and the six skills (with pre-defined rating scales). The examiners are specifically assessing the surgical indications, complications, and most importantly, the underlying ethics and professionalism of each candidate.
Approximately 700 candidates take this examination each July. The exam consists of two hours of examination time, divided into four 25 minute periods with two examiners in each period. The examiners independently grade each case presentation. The Oral Board examiners are all volunteer orthopaedic surgeons who have been re-certified at least once. Notification of pass/fail is provided approximately 2 months after the exam and candidates have ten years before re-certification is necessary.
I head down for the briefing session and meet up with my co-fellow Eric, who helps allay my uncertainties about the upcoming venture. I also have the opportunity to chat with Dr. Sandy Emery, a long-time mentor and ABOS representative, who further puts my mind at ease. I know I’m ready.
The entire process requires organization. An excel file is a great way to keep track of the individual cases during the board collection time frame. Items to include might be date of surgery, medical record number, patient initials, patient age, surgery details, medical co-morbidities, CPT codes, ICD-10 codes, and complications. This excel file should be kept up to date continuously. Complications should be included the day they are observed, so they are not forgotten. Cases should be uploaded into the ABOS website at least weekly (if not daily) as they are completed, rather than waiting until the end of the board collection period. It is simply too much information to add at the end of six months.
Preparation is vital and will make the process smooth instead of stressful. The examiners simply want to be assured that candidates are organized, have good indications for surgery, are ethically sound, and most importantly, are safe. Complications are going to occur and are expected. In fact, if there are few or no complications listed, that might be considered a “red flag”. Every possible perceived complication should be listed, even if it might be ‘benign’, such as a hypertrophic scar, an anesthetic reaction, or an unplanned ED visit. The good news is the vast majority of examinees pass Part II (2014 pass rate: 93%, 2015: 95%, and 2016: 96%).
Candidates who pass the examination are certified and are diplomates of the American Board of Orthopaedic Surgery. They receive a certificate that is valid for 10 years. Then, they have the opportunity to re-certify through various maintenance of certification options, so as to demonstrate their ongoing professional development and continued practice improvement.
I finished defending my indications for a single stage flexor tendon reconstruction, answering some tough questions (a few I didn’t know, but looked up thereafter), and then heard the final bell sound. In my mind, I knew I had passed, and celebrated the end of a long process, and the beginning of life as a ‘board certified orthopaedic surgeon’.
References
https://abos.org/certification-exams.aspx (accessed July 28, 2017).
DeRosa GP. Recertification: history of ABOS efforts. Clin Orthop Relat Res. 2006 Aug;449:149-54.
James MA, Seiler JG 3rd, Harrast JJ, Emery SE, Hurwitz S. The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am. 2012 Jan 4;94(1):e2(1-12).
