The American Board of Orthopaedic Surgery (ABOS) and the American Academy of Orthopaedic Surgeons (AAOS) have a long, successful partnership. Each organization has separate, important missions in improving the practice of orthopaedic surgery. The ABOS establishes educational standards for orthopaedic residents and evaluates the initial and continuing qualifications and competence of orthopaedic surgeons. The AAOS provides education and practice management services, advocates for improved patient care, and informs the public about the science of orthopaedics.

In 2010, when Maintenance of Certification (MOC) began, input from an ABOS/AAOS Task Force helped to design a program to meet the requirements of the American Board of Medical Specialties (ABMS). The ABOS/AAOS MOC Task Force still holds regular conference calls to consider many issues of importance to AAOS members and ABOS diplomates.

The ABOS MOC program is intended to foster career-long practice improvement and assess the knowledge, skills, and professionalism of ABOS diplomates. To improve the relevance of MOC and minimize the burden on orthopaedic surgeons, a wide variety of existing activities (local, regional, and professional) have been recognized to be of value and will remain an important part of this process.

The role of recertification exams
When certificates became limited to 10 years in 1986, recertification examinations became an important part of assessing diplomates' knowledge during their professional careers. Over the past 30 years, recertification examinations have changed to offer more choices. An oral recertification examination was offered beginning in 1993. Three years later, a computer-based examination became available at locations throughout the United States.

In 1998, practice-profiled examinations in Sports Medicine and Adult Reconstruction were offered. The Certificate of Added Qualifications (CAQ) Hand, although not a practice-profiled examination, began in 1989. An exam for surgery of the Spine was added in 1999. Although the Adult Reconstruction and Spine practice-profiled examinations remain today, Sports Medicine and Hand are now Certificates in Subspecialty Certification, which eventually resulted in combined recertification examinations, so orthopaedic surgeons could recertify both their general certificate and subspecialty certificate with a single examination.

The process of creating examinations is long, laborious, and expensive. Much of the work is done by experienced orthopaedic surgeons who volunteer their time and expertise to create the questions. Each member of the Question Writing Task Force is required to submit potential questions. Once questions have been developed, members of the Field Test Task Force make sure the questions are appropriate. The ABOS directors who are part of the appropriate committees, also help finalize the questions. Psychometricians review and edit all the questions.

Although the tests are rigorous, 97 percent of orthopaedic surgeons who took a recertification examination in 2015 passed. For the past 5 years, the pass rate has been at least 95 percent. The pass rate for the general written recertification examination is even higher. But success does require preparation.

Improving the exams
In the past year, the ABOS has surveyed diplomates to help improve recertification exams. Last fall, as the American Board of Anesthesiology was moving to a "question-a-week" format, the ABOS asked diplomates what they thought of the idea. More than half thought it was a bad idea, giving it the lowest rating on a five-point scale.

On the other hand, more than 1,000 diplomates provided written feedback, and many indicated that they wanted examinations that mirror their practices. That sentiment was reinforced by responses to the 2016 communications survey. These results reflect the increasing specialization among orthopaedic surgeons.

At the 2016 ABOS Winter Meeting, the ABOS directors considered adding more specialized examinations to meet this demand. Adding an examination requires enough diplomates in that specialty to write the questions; more importantly, enough diplomates must take the examination for the results to be statistically relevant.

For example, approximately 1,600 orthopaedic surgeons have applied to take a 2017 recertification examination. Only 17 indicated a specialty in Oncology—not enough for a valid, reliable examination. So the desire for practice-specific exams must be tempered with the need for sufficient diplomates sitting for the exam.

As a result of these deliberations, however, the ABOS is making the following changes, also summarized in Table 1. One change that has no effect on exam reliability is eliminating general orthopaedic questions on specialty exams.

• Starting in 2017, the ABOS will eliminate the 80 general orthopaedic questions that have been part of the practice-profiled recertification examinations in Spine and Adult Reconstruction. Those examinations and the general orthopaedics examination will consist of 150 questions pertinent only to those practice profiles.
• Starting in 2017, the recertification examinations in the fields of Orthopaedic Sports Medicine and Surgery of the Hand will be available to orthopaedic surgeons who do not have those subspecialty certifications, but who wish to be examined in these practice-profiled areas. In addition, these two recertification examinations will consist of 175 questions in these practice areas with no general orthopaedic questions. They will continue to be administered in September (Hand) and October (Sports). To use these examinations to renew Subspecialty Certification, diplomates must still have passed the initial subspecialty examination and hold a Subspecialty Certificate.
• Starting in 2018, new practice-profiled examinations will be offered in the following fields:
• Orthopaedic Trauma
• Pediatric Orthopaedic Surgery
• Foot and Ankle Surgery

Each of those examinations will have 150 questions, pertinent only to those specialties; exams will be administered in March and April.

The ABOS hopes these changes and new exam offerings will be well-received. The ABOS has notified diplomates who have already applied for a 2017 recertification examination about these options. The changes were also announced in the Diplomate enewsletter, which is sent to all ABOS diplomates. Already, more than 40 diplomates have asked to change their examination type and/or year. Many others have the option to change, if they desire. Those wishing to make a change must let ABOS know in writing by Aug. 31, 2016.

What's next?
As of now, the ABOS does not anticipate more specialized exams due to the minimum number of examinees required for valid scoring. Diplomates whose practices are not similar to any of these practice-profiled or subspecialty exams will continue to have the option of taking the oral examination, which will truly match their practices because it is based on 12 of their cases.

The ABOS will continue to review recertification exams. Ideas that will be considered include writing questions specifically for recertification exams (rather than accepting repurposed questions from the Part 1 pool) to minimize the critique that questions are irrelevant to practice. Other possibilities are developing written exams or case-based exams (similar to the oral exam) to be taken at home, customizing exams to specific case list profiles, and exams that may be retaken to achieve a passing score.

The ABOS wants to continue to hear from diplomates and plans to continue conducting surveys. Look for them, complete and return them, and do not hesitate to contact any ABOS director or the ABOS office with questions or concerns.

J. Lawrence Marsh, MD, is the ABOS president. Douglas W. Lundy, MD, is the ABOS treasurer and chair of the oral examination committee.

Learn more
For more on the changes to MOC recertification examinations, see the "Across the President's Desk" column, and visit the ABOS website, www.abos.org