Although the structure of the American Board of Orthopaedic Surgery's (ABOS) oral examinations has changed over the years, the exams are still an integral component for certification and a good option for Maintenance of Certification (MOC).

Candidates must pass the Part II oral examination as the final step toward achieving initial ABOS Board Certification. Each year, approximately 750 surgeons take the ABOS Part II oral examination. In addition, approximately 140 orthopaedic surgeons opt for an oral examination as the last step in their MOC cycle for recertification. In comparison, approximately 1,500 orthopaedists elect to recertify through a computer-based examination each year. Although the computer-based examinations provide an excellent evaluation of a Diplomate's fund of knowledge, the oral examination is based on the surgeon's actual practice and patients.

Prior to this year, Part II oral examination and oral recertification examination candidates submitted all cases within a 6 consecutive months time period with no cap on the maximum number of cases to be entered. The case list process has now been standardized and shortened for Diplomates in the MOC process, as follows:

• Diplomates in the MOC process must submit up to a maximum of 75 surgical cases, starting with the first case of the calendar year 2 or more years prior to the examination.
• Candidates taking the ABOS Part II Oral Examination must include all cases for 6 months (April through September) of the year prior to their examination.

Preparing the exam
Volunteer orthopaedic surgeons experienced with the oral examination process select 12 cases from the submitted case list to be used in the examination. Specific guidelines are used in the selection process. The Diplomates receive a defined list of what records need to be uploaded to the ABOS Scribe system for each selected case. The ABOS continues to work diligently to eliminate the need to upload documents not critical for the examination.

With the development of an examination based entirely on digital images and records, Diplomates are no longer required to bring large volumes of paper records to the examination. Changes implemented this year make it easier to upload and order the records.

An examination based entirely on electronic records has also increased the efficiency of the testing process. Detailed instructional videos on how to upload documents and prepare for the examination are available on the ABOS website (www.abos.org). Staff in the ABOS office are readily available to answer questions by phone. Information on all application deadlines can be found on the ABOS website. Information technology support is also available.

Examination day
On the day of the examination, examiners and examinees receive separate briefings from ABOS directors. Each oral examination consists of four 25-minute sessions, with a break between each session. A bell indicates the start and stop of each 25-minute session.

The examiners in each examination panel have areas of expertise that align well with the examinees' subspecialty practice patterns. Typically, the examinee is questioned about three cases in each of the four sessions. This format typically gives the examinee the opportunity to present all 12 uploaded cases.

By the end of the entire examination process, a large number of scoring data points are generated for each examinee, which improves the statistical reliability of the exam. Examinees are encouraged to prepare by carefully reviewing their cases and the videos on the ABOS website. Spending time creating a quality case summary for each case can be particularly helpful; the case summary can be uploaded with the other case documentation.

Examiners use a standard scoring rubric to measure each candidate. The following elements are included in the final score results:

• data gathering
• diagnosis and interpretive skill
• treatment plan
• technical skill
• outcomes
• applied knowledge
• surgical indications
• surgical complications
• ethics and professionalism

Debriefing sessions with examinees after each session provide valuable feedback to the ABOS. This information, combined with feedback from the examiner debriefings, has resulted in multiple changes to the current examination process.

After the oral examinations are complete, the ABOS works extensively with psychometricians to ensure the validity of the examination. Examiners are statistically rated on severity and consistency and adjustments are made so that candidates pass or fail based on the examination—not which examiners conducted it. After receiving and analyzing data from psychometricians, the Oral Examination Committee sets the pass/fail point and notifies examinees that their results are posted on the password-protected area on the ABOS website.

Last month, nearly 200 board-certified orthopaedic surgeon volunteers traveled to Chicago's Palmer House Hotel and spent several days working as oral examiners. Volunteer examiners come from private and academic practices and represent all regions of the country. Without their generous contribution of time and effort, the ABOS oral board examination process would not be possible. The dedication and commitment on the part of the volunteers to maintaining a standard of quality and safety in orthopaedics is commendable.

The oral examination provides an excellent "snapshot" of a surgeon's practice and is an important component in assuring the public about the quality, safety, and competence of an ABOS board-certified surgeon. That, in turn, preserves the value of the ABOS Certificate for the Diplomate. The ABOS is committed to continued refinement and improvement of the process.

What's next?
The ABOS is currently evaluating a virtual practice evaluation (VPE) as a possible option for the final step in the MOC cycle. Diplomates would prepare for the VPE just as they would for an oral examination. They would submit a case list and 12 cases would be selected. They would upload the required records and images into the Scribe system. However, they would not have to travel to Chicago; their cases would be evaluated by examiners in Chicago without the need for the examinees' presence. The ABOS staff and board are working with psychometricians to evaluate the validity and reliability of the VPE as an assessment tool, with the possibility of offering it as a future MOC assessment option.

James R. Roberson, MD, is president of the ABOS; Douglas W. Lundy, MD, MBA, is the chairman of the oral examination committee of the ABOS and a member of the AAOS Now editorial board; and David F. Martin, MD, is the ABOS executive medical director.