Published 11/1/2017
David Hamilton, MD

How to Prepare for the American Board of Orthopaedic Surgery Exam

Long-time instructor at AAOS board review course offers thoughts and advice

Taking the American Board of Orthopaedic Surgery board examination can be an intimidating experience for orthopaedic surgery residents. Recently, David Hamilton, MD, a PGY-5 resident at the University of Kentucky, spoke on behalf of AAOS Now with A. Jay Khanna, MD, of Johns Hopkins Medicine, on how to best prepare for the exam. Dr. Khanna has been teaching at the AAOS Orthopaedic Board Preparation and Review Course since 2004, and currently codirects the course with Frank Shen, MD, of the University of Virginia.

Dr. Hamilton: How would you describe the value of taking a board review course, as opposed to studying on one's own?

Dr. Khanna: As the board examination approaches, it's helpful to get all of the essential knowledge repackaged in a format that one hasn't seen previously. Lectures in residency programs often reflect the biases of faculty members, who tend to present on topics important to them, and demonstrate their own preferences for technique. A board review course, however, is focused solely on helping a resident pass the exam.

Dr. Hamilton: Some board review courses are held in the summer, just before the board exam. Is there an advantage to holding the course in April, as the Academy does?

Dr. Khanna: There are some advantages to taking a review course right before the boards. You can go on lockdown mode and cram for the exam. On the other hand, the lead time of the Academy course allows the resident more time to synthesize the information, then go back and review what is most relevant prior to the exam.

Dr. Hamilton: What happens at a board review course?

Dr. Khanna: At the Academy board review course, repetition is a key strategy. Every lecture begins with a preview of the material we are going to present. Then we give the lecture and review what we discussed. And at the end of every subspecialty section, there is a 30-45 minute high-yield review lecture, during which the faculty focus on slides that yield the highest amounts of information. That way, if somebody was previously distracted or overwhelmed, he or she can still obtain the most important information.

We like to encourage our faculty members to "tell them what you're going to tell them, tell it to them, and then tell them what you told them."

Prior to the course, I recommend going over as much material from a review source as possible, especially in one's weak areas. We suggest that the residents show up for the course well rested and ready for 12-hour days, and to prepare for each subject by reviewing information the evening before.

Dr. Hamilton: Is there value in attending a board review course prior to a resident's chief year?

Dr. Khanna: I think there is a huge value in that. I attended three review courses during my residency—one in my third year, one in my fourth year, and one in my chief year. I enjoyed taking a week each year to focus on studying for the Orthopaedic In-Training Examination [OITE], because there is a high degree of correlation between chief year OITE scores and board scores. Three courses might be overkill for the typical resident, but I think it's reasonable to consider attending a second review course, especially for anyone who may be struggling on their OITEs. I like to say that if a resident tends to score below the 30th percentile on their OITE examinations, they really should consider doing something extreme for the board exam, such as attending more board review courses.

Dr. Hamilton: That's great advice. What concerns do you hear from residents preparing for the board exam, and what general advice do you have?

Dr. Khanna: If you're a second-, third-, or fourth-year resident, my best advice is to read and continue reading. If you're 3 months out from the exam, reading isn't going to move the needle much. But if you have the time, the best thing one can do is differentiate learning orthopaedic surgery from learning to pass the board examination. These are two very different things. Textbooks and journals can help make you a great orthopaedic surgeon with a great fund of knowledge, but those aren't the strategies you need to obtain a good board score.

Throughout residency, therefore, it's important to have a two-pronged approach to learning—one toward developing a good core base of knowledge for your overall clinical practice, and one toward passing the board examination. For the board examination, reading the AAOS Orthopaedic Knowledge Updates, the AAOS Comprehensive Orthopaedic Review and other good review books will help a lot if done in the early years and re-read during one's fourth and fifth years. I also recommend doing plenty of self-assessment examinations and going over thousands of old OITE questions.

As residents get to their fourth year, they should look at their OITE scores, and if they're in the 70th percentile or better, they can continue whatever they're doing and focus on their subspecialty interest. If a resident is in the 30th percentile or lower, he or she really needs to focus on changing something to improve that overall score in his or her chief year.

To summarize, board preparation strategies include answering thousands of practice questions, attending review courses, and reading board-focused review texts.

Dr. Hamilton: These are good things to keep in mind. Are there any specific techniques you recommend?

Dr. Khanna: When I took the board exam in 2003, I reviewed all of my educational materials in electronic format. Whenever I found a gap in my knowledge or came across something I couldn't memorize, I would cut and paste that information into a word processing document. By the time I was studying for the boards, I had a 300-page document that contained all of the information that was difficult for me. As I became confident in a topic, I would delete it from my document, so I could continue to focus on my weaknesses.

The overall strategy should be focusing on improving your weaknesses, not reviewing your strengths.

Dr. Hamilton: Do you have any recommendations for the last couple of weeks prior to taking the boards?

Dr. Khanna: During the last couple of weeks, don't deviate too much from your usual life routine, especially if you've failed the exam before or if you tend to stress excessively before exams. Keep up with your sleep schedule, exercise routine, and socializing. Resist the temptation to become a hermit, studying for the exam 20 hours a day.

In the weeks before the exam, when people are stressed, it's difficult to read material and retain it. Answering practice questions is a very engaging way to link your mind to the material. Getting feedback from the correct answers and discussion paragraphs in practice tests not only tends to decrease anxiety, but also allows the resident to hone his or her test taking skills.

David Hamilton, MD, is a PGY5 orthopaedic resident at the University of Kentucky.

Dr. Khanna's top three tips for board preparation

  • For the junior resident, realize that studying for the board examination is different from learning orthopaedic surgery, and make that part of your study plan early on.
  • Answer as many practice questions as you can, because there are only a certain number of ways a test writer can ask certain questions. Answer thousands of questions—5,000 or more.
  • Avoid the temptation to study your strengths and make them stronger. Focus, instead, on your weaknesses.