Eligibility Requirements

The Part II oral examination is the second part of the ABOS board certification process. The Part I examination is a written examination, typically taken shortly after residency graduation. In order to be a candidate for the Part II oral examination, the candidate must have successfully completed 5 years of accredited post-doctoral residency education. Foreign medical graduates should directly consult with the ABOS regarding post-doctoral education status as performing multiple fellowships will often not be accepted as a viable substitute for residency education. Additionally, candidates must have previously achieved a passing grade on the ABOS Part I written examination. After passing the ABOS Part I examination, a candidate has 5 years to successfully complete and pass the ABOS Part II oral examination process. Time spent in fellowship does not count against these 5 years as long as a fellowship lasts longer than 6 months. Once these requirements are met, a candidate is considered board eligible.

After completion of all residency and fellowship training, a board eligible candidate may begin the part II examination certification process. Candidates should make every effort to begin the process as soon as all fellowship training is complete because it is a nearly 2 year process that begins on November 1 and ends after completion of the oral examination 2 years later in July. It is imperative that each candidate registers on the ABOS Web site and follows all application requirements. A candidate must have hospital and surgical privileges on or before November 1 in order to be eligible for the oral examination 2 calendar years later. Therefore, it is important that a candidate balances the desire to take time off following orthopedic training and the need to have privileges prior to November 1 in order to start the Part II certification process. The candidate must be continuously and actively engaged in the practice of orthopedic surgery at one location for at least 17 consecutive months. Therefore, a change in job location following November 1 or a prolonged absence from clinical practice will likely delay a candidate’s ability to initiate the board certification process.

Case Collection

Once a board eligible candidate is officially enrolled and has entered the board certification process, he or she will enter into the case collection period. Typically, the case collection period begins on April 1 of the following year, but this can change based on the discretion of the ABOS. For example, if a candidate enters into the board eligible period on November 1, 2024, then the case collection period will typically begin April 1, 2025. However, the ABOS reserves the right to proactively or retroactively change the start and end date of the case collection period, so candidates should be flexible and ready to adjust as directed.

The case collection period lasts for 6 months with September 30 the final day of the collection period unless otherwise indicated by the ABOS. Candidates will track cases and all required data for cases on the Web site provided by the ABOS. It is usually best to log cases as they are performed as opposed to waiting for the end of the 6 months to retroactively log cases. Additionally, there is a minimum case requirement for the 6 month case collection period, which is typically at least 30 cases as the primary surgeon. However, this can also be subject to change pending direction from the ABOS, so candidates should verify the minimum case requirement for their examination cycle. Failure to perform the appropriate number of surgical cases as the primary surgeon will result in the inability to sit for the current examination cycle, and the candidate will have to undergo case collection the following year. It should be noted that only cases where the candidate is the primary surgeon will be eligible for inclusion on the case collection list.

Each candidate must submit a finalized case list, application (found on the ABOS candidate Web site), and application fee by November 1 to maintain eligibility for the current examination cycle. Additionally, the ABOS will ask for local peer review references as part of the application process, so candidates should be planning accordingly to secure timely peer review references. There is usually a late deadline (November 15), but this does require an additional late fee. Candidates should note that the application is thorough and requires hospital verification of the case list among other additional requirements. Therefore, candidates should be proactive in gathering all necessary information well in advance of the November 1 deadline to ensure successful and timely completion of the application and case list process.

Oral Examination Mechanics

The ABOS will review each submitted application and case list. Candidates will receive a letter the following year, usually in April, notifying them whether they qualify to sit for the official Part II oral examination. Candidates can also review their selected cases for the oral examination on their ABOS Web site dashboard. A total of 12 cases will be selected for each candidate. The supporting documentation for each case typically includes the candidate’s medical records for the patient surgical encounter (initial history and physical, follow-up notes, operative note, postoperative follow-up notes, any additional consult notes, etc.), imaging (pre-operative, intra-operative if applicable, post-operative if applicable), surgical consent forms, and any additional documents requested on the ABOS Web site. Inability to provide adequate supporting documentation may result in disqualification from the examination, so it is imperative to have an organized system for tracking all relevant patient records during the case collection period. Additionally, candidates must ensure that all record obtainment and disclosure is Health Insurance Portability and Accountability Act (HIPAA) compliant, either by redacting all patient identifying information or by having the patient sign a HIPAA waiver consent form and including this with supporting documentation.

All supporting documentation, along with an oral examination fee, must be filed by the selected deadline, typically in June. Similar to the previous application deadline in November, there is usually a late deadline 2 weeks beyond the primary deadline, although this requires an additional late fee as well.

Oral Examination Day

Each year the examination is held at the Palmer House in Chicago, Illinois. Candidates can find lodging wherever they please, though it is typically most convenient to stay at the Palmer House Hotel. It is recommended that candidates arrive at least 30 minutes early for their examination start time as being late may result in a failing grade. The examination is broken into four 30 minute test periods with a 5 minute break between periods. Each period will feature 2 unique examiners. A candidate will report to an examination booth and remain in the same booth for the entirety of the examination. Examiners will rotate among the booths after each period for a total of 8 unique examiners during the examination. Each period will focus on 3 designated cases from the case list. There will be a computer in each booth to allow for visualization of all supporting documents as needed during the examination process. Candidates should familiarize themselves with the computer when they first arrive at their assigned booth. It should be noted that all assigned examiners are familiar with a candidate’s entire case list, and they are allowed to ask relevant questions from any case at any time. Candidates will be judged based on a published scoring rubric on the ABOS Web site, and it is recommended that candidates familiarize themselves with this scoring rubric to understand the requirements for a passing grade.

Once the examination process is completed, the candidate is free to leave. Examination results are typically posted online in late August.

Documentation

Candidates should be careful to meticulously document in the electronic medical record system, especially all conversations related to surgical interventions. Candidates should clearly document indications for surgery, alternative options for the patient, and risks and benefits of each decision. If conversations are had with a colleague involved with the patient’s care (eg, consulting with a pediatric orthopedic specialist regarding management of physes), then these conversations should be documented accordingly. Ultimately, each surgical encounter should demonstrate shared decision making with the patient and physician, and the process of these conversations should be well documented. Candidates should avoid all smart phrases and over-using the copy forward button as each patient encounter should demonstrate unique conversations and features. Incorrectly copying inaccurate information is not only a potential issue with insurance billing, but it is an easy way to lose points in the scoring process. Therefore, candidates should resist the urge to rely on the copy forward button. If dictation software is used, then candidates should carefully review all notes prior to signing them to ensure there are minimal to no dictation or typographical errors Additionally, avoid using uncommon abbreviations. All notes should be self-evident and naturally lead the examiners along the thought process of the physician and patient.

It should be noted that uploading consent forms is required for each chosen case. Therefore, it is recommended that the candidate fills out and performs all surgical consent forms and keeps a copy of the consent form in a HIPAA compliant manner if the consent is not directly loaded to the electronic medical record (EMR). This will reduce the need to track down consent forms after the fact. All patient encounters for a chosen case must be reported. Therefore, it is important that every patient’s note is of the highest quality in case it becomes a chosen case. For example, if a case performed before the case collection period develops a complication that requires surgical intervention during the case collection period, then all documentation from the first surgery must be provided. Therefore, candidates should approach every patient encounter from the start of practice like it will ultimately be a chosen case for the Part II examination.

Lastly, all complications must be appropriately documented and reported on the case list system. Candidates should avoid any urge to cover over, minimize, or improperly document complications. Often the ABOS examiners are more concerned about how the candidate manages a complication as opposed to the fact that a complication occurred. Examiners should “run to the complications” with appropriate intention to ensure the best patient outcome possible, and such a process should be clearly documented when performed.

Management of Imaging

Candidates must obtain appropriate imaging on the electronic medical record (EMR) system and ensure that all preoperative, intraoperative, and postoperative images are readily accessible. If MR images are uploaded to an outside server, then candidates must ensure they have access to these images at all times. Candidates should also plan how they will keep track of intraoperative arthroscopic photos. There are a variety of ways to do so, and each candidate should develop a HIPAA compliant system that works for their practice. Ideally, all arthroscopic photos should be stored either electronically and/or with a hard copy as cases are completed in order to allow for easy access once the case list is published. Intraoperative c-arm fluoroscopy images may be hard to capture depending on your hospital or ambulator surgery center’s technology abilities. Every effort should be made to ensure appropriate obtainment of all intraoperative photos prior to the c-arm fluoroscopy machine being shut down.

Case Selection

Candidates should be mindful of the cases they perform during the case collection period, but they should not try to “cherry pick” or self-select easy cases. The presented cases should be representative of the candidate’s practice, and difficult cases should not be automatically referred out or performed with a co-surgeon. One major purpose of the Part II examination is to ensure that candidates are performing appropriately indicated procedures in an effective manner. Therefore, candidates should be more concerned about ensuring that all cases are appropriately indicated with support from the literature, and such support should be used to defend case selection during the oral examination. As long as a difficult case is within the scope of practice for the candidate, then it should be welcomed by the candidate. Sometimes only performing easy primary cases can be a red flag sign and invite more difficult questioning. Candidates should strive to have a balanced case mix that reflects their real-life practice. If a case is truly beyond the scope of the candidate or the candidate is not comfortable performing it, then it is certainly appropriate to refer to a different provider and/or recruit a co-surgeon.

Tips for Surgical Cases

As previously mentioned, candidates should perform surgically indicated procedures after fully completing the shared decision making and informed consent process. While the exact surgical technique is less consequential (eg, transtibial anterior cruciate ligament [ACL] femoral tunnel reaming vs medial portal ACL femoral tunnel reaming), performing the technique effectively is essential. Therefore, candidates should focus on the techniques that they are most comfortable with and not experiment with new equipment, techniques, or implants. Additionally, candidates should avoid industry-driven techniques or products that do not have robust literature to justify their use. Performing a technique or using an industry-driven product that is not supported by the literature introduces the possibility of losing significant points within the scoring rubric. In the event of an intra-operative complication, candidates should have a low threshold to consult a colleague if managing the complication is beyond their scope of comfort. All conversations with a colleague consulted intraoperatively should be well documented. If a colleague scrubs into the case, then this should be appropriately documented as well. It should be noted that having a colleague scrub into a case to help manage an unexpected complication does not meet the requirement for a co-surgeon case, and this case should still be reported on the case log system. Lastly, candidates should be very “hands on” throughout the documentation and surgical process. Relying on trainees or physician extenders may increase the risk of adverse outcomes or inappropriate documentation for which the physician will ultimately be held responsible. Most candidates prefer being extra involved with things like positioning the patient, closing wounds, taking out sutures in clinic, and so forth.

Tips for Examination Day

Preparing for examination day requires candidates to be familiar with each case and all of its supporting documentation. Candidates should be prepared to provide evidence-based reasoning from the literature to support their clinical decision-making process (eg, graft choice for ACL surgery, decision to include or not include an extra-articular IT band tenodesis). Candidates should be ready to anticipate relevant questions not only about presurgical, surgical, and postsurgical decisions, but also about the entire surgical process, for example, patient’s relevant medical history, selection of prophylactic antibiotic, use of tranexamic acid, and DVT prophylaxis selection. If a candidate does not know the answer to a question, then he or she should admit this as opposed to guessing or making up an answer. In some scenarios, examiners want to continue a line of questioning until the candidate gets to the point of not knowing the answer to ensure that the candidate is comfortable with admitting lack of knowledge. Depending on the question, not knowing the answer may not result in a loss of points. No matter what, the candidate’s primary focus should always be on giving a fully honest answer at all times. Often the examiner is simply trying to better understand a candidate’s thought process, and candidates should resist the urge to become defensive or challenging in their responses.

Passing the Examination

If a candidate is intentional throughout the ABOS Part II examination process, he or she can often expect a passing result when the results are posted. However, this should not be taken for granted. While the ABOS Part II examination used to have a pass rate well above 90%, the past 2 years at the tie of publication (2022 and 2023) have seen pass rates below 90% (83% and 87%, respectively). While the reason for this is a bit unclear, it should not cause fear in candidates. Instead, it should invoke a commitment to excellence throughout the ABOS Part II process and a commitment to appropriately indicated surgical and clinical decisions. Candidates should not assume they will pass, but instead they should put in the hard work needed to achieve the most rigorous standards in their practice, knowing that this will help them be the best doctor possible while also optimizing their chances of examination success.