ABOS: 90 Years of Doing the Right Thing

In 1934, the American Board of Orthopaedic Surgery (ABOS) was established at the Palmer House Hotel in Chicago, where the ABOS administers the ABOS Part II and Oral Recertification Examinations to this day. In partnership with groups such as AAOS, the ABOS is proud to be the leading board certification organization of the past, present, and future for orthopaedic surgeons.

One phrase that the Board always goes back to when making decisions is “doing the right thing.” It is the title of the book written by former ABOS Executive Director G. Paul DeRosa, MD, for the ABOS’ 75th anniversary. He wrote: “It has been pointed out to me on numerous occasions by the Board’s current directors (specifically, [Chris Harner, MD]) that throughout its history ‘doing the right thing’ has been the foundation of the Board’s policies. The Board was formed as a call for doing the right thing—to help the public and all of medicine in identifying capable orthopaedic surgeons. Later on, it ‘did the right thing’ in establishing the Orthopaedic Residency Review Committee as well as implement a process for recertification. Most recently, the Board has continued to ‘do the right thing’ in formulating its Maintenance of Certification (MOC) program.”

Dr. DeRosa’s book was written 15 years ago; however, the Board still follows that mantra not only by creating and improving Board Certification and MOC programs to make sure they are relevant and not overly burdensome to orthopaedic surgeons, but also by serving orthopaedic patients. The ABOS mission is to protect the public, and ABOS is proud to have been dedicated to that mission for 90 years.

The Board takes the mission of protecting the public seriously and often receives questions from orthopaedic surgeons about why the Board requires ABOS Diplomates to be evaluated through the ABOS Peer Review and ABOS Case Lists Programs every 10 years. Surgical knowledge is measured through an ABOS Knowledge Assessment and also through the CME and Self-Assessment Examination requirements. However, ABOS Board Certification is more than just a “test.” Rather, it is designed to show that a surgeon is practicing safe, effective, and ethical orthopaedic medicine, and that is why regular peer review and case-list evaluations are important. Having a license allows you to be a surgeon, but to be an ABOS Board Certified Orthopaedic Surgeon, there is a high level of professionalism that is and has been required for 90 years.

Case lists and peer review have been part of the ABOS since its founding. As Dr. DeRosa wrote in his book, “Applicants had to meet the educational requirements of the Boad, submit a case history with 25 consecutive cases, and provide evidence of excellent moral character.”

The Board has worked hard over the 90 years of its history to always strive to make ABOS programs and processes less burdensome. Over the past decade, the ABOS has improved the methods that Candidates and Diplomates utilize to enter their surgical case lists. They log into the ABOS Scribe Case List system and enter basic information about the cases. The ABOS has changed the complications classification system, making the process clearer for surgeons.

With both the peer review and case list, these documents are reviewed by practicing orthopaedic surgeons to see whether further investigation is needed. The ABOS Credentials Committee discusses each of these individuals and makes decisions concerning their continued participation in the certification process. Any adverse actions that the Board takes are appealable by the Candidate.

In 1935, 1 year after the founding of the Board, the first ABOS Examination for Certification was administered, which consisted of three parts:

1. a clinical portion based upon examination of the patient
2. an oral examination conducted by a committee of three members of the Board
3. a written examination consisting of a single essay question requiring a comprehensive answer to be completed in 1 hour

Eight years later, in 1943, ABOS decided to separate the Board Certification examination into a Part I Examination (completed after residency) and a Part II Examination (completed after a surgeon passed Part I and practiced for 2 years). Both of those examinations are offered today, and they continue to be separated by 2 or more years.

The ABOS Part I Examination has been a multiple-choice examination for decades. From 1972 to 2008, it was offered once a year in Chicago. Many Diplomates remember taking their Part I Examination that way, with hard-copy examination books containing the questions and separate answer sheets completed with No. 2 pencils. Since 2009, the examination has been offered in digital form at testing centers throughout the world. Several years ago, the ABOS started collaborating with AAOS, and now the ABOS Part I Examination and the AAOS Orthopaedic In-Training Examination^® are roughly linked, each utilizing the same blueprint.

The Part II and Recertification Oral Examinations have transitioned from Candidates and Diplomates being examined on standardized cases to the examination being solely based on an individual’s own surgical cases. For many years it has been completely electronic, but there was a time when Candidates brought suitcases full of patient notes and images.

Several years ago, the ABOS introduced the ABOS Knowledge, Skills, and Behavior Program (ABOS KSB) for residents. Although some assume that the ABOS KSB was the first foray into residency education for the ABOS, that is not the case. The Board issued its first requirements for resident education curricula and lengths of rotations more than 80 years ago in 1943. Also, ABOS has been involved with the Residency Review Committee, now known as the Accreditation Council for Graduate Medical Education Review Committee (ACGME RC), for many years. Three ABOS directors serve on the ACGME RC, and the ABOS executive director serves as an ex-officio member of that committee.

In 1934, orthopaedic surgeons were generalists. For those taking the 2024 ABOS Part II Oral Examination, only 9 percent of them indicated on their application that their specialty is “general orthopaedics.” The ABOS has recognized two subspecialties in the field by creating the Subspecialty Certification in Surgery of the Hand (1989) and Orthopaedic Sports Medicine (2007). Practice-Profiled Recertification Examinations have been offered in adult reconstruction and spine surgery for many years; seven others were added beginning in 2017, and eventually no general orthopaedic surgery questions were included on Recertification Examinations. The introduction of the ABOS Web-Based Longitudinal Assessment (ABOS WLA) Pathway in 2019 let Diplomates select Knowledge Sources to review in their specialty, or any specialty, on which to be examined. For those surgeons who truly want to be assessed on their practice, an Oral Recertification Examination is also an option.

The Board debated the concept of recertification for many years. The ABOS Recertification Program was implemented in 1986 and then transitioned into the ABOS MOC later. Those who were Board Certified prior to 1986 received lifetime certificates, and the Board has honored those certificates over the past 40 years. However, with surgical knowledge and processes changing, orthopaedic surgeons must keep up with these changes, and the Board believes that the ABOS MOC process upholds its motto of doing the right thing, both for orthopaedic patients and for ABOS Diplomates. In addition, MOC is more than a test, with professionalism being a major part of the process to allow a Diplomate to continue to be Board Certified by the ABOS. When seeing an ABOS Board Certified Orthopaedic Surgeon, whether in 1934 or 2024, patients know that the surgeon has the requisite knowledge, skills, and behavior.

The ABOS continues to adapt. In 10 years, what is going to be written in the article about the ABOS’s 100th anniversary? How will artificial intelligence impact ABOS Board Certification and orthopaedic surgery? How will the ABOS KSB impact residency education? No matter what changes, orthopaedic surgeons and patients can be sure that the ABOS will continue to do the right thing.

Frederick M. Azar, MD, is chair of the ABOS 90th Anniversary Task Force.

James D. Kang, MD, is president of the ABOS.

David F. Martin, MD, is executive director of the ABOS.

David Elstein is manager of education and communication for the ABOS.

Reference

1. DeRosa GP: Seventy-Five Years of Doing the Right Thing: A History of the American Board of Orthopaedic Surgery. Chapel Hill, NC: American Board of Orthopaedic Surgery; 2009.