ABOS Part I: Why Are More Residents Struggling (and how to prevent it)

The ABOS Part I results are out.  And this year, the results are looking bad.  While we await official statistics from ABOS, this year is reported to have a substantially higher failure rate.  The highest reported failure rate was in 2011, with 21% of first time test takers unsuccessful.  And this year seems to be worse!

Historically, most first-time examinees have passed Part I. ABOS reports that the first-time pass rate has ranged from 92% to 98% over the past five years. In one published analysis, pass rates among examinees linked to the prior year's OITE were 92.9% in 2021, 98.1% in 2022, and 98.4% in 2023.

There has been considerable discussion among residents and educators about whether the failure rate is now increasing. And it raises an interesting question: Why?

Some Possible Explanations

The COVID effect. The residents graduating in 2026 were medical students during the height of COVID and entered orthopaedic residency in 2021. Disrupted clinical rotations and altered educational experiences early in their training could have produced small knowledge gaps that only become apparent on a comprehensive examination years later.

Question-bank recognition versus true understanding. Completing thousands of questions is not necessarily the same thing as mastering orthopaedics. Once you've seen a question several times, getting it right may test recognition more than knowledge.

We may be starting too late. Perhaps the most important explanation is also the simplest: too many residents think of board preparation as something that begins during PGY-5.

Earlier subspecialization. Residents increasingly develop strong interests in sports, joints, trauma, hand, spine, or other subspecialties well before graduation. Meanwhile, Part I remains an examination of general orthopaedics and basic science.

There is simply more orthopaedics to know. Our specialty continues to expand. New techniques, implants, classifications, imaging modalities, and evidence are continually added to an already enormous body of knowledge.

Is There a COVID Effect?

The timing is certainly interesting. The residents taking Part I in 2026 generally began residency in July 2021. Their medical school clinical education occurred during the COVID pandemic, when rotations, operative exposure, conferences, and traditional educational experiences were disrupted across medicine.

Does that mean COVID caused a higher ABOS failure rate? Absolutely not - we do not have evidence to make that conclusion. But it is reasonable to ask whether educational disruptions early in medical training can leave small gaps that become visible years later when someone is tested across the entire breadth of orthopaedics.

It will be interesting to see whether this proves to be a one-year phenomenon or persists across several graduating classes.

Doing Questions Isn't the Same as Learning

Question banks are incredibly valuable. But there is a trap.

Imagine that you've completed a question bank twice. On your third pass, you see a radiograph and immediately remember: "Oh yeah - I remember this question. The answer is C." You got it right. But did you actually know the material?

There is an important difference between recognition and retrieval. True learning means being able to encounter a clinical situation you haven't seen before, retrieve the relevant information, and apply it correctly. That is much closer to what Part I is asking you to do.

Don't just ask: "Did I get the question right?" Ask: "Could I explain why the other four answers are wrong?"

That is a much better measure of whether you have mastered the material.

Don't Let Your OITE Score Give You False Confidence

The OITE is an extremely useful benchmark, and there is now a formal linking effort between AAOS and ABOS. The organizations place common questions on the OITE and Part I to estimate an OITE score corresponding to the Part I passing standard.

A recent study of 2,247 residents found that achieving the linked OITE threshold was highly predictive of subsequently passing Part I. That's reassuring - but don't aim for the line. We await detailed correlations from ABOS, but scoring above the linking threshold may give a false sense of security.  Whereas those residents who are below the threshold develop a sense of concern and put forth more study efforts.

If your OITE performance suggests that you are probably going to pass Part I, that's very different from being comfortably prepared for Part I.

Build a margin of safety.

Are We Becoming Too Subspecialized?

There is another possibility that has nothing to do with COVID. Orthopaedic residency has become extraordinarily subspecialized.

By PGY-4 or PGY-5, many residents know what fellowship they are pursuing. A future sports surgeon may spend enormous amounts of time thinking about ACL reconstruction, shoulder instability, and rotator cuff tears. A future arthroplasty surgeon may know every nuance of spinopelvic mobility and revision total hip arthroplasty.

But Part I doesn't care what fellowship you're doing.

The ABOS blueprint covers general principles, spine, upper extremity, lower extremity, pediatrics, and neoplasms. The examination contains approximately 320-330 questions and is designed to test both knowledge and the application of that knowledge to clinical problems.

You still need to remember pediatric deformity, tumor pathology, brachial plexus anatomy, metabolic bone disease, scoliosis, hand anatomy, biomechanics, and everything else you learned years ago.

We may be becoming better subspecialty surgeons while simultaneously becoming less prepared for an examination of general orthopaedics.

A Better Way to Think About the Boards

The goal of residency isn't to produce residents who can memorize enough facts during PGY-5 to pass an examination. The goal is to produce knowledgeable orthopaedic surgeons. Fortunately, those goals largely overlap.

ABOS explains that its Part I blueprint is developed with orthopaedic subject-matter experts, including residency program directors, and is periodically updated to reflect changes in practice. Questions undergo multiple levels of review, and psychometric analysis is used after the examination to evaluate question performance and account for differences in examination difficulty from year to year. ABOS does not predetermine how many candidates will pass.

So rather than asking, "When should I start studying for boards?" ask a different question: "How can I use the next five years to learn orthopaedics?"

Learn the material on the rotation when you have patients to attach it to. Read about tomorrow's cases. Do questions throughout residency. Pay attention to your OITE weaknesses. Go back and review material you haven't seen in several years.

Then, when PGY-5 arrives, board preparation becomes what it should be:
REVIEW RATHER THAN RESCUE.

The Most Important Lesson: Start Early

This is the message I want junior residents to remember.

You should not begin studying for ABOS Part I during PGY-5.

You should begin studying for Part I during PGY-1.

That doesn't mean an intern should sit at home every night reading a board-review book for three hours. It means changing the way you think about residency.

Every rotation is board preparation.

If you're on pediatrics, learn pediatrics now.

If you're on tumor, learn tumors now.

If you're on spine, learn spine now.

When you leave a rotation, you may not see some of that material again for two or three years. The resident who learns each subspecialty well while actually rotating through it has a tremendous advantage over the PGY-5 trying to relearn five years of orthopaedics in three months.

Read Around Your Cases

One of the best ways to learn orthopaedics is remarkably simple: read about the patients you are taking care of.

If you're fixing an ankle fracture tomorrow, don't just memorize the steps of the operation. Read about ankle fractures. What are the Lauge-Hansen patterns? When should you stress the syndesmosis? What are the indications for fixation of the posterior malleolus? What structures are at risk with your approach?

Cases give information context. Information attached to an actual patient is much easier to remember than information encountered randomly in a textbook.

Do Questions Throughout Residency

Don't save question banks for PGY-5. Questions are one of the best ways to identify what you think you know but actually don't know.

Ten questions a day doesn't sound impressive. But 10 questions/day x 300 days/year = 3,000 questions/year.

Over several years of residency, that becomes an enormous amount of retrieval practice. More importantly, questions expose your weaknesses early enough to fix them.

Resources Worth Using

ABOS Part I Blueprint - Start with the source. The ABOS Part I Blueprint tells you what the examination is designed to assess and can be used to guide education and examination preparation.
https://www.abos.org/certification/part-i/blueprint/

Orthobullets - Particularly useful during residency because it can be incorporated into everyday clinical learning: see a diagnosis, read the topic, then answer the questions.
https://www.orthobullets.com/

AAOS ResStudy - Provides thousands of questions drawn from AAOS self-assessment examinations and allows residents to create customized quizzes, take simulated examinations, and review explanations and recommended readings.
https://www.aaos.org/education/examinations/ResStudy

AAOS Resident Orthopaedic Core Knowledge (ROCK) - Provides a structured curriculum across orthopaedic subspecialties and is useful for residents who prefer systematic study rather than jumping from topic to topic.
https://www.aaos.org/education/resident-orthopaedic-core-knowledge/

JBJS Clinical Classroom - Uses adaptive learning and assessment probes across orthopaedic subspecialties, including material useful for OITE and ABOS Part I preparation.
https://clinicalclassroom.jbjs.org/residents-and-resident-directors/

OITE - Treat the OITE as your annual diagnostic test. Review subspecialty performance, identify weak areas, and use the score report to create a study plan for the following year.