The American Board of Orthopaedic Surgery Response to COVID-19

The nation and its healthcare providers have entered an unprecedented era of healthcare delivery. Although local disasters such as floods, earthquakes, hurricanes, and tornadoes have impacted segments of our country, no currently practicing physician has ever before experienced a national pandemic of the magnitude and severity of the COVID-19 crisis. Thus, we have never before had to acknowledge and evaluate the impact that a pandemic of this type will have on Graduate Medical Education and Board Certification. The primary concern of the American Board of Orthopaedic Surgery (ABOS) is protecting the public while also ensuring the well-being and competency of orthopaedic surgeons because we treat and suffer from this disease. We applaud the extraordinary efforts being made by our nation's healthcare professionals including many of our ABOS Diplomates and Candidates. We recognize that our focus in the near term will remain on the global crisis from both the professional and personal standpoints. The primary objective for our residents, fellows, and Diplomates should be to safely and successfully manage our families, patients, practices, and hospitals through this crisis collaboratively across all specialties. The ABOS will make every attempt to allow physicians to focus on the needs of their community and minimize the impact on their ABOS Board Certification processes. We are committed to flexibility in all our programs because we fight through the challenges ahead.

The Board appreciates and fully supports innovative approaches across our profession to maintain the educational process and content. We recognize that, despite these efforts, there remain real disruptions to education. We also recognize that there may be continued future disruptions depending on the time course of this pandemic. The Board will continue to carefully evaluate every step of our Certification processes and will remain flexible in this ever-changing environment while maintaining our historically high standards. In evaluating the basis of the ABOS response, the Board has been driven to remain true to our mission statement:

To ensure safe, ethical, and effective practice of orthopaedic surgery, the ABOS maintains the highest standards for education, practice, and conduct through examination, certification, and maintenance of certification for the benefit of the public.

ABOS Residency Education Requirements

The current ABOS time requirements to complete residency education and be considered potentially eligible to take the ABOS Part I examination include the following:

• (1) Sixty months of Accreditation Council for Graduate Medical Education (ACGME)–accredited residency education

• (2) Forty-six weeks of full-time orthopaedic education per year (maximum 50 weeks)

Changes were instituted in July 2018 so that the 46 weeks of education is now averaged over a five-year program to allow for extended absences. The ability to average time away from education year over year was designed to provide flexibility for extended absences, including illness and paternity/maternity leave. This policy may allow for an ability to deal with time loss secondary to the viral pandemic and potential quarantine or illness issues. If the COVID-19 crisis follows a time course that is not prolonged, residents should be able to meet these time requirements without extending their residency training period. If that is not possible, the ABOS is committed to working with Program Directors on a case-by-case basis.

Regarding specific educational content requirements, the postgraduate year one (PGY-1) presents the most specific requirements with the least time within which to adapt and respond to recent disruptions in rotations. The ABOS is committed to working with Program Directors because they look for innovative ways to approach these issues as they arise over this year and next year.

The PGY-2 to 5 educational requirements are as follows:

• (1) Forty-six weeks adult orthopaedics

• (2) Forty-six weeks of fractures/trauma

• (3) Twenty-three weeks of children's orthopaedics

• (4) Twenty-three weeks of preclinical and/or clinical specialties

• (5) Forty-six weeks at the discretion of the Program Director

These experiences, spread over 4 years, should allow residents and Program Directors the opportunity to accommodate for deficiencies that may result from the current crisis. Once again, the ABOS will remain flexible in responding to individual challenges, as identified by Program Directors. Recognizing that other groups (ie, the ACGME) evaluate educational standards, we defer to them regarding their response to overall program requirements. This will be pertinent for program surgical case experience minimums. The ABOS currently does not have specific surgical case number requirements.

The current priority must be to support our institutions in dealing with the COVID-19 pandemic—that priority presents not only unique educational challenges but many educational opportunities as well. We will work with Orthopaedic Residency Program Directors as this situation continues to evolve to better understand innovative ways to meet educational requirements. Our goal is that the experience of the current group of residents and fellows should be marked in a positive way obtaining valuable educational experiences while appropriately responding to the pandemic both personally and professionally.

ABOS Part I: Written Examination

The ABOS Part I computer-based written examination is scheduled for July 9, 2020. It is scheduled to be delivered via Prometric Testing Centers. Currently, those centers are closed. The ABOS is developing alternatives should the centers remain closed past that date. Possible options include consideration of alternative testing centers, different delivery methods, or delaying the examination date. The ABOS remains committed to delivering the examination before the end of 2020. If residents believe that the uncertainty that our current status creates is too challenging to plan for a successful examination; they will certainly have the option to defer the examination until 2021.

ABOS Part II: Practice-Based Oral Examination

The ABOS Oral Examination, traditionally delivered in the Palmer House Hilton Hotel in Chicago, IL, presents a unique set of issues in examination delivery. The Oral Examination consists of four 25-minute case-based question and answer sessions delivered by four pairs of examiners. It uses an immense amount of information, including examinee-specific uploaded medical records and imaging. Although we hope we can deliver the examination in its usual format during the third week of July, the ABOS Oral Examination committee is exploring all options, including alternative dates and formats.

The impact that the pandemic will have on case numbers during this calendar year may impact candidates who began case collection on April 1, 2020, in preparation for the 2021 ABOS Part II Oral Examination. In light of this potential issue, the ABOS has modified its approach for the 2021 Case List collection process. This modification was designed to help those individuals whose practice caseloads have been negatively affected by the pandemic, ensuring each Candidate every opportunity to reach the caseload minimum and effectively represent their typical practice pattern. Based on the past year's applicant case logs, we estimate that more than 200 candidates would have failed to meet the minimum number of surgical cases performed in 6 months (35) to be eligible to sit for the examination. Thus, the case collection period has been expanded to make up for low volume months. The case collection period will be back dated to January 1, 2020, and extended until September 30, 2020. Starting with the first day in January, Candidates must collect and submit all consecutive surgical cases that they perform as primary surgeons for a minimum of six consecutive months. At that point, if the candidate has reached 250 or greater surgical cases, they can cease collecting. If not, they will continue to collect until 250 cases or the date September 30 is reached, whichever comes first.

ABOS Continuing Certification

The variety of options available for ABOS Recertification offers flexibility for the practicing ABOS Board–Certified Diplomate. The ABOS Web-Based Longitudinal Assessment (ABOS WLA), which was introduced in 2019 and has been used by more than 9,500 Diplomates, remains an option this year and may be appealing to those Diplomates who have experienced a practice slow-down secondary to the pandemic. Orthopaedic surgeons have reached out to the ABOS offices inquiring as to opening the ABOS WLA Assessment window sooner than the expected date April 15 so that they could begin answering the assigned questions for their 15 Knowledge Sources. In response to the pandemic and our Diplomates' needs, we extended the time to participate by opening the examination window earlier (April 1, 2020) and making it available until June 1, 2020. Our desire is to let Diplomates complete this now while potentially not as busy as we hope to be again later in the spring.

In addition, Marc Swiontkowski, MD, and the Journal of Bone and Joint Surgery have graciously provided four new ABOS WLA Knowledge Sources focused on the COVID-19 pandemic that have been fast-tracked through the editorial process.^1,2,3,4 Diplomates may want to select these for your review to add to your understanding of this healthcare challenge.

ABOS Diplomates preparing and planning to take one of our nine practice-profiled computer-based test later this year need to monitor the ABOS website and e-mail messaging because we hope to deliver those examinations on time and in normal fashion. The exception is the oncology examination because it has not yet been created.

Diplomates who are planning to recertify via the practice-based ABOS Oral Recertification Examination this summer (July 20, 2020) similarly will be messaged regarding any need for change when the Board has determined the time course of the pandemic and the safety and ability to travel to Chicago for the examination.

Given the 10-year cycle of continuing certification, many ABOS Diplomates are not at a point in their cycle when they need to use any of these examination or assessment options, but the ABOS encourages participation in Self-Assessment Examinations and Continuing Medical Education activities during this time. Lifelong learning and maintaining competence remain even more critical during times of crisis. We encourage everyone to take advantage of the many opportunities for education offered by the American Academy of Orthopaedic Surgeons (AAOS), our subspecialty societies, JAAOS, JBJS, and other journals during this period.

Summary

The first and foremost concern for the ABOS is the safety of patients and healthcare professionals while they work to end this pandemic. ABOS Board Certification (both initial and recertification) must retain its value in reassuring the public as to the quality of our profession. The ABOS is dedicated to accomplishing these goals by embracing flexibility in these challenging times while maintaining the standards we have followed since 1934. As Paul DeRosa so aptly reminded the Board during his many years as Executive Director“Do the right thing⁵ and this has served the ABOS well for 85 years,” we will continue to follow this mantra as we work with all of our stakeholders moving forward.

The current crisis will continue to have a profound and disruptive effect on all of us and all of our programs. However, this time offers us opportunities to be flexible and innovative, to learn in ways that many of us have never learned before. We need to respond to the challenge and use it as a period of growth. We need to, as Program Director Joseph K. Weistroffer, MD, stated in a recent presentation, likening our situation to an airplane in distress, “follow the rules until we cannot and then do what we need to do to land the airplane.”⁶ Once we are on the ground safely, we can be flexible in how we move forward. We need to continue to learn through adversity and make this a period of time that adds value and meaning to those involved, taking advantage of every opportunity to learn and improve. We are defined by our response to crises.

John R. Potts III, MD, recently said this about the current pandemic:⁷

“…there are opportunities that are truly unique, at least in our lifetimes. In coping with this historic challenge. Residents/fellows and faculty members will witness the value of preventive care and coordinated public health systems. They will, by necessity, grow through interdisciplinary and interprofessional teamwork in ways never before possible. They will experience in real time the extreme boundaries of systems-based care. And, they will develop deep, lifelong friendships that are born through mutual adversity. When this passes, as it inevitably will, our world will be changed. But, our health care systems, our programs, and each of us will be better on the other side.”

The ABOS pledges to be flexible and understanding as our Diplomates strive to “do the right thing.” We recognize that many questions will arise during the next few months. The dedicated ABOS staff remain committed to helping you while also maintaining safe standards of working from home and social distancing. To reach our staff, you can call the ABOS office or e-mail your personal certification specialist. Please be safe as we fight this pandemic. Our patients need us now but will need us even more so when the pandemic has cleared.