The History of the ABOS Part II Oral Examination

Every July in Chicago, approximately 800 orthopaedic surgeons sit for what many consider the most demanding exam of their careers: the ABOS Part II oral examination. The exam has been part of the board certification process for decades, and its format — live, face-to-face, case-based — has remained remarkably consistent even as orthopaedic surgery itself has transformed.

The Mission of the ABOS

The American Board of Orthopaedic Surgery was founded to establish and maintain standards for orthopaedic surgery certification in the United States. As one of the member boards of the American Board of Medical Specialties (ABMS), the ABOS oversees a two-part certification process: Part I, a written examination testing fund-of-knowledge, and Part II, an oral examination testing clinical judgment and decision-making.

The Part I exam is a prerequisite. Candidates must pass it before becoming eligible for Part II. But while Part I tests what you know, Part II tests how you think under scrutiny — and that distinction is what makes the oral boards uniquely challenging.

How the Exam Works

The Part II oral examination is structured around four 30-minute testing periods. Each period is conducted by two examiners. Between periods, candidates receive 5-minute breaks. The entire exam takes place over a single day.

Preparation begins months before exam day. Candidates submit their surgical case lists through the ABOS Scribe system, an online platform where they document cases performed during their practice period. Case selectors — appointed by the ABOS — then review these submissions and assign 12 cases that the candidate must be prepared to discuss in detail.

During the exam itself, examiners walk candidates through their assigned cases and may introduce additional clinical scenarios. The conversation covers indications, surgical technique, complications, alternative treatments, and clinical reasoning. Examiners probe not just for correct answers, but for the candidate's ability to think through problems systematically.

The Scoring Rubric

Each case is evaluated across nine categories using a 0–3 scoring scale. These categories assess different dimensions of clinical competence, from data gathering and diagnosis to treatment planning and complication management.

The rubric is designed to reward structured clinical reasoning — not rote memorization. A candidate who demonstrates a sound thought process but arrives at a slightly different conclusion can score well, while a candidate who gives the “right answer” but cannot explain their reasoning may not.

This is a critical distinction that many candidates underestimate. The scoring system explicitly values how you arrive at your answer, not just the answer itself.

The 2022 Failure Rate

In the 2022 examination cycle, the ABOS reported a 17% failure rate for Part II — the highest in recent history. That number sent a ripple through the orthopaedic surgery community. Nearly one in five candidates, all of whom had completed residency and passed Part I, did not pass the oral boards.

The reasons behind the spike are debated, but the number itself underscored something that experienced surgeons have long understood: knowledge alone is not sufficient. The oral boards test a different skill set than any written exam, and candidates who don't prepare specifically for the oral format are at risk regardless of how much they know.

How the Exam Has Evolved

While the core format of the Part II exam has remained relatively stable, the context around it has shifted significantly. The case submission process moved to the electronic Scribe system, replacing earlier paper-based methods. The types of cases seen in practice — and therefore submitted for examination — have evolved with advances in implant technology, minimally invasive techniques, and subspecialty care.

The candidate pool has also changed. With increasing subspecialization in orthopaedic surgery, candidates today may have deep expertise in one area but less breadth across the full scope of orthopaedic practice. The oral boards, however, still require candidates to demonstrate competence across their submitted case mix — which means preparation must address potential gaps in breadth, not just depth.

The Shift Toward Composure

Perhaps the most significant evolution in ABOS Part II preparation has been the growing recognition that composure under pressure is a trainable skill, not just a personality trait. The candidates who fail aren't typically the ones who know the least. They're the ones who freeze when challenged, argue with the examiner, or spiral after a difficult question.

Modern preparation approaches have shifted accordingly. The emphasis is less on memorizing more material and more on practicing the performance itself — presenting cases clearly, handling pushback calmly, recovering from stumbles, and maintaining composure across all four testing periods.

This mirrors what we see in other high-stakes performance domains. Surgeons don't just read about procedures; they practice them. Athletes don't just study game film; they train under pressure. The oral boards are no different. Preparation that doesn't include realistic, pressure-tested practice is fundamentally incomplete.

The Core Mission Endures

Despite all the evolution in format, technology, and preparation methods, the fundamental mission of the ABOS Part II remains unchanged: to ensure that board-certified orthopaedic surgeons can demonstrate sound clinical judgment under direct scrutiny. It's a high bar, and it should be.

Understanding the history and structure of the exam is the first step toward preparing for it effectively. The candidates who perform best are the ones who respect what the exam actually tests — not just knowledge, but the ability to think clearly, communicate effectively, and maintain composure when the pressure is on.