The Question Every ABOS Examiner Asks: “What Happens Without Surgery?”

You've just finished presenting your surgical case. The examiner looks at you and asks: “What would have happened if the patient did not have surgery?”

This question — about the natural history of disease — is one of the most frequently asked questions on the ABOS Part II oral examination. And it catches more candidates off guard than almost any other.

Why Examiners Ask This

The ABOS scoring rubric includes a category for Surgical Indications. At the expected level (score of 2), the examiner needs to see that non-surgical treatment was considered and that the surgery was sufficiently indicated based on the workup.

Asking about natural history tests whether you truly understand why surgery was necessary — not just that you performed it. A surgeon who operates without understanding what would happen without intervention is a surgeon who may be operating unnecessarily.

The examiners want to hear that you made a deliberate decision to intervene — one based on understanding both the surgical and non-surgical paths.

What a Strong Answer Sounds Like

A strong answer to this question has three components:

1. The natural progression. What would the patient's condition look like in 6 months, 1 year, 5 years without intervention? Be specific about functional decline, pain trajectory, or structural deterioration.
2. The conservative alternatives. What non-surgical options exist? Physical therapy, bracing, injections, activity modification, watchful waiting. Show that you considered them — and explain why they were insufficient for this particular patient.
3. The decision point. What specifically tipped the balance toward surgery? Was it failure of conservative management? Progressive deformity? Functional limitation that non-operative treatment couldn't address? This connects your understanding of natural history to your surgical decision.

What a Weak Answer Sounds Like

• “The patient would get worse.” — Too vague. Worse how? Over what timeframe? The examiner wants specifics.
• “Surgery was indicated based on the imaging.” — This doesn't answer the question. Imaging findings alone don't justify surgery — clinical correlation with the patient's symptoms and functional status does.
• “I don't know what would happen without surgery.” — This is honest, but it's a significant gap. If you don't understand the natural history, how did you justify the intervention?

How to Prepare

For every case in your submitted list, you should be able to articulate the natural history of the underlying condition. Since case selectors assign your 12 exam cases from your submitted list, you need this answer ready for every submission — not just the ones you'd prefer to present.

Key preparation steps:

• Review the natural history for each diagnosis in your case list. What does the literature say about untreated progression? What do you see in your own clinical experience?
• Practice answering this question out loud. During mock oral exams, have your practice examiner ask “What if you didn't operate?” for every case. Make your answer automatic.
• Connect it to your surgical decision. The natural history answer should flow naturally into why surgery was the right choice for this patient at this time.

Beyond Natural History

This question is part of a broader pattern: the examiners are testing whether you're a thoughtful, deliberate surgeon — not one who operates reflexively. Every aspect of the scoring rubric rewards clinical judgment over technical aggression.

Understanding natural history demonstrates that you see surgery as one option among several — chosen deliberately when the evidence supports it, not as a default response to every pathology.