Friday, January 30, 2015

It's that time of year again

Hopes are high; everyone is prepared; all the talk is over. The big day is finally here.

No, it's not about the Super Bowl. It's about the American Board of Surgery In-Training Examination (ABSITE).

Every year at the end of January, all surgical residents take a five-hour, 250 question multiple-choice test. For many, it can be a watershed moment because their careers may be on the line.

I have written about the use of the ABSITE as a criterion for resident promotion. Whether you think it should be or not, it is used that way—sometimes as the only criterion. You can bet that in a few weeks, some residency programs will post notices saying they are looking for a categorical PGY-2 or 3 due to an "unexpected" vacancy for July 2015.

Another attending surgeon and I used to take in-house call the night before the examination so that all of the residents could take the test after a decent night's sleep.

Now the test may be given on different days so that the entire group does not have to take it at once.

One difficult situation I faced as a program director was when I had a good clinical resident who just could not do well on a multiple-choice examination. I had to decide whether keeping a resident who scored at the 10th percentile was worth the gamble. Scoring in the 10th percentile or less on a regular basis means that the resident has a good chance of failing the written board examination.

Of course, the very nature of percentiles is that 10% of those who take the test will finish in the 10th percentile or below. Also, the failure rate of the written board examination has hovered around 25% for many years.

The problem for programs is that the Residency Review Committee for Surgery mandates that 65% of a program's graduating residents must pass both parts of the board examination on the first attempt.

Of the many things I do not miss about practicing medicine during this turbulent era, the palpable level of anxiety surrounding the buildup to the exam and waiting for the dreaded results to come back rank high on the list.

I wish all residents who are taking the test the best of luck. I hope you were reading all along and not trying to cram a year's worth of studying into the week before the test.

May you all score above the 50th percentile.


artiger said...

Well, I'm glad to see that faculty members are pitching in to allow for the residents to get properly rested for the exam. We used to just take the thing coming straight out of the OR, or after being up all night. Hardly optimal.

I was one of those suboptimal test takers in residency, but was reasonably good clinically. At least I think I was, as they kept me on for some reason. Maybe because I was a replacement myself. I don't know, but I'm grateful that my PD looked beyond my test scores.

Anonymous said...

Anonymous Europe: Surgery as a multiple choice test.... sounds crazy. Sorry guys, but do you really think that in our profession this is the best way to evaluate residents? What about hand-craft? What about initiative? What about being able to assess a patient correctly? I am pretty sure you can not really measure these things with some multiple choice test... The other thing (this may be very European): residents work over 80 hours a week in the hospital (or so they tell me). When are they supposed to learn for this exam?
Another thing (again very European): I love my job, I truly do (I am the one with a huge bunch of documented call hours usually, thanks to my US work training for which I am utterly grateful!) But what about private life? I also learn at home for the operations and look things up but this sounds pretty crazy to me....

Anonymous said...

All I have to say is my prayers are with you all. At the same time ... a surgeon getting a MCT? Totally agree on the hand dexterity and the like being on a surgeon exam. Patients care that their hands are steady and can find their rectus abdominus from their gluteus maximus. You know what I mean???

Skeptical Scalpel said...

Good comments but how else would you assess resident knowledge? There are about 6000 categorical residents in the US. You can't interview them all or watch all of them take care of patients or operate. There is much more to surgery than operative skill.

Anonymous said...

Brilliant last sentence, "May you all score above the 50th percentile." Well put.

Skeptical Scalpel said...

Thanks for the kind comment. It's nice when someone appreciates one's work.

alphadoc1 said...

Quick question concerning ABSITE...just rec scores however I received my score report with a different ID # than my SS#???

Any comments on how to proceed?

thank you

Skeptical Scalpel said...

The ABS shouldn't be using your SSN for identification. You should ask you program director to contact the board on Monday and ask them to clarify the situation.

Anonymous said...

So in the long term what happen to your residents who scored below the 50th percentile that were good clinical residents? Did you give them another chance to see if they improve in yr 2? If they did not improve on absite in yr 2, did you have to let them go? I just have a hard time imagining that a surgical resident after going through undergrad and med school, taking usmle step exams would find themselves struggling on a MCT. It has to be a combination of anxiety and lack of preparation for those in the bottom 25 percent, am I wrong? I figure if you are prepared and you have anxiety you would be capable of at least being in the top half in the country. I use to get nervous during exams in my medical career, but knew I had to step up my preparation to the max to overcome any anxiety for that day. I am not a surgeon though. What is considered not failing on the absite, being in the top 60 percent of students?

Skeptical Scalpel said...

I never used the 50th percentile as the cutoff. People who scored in the single digits were warned and given remedial work and extra tests in order to prepare better. It usually didn't work. Two years in the double digits and I had to let a few go.

Everyone cannot score well on the in-training exam because by definition, 50% of residents will be below the 50th percentile and 10% will be below the 10th percentile.

Here's a link to a post I wrote about why it was so important for residents to score well on the exam --

Anonymous said...

Very interesting, thanks. I did read the other link you provided and the comments. Just out of curiosity, what happen to the residents who get fired? Is it true most become residents in anesthesia and Emergency? I read other comments in the other post. I found it interesting that a surgical resident wanted to know the accountability with a program: teaching, seeing cases, etc. I found he/she comment interesting, but then I thought if we had in training exams in IM would we be able to teach very broadly in the first year. With lack of time and the patient population increasing every year, its almost impossible. So I say the resident gots to read and cover all the material. Second, I feel like a resident has to research a program when applying. Usually it is no secret how a program prepares a resident, so you cannot say after the fact oh they didnt prepare enough, I didnt see a particular case that was covered on the case, etc.

Skeptical Scalpel said...

There's not a lot of data on what happens to residents after they are let go. Some go into anesthesia, but emergency medicine has become very competitive these days.

It would be a great research project to find out where they end up, but it would be difficult to identify and track them.

Anonymous said...

Absite 2016: PGY 3 bell curve: truly shocked! a difference between 6% questions correct correlated with 41 percentile of a difference! I am looking at all 3 years scores below the 50th percentile and although a good clinical decision maker, am afraid that my career is in serious jeopardy.
I am trying to decide between applying for
Want to be a general surgeon with something additional to bring to the table.

1) any advice on choosing between these fellowships keeping in mind that I want to operate and have a good lifestyle too

2) with terrible absite percentile scores are my fellowship chances ruined? what now?

Skeptical Scalpel said...

Of the three fellowships you are considering, trauma/CC/ACS is probably the easiest one to obtain. It features a lot of operating, some or most of which is after hours which could impact your lifestyle. The other two fellowships generally involve fewer emergencies. As far as I know minimally invasive fellowships are numerous and unlike the other two, have no oversight by an accrediting body.

If what you say is correct about the 41 percentile difference for 6 wrong answers, that's a big penalty to pay. I don't know how to reconcile that. You didn't mention your actual scores. Three years below the 50th percentile may not necessarily be a disaster. There's a big difference between a score in the 35th percentile and one in the single digits. The latter could be a big problem. Also if the trend is steadily downward, that's not good.

My advice would be to apply to many programs in whichever subspecialty you would like to do. You can tell by the number of interviews you get what your chances would be.

Good luck.

Anonymous said...

Hi Surgical Scalpel,
I'm a pgy 3 resident with below average absite scores (under 50). I'm a categorical at a community program and am doing well clinically. Worried about fellowship applications. I like almost all my rotations. At this point my goal is simply to complete a fellowship. May I ask, what options and where would the best odds of matching into a fellowship be for a less competetive candidate?
Mis, trauma, transplant?
I'm sorry for the general question and thank you in advance.

Skeptical Scalpel said...

Go to and click on New! NRMP Results and Data Specialties Matching Service, 2017 Appointment Year, a report summarizing all fellowship Matches.
Go to Page 31 and you will see the results of the subspecialty matches run by the NRMP. You should browse the next several pages too.

Critical care and transplant have the lowest percentage of US grads and positions filled. MIS, straight trauma, and acute care surgery matches are managed differently. I don't have any figures for them. You should be aware that the latter three are not recognized by the American Board of Surgery so you can't become certified in them.

You may want to talk to your program director or chairman and get their opinions.

I hope this helps.

Anonymous said...

Hello Skeptical Scalpel!

Do you know any programs in the US that would allow non-resident members to take the Absite with them?

Thank you for your help!

Skeptical Scalpel said...

Sorry. I am not aware of any programs the would.

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