Okay, so we're going to get started just because of time constraints. So first I'd like to welcome everyone to tonight's webinar hosted by the American Orthopedic Society for Sports Medicine, and the webinar is titled ABOS Part 2 Board Preparation. So I am Ryan Roach. I'm one of the assistant professors of orthopedic surgery at University of Florida and also one of the team physicians. And I am a ABOS certified surgeon that specializes in sports medicine. And again, I want to thank everyone for joining tonight. Okay, so before we get started, we have to, these are the disclaimers and they're here just to review and also all of our faculty disclosures, again, just there for you to review. And so besides thanking AOSSM for hosting us, I want to thank our great panelists for joining us this evening. And we really do have a spectacular crew besides being all-stars in orthopedic surgery. They're also really recent graduates of the ABOS, and actually some of the presenters are still within the board collection period. So we have a lot of good opinions here and a lot of good people to help answer questions. So to introduce everyone, we have Dr. Michelle Kew, and she's currently at Hospital for Special Surgery where she's an assistant professor and specializes in sports medicine. We have Dr. Jon Wright, who is my partner here at University of Florida, and he also is part-time at the VA. So we have, if you have any questions about the VA and board collections, he's here to help us with that. We have Dr. Ryan Rauck, who is the assistant professor of orthopedic surgery at The Ohio State University and specializes in shoulder and sports medicine. And then Dr. Spencer Stein from NYU, and he specializes basically in everything. So shoulder, elbow, hip, and knee injuries. Okay. So the goal of tonight, we're going to give you some brief presentations and then really open it up for question and answers. So use the question and answer tab to submit your questions and I'll sort through those and we'll help get those answered. So I'm going to give you a brief intro. Now, you guys are all within your collection period. If you're sitting this year, some of you may not. The biggest change is that the start date for the ABOS part two has gone back to January instead of what most of us have dealt with. So the goal of the part two is stated on the ABOS website is really to assess a candidate's practice. It's not to change your practice. It's really just to assess it. It gives the applicant an opportunity for self-evaluation. As part of it, you have to submit your case list. And at the end of your collection, you will actually get a report in terms of feedback and how your case list number of cases, number of complications compares to everyone else in the country. And so you get some feedback on that. And obviously the case list is then the basis for your 12 selected cases. So the rules, I have these here. I'm not going to go through them. They are on the ABOS website. Obviously there are rules to sit for the boards and they are very specific. And I do recommend reading through those. Obviously to sit, you have to be eligible. So you want to make sure that you go through the rules. And same with the calendar. The calendar is here just to reference. Now, most of you on the webinar are probably within board collection. I think the biggest change here is that instead of the April start date for us, the new start date has been pushed to January. And so this is the first year that it was scheduled to do that. Some of us during COVID had it forced upon us. So this may be something the board does in the future. I guess we have to wait to see, but at least for this year it is, it has already started. And again, there are associated fees. You do have the opportunity to submit things late. However, again, there will be a penalty associated with that. I think the biggest takeaway from my slides is make sure you check out the ABOS website. You see here that basically part two is broken down into every section. And they actually really do have great resources on the website, including their video. This is the video for 2025 applicants. And so it's over an hour and a half and they go through a great Q&A and there's a lot of useful information. So I'd recommend everyone read that. The scoring rubric, I also think this is really important for you to look at. I think there's a lot of anxiety around the boards. And when you sit down and actually look at what they're testing you on, I think this can make you feel a lot, a little bit better. So most people think that it's about the actual surgery they do and whether or not they have complications. Well, if you look at the scoring rubric, those are only two points out of eight. And even having a complication, it's not about, you're not going to get a zero just for having a complication. If you manage the complication well, you're still going to get points for that. And so it really isn't just about doing surgery and avoiding complications. It's more about the thought process, making sure that you're organized, that you're documenting appropriately, and that you're doing a good surgery. If you do have complications, you're handling appropriately and you're using up-to-date medical knowledge. So the ABOS does publish their pass rates. I think this has also been a point of anxiety for many people, including me, because I sat during a time when the failure rate was a little higher. Historically, the passing rate was in the nineties. And then recently we've seen a drop-off 2022 is one of the lowest. And now in 2023, we see it increasing. And on the ABOS webinar, they did ask about this and really no one knows why yet, but the ABOS is looking into that. And so besides the ABOS, there's a ton of other resources. But like my first bullet suggested, ABOS is really your place to go. If you have questions, you can email them. They're very receptive and everyone's practice is a little different. And the rules certainly, you know, there's questions about how those rules apply to your practice. So just make sure you check that out. Obviously there's webinars and the AOS has board preparation courses. And I think the other big point or area to look to is your colleagues. And so as you get ready, you want to practice with faculty and also people that are going through it as well. This is just from AOS Now, just 13 tips for passing. Some of them are a little much, I've highlighted what I think is important. Do indicated surgeries, document well, follow up. So make sure that you try to follow up with your patients. If you can't obtain follow-up, we'll kind of go through some tips on that. Make sure that you document surgical consent and don't give the board examiner too much information because that just leads to more questions. Okay. Thank you. Thanks, Ryan. So I'll be taking over and talking more towards the people who are currently collecting, talk about the application process, how to fill out the form online, and then how to finalize your case list. So like I said, a little bit going over the application, really how the form looks like online to collect your cases. And then we have to do with the final step to submit everything at the end. So the application is pretty lengthy. A lot of it is inherent knowledge to you, kind of more basic personal demographic information, but some things that they will require. Your current practice locations. They'll want a list of your current partners with your emails. And they also will require five ABOS diplomats in your area. You need to submit their emails. They cannot be your partner. So if somebody, if you live in or practice in a rural area, this can be physicians who refer to you or somebody who's in your area who's not part of your practice. These will be contacted to fill out a peer review form. The application will also require your current and active license information. So making sure you know your initial licensing date, which I found hard to find, and as well as a current expiration date. And they'll also want any current and previous hospital appointments. And this includes locations where you will not or might not have any procedures. They'll want any affiliation with your hospital that you might have any privileges at. And they will need a letter verifying these privileges from your credentialing office. And this is different than your initial appointment letter from when you started your job. This is just a letter verifying that you have privileges at these various sites from your institution. And then you'll also need a list of some head administrative staff with some emails. So starting to get this collected early just because it's hard to figure out who these people are, who's really head of nursing, who's the chief of the ER for this particular site that you might operate at. Making sure you have all that information beforehand is helpful to get the application process going. And then you'll also get the application on time at the end when you're scrambling to get all your cases together as well. So when we move on to collecting cases. So you're going to collect all of your cases in a six-month period. And these are going to be cases where you're the primary surgeon. And I know people have other questions about what does it mean to be a co-surgeon, an assisting surgeon. So when you are the primary surgeon, these are the cases that you will collect. And there's also a list of cases on the AWS website about which ones you should not submit. So bedside INDs, some x fixes, they just make sure that the code is not on that list. If it's something that you're concerned about submitting, there's a very long list of codes that you can search for to make sure that the case you're submitting is actually one that needs to be collected. There's also an AWS HIPAA form that's optional. And then our next talk will touch on how this can become important as you're submitting your 12 cases. There's two different options. You can either consent to every patient that you consent for surgery for use of their HPI or predicate health information in your AWS submission. Otherwise, if you don't get this form signed by the patient when you're submitting your documentation to the AWS for your 12 cases, you'll have to redact your documents. And I think the next talk will touch on that. So I'll let them speak a little bit more about the pros and cons of each option. Another tip that I've heard from other people who are sitting for boards is consider hard copies of all your consents and orthoscopic photos. We have e-consents where I practice, and so those are stored in the chart. But paper consents could get lost and they might not get scanned in or something might happen. So making sure that you have all this documentation, because it will be important once you have to submit these cases if it does get picked. And then the scribe is what they call their case documentation interface. The first thing you'll do is add all the surgery centers that you potentially might operate at. And then when you're doing a case, what I would do is whenever you book somebody or the morning of a surgery, you just add them to your scribe. You'll need the patient's email to complete this form, and this adds them to your case list and then allows you to fill in all the necessary information, the MRN, the ICD-10 code and CPT code associated with your case, and even a small brief description of the procedure. And then we'll go over what the scribe looks like in the next couple slides to show you where all the information that they require you to fill in. And when you submit somebody for scribe, that sends the patient a patient report outcome email that they will fill in as you go along their post-operative course. And so this is what the scribe looks like. Those of you who are currently collecting are probably familiar with it. This is all the information that you require from the ABOS to put for each case. And I highlight the date of last follow-up because this is probably the last data point that you'll fill in as you're finalizing all your follow-ups as you get towards the submission date. And then they'll also ask you about unexpected re-operation within 90 days, unexpected readmission within 90 days, and any different complications, which I'll show. There's a ton of different options that you can pick from. If you're not sure, then I think reporting it is generally what people will recommend, or asking somebody who sat before, like, do you think this qualifies? But I think over-reporting, you're not going to report every little scratch that the patient has around their wound, but any concern for a wound infection, or if it's erythematous on your exam, if there's something that you're worried about, I think it's, people will ask us later what their thoughts are, but I think I've been told it's reasonable to report, and then you can describe it if the case gets picked, and then explain what your thought process was on treating that erythema, and then that can give you some talking points in your case as you walk through how you would deal with the wound infection postoperatively or something similar. And this is just an example. These are all the surgical complications that they have listed, and then once you click the box, you can select the level of, I guess, danger to the patient. Did it require another operation? Was it just a noting of the complication? And then similarly with the medical complications, everything from blood transfusion to death is listed here, and then you'll describe, though there's a section to describe exactly what happened and how you treated the complication. So once all the information is in, you've seen them in clinic, you're nearing the end of your documentation period, you're getting close to finalizing everything. You have to finalize every single detail, and so what I thought was helpful, I just had MyScribe open when I was in clinic, and if somebody came in with a complication, I would type it in there so you just kind of freshen your mind so you don't forget it. And then also the last follow-up date is kind of a pain. You have to make sure that you have their last documented follow-up date, and that's usually, like I said, the last data point that you'll put in as you get closer to submitting. And then finalizing everything, like I said, finalize all your complications, all the follow-up dates, and then really make sure that everything's been entered. If you finalize your case list and you realize that you've forgotten to add a case, you have to email the ABOS to reopen it for you to edit, so it's a little bit of a pain, so just make sure that everything has been entered correctly. And then once you finalize the case list, you'll obtain a signature page for each center that you operate at. This tends to be the longest, kind of most tedious portion, just because you have to wait for someone to respond to you, make sure that they get the correct signature page from the medical records department and send it back to you. So just make sure you start this a little bit on the early side so you're not scrambling with the deadline to get some administrative person at your office to get this signed and sent over to you. And one thing that I think we didn't, some, most people don't, might not know is that you need a signature page even if you perform no cases at a particular site. They want to know, just for documentation purposes, that you did zero cases. It has to be signed by someone from that medical records department just to verify that you in fact did no cases at that site and submit it in addition to your other case lists. And so the ABOS for my session, they'll review your cases between August and April and send you your selected cases April 2025. Yours will be based on your kind of accelerated ABOS start date and then they select 12 cases from this case list and the next talk will go over what to do when those 12 cases are picked and kind of how to move forward from there. Great, thanks Michelle. So yeah, we'll, myself and Spencer will talk about what to do after they pick your 12 cases. And so we'll break this down into uploading your documentation and preparing for the examination and then a little bit about sitting for the examination itself. And so the, the first thing when they give you your 12 cases, you have a few weeks essentially to upload your documentation. So I think whenever they send that out, first thing I would do is go look at those 12 patients and some will have complications. You'll kind of be expecting that they're probably going to be picked, but others, maybe patients that did well and then you'll look back and realize they never came back after their six week post-op. So the first thing I would do is really log on and check your documentation as well as your follow-up for those 12 cases, because if the follow-up is poor, I would reach out to the patient and try to bring them in for an in-office visit or at the very least do a telehealth appointment so that you have some documentation in there that, that you have followed up with this patient longer than, you know, six weeks. And then the uploading the documents is a very cumbersome task. I think especially like the first one you do will take a long time. So definitely dedicate some time to this. There's a lot of good videos on ABOS. It's going to be EMR dependent in my case, and I assume for the majority of people it was on Epic. So I would go through, I would save each note as a PDF. So you basically have to select print, then Adobe PDF, save, open it in Adobe. And if they didn't sign a waiver, so you didn't have permission to use their PHI, you can use this redacted PDF feature on the paid version of Adobe, and it actually makes it super easy. So I had several patients that did not have the permission to use their information, but it does not take long to do that. Otherwise you'd have to go in and manually do it yourself. So I'd encourage you to try to find, if you don't have the paid version, find a, you know, if your hospital does. You can probably get a free trial too. I think they use a free trial to redact. If you can get them to sign that consent, it'll just make life easier. And I don't actually believe ABOS requires you to submit that consent. You just have to kind of keep it in your records. One of my hospitals, sorry, one of my hospitals, they said, you actually don't even need to get that because it's kind of part of the initial paperwork they signed. So you may want to speak to your hospital admins about that paperwork, you know. Ryan and Spencer, yeah, I think that's such a good point. I just, in talking to people about their frustrations with the ABOS, you know, part two, the redaction part, it constantly comes up. And I would say that we're not getting paid by Adobe. However, that really made my life a lot easier. And so I can't stress that enough. Yeah, someone told me that very late in the game and it made things a lot easier, a lot less stressful. So yes, there is an easy way to do it, fortunately. The other thing with your documents is just to make sure you keep them organized. And so in the ABOS printout for the uploading documentation, they actually want you to upload it in this document style. But it does help for you to stay organized, to really do a case number, what document it is, and then the date. And so essentially, I ended up with my 12 cases listed out like this. And you can see for each one, case summary, consents, culture results, fortunately that one was an infection, post-op visits, all that stuff. So you just have it all there. Because saving on the computer is one thing, but then making sure that it actually all gets uploaded onto the ABOS website is another kind of stressful aspect, so you want to make sure that despite you saving it, that it actually ends up being submitted with all your information. As far as imaging, so for, I think sports is a little unique, maybe spine would be the other one where there's potential for a lot of different images. So pre-op, I think x-rays are important to include for pretty much every patient. For the MRI, you can combine frames so that you could have a two-by-two screenshot that would count as one image when you upload, so that can be helpful to show everything you may need on various three-dimensional imaging, whether it's CT or MRI. Intra-op, so I'd include fluoro for scope pictures. Same deal, you have 12 photos, so I would basically for the diagnostic, I would include a full page as one image, and then for the more important or specific things like an anchor pulling out or something like that, then I would make that one picture of the whole file just to help, you know, really emphasize what I wanted. And then post-op, you have 12 images as needed, so depending on, you know, the trauma case or whatnot, you can follow or do all your post-operative x-rays. And then the case summary is a, this I would view as a very important part to like spend time on because it's going to be what you, or at least in my case, directly read to the examiner. So it really is a one or two-minute summary of what happened, and so I won't spare you from reading this whole thing, but basically it's going to tell you what they came in with, what the thought process was, what you did, how it went, and kind of like a final conclusion. And that's usually what I would start every case with, and I think Spencer can comment a little bit on the other stuff as well. Yeah, I mean, you know, this is very important too. You're going to be submitting this, obviously, once your case is selected, and it takes a little bit of time, so definitely don't wait till the very last minute because it definitely takes a little bit of time. And, you know, like Brian's saying, you can kind of review this not only before the case, but you may be actually reading this or kind of referring to it at least. And then, yeah, some of the parts that they asked me here are like, were you happy, what were the complications, what went well, what would you do differently? So you have to plug that in, but it's also helpful because it will help you to prepare. And then as far as preparing for the exam, so definitely that Ryan Roach showed the rubrics, I would read through that to kind of understand what they're really testing you on. And then for each case, I would go through and think about just what potentially they could ask you. And so knowing some background literature, really talking to your colleagues and partners that have been through it to see what they would ask. And then for cases with complications, be prepared to talk about it, how you recognized it, how you could potentially avoid it and how you addressed it or what you would do differently. And so I think just kind of really owning your complications is going to go a long way to help you. So some of this, like this example was a humeral shaft RAF, so part of it is going back to ortho bullets, just looking at the basics, like what are the typical indications? And then some questions, it's hard to predict, but, you say, oh, the alternative was I could have done a Sarmiento. They may say, well, how would you manage it in a Sarmiento? So just kind of really taking down different paths of where the examiners could potentially go. And then some of the common debates as far as like approach, nail plate, what do you do if it's a radial nerve palsy? And then for some reason, DBT prophylaxis, you'll see on a lot of the ABOS videos, but it comes up for a lot of cases. So I'd always just be prepared to know if you did anything or why. Yeah, really great points. I mean, I think this is an indications and complications exam. So, and, you know, if you get a complication, I mean, don't, don't freak out. Don't be nervous. Everybody that operates gets complications. And as long as you're able to explain it, discuss your thought process, it actually may be somewhat beneficial because you're going to take up the time and before you know it, you know, your session's going to be done, you're going to hear the bell. So yeah, maybe some of this might be mine. I mean, I think we spoke about this, but I think it's really important to present your cases to your colleagues and your senior partners. And yeah, as Ryan was saying, I mean, sometimes it's just simple things like tip apex distance came up, you know? So it's like things that you like, like you're thinking about really complex stuff, but sometimes you actually, you do have to go back to basics, know the basics because they will ask that, especially if you get chosen for sports. So they'll tell you what you get chosen for, depending on, I guess, what type of cases. So I got chosen for sports, but I had some trauma on that, which I think is good to have. And so the sports examiners will probably ask you more of the basic trauma stuff. So that's helpful. Obviously take notes. And then, yeah, I think it's great to have a file for each case. Any case that I had a complication, I would speak to my partner or just speak to people about it and just take notes immediately, like a reward document. So that when I went back later and I had to fill out the paperwork or I was preparing for the exam, I knew what was in my mind at that moment. And then the exam day itself, there's, again, the ABOS website is a very good resource for this, but you'll stay in the same room and the examiners will rotate in. So there's two examiners every once in a while, there'll be an additional person in the room. That's an observer. So you'll go through three cases each in four separate sessions. And so it's about seven or eight minutes a case. And at least what I did, and I think there's different ways of doing it, but I would practice reading the case summary while you're showing the pertinent imaging. So kind of reading your case summary, and then on the side, you'll have the imaging being displayed for the examiners, but really just kind of having that first case summary or down pat, and then you'll see kind of where the examiners take it from there. But I think that at least sets it off on a path where you're more in control. Yeah, that's a great point. I mean, just like you would be practicing a presentation, you want to kind of read through it definitely before the exam, and so it just kind of flows out. And then, so this is a two philosophies. So everybody kind of says, present the facts, like don't give too much information. Ryan Roach just told us that there's like an academy paper on this, like just keep it simple. But some of them, and this actually comes from Dr. Vigil, he said, you know what, that may not be correct. Discuss the case and like kind of lead the narrative, like you give the information, let them interrupt you, and let them ask you questions. So, you know, think about that. Think about, and I did that, and I think it worked out well. Like I said, before you know it, the bell was over. I gave all the information. I kept talking. I let them interrupt me. So, I mean, it's probably a balance. You don't want to go crazy with it, but I think it's probably better to actually lead the narrative and say, here's what the case was. Here's what I was thinking. Here's why I did it. Here was my indication. Here was my differential diagnosis. And you will be amazed at where things can go when you have time. So, one case I had, sports, but a lot of trauma cases as well. So, it was an open reduction of a sub tailor for actual dislocation. And it somehow got down this like rabbit hole of what position would you fuse an ankle? And I was like, I have no idea. I just, I'm just trying to get through the x fix. So, you know, having more kind of comments about stuff, I think is, can definitely help cut down the time and make the day move smoother. I mean, my story on this is like, I completed my cases for that session and everything went fine. And then they just randomly asked me, did you need a knee scopes? I don't, I didn't have a regular like menisectomy. I don't think on my case list. Yeah, I do. And then what would you get for DVT? Like they started, what is JVGSA? You should get for DVT, prophylaxis and knee scopes. Like just random, like, so it's probably better to kind of like run the narrative, lead the narrative and then, you know, hopefully run out of time. So that's it for the slide portion. So now we'll kind of move it to more of an interactive or Q and A session. So I'll turn it back to Dr. Roach here to moderate this. Oh, well, great job guys. And so just for everyone, all the participants, make sure you're sending the Q and A's. We do have a few, but obviously we want to use this time to answer all of your questions. So please do submit those so that we can address them. And so I think you guys just hit on an important point. So in terms of the actual interview day, how do you handle when a person tells you like you did something wrong or, you know, why didn't you do this? Or why didn't you do that? Any tips on just handling a tough interviewer? Humility. I'll start. No one wants, the examiners are testing you and they're not trying, you know, I've heard the people who fail or try to fight with their examiners. You can maybe disagree with them once, say, well, I did this, but if they push the point, say, you're right, I should have done this differently. If they're telling you, you should have done something differently. Don't be fighting with the examiners. This is not the avenue or the place to debate different techniques if they're convinced one's the right way, because they're the one grading you. That's my thought on it. Yeah. And I think that's a great point. We just got a question about, can we give specifics about why people fail? You know, in talking to a lot of people, the number one reason I have heard is confrontation. So either you're arrogant and you think you know everything. So like Jon said, you're not humble or you just argue. And so I definitely do not recommend using this time to argue. If you have a point, you have to, you know, you try to make your point and back it up with literature. It is okay to treat people differently. You know, there are very few things in orthopedics that are hard and fast, maybe the tip apex distance, right? But, you know, meniscal repairs, there's a lot of different ways to do it. And you may be asked, why didn't you do it this way? It's not a time to fight the person. And it's also not a great answer to say, this is just how I do it, or this is how I was taught in fellowship. You do have to have some backing to it. You know, I do it this way because this paper showed that, or this is, you know, et cetera. And it's also okay to say, hey, look at like, looking back, like I have changed my practice a little bit and I maybe would have done things a little differently. Yeah, I think you could say I learned from that case or I do things differently now. But you know, it's interesting, just like you said, the percent of failure went up a little bit in my year 22. And we don't really know why. And from speaking to people that didn't pass the first time around, they don't get a lot of feedback. So it's a little, I mean, it is a little bit tricky to figure it all out. You know, one thing I did hear from a board examiner on failures, one of them thought because the applicants didn't get through all the cases, because there's that scoring rubric with all those things. And you have about eight minutes per case. You thought some people get bogged down or they don't lead the discussion. So like Spencer was saying, kind of lead the discussion. You got to get the examiners through all those scoring points within your seven minutes. If you let them get you bogged down in one area and focus completely on that, see your complications. Well, that's only one of nine things. If you spend five minutes on that, it's going to be hard to get through all your cases. So actually the one examiner said, if you don't drive the narrative and get enough points, you can fail just because you didn't get through things. That's on the examiner. They're supposed to be driving it too. But if they're not, you kind of should push that to make sure you get through everything. Great point. I mean, I think that goes back to practicing with some colleagues or mentors, if you can, and let them be the examiner. And you practice like moving through the case, get through the case in a timely fashion. I do think they try to just press you, even if they don't necessarily disagree with you, they just want to see how you're going to respond to things. So I think like everyone's saying, staying humble and just saying, well, I interpreted it this way, but I can see why you may think it's a different way or looking back potentially. But I think for certain things, you can stand your ground, understanding that there are multiple ways to look at it or interpret things. Okay. So another big one is complications. So a few questions about complications. What does everyone consider a complication? What is too much to report? What is too little to report? And then what are tips and tricks, best practice for handling complications when you're in board collection? Sure, I can start. So I think there's two philosophies. One is like you report every little thing like hyponatremia, post-op day one, anemia, everything. And then you end up with your case of, let's say a hundred cases and you have 50 complications or something like that. And then that way the bad complications maybe get diluted out because they don't necessarily pick up on it because they are looking at all the hyponatremia and all that. That, to be frank, was just seemed like a little too much work to go through and look at all that. So I don't So I reported things like going back to the OR, hardware failure, infection, antibiotics, like doing things that like changed clinical management for me. So that was my philosophy. It's one thing, someone asked here too, how do they select cases? I know there's a computer that looks through your cases first and selects like 12, but then they actually have examiners review each case log and see if they agree with the computer or choose a different case. And I've talked with some of the examiners, they choose cases with complications. If you did 50 total needs, they're not going to choose a bunch of simple cases. They're going to choose the one with the complication because it gives them something to talk about, the scoring rubric includes that. So I would list your complications. I don't know about going overkill too. I think the average is about 25% of cases have complications for the boards. And that's probably where you want to be. Every time someone dropped one gram of hemoglobin, I wouldn't list that as a blood loss anemia. But if someone was lightheaded after state of day in the hospital, got transfused, I would list that one, you know, a tiny creatinine bump, probably not. But if they went to AKI and needed a consult medicine, probably worth putting that one since those are all listed as complications on their list. I think it's important to note it goes the opposite too. So if you under-report, that's also a red flag. So if you're going to submit your cases with no complications, that'll generate some heat in terms of the evaluation of your cases. So you want to be honest. I think that's the best answer. You know, if you think it was a change in practice or something that was unexpected, then I think you should report that. There was a question about like, what quantifies anemia and when do you report that, especially if they're coming in anemic? Anyone want to tackle that? Yeah, I respond to that one. I mean, I did anemia, they required a post-op transfusion. So I do a lot of 90 year old hip fractures. And so they invariably need a unit or two. And so if they had a transfusion, like I think John said, that you just document that. There's studies that show there's a maybe high risk of infection with the transfusion and various procedures. So I think they could definitely talk about that in the case if it gets picked. I think just regarding just documentation of complications, like everyone has said, it happens, just make sure you write it down and then what you did about it. So even on these patients are on the medicine service or your co-management service, I would kind of document and say, spoke to co-management attending, plan for transfusion, or like we'll talk to renal, just make sure that you feel like you're involved in their care, even if they're not on your service directly, or they're being managed by medicine. These things, they're going to ask you, well, did you abandon your patient in AKI? And then if you have a note saying, oh no, we talked to renal, the plan is this, then they know that you're involved. Even if it's not your technically specialty, they're still your surgical patient postoperatively. Yeah. And again, I think Michelle, you nailed it with that documentation is key. And so even if it's like not an inpatient, let's say you have an ACL that has a complication, you can document that you talked to your partner, that you talked to a colleague, and that shows that you're trying your best to do what's right for that patient. If you did call your colleague and you asked them their advice, but you didn't document it, it didn't happen. And so make sure you use your documentation to back up your good treatment of your patients. I did the same thing, Priyanka. If it's a case where it's not a slam dunk diagnosis, or it's not the easiest surgical decision-making, you ask a fellowship colleague or somebody from residency, and then you document, Dr. So-and-so and I spoke on the phone, imaging was reviewed, exam was reviewed. They agree with my plan going forward for X procedure. And then when they ask you, why did you do this crazy surgery? You say, oh, I spoke to my mentor. We went over the imaging and they agreed this was the best option for the patient. And then that gives you some backup. And depending on what situation you're practicing in, if you do have a tough preoperative indication, if you are a co-surgeon, you do not list that case. It's only if you're the primary surgeon. So if you have a partner that's willing to scrub with you and list as a co-surgeon, then that doesn't end up on your list. Now, if that patient has a complication and you then become the primary surgeon because you wash the patient out, for instance, well, then it will retroactively actively be on your list. So you don't want to use that to avoid patients, but there are tough patients that you may utilize a colleague to help you out. And I think the good point with that is that if you have a case that during your board collections has a complication, but you did the surgery before, that may be another time where you want to rope in a colleague. Because then again, if you're a co-surgeon, it doesn't retroactively get included. Whereas if you do it by yourself, then you have to go back and include the first surgery and all that as well. So depending on your indications and documentation and all that, that's another option to consider for the tougher cases. There's a question about how to handle complications that you refer to a partner, for example, something that gets sent to foot and ankle to assist you in a complication of your own. I'll try and answer that one. I appreciate everybody else's input too. I feel like if you referred somebody, what I've been told is you scrub into the case or you're still involved, preferably kind of making sure that they're doing well. Just even if you refer them, just stay involved a little bit to make sure that you don't quite want to abandon them. As I think that's a big part of the ABOS is don't abandon your patients, either post-op or if you have to refer them out, just make sure that you're aware of what's going on with them. Yeah. And a great, great thing there is like a telephone encounter. Just, you know, if they have surgery with one of your partners, you call the patient, see how they're doing, drop a note saying that you did that. And that's a really good move. Okay. So there's a bunch of questions. So for the documentation that you submit, how granular is it? Are you sending office visits and op notes only, or are you including nursing notes from the floor, PT progress notes, et cetera? AVOS is actually pretty specific on that. They say don't include PT notes, consult, service notes, unless it's particularly important for this case, so they don't want all that granular stuff. The examiners don't actually see your documentation, they sit down with you. They have nine minutes to look through everything. They don't want hundreds and hundreds of PT notes that don't say anything either, so they're getting less granular than they used to be. They want your notes, and now someone asked about resident notes, like in an academic centers. Definitely include those, like that's part of the post-op follow-up. Now hopefully you're seeing those patients and putting attestations or addendums on them. You can't just have the, you know, I hear that's bad too if you're an academic center, and the resident sees the patient for a hip fracture, consents them, their names on the consent, and you just have a co-signature, that's a red flag. The examiner's like, did you even talk with the patient? If you're gonna submit that type of resident note, that's good, but you shouldn't have documentation on there too saying what you did as well, that you talked about risks and benefits. Sorry, I just went on. The other thing I was thinking of, the consent forms there, you should submit the actual consent form your hospital has, that's the generic consent form, but what I saw the examiners cared more about was that my documentation in the note saying I talked with the patient about risks and benefits, discussed the risks I talked about, actually documented that on the H&P, and then they looked, oh you did the formal consent, okay, but what they cared about was actually that discussion, where we actually got consent, discussed risks and benefits, so make sure you're documenting that, for sure. Yeah, in terms of the granularity, I think John, you nailed it. This is, you want to submit things that support your argument in terms of the case, or defend anything that happened, complications, if there's anything, you know, if there's a note relevant to something in the patient's care that's pertinent, then you include it. Otherwise, you don't need to submit everything. Now, are case timings also reported, like if a case takes longer than would be expected, is that raising a red flag? Unless you submit it, it doesn't get submitted automatically. If you say your tourniquet time was three hours, they're going to notice that, but if that's not in your documentation, it doesn't get automatically reported like, I believe it used to, now they don't see that. I think they asked for when you, on the scribe, I think there's a... Oh, they might, huh? But it's just your report of it, I think, not 100%, but I doubt they're looking that specifically, maybe, as far as what cases to pick. All right, did anyone participate in any online or in-person board review courses? Would you recommend participating in these courses? Or, in your experience, was it enough to just discuss with partners, colleagues, etc.? I actually did the actual ABOS, well, the AOS board review course. I found it useful to hear people presenting. I didn't actually pay the extra to present my own cases. I didn't have them prepared enough, honestly, for that, but it was useful to hear other people presenting, because I heard some good things and a lot of bad things, like people who were giving too much details, and so I learned what not to do, and also some things to do. So I found it useful to hear people presenting, but I thought for that reason the board review course was kind of good, to hear some other people present, and then hear what everyone commented on how they could fix their presentation. But for me personally, I just presented my harder cases to my senior colleagues and discussed them there. So that was more useful to actually talk to my colleagues for my own cases, but hearing other people's, I thought, was useful. Okay, good. Yeah, and so I think that, you know, attending a review course isn't the answer to passing. It helps. I think what you're doing tonight, though, like the webinars, just obtaining information, that's the key, but the key really is going to be practicing and making sure that you, you know, from the start, submit all the right documentation. You document everything. You indicate the right patients, but when it comes to presenting, you want to make sure that you go through it a few times before you're in front of the board examiner. Okay, all right, sorry, I'm reading through these. Some of these we've answered. So one brought up about documentation, there are red flags that cause failure. I don't know that there's a scoring rubric. You can fail one section and not fail the whole case, but I've heard one thing from a couple examiners that really bothers them. If you didn't have that risks and benefits discussion, to have it documented, you're not actually obtaining informed consent. All your notes said was they had this fracture, we signed them up for surgery, and their generic consent for your hospital. I heard that in the past has been a red flag for examiners that, hey, they're not actually talking about risks and benefits and alternatives with patients. So that's one thing I've heard in the past have harped on, that you really need that documented, that you're having those discussions with people. Yeah, and I just had that. Actually, my consents were typically not that tailored, like it wouldn't mention infrapatellar numbness for ACLs or stuff like that. So I think having it in your note, so I did have to make dot phrases for the common things I do, whether shoulder arthroplasty or cuff, talking about specific complications for that, like scapular fractures for reverse, but I didn't go through and actually change all my consents specifically. I think in an ideal world, you would do both, but having it somewhere where you could say, yes, I did talk to the patient about that is very important. And I do think, like you said, anywhere is appropriate, right? And so you're going to sit in front of the board examiner and say, hey, look, I had this discussion and documented it here. But I do think it is important to document somewhere that you had a complication-specific talk. You can't just say risk benefits and alternatives were discussed. For fractures, you need to tell them that there's a risk of a malunion and a nonunion. The surgery-specific complications are very helpful. It kind of goes back to what Spencer was talking about. You want to dictate the conversation. So if you say, if you have in your documentation that you had the conversation, then the board examiner can't ask you about that. You just say, hey, look, there it is documented. We talked about malunion and nonunion. We talked about infection. We talked about infrapatellar numbness. And so it makes it a lot easier than having to explain, well, we did talk about it. I just didn't document it. And then always put nonoperative management was discussed. I think that's a safe thing to include for every patient, no matter how clear the indications are. Right. I mean, even in the rubric, that's one of the surgical indications. Non-surgical treatment is above the expected level and has not sufficiently relieved the patient's symptoms. Again, excellent. You need that documented somewhere. Actually, I think this is a great question. So even though this is a sports medicine webinar, most of us take trauma calls. So let's say you have a patient that you X-fix. You're on call. You have to X-fix them. But you transition care to the other team. How do you handle the follow-up there? Do you have to round on them every day? Do you have to submit all their notes? What's best practice there? I'll tell you what I did. Once I did the sign-off, I did my op note. And then I did the next day and said I signed off to the trauma team. And the trauma surgeon took them the next day. I didn't actually continue to follow that patient. And talking about the board examiners who choose cases, they're not typically choosing those cases. That, oh, you were on trauma call and X-fixed an ankle that your partner then fixed. They don't really want to talk about that. So that's not one they're trying to pick. Now, could it randomly get picked? Maybe. But that's not what they're aiming for. So I didn't follow all those people for a year if I was only involved at a 3 a.m. X-fix that then my trauma partners took from there. So I actually did have one of those picked. Yeah. Well, it was a sub-tailor fracture dislocation. So I included it because I did an open reduction and then an X-fix. But then my partner did the rest. Fortunately, she stayed within my same system. So I could include all the X-rays and post-op management and stuff. And so there wasn't a whole lot to discuss, which is, I think, how we ended up way off on tangents. But yeah, for me, I did not follow her myself. I did the 3 a.m. X-fix. I documented in the op note her care is going to be assumed by my trauma and foot and ankle colleagues for definitive management. And that was it. That was the last note I ever wrote on her. I was able to include all that extra post-op stuff just from her being in the same hospital system. But I was not involved in anything beyond that. And I think part of it is like you have to be a good doctor or physician. But I don't know if they want you just totally changing your practice for the sake of the exam. And the reality is I have nothing else to offer that patient. I mean, she's in much better hands with my colleagues. And Ryan, that's a great point. ABOS doesn't want you to change practice. They want to just assess your practice. And so in reality, no one is going to continue care on a patient that they X-fix and then transition care. Transitioning care is a normal part of a practice. So you just have to document that that happened. And I think if you do that, you say that the care is going to be assumed by this doctor now and you put that in a note, I think you're safe. How specific are the examiners regarding ICD-10 codes? For example, if my EMR auto-populates all cuff tears to the incomplete cuff tear code, will the examiners care that the ICD-10 code shows an incomplete tear or the clinic notes oppose that? And it was a complete tear. So you actually submit your own ICD-10 codes for the case. It's not whatever your hospital bill, it's whatever you put in scribe. Now you should talk with your hospital records department because they're the one to have to certify your cases. So if they're going to put up a stink that you have different ICD-10 codes on your list, that's where the only issue could come from. But you're submitting your own ICD-10 codes, not what the hospital submitted. So talk to your records department, make sure they're good with that. Maybe if you're worried about it. I don't believe they see, they do not see what you bill. Now, if you're putting in your procedure, like 13 procedures and like you're treating like multiple things in one stage, when it's probably you should just treat one, you know, it's probably a red flag. Okay. So a couple of other questions. So, you know, virtual visits are kind of a new thing post COVID. Any tips on virtual visits? Do you recommend them, tips for documentation, et cetera? I mean, I liked them for sure. I didn't make them routine, but I have a couple of people who I, you know, fixed a fracture and then they went home to a city a few hours away. So I at least documented one virtual visit where I talked to them, saw how they're doing, made sure they'd established care with a local surgeon. So for cases like that, for sure do a virtual visit. You have a patient, hip fracture, went home, can't get back to clinic for some reason, document virtual visits. I don't think there's any problem with that. Now, if you're doing every post-op visit virtual, they probably wouldn't like that because they want you to actually examine your patient some, but I don't think there's a problem if you have virtual visits as part of your routine practice, especially for people who have trouble making it in. And I'd say if they're, if they go out of town or out of state or even out of country, just documenting, like even an email, I had a patient who was from London who went home after surgery. So I emailed her and said, how are you doing? And I put a note documentation saying, email patient, she has x-ray, she found follow-up in London, she's doing fine, doing XYZ with physical therapy, just to know, again, that you're not abandoning your patient once they leave your OR, because we can't do virtuals if you're not in that state or have a license in that state. So I think a telephone account or documentation, just calling them and saying, how are you doing? Do you find a surgeon? How was your x-ray? Just making sure that, again, just documenting that you're following them postoperatively, even if you can't see them face to face. Okay. So another question from the group, how do, how long do you follow your post-ops? And I would add a second to that. Like what, what, what do you, what's best practice for patients that don't follow up? And I think Michelle, you kind of hinted on that. So how long will you follow your patients? I think it depends on the case. And a lot of it will be because you're in collections the turnaround is like a few months before they pick your cases. So obviously those patients are not going to have super long follow-up. So I think you do as best as you can. And then whatever 12 cases they pick, just look at those and try to get all of them to come back or some type of documentation, particularly if they had poor follow-up. I think it definitely depends on your case too. If it was my shoulder arthroplasty, I'm following for life. So I better have that year follow-up for most of those for carpal tunnel and six weeks is probably okay. If they're doing great, right. And rotator cuffs, I tend to follow for six months. They want to make sure you're not just abandoning patients post-op, but it really depends on the surgery you do for them. Now, as for loss to follow up patients, they do want to see that you're trying to get ahold of them. We're all going to lose patients to follow up. And they understand that I did one shoulder revision. The guy came back once and then never showed up again. So I documented all the times we called him when my scheduler tried to send him a letter, when I finally got an email back from him, like, Hey, how are you doing? He's like, I'm doing great. I'm like, you want to come back for an appointment? And he didn't reply, but I documented that. So I tried, we gave a good effort. They want to see that you're trying. They know some people aren't going to show up and you're not going to fail because of that, but you might fail if you don't at least try and document it. Yeah. If you have a post-op that no shows, I would definitely have a note that, you know, we contacted the patient, we called them. Now, one of my colleagues said he sent a certified letter to the patients and that, I mean, that might be a little bit overkill, but I think you can consider it. Just have your office manager do it. But at least have a note that you tried to call them. You left a message and they know show. On that note, I did. If you have a HIPAA compliant storage system, I had like a list of my patients and was seeing all their follow-ups. Like, did they miss their two weeks? Did they miss their six weeks? And if someone did miss, I made sure we followed up on it. Okay. Doctors we have time for one more question. Okay, guys. So I'll end it with a toss up for each of you. Okay. So looking back at your, you know, when you were in this position, what is one thing you would have done differently or changed in terms of your preparation for the boards? Well, I guess mine's easy. I'm still preparing. So I'll listen to all your guys' answers. I guess in the documentation part of things, just really being meticulous on making sure that everything is getting written down as you're trying to balance starting a practice and doing cases. And it can get overwhelming to make sure this silly form gets filled out, but doing it all the way at the end is kind of painful. So just doing it along the way, I think is helpful to keep you on track with all the documentation until you're scrambling at the very end to submit it on time. Yeah, I'll second that. I mean, take plenty of time to have all your stuff together, you know, have all your notes together to collect all your paperwork and to write your case summaries, and then give plenty of time to talk to other colleagues and just practice, practice your presentation, you know, in front of the mirror, whatever you want to do as much as possible. That will really help you and really calm your anxiety. Yeah, I just agree with Michelle too. Stay up to date as you're actually in collection, make sure you're doing it as you go, as complications come around and do it, because by the time the case selection ends, you got like a month to finalize everything. That's a nerve wracking time. If you kept up the whole time, it's more, it makes it much easier. Same thing, once they give you your 12 cases, get to it early, get those HIPAA forms if you haven't had the patient sign them yet, which I didn't, I did that later, or start redacting, download all the documents, or start redacting, download all the documents, get things uploaded. I used to have some buddies who did it like last day, and then they couldn't get it done. So they scramble for the next week at vacation time and pay the late fee. Like don't do that, get it done early. And their system's nice because once you upload, you can actually see what it's going to look like to the examiner. You can see exactly what the x-rays are going to look like, how you can present them. So if you do that early, then you'll know you're all set with everything. Yeah, I think mine, similar vein, but basically I would dedicate some time, maybe like every couple of weeks to kind of go back and look at the prior two weeks and like check in on your documentation for the cases you've done that week, those couple of weeks, as well as like the post-ops, just to make sure you're keeping up and people aren't falling through the cracks. So you kind of get to that where they tell you, ask you your 12 cases and you realize, wow, I only saw this person two weeks post-op and then never again. So I think the more you can stay in front of that stuff, the less painful it is for you at the end, but it's still incredibly painful. Yeah. And I think for me, it's all of those things. But I think the thing that helped me the most was actually just sitting down and reading the rules early, which I don't typically do. But when I did that, I said, oh crap, there's this HIPAA form. Oh crap, there's this. Oh, I got to do this. And by having the HIPAA form filled out early, I built it into my preoperative evaluation. So I was able to have all my patients consented. I had them signed up for the patient reported outcomes. And I wouldn't have done that had I missed it. And the ABOS website has all that. The other big thing is like when you go to name your files, they are very specific on how they want you to name it. And you got to read the rules. Otherwise, you're going to name all your files incorrectly, and you're going to have to redo them all, which is a huge pain in the butt. So just look at the rules that the ABOS has there. They're there for a reason, and they're really thorough, and they'll help you get through it. Thank you, Dr. Roach. That concludes our presentation for this evening. We would like to express our gratitude to the panelists and presenters who contributed to tonight's webinar. We also want to thank you for joining us. If you wish to obtain CME credit for this activity, please take a moment to complete a brief evaluation by logging into your account at education.sportsmed.org, clicking on My Resources, and then selecting this webinar. You will also receive an email reminder with instructions. Additionally, this webinar has been recorded and will be available on demand within the next 24 to 48 hours. Again, thank you for attending and participating in the session. Have a wonderful night. Thanks, everyone.

ABOS Part 2 Board Preparation

American Orthopedic Society for Sports Medicine

application process

case documentation

examination preparation

ABOS