n Feature Article
Analysis of the Basic Science Section of the
Orthopaedic In-Training Examination
Shahin Sheibani-Rad, MD, MS; Steven Paul Arnoczky, DVM; Norman E. Walter, MD
abstract
Full article available online at Healio.com/Orthopedics. Search: 20120725-28
Since 1963, the Orthopaedic In-Training Examination (OITE) has been administered to
orthopedic residents to assess residents’ knowledge and measure the quality of teaching within individual programs. The OITE currently consists of 275 questions divided
among 12 domains. This study analyzed all OITE basic science questions between
2006 and 2010. The following data were recorded: number of questions, question
taxonomy, category of question, type of imaging modality, and recommended journal
and book references. Between 2006 and 2010, the basic science section constituted
12.2% of the OITE. The assessment of taxonomy classification showed that recall-type
questions were the most common, at 81.4%. Imaging modalities typically involved
questions on radiographs and constituted 6.2% of the OITE basic science section.
The majority of questions were basic science questions (eg, genetics, cell replication,
and bone metabolism), with an average of 26.4 questions per year. The Journal of
Bone & Joint Surgery (American Volume) and the American Academy of Orthopaedic
Surgeons’ Orthopaedic Basic Science were the most commonly and consistently cited
journal and review book, respectively.
This study provides the first review of the question content and recommended references of the OITE basic science section. This information will provide orthopedic
trainees, orthopedic residency programs, and the American Academy of Orthopaedic
Surgeons Evaluation Committee valuable information related to improving residents’
knowledge and performance and optimizing basic science educational curricula.
Drs Sheibani-Rad and Walter are from the Department of Orthopaedic Surgery, McLaren Regional
Medical Center/Michigan State University, Flint, and Dr Arnoczky is from the Laboratory for
Comparative Orthopaedic Research, Michigan State University, East Lansing, Michigan.
Drs Sheibani-Rad, Arnoczky, and Walter have no relevant financial relationships to disclose.
Correspondence should be addressed to: Shahin Sheibani-Rad, MD, MS, Department of Orthopaedic
Surgery, McLaren Regional Medical Center/Michigan State University, 401 S Ballenger Hwy, Flint, MI
48532 ([email protected]).
doi: 10.3928/01477447-20120725-28
AUGUST 2012 | Volume 35 • Number 8
e1251
n Feature Article
T
he
Orthopaedic-in
Training
Examination (OITE) has been administered to orthopedic residents
by the American Academy of Orthopaedic
Surgeons (AAOS) since 1963.1 The OITE
was the first standardized test developed
by a specialty to assess residents’ medical
knowledge.2 Previous reports have shown
that performance on the OITE correlates
with a passing score on the American
Board of Orthopaedic Surgery written examination, thus increasing its emphasis by
residency programs.3
The OITE comprises 275 questions divided into 12 content domains. The OITE
allows the assessment of a resident’s
progress compared with peers in the same
year in training and prepares them for the
American Board of Orthopaedic Surgery
certification examination. The published
answers and personal score reports provide test takers with an opportunity to
review their answers and learn from their
mistakes. The reference articles included
with each question represent a survey of
the current orthopedic literature. A small
number of questions are excluded each
year by the AAOS after the results are examined.
Several publications have analyzed the
literature as a tool for preparation for the
OITE.4-8 However, to date, no in-depth
analysis has been performed on the question types that constitute the basic science section of the OITE. Knowledge of
the fundamental basic science aspects of
musculoskeletal biology, pathology, and
biomechanics is the foundation for the
practice of orthopedic surgery and, thus,
an important component of the OITE.
Therefore, the purpose of this study was
to review and characterize the basic science section of the OITE between 2006
and 2010. This information will be a useful tool in helping residents prepare for
the OITE and ultimately the American
Board of Orthopaedic Surgery examination. In addition, it may help examination
writers to ensure adequate coverage on
future examinations and faculty to direct
e1252
Table 1
Number and Percentage of Basic Science Questions Per Year
Parameter
Basic science questions, No.
Items deleted, No.
2006
2007
2008
2009
2010
33
33
35
33
33
1
1
1
1
1
Total questions, No.
271
268
270
270
262
Percentage
12.2
12.3
13
12.2
12.6
journal club topics and didactic lectures to
improve educational curricula.
Materials and Methods
A systematic review was conducted
of the OITE to identify all basic science
questions between 2006 and 2010. All basic science questions as delineated by the
AAOS were analyzed. Items that the test
makers deleted due to poor performance
were not included in this study. The number of basic science questions were recorded for each year, as well as the total
number of questions counted for each
year. The percentage of questions covering basic science topics were then calculated for each year.
The basic science questions were
then stratified according to the taxonomy classification originally described by
Buckwalter et al.9 Recall-type questions
(level 1 taxonomy) require examinees to
remember specific facts about the entity
tested. Diagnosis-type questions (level 2
taxonomy) require examinees to establish
a diagnosis from clinical history or radiographic examinations provided in the
question stem. Evaluation and decisionmaking–type questions (level 3 taxonomy) represent the highest order of cognitive questions tested. This type of question
typically provides a short history and/or
radiographic imaging and asks examinees
to establish a diagnosis and a subsequent
treatment plan.
Questions that provided a figure illustrating an imaging modality were also
recorded. These included radiographs,
computed tomography scans, magnetic
resonance imaging, clinical photographs,
and histological biopsies. Finally, the basic science questions were further stratified into 3 categories: anatomy, biostatistics, and basic science (eg, genetics, bone
metabolism, and cell replication).
The cited readings provided by the
AAOS Evaluation Committee within the
OITE answer key for each basic science
question were also recorded. The readings
were classified according to type of reference, including textbook, review book,
and journal, and subclassified per title
of reference. The most commonly cited
sources were then determined.
Results
The OITE included a total of 1341
questions over the 5-year study period,
with an average of 268.2 questions per
year (range, 262-271 questions). The basic science section of the OITE included
a total of 167 questions over the study period, with an average of 33.4 questions per
year (range, 33-35 questions). During the
study period, 1 basic science question was
deleted by the AAOS committee, bringing
the total of basic questions to 162, with an
average of 32.4 questions per year (range,
32-34 questions) (Table 1).
Taxonomy classification was then
assessed for the entire basic science domain of the OITE over the study period.
Of the 167 basic science questions, level
1 taxonomy questions (n5136 [81.4%])
were most often tested, followed by level
2 taxonomy questions (n524 [14.4%])
ORTHOPEDICS | Healio.com/Orthopedics
Basic Science Section of the OITE | Sheibani-Rad et al
and level 3 taxonomy questions (n52
[1.2%]). An average of 27.2 level 1 taxonomy (range, 23-32 questions) and 4.8
level 2 taxonomy (range, 2-7 questions)
appeared over the study period. On average, fewer than 1 level 3 taxonomy question (range, 0-2 questions) was tested
each year (Table 2). Less than one-fifth
(n531 [19.1%]) of all basic science questions were associated with images, with
the most common modalities being radiographs (n510 [6.2%]) and histology
(n59 [5.5%]) (Table 3).
Over the study period, 269 citations
with an average of 53.8 references appeared per year in the OITE basic science
domain. An average of 1.66 citations appeared per basic science question (269
citations per 162 questions). The recommended references were most often
derived from journal articles (49.4%),
followed by review books (39.0%) and
textbooks (13.4%). Of the 269 recommended references over the study period,
13 journal references were cited at least 2
times. The most frequently cited journal
was the Journal of Bone & Joint Surgery
(American Volume) (n536 [13.4%])
(Table 4). Of the 269 recommended references over the study period, 13 book
references were cited at least 2 times. The
most commonly cited review book was
Orthopaedic Basic Science by the AAOS
(n567 [24.9%]). The most commonly cited textbooks were Anatomy for Surgeons
and Surgical Exposures in Orthopaedics,
each with 6 (2.2%) citations (Table 5).
Of the 162 basic science questions
included in the scoring, 9 were biostatistics questions, with an average of 1.8
questions per year (range, 0-4 questions).
Twenty-one questions were anatomy
questions, with an average of 4.2 questions per year (range, 1-9 questions). The
majority of questions were basic science
questions (eg, genetics, cell replication,
and bone metabolism), with a total of
132 questions and average of 26.4 questions per year (range, 21-29 questions)
(Table 6).
AUGUST 2012 | Volume 35 • Number 8
Table 2
Questions Stratified According to Taxonomy Per Year
Taxonomy
Level
2006
2007
2008
2009
2010
Total
1
26
28
32
27
23
136
2
6
4
2
5
7
24
3
0
0
0
0
2
2
Table 3
Questions with Imaging Modality Tested
Imaging Modality
2006
2007
2008
2009
2010
Total
Clinical photograph
0
0
1
0
1
2
Radiograph
3
1
1
1
4
10
Histology
3
1
1
1
3
9
Computed tomography
1
0
0
1
0
2
Magnetic resonance
imaging
1
1
0
2
4
8
Table 4
Journals Referenced More Than Once in the Basic Science Section
Journal
2006
2007
2008
2009
2010
Total
JBJS(A)
8
2
8
11
7
36
CORR
2
2
1
7
2
14
ICL
1
0
2
0
0
3
JAAOS
2
1
0
2
4
9
NEJM
2
1
0
0
3
6
JOR
2
0
0
0
1
3
JBMR
1
1
1
1
0
4
Orthopedics
0
1
0
1
0
2
JBJS(B)
0
0
1
1
1
3
JBiMR
0
1
0
1
0
2
AJSM
0
0
1
0
2
3
Chest
0
0
1
0
1
2
OCNA
0
0
0
1
1
2
Abbreviations: AJSM, American Journal of Sports Medicine; CORR, Clinical Orthopaedics
and Related Research; ICL, Instructional Course Lectures; JAAOS, Journal of the American
Academy of Orthopaedic Surgeons; JBiMR, Journal of Biomedical Materials Research;
JBJS(A), Journal of Bone & Joint Surgery (American Volume); JBJS(B), Journal of Bone &
Joint Surgery (British Volume); JBMR, Journal of Bone and Mineral Research; JOR, Journal
of Orthopaedic Research; NEJM, New England Journal of Medicine; OCNA, Orthopedic
Clinics of North America.
e1253
n Feature Article
Table 5
Books Referenced in the Basic Science Section More Than Once
No. of References
Book
2006
2007
2008
2009
2010
Total
Orthopaedic Basic Science
8
13
13
19
14
67
Green’s Operative Hand Surgery11
0
0
2
0
0
2
0
1
2
2
1
6
0
1
4
0
0
5
Anatomy for Surgeons
0
2
4
0
0
6
Review of Orthopaedics15
0
6
6
1
0
13
Orthopaedic Knowledge Update 816
1
0
3
0
0
4
Atlas of Human Anatomy17
1
1
0
0
0
2
Orthopaedic Knowledge Update 9
0
0
0
5
3
8
Orthopaedic Knowledge Update:
Musculoskeletal Tumors19
2
0
0
2
6
10
Lovell and Winter’s Pediatric
Orthopaedics20
0
0
0
1
1
2
Surgery for Bone and Soft-Tissue
Tumors21
0
0
0
0
2
2
AAOS Comprehensive Orthopaedic
Review22
0
0
0
0
5
5
10
Surgical Exposures in Orthopaedics
12
Grant’s Atlas of Anatomy13
14
18
Abbreviation: AAOS, American Academy of Orthopaedic Surgeons.
Table 6
Questions Per Topic Per Year
No. (%)
Topic
2006
2007
2008
2009
2010
Anatomy
2 (6.3)
5 (15.6)
9 (26.5)
4 (12.5)
1 (3.1)
Biostatistics
1 (3.1)
0 (0)
4 (11.8)
2 (6.25)
2 (6.2)
29 (90.6)
27 (84.4)
21 (61.7)
26 (81.25)
29 (90.7)
Basic sciencea
a
Bone metabolism, cell replication, tumor, and genetics.
Discussion
The OITE serves as an important
educational tool for resident trainees, as
well as individual residency programs.
It is used to identify deficiencies in the
knowledge base of individual trainees and
to direct journal club topics and didactic
lectures to improve the educational curricula of orthopedic residency programs.
Previous analyses of OITE questions
have focused on the pathology,4 foot and
e1254
ankle,5 hand,6 sports,7 trauma,23,24 shoulder and elbow,25 hip and knee reconstruction,26 pediatric,27 and spine28 domains. To
the current authors’ knowledge, this study
is the first to analyze the basic science domain of the OITE.
The basic science domain of the OITE
constitutes a large portion of the entire
examination, with an average of 26 questions representing 12.2% of OITE questions per year. It is consistently in the
top 3 domains of the OITE in regard to
the number of questions tested. Between
2006 and 2010, only the trauma domain
had consistently more questions than the
basic science domain. Faculty should incorporate more teaching sessions dedicated to basic science into their education
curricula.
Orthopaedic In-Training Examination
questions are created and classified with
the use of taxonomies described by
Buckwalter et al.9 Level 1 taxonomy incorporates basic knowledge recall and
represented 81.4% of questions within the
basic science domain over the 5-year study
period. Level 3 taxonomy, which requires
a higher function because the questions
typically provide a short history and/or
radiographic imaging and ask examinees
to establish a diagnosis and a subsequent
treatment plan, represented 1.8% of questions during the study period. In contrast,
level 3 taxonomy represented 41.9% of
foot and ankle domain questions,5 25.5%
of sports domain questions,7 and 4.4% of
shoulder and elbow domain questions.25
The variation may be due to (1) the fact
that basic science questions aim to identify a certain fact regarding a particular
topic, and (2) different interpretations of
the taxonomy classification scheme by the
different study authors.
Previous reports have indicated that
successful performance on the OITE correlated with frequent review of current orthopedic journals, specifically the Journal
of Bone & Joint Surgery (American
Volume) and Clinical Orthopaedics and
Related Research.29 In the current analysis
of the reference list within a 5-year study
period, journals accounted for approximately half of the citations. The Journal of
Bone & Joint Surgery (American Volume)
was the most frequently cited journal,
followed by Clinical Orthopaedics and
Related Research, emphasizing the importance of reviewing core orthopedic
journals during journal clubs. Review
books accounted for 39% of books cited
in the basic science domain. The AAOS’
ORTHOPEDICS | Healio.com/Orthopedics
Basic Science Section of the OITE | Sheibani-Rad et al
Orthopaedic Basic Science accounted for
63.8% of these references. The current
authors recommend incorporating this
review book into basic science curricula.
Lastly, the current analysis found that
an average of 6 questions from the basic
science domain were related to anatomy
and biostatistics (4.2 and 1.8 questions,
respectively), with the majority related to
general basic science.
A limitation of the current study was
only reviewing questions in the basic science domain as classified by the program
director’s annual report. Questions related
to basic science, including anatomy, may
appear in other domains. Another limitation was the descriptive nature of the
study. Nevertheless, basic science is one
of the most fundamental and rapidly expanding aspects of orthopedic surgery and
encompasses many different scientific
specialities, such as genetics, biomaterials, biomechanics, and therapeutic drug
development. Therefore, this analysis of
the basic science domain may allow focused residency curricula and resident
preparation for future OITEs.
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