Assessing The Strengths And Weaknesses Of The ABFAS Board Qualification Exams

I took the American Board of Foot and Ankle Surgeons (ABFAS) qualification exams last month. I thought I would share input from exam experience as well as that of my fellow residents. I will not discuss any specific questions asked. I will not divulge any tested cases. I merely want to look at the test overall and offer my opinions on its strengths and weaknesses as well as my suggestions for improvements for what they are worth. 

The total cost for foot surgery didactic, foot surgery computer-based patient simulation (CBPS), rearfoot/reconstructive ankle (RRA) didactic, and RRA CBPS was $1,925. That is a hefty price, especially for a resident. That is more than half a month’s salary. Then when you pass the exams and attain board qualified status, there is a $200 annual fee to maintain that status. 

Subject matter was all over the place. I know I can only speak of my study strategies and for my co-residents that studied with me, but I felt like we covered all the major topics thoroughly. We read the McGlamry textbook chapters on flat feet, cavus feet, hallux valgus, rheumatoid arthritis, ankle fractures, pilon fractures, etc. When the three of us third-year residents met up the day after the exam, we all said the same thing; “All of that time spent studying was useless.” 

We began casually studying around October or November of 2019. Then starting in January 2020, we really dug in, spending a lot of time together and separately, studying and sharing knowledge. I checked with residents from other programs and they all had similar study strategies. We also utilized some online study aids for the boards. They were pricey but offered practice in both the didactic question styles as well as the appropriate way to tackle the CBPS portion. Still, even with all of that preparation, we felt like it did not cover any of the concepts tested on the actual exam. Those who have yet to take the exam ask the same question, “How would you study differently now that you know what they were asking?” My response has been the same to all of them. “I could not even tell you where to find the information that was on that test.”

One Resident’s Experience With The Didactic Portion Of The ABFAS Qualification Exam

The didactic portion was my weakest part on the exam and, in my opinion, the weakest part of the exam itself. It is important to understand that this test is dynamic. It is designed to give you exam questions that are consistent with your level of knowledge and analyze your responses. This sounds great in theory. 

In our training, we have all had that one attending that had in-depth knowledge on some obscure pathology or treatment that no one else does or sees. Well, with this exam, it feels like they just went around the county, found those doctors and had them write the exam. If you weren’t that doctor or closely affiliated with that doctor, you had absolutely no idea what they were talking about. Now take that idea, multiply that by 80 and you have the ABFAS didactic exam. This exam is full of obscure, poorly written questions that do not test the basic knowledge of foot and ankle surgery, but do test you on that one paper that was written 60 years ago that is no longer relevant.  

Just when we thought that was enough, then there was a question with an image. Oh, the images. There were pictures that were so zoomed in they offered no anatomical landmarks to help you ascertain what you were looking at. There were radiographic images that appeared to be cell phone pictures taken of a computer screen. I will say that the magnetic resonance imaging (MRI) and computed tomography (CT) images were decent in quality, but there were few of these images. For $2,000 an applicant, please, ABFAS, put some effort into your image bank. It was disgraceful. 

Emphasizing More Clarity With The Answer Choices And Case Descriptions In The CBPS Examination

The case portion of this exam is unique. If you extensively practiced on one of the paid board preparation sites, or did the free practice cases ABFAS offers over and over again, this portion was not so bad. 

The key to this section is familiarity with the choices, such as various diagnostic tests you may want to order. For instance, there are options for pedal pulses, dorsalis pedis pulse and posterior tibial pulse. Now if you didn’t know that pedal pulses is an option, you may waste two choices just on dorsalis pedis and posterior tibial pulses. Another example is erythrocyte sedimentation rate (ESR). If you type ESR into the search box, this yields nothing. If you type “sed rate,” bingo. However, if you did not know that or did not figure that out, you may end up scrolling through the extensive list looking for what you need. That time is costly. 

Accordingly, when it comes to structure, I implore those of you out there preparing to take this exam to familiarize yourself with the choices so you know the best term to type into the search bar. This will make this section seem less intimidating. 

As far as case topics go, I feel they are all reasonable. Nothing was overly complicated in my opinion. The cases can be somewhat vague as there are typically only one or two sentences presenting the case and you have to go from there. One of our residents called the ABFAS phone number and surprisingly spoke to one of the members responsible for creating the questions. He was told that as long as it appears that we have a fluid plan and hit all of the pertinent findings/labs/diagnostics, etc., then we will be fine. 

That said, I will let you know in a month and a half how that played out. The most confusing part about the CBPS exam, I would say, is the treatment portion. This is where you choose how to treat a simulated patient. Now, let us say someone presents a bunion case and asks how you would treat it. You can rattle off any number of procedures to surgically correct the bunion. All are debatable and/or reasonable. This is where some got tripped up trying to find the answer the test was looking for. I’m not saying my procedure choices were superior, but I feel that success in this section should rely on choosing appropriate, reasonable treatments and procedures for the given pathologies. It should not require you to choose one specific procedure that the test writing physician had in mind. This makes the grading of this portion more subjective but also takes into consideration the possibility of many different treatment paths for a certain pathology. 

How Do We Fix This? 

I was always told never to complain about something unless you have an idea on how to fix it. Accordingly, I would like to offer my suggestions.

The didactic portion for both the foot surgery and rearfoot/reconstructive ankle  parts of the exam needs to be completely rewritten. If this test is to examine the proficiency of our surgical skills and procedure selection, it needs to be written as such. When I am teaching residents or students about Lisfranc injuries, I could care less that they know he served with Napoleon in the 1800s. That information is useless in the operating room. I want to know that they can identify the injury and form a valid and reasonable treatment plan based off of the findings. The majority of this test needs to address the pathologies that we see frequently as podiatrists. It needs to make sure we understand the clinical workup and surgical decision-making process. It also needs to evaluate our understanding of the indications, steps, and complications of these procedures. Obscurity and minutia do not prove proficiency.

The CBPS portion is reasonably written. I think that the explanations of the exam that are available on the ABFAS website may be just a little too vague. Perhaps more in-depth explanations of how the cases are graded will help everyone understand how to prepare. There is a lot of “Do I do a fusion or an osteotomy? Which one do they want?” questions. If this portion of the exam is in fact graded based on reasonable treatments and procedures, then more clearly conveying this to the test takers could make a big difference. 

Secondly, in regard to the CBPS, I will say that there could be improvement in the amount of options per section. Only having 10 choices with which to complete the physical exam is kind of limiting. I certainly don’t think that having unlimited options is a good idea. I just think that 10 is too little and perhaps 15 may be a little more reasonable. For labs, it would be nice to have a basic metabolic panel (BMP) choice instead of using seven options to get the same BMP information. Having only three options for diagnosis is also difficult. There are often many things that can be diagnosed from the cases. Maybe increasing this to five options would allow for a more comprehensive diagnosis. 

In Conclusion

I have often heard the ABFAS exam is the only board certification that matters. More and more hospitals are using it as a standard requirement to obtain surgical privileges. I feel that having a surgical board is a good idea. It shows that we have demonstrated our basic surgical knowledge. Our only downfall is that this test struggles to adequately do so. I know many residents that have the same opinion. We are all willing to help rectify the issues we see in this process. We only need for our opinions to be heard and acted upon. 

Dr. Bishop is a third-year resident at Alliance Community Hospital in Alliance, OH.