Orthopedics

Feature Article 

Analysis of the Sports Medicine Section of the Orthopaedic In-Training Examination: Improvements in Levels of Evidence and Question Taxonomy Over a 12-Year Period

Joshua C. Luginbuhl, MD; Andrew D. Sobel, MD; Mary K. Mulcahey, MD

Abstract

There has been a recent shift within the orthopedic literature to publish articles with higher levels of evidence. In this investigation, the trends in question taxonomy and the levels of evidence of the references for sports medicine questions on the Orthopaedic In-Training Examination (OITE) during a 12-year period were evaluated. Sports medicine questions were obtained from the OITEs administered between 2005 and 2007 and between 2014 and 2016. The taxonomy of each question was characterized, and levels of evidence for all references were assigned using American Academy of Orthopaedic Surgeons guidelines. Question taxonomy and article levels of evidence from 2005 to 2007 were compared with those from 2014 to 2016. Sports medicine questions comprised 8% of the OITEs in both examination groups. The questions from 2014 to 2016 had a higher mean taxonomic level (2.26 vs 1.52, P=.0001) and a greater proportion of studies with high levels of evidence (levels 1 and 2) (21% vs 10%, P=.027). However, references with low levels of evidence or nonprimary resources made up 82.2% and 68.5% of the total references on the older and more recent examinations, respectively. References from 2014 to 2016 were, on average, 2 years older than those from earlier examinations. This study indicated that sports medicine questions on recent OITEs cite references of higher levels of evidence and contain higher taxonomic question structure than examinations 10 to 12 years ago. However, the majority of questions still cite articles with low levels of evidence or nonprimary sources. These findings can be used to guide resident education and continue improvements in the selection of references for questions on the Sports Medicine section of the OITE. [Orthopedics. 2020;43(5):e460–e464.]

Abstract

There has been a recent shift within the orthopedic literature to publish articles with higher levels of evidence. In this investigation, the trends in question taxonomy and the levels of evidence of the references for sports medicine questions on the Orthopaedic In-Training Examination (OITE) during a 12-year period were evaluated. Sports medicine questions were obtained from the OITEs administered between 2005 and 2007 and between 2014 and 2016. The taxonomy of each question was characterized, and levels of evidence for all references were assigned using American Academy of Orthopaedic Surgeons guidelines. Question taxonomy and article levels of evidence from 2005 to 2007 were compared with those from 2014 to 2016. Sports medicine questions comprised 8% of the OITEs in both examination groups. The questions from 2014 to 2016 had a higher mean taxonomic level (2.26 vs 1.52, P=.0001) and a greater proportion of studies with high levels of evidence (levels 1 and 2) (21% vs 10%, P=.027). However, references with low levels of evidence or nonprimary resources made up 82.2% and 68.5% of the total references on the older and more recent examinations, respectively. References from 2014 to 2016 were, on average, 2 years older than those from earlier examinations. This study indicated that sports medicine questions on recent OITEs cite references of higher levels of evidence and contain higher taxonomic question structure than examinations 10 to 12 years ago. However, the majority of questions still cite articles with low levels of evidence or nonprimary sources. These findings can be used to guide resident education and continue improvements in the selection of references for questions on the Sports Medicine section of the OITE. [Orthopedics. 2020;43(5):e460–e464.]

The American Board of Orthopaedic Surgery (ABOS) was established in 1934 with the intention of creating a universal standard of education. By 1936, the ABOS instituted the first formal requirements for certification to monitor physician quality and to ensure public trust.1 In addition to the certification examination administered by the ABOS, the American Academy of Orthopaedic Surgeons (AAOS) developed the Orthopaedic In-Training Examination (OITE) in 1963 to assess whether each orthopedic residency program was attaining its educational goals and maintaining a minimum standard for orthopedic education. Currently, this annual examination consists of 275 questions divided among 12 sections, with the Sports Medicine content domain comprising approximately 8% of the OITE.2 These questions are based on meaningful publications that highlight concepts deemed most important by test makers.

In 2003, The Journal of Bone and Joint Surgery (JBJS) began rating the levels of evidence (LoE) of its published studies and The American Journal of Sports Medicine (AJSM) began a similar practice shortly thereafter with its own categorization based on work from the Oxford Centre for Evidence-Based Medicine.3,4 Coinciding with these ratings, the proportion of level 1 and 2 studies in AJSM increased significantly from 1996 to 2011.5

Despite a trend toward the publication of higher-quality studies in the orthopedic literature, there are few analyses examining whether there has been an increase in the citation of publications with the highest LoE on the OITE. Recently, there have been investigations focusing on the LoE in content domains other than the Sports Medicine section. Walsh et al6 and Grandizio et al7 found significant increases in the LoE of publications cited in the Foot and Ankle section and the Hand section, respectively, during their 15-year study periods. However, despite these positive trends, the majority of the references cited on the OITEs from 2010 to 2012 were level 4 or 5 evidence.8

The primary purpose of this study was to assess the trends related to LoE of cited references in the Sports Medicine content domain on the OITE during a recent 12-year period (2005–2016). Secondary purposes were to analyze trends in question taxonomy, age of references, and most commonly cited publications. The authors' null hypotheses were that there would be more cited references of the highest LoE and that average question taxonomy has increased during the past 12 years of examinations.

Materials and Methods

Orthopaedic In-Training Examinations from 2005 to 2007 and from 2014 to 2016 were obtained, and the questions and their associated references within the Sports Medicine sections were evaluated by 2 of the authors (J.C.L., A.D.S.). Data were compared between the 2 groups of examinations; the past examination group was from 2005 to 2007, and the present examination group was from 2014 to 2016. Total numbers of sports medicine questions and the percentage of the OITEs dedicated to these questions were determined.

Question Taxonomy

The question taxonomy was determined based on the classification system of Buckwalter et al.9 Taxonomic level I (ie, tax I) was assigned to questions that tested isolated recognition and recall, tax II was assigned to those testing comprehension and interpretation, and tax III was assigned to those testing the application of knowledge. The number of questions with each taxonomic level from the past and present examination groups was summed, and the proportion of questions with each taxonomic level was compared between groups. Mean taxonomic levels were then compared.

Number of References

The full manuscripts of all journal articles cited in the examination questions were reviewed. Summaries and descriptions of other nonprimary references (eg, books, technique guides, etc) were also evaluated. The number of references for each question was determined and totaled for each examination group. Mean number of references per question and proportions of questions with 1, 2, or 3 or more references were compared between examination groups.

Level of Evidence

The LoE of each reference was categorized based on the recommendations from the AAOS.10 References were categorized as being either of the highest LoE (levels 1 and 2), high LoE (levels 1–3), low LoE (levels 4–5), or review and other nonprimary references. The total number of references in each category was determined, and proportions of references in these categories were compared between past and present examination groups.

Age of References

The year of publication was determined for each reference, and the age of the reference was calculated by subtracting the year of reference publication from the year of examination administration. Mean reference age was calculated for the past and present examination groups and compared.

Most Common Sources

The number of unique publications (ie, sources) were summed for the past and present groups, and the citation frequency for each source was totaled. After sorting the sources by citation frequency, the number of review and non-journal publications in the top 10 most-cited sources was determined.

Statistical Analysis

Descriptive statistics were used to identify means and proportions in all data categories. Continuous data for the past and present examination groups were compared with independent, 2-tailed Student's t tests. Categorical data for the examination groups were compared using 2 × 2 contingency tables and Fisher's exact test. All analyses were performed using the GraphPad QuickCalcs website (GraphPad Software, La Jolla, California). Statistical significance was present in comparison testing if P<.05.

Results

Review of the 6 years of OITEs yielded 125 questions and 264 references within the Sports Medicine sections. Questions within the Sports Medicine section accounted for 8% of the total number of questions on both past and present examinations (P=1.00). Characteristics of the sports medicine questions and their associated references on all examinations are summarized in Table 1.

Question Taxonomy and Level of Evidence for References Used for Sports Medicine Questions on Orthopaedic In-Training Examinations Between 2005 and 2007 and Between 2014 and 2016

Table 1:

Question Taxonomy and Level of Evidence for References Used for Sports Medicine Questions on Orthopaedic In-Training Examinations Between 2005 and 2007 and Between 2014 and 2016

The mean taxonomic level of questions on present OITEs had increased from past examinations (1.52±0.76 vs 2.26±0.89, P=.0001). This increase was driven by a significant reduction in tax I questions (63% vs 29%, P=.0002) and a significant increase (244%) in tax III questions (16% vs 55%, P=.0001).

Despite no difference in the percentage of sports medicine questions on the past and present OITEs, present OITEs cited 28 (24%) more references than on past examinations, increasing the mean number of references per question by 19% (from 1.97±0.41 to 2.35±0.66, P=.0002). There were no questions on present OITEs citing only 1 reference compared with 10% of questions on past examinations (P=.012), and there was a higher percentage of questions on present examinations citing 3 or more references than on past examinations (27% vs 7%, P=.0034).

There were many significant differences in the LoE of the references cited on past and present examinations. Significantly higher percentages of references on present OITEs were of the highest levels of evidence (21% vs 10%, P=.027) and high levels of evidence (32% vs 18%, P=.015) compared with past examinations. Fewer citations were generated from review and other nonprimary references on present compared with past OITEs (36% vs 59%, P=.0002).

References on present examinations were older than those cited on past examinations (7.14±7.20 vs 5.08±4.61 years, P=.007). Past examinations cited work from 31 different sources, whereas present examinations cited work from 42 different sources. The top 10 most-cited sources on past examinations included 6 review and non-journal publications, whereas 2 of the top 10 most-cited sources on present examinations were review and non-journal publications. The most commonly cited source for both examination groups was AJSM, generating 31% of references on past examinations and 20% of references on present examinations. The second and third most commonly cited sources were Orthopedic Knowledge Update: Sports Medicine 3 (13%) and Instructional Course Lectures (6%) on past examinations and the Journal of the Academy of Orthopaedic Surgeons (14%) and JBJS (12%) on present examinations.

Discussion

The OITE has been a perennial assessment of orthopedic resident proficiency since 1963. It serves as a benchmark for residents, and scores on this examination have been correlated with ABOS Part I performance.11,12 The importance of the examination has resulted in many investigations into its structure and composition to aid residents in their preparation and development of a foundation in orthopedic knowledge.13–17 Although the Sports Medicine section comprises a substantial proportion of the examination,2 there has been no publicly available investigation into the complexity of the examination questions and the LoE of the cited references in this section. The authors have demonstrated that during the past 12 years, the questions on the OITE have become more difficult, with references that are more numerous, of higher LoE, older, and from major orthopedic journals.

The current results indicate that the Sports Medicine section of the present examinations (2014–2016) had significantly more references of high and the highest LoE than past examinations (2005–2007). This positive trend is consistent with recent changes in other content domains of the OITE. Walsh et al6 and Grandizio et al7 found that the questions on the Foot and Ankle section and Hand section, respectively, cited references with higher LoE on OITEs from 2010 to 2012 than OITEs from 1995 to 1997. The increasing LoE of the cited references in OITE questions models the changes seen in orthopedic literature on the whole since documenting the LoE for journal articles was initiated by JBJS in 2003.3 Many major orthopedic journals, including AJSM, have begun noting the LoE of their published manuscripts and have also placed a focus on increasing quality of scientific methodology.4,18–20 Consistent with this emphasis, the proportion of studies with level 1 and 2 evidence in AJSM increased significantly from 1996 to 2011.5 Despite this trend, studies with lower LoE still predominate the orthopedic literature.8 The current results also demonstrate this; references with low LoE (levels 4 to 5) comprise 33% of all sources and 51% of all journal articles cited on the Sports Medicine sections of present OITEs. Although there is a growing emphasis on studies with high LoE, lower-level studies should not be neglected. It is not possible to perform randomized, controlled trials to answer all clinical questions,21 so studies of lower LoE can often be designed to provide guidance on appropriate management.

Although the current study indicates that the LoE of the references cited in the questions in the Sports Medicine section of the OITE have changed over time, so too have the characteristics of the questions themselves. Question taxonomy can serve as a surrogate for cognitive complexity.9 Many medical specialties have found it imperative to assess the knowledge of trainees with complex questions that require them to “manipulate factual knowledge to solve diagnostic problems and develop treatment plans.”22 The current results demonstrate that the average question taxonomy increased almost 50% on present examinations and that questions of the highest taxonomic order (tax III) are now the most commonly used. Similar trends have been observed in other content domains of the OITE.6,7,14,15 Given that the most common study technique of residents for the OITE has been the completion of practice questions,23,24 the current results suggest that residents may be able to better prepare for the OITE, and for clinical practice, by focusing on tax III questions rather than basic recall (tax I) questions in their studying.

The limitations to this study are similar to other related investigations.2,15–17 This study focused on questions that were listed in the Sports Medicine section of the OITE. Although this includes the majority of sports medicine–related questions on the examinations, sports medicine concepts are often tested in the Shoulder and Elbow, Foot and Ankle, and Pediatric sections as well. Therefore, the authors may not have considered all of the sports medicine–related questions on the OITE examinations from the past 12 years. Furthermore, although the authors used guidelines set forth by the AAOS10 to assign the LoE to each journal article, they did not cross-reference to any LoE listed in the description, abstract, or body of the manuscripts, which may have caused some discrepancies. In addition, assigning a taxonomic level to an examination question is somewhat subjective; thus, the authors' assignments may be different from those of other reviewers. However, there seems to be high concordance among those evaluating questions, whether they be orthopedic residents or OITE committee members,9 therefore reducing the concern of subjectivity in the current analysis. Finally, the authors were unable to obtain 3 references for 3 questions on the 2005 examination and were therefore unable assign LoE for them. A post hoc analysis including these 3 references and making the assumption that they are all level 1 or 2 evidence indicated that only the comparison between the proportions of references being of the highest LoE would lose significance (P=.07). Despite this, only 16% of all references were level 1 or 2 evidence, so it is improbable that all 3 would be of the highest LoE.

Conclusion

There are more publications with high LoE and fewer review and nonprimary sources cited in questions within the Sports Medicine content domain of the OITE on recent examinations compared with examinations produced 12 years ago. Despite this, the majority of references cited are not level 1 to 3 studies, even with a 24% increase in the number of references cited. Questions have also become more challenging on present examinations: the average taxonomic level of questions has significantly increased and has been driven by a 244% increase in tax III questions. The OITE is constantly evolving; however, the results of this study may allow for residents to better prepare for the annual test and to build a foundation of orthopedic knowledge from sources deemed most important by test makers.

References

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Question Taxonomy and Level of Evidence for References Used for Sports Medicine Questions on Orthopaedic In-Training Examinations Between 2005 and 2007 and Between 2014 and 2016

ItemOverall2005–20072014–2016P
Sports questions, No. (% of all questions)125 (8)63 (8)62 (8)1.00
Buckwalter classification of question taxonomy
  Tax I, No. (% sports questions)58 (46)40 (63)18 (29).0002a
  Tax II, No. (%)23 (18)13 (21)10 (16).65
  Tax III, No. (%)44 (35)10 (16)34 (55).0001a
  Mean (SD)1.89 (0.90)1.52 (0.76)2.26 (0.89).0001a
References
  Total, No.264118146
  Per question, mean (SD)2.111.97 (0.41)2.35 (0.66).0002a
    1, No. (%)6 (5)6 (10)0 (0).012a
    2, No. (%)95 (79)50 (83)45 (73).19
    3+, No. (%)21 (17)4 (7)17 (27).0034a
    Mean (SD)2.16 (0.58)1.97 (0.41)2.35 (0.66).0002a
Level of evidence, No. (%)
  Highest (levels 1 and 2)42 (16)12 (10)30 (21).027a
  High (levels 1–3)67 (25)21 (18)46 (32).015a
  Low (levels 4–5)75 (28)27 (23)48 (33).077
  Review and other nonprimary sources122 (46)70 (59)52 (36).0002a
Age of sources, mean (SD), y6.22 (6.25)5.08 (4.61)7.14 (7.20).007a
Authors

The authors are from the Department of Orthopaedics and Sports Medicine (JCL), Temple University Hospital, Philadelphia, Pennsylvania; the Department of Orthopaedic Surgery (ADS), The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; and the Department of Orthopaedic Surgery (MKM), Tulane University School of Medicine, New Orleans, Louisiana.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Joshua C. Luginbuhl, MD, 3401 N Broad St, 5th Fl, Boyer Pavilion, Philadelphia, PA 19140 ( joshluginbuhl@gmail.com).

Received: January 18, 2019
Accepted: May 20, 2019
Posted Online: July 07, 2020

10.3928/01477447-20200619-02

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