Levels of Evidence Are Low for Clinical Management Questions on the Orthopaedic In-Training Examination

Abstract

The Orthopaedic In-Training Examination (OITE) has been administered to orthopaedic surgery residents throughout the United States since 1963 and, over the past forty-five years, has become “an integral part of orthopaedic education.”1 The test was designed as an educational tool for residents, but it also is used to assess the performance of residents relative to that of others. Additionally, an implicit function of the test is to help to define the corpus of core knowledge for orthopaedic surgery residency. As noted by the participants of the Academic Orthopaedic Society symposium on musculoskeletal education2, “Testing organizations are influential in shaping the curriculum. Faculty are correct to teach what students need to know to pass their [tests].” The Evaluation Committee of the American Academy of Orthopaedic Surgeons (AAOS) writes the questions, amalgamates the examination, and scores the OITE. As such, test takers can reasonably infer that the material tested on the OITE reflects the Academy’s vision of the orthopaedic surgery core curriculum for residents in training, and, owing to the central position of the AAOS, the OITE is an important influence on the orthopaedic surgery curriculum for residents in the United States. For this reason, among others, it is worthwhile to examine the OITE for the purposes of studying what exactly residents are expected to master. One aspect of that analysis centers on the levels of evidence on which the OITE questions are based. Although the principles of evidence-based medicine3 do not limit the practitioner to the randomized trial (or any particular study type), there has been particular recent emphasis on the level of evidence associated with individual studies. In their editorial introducing the policy of explicitly listing this level, for example, the editors of this journal stated: “Orthopaedic surgeons have always based their clinical care on evidence… …