Preparing for the Plastic Surgery In-Service Exam: Evidence-Based Essentials for the Plastic Surgery Resident.

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Sir: The Plastic Surgery In-Service Training Exam is designed to objectively assess plastic surgery knowledge in five competency sections: core surgical principles, comprehensive, hand/extremities, cosmetic/breast, and craniomaxillofacial. The American Society of Plastic Surgeons In-Service Exam Committee consists of five subcommittees that oversee the creation of exam questions. The National Board of Medical Examiners administers the exam and, in combination with the In-Service Exam Committee, analyzes the performances of each question and examinee annually. Scoring at a lower percentile compared to peers on the Plastic Surgery In-Service Training Exam correlates with a higher risk of written examination failure.1 The transparency of syllabi has led to multiple publications analyzing the sources of citations and the frequency of tested subjects—specifically, lower extremity, aesthetic surgery, and craniomaxillofacial.2–5 A 2016 publication delineated the most frequently cited sources after reviewing 5386 references from 2000 questions from 2006 to 2015. The most frequently referenced journals were Plastic and Reconstructive Surgery (38.5 percent), Clinics in Plastic Surgery (5.6 percent), Journal of Hand Surgery (5.1 percent), and Annals of Plastic Surgery (3.8 percent), with a mean lag time of 9.1 years from publication to appearance in the exam.2 Textbook citations included Plastic Surgery, 2nd Edition (Mathes) (7.1 percent), Green’s Operative Hand Surgery (7 percent), and Grabb & Smith’s Plastic Surgery (6.7 percent).2 Similar studies have been conducted with respect to three of the five exam section competencies. In a 2015 study, 107 lower extremity questions (9.1 percent of all questions) from 263 citations were reviewed over a 5-year period (2008 to 2013). Of these 263 citations, 144 (54.9 percent) came from Plastic and Reconstructive Surgery, followed by Annals of Plastic Surgery (4.2 percent), with a mean publication lag time of 5 and 6 years, respectively.3 The most frequently referenced textbooks were Plastic Surgery, 2nd Edition (Mathes) (21.9 percent) and Grabb & Smith’s Plastic Surgery (14.1 percent).3 In a review by one of the same authors, 301 aesthetics-related questions (26 percent of all questions) over a 6-year period (2008 to 2013) were analyzed. Similarly, Plastic and Reconstructive Surgery (58 percent), Clinics in Plastic Surgery (7 percent), and Aesthetic Surgery Journal (6 percent) were the most frequently cited journals, with a mean publication lag time of 5 years.4 The most frequently referenced textbooks were the Art of Aesthetic Surgery (13 percent) and Plastic Surgery, 2nd Edition (Mathes) (13 percent).4 Finally, another similar study reviewed 1174 pediatric craniofacial questions (12.5 percent of all questions) with 304 citations over a 6-year period (2010 to 2015). Correspondingly, Plastic and Reconstructive Surgery (34.5 percent) was the most frequently cited journal, followed by Journal of Craniofacial Surgery (10.2 percent), with a mean publication lag time of 7.3 years.5 The most frequently referenced textbook was Grabb & Smith’s Plastic Surgery (17.6 percent), followed by Plastic Surgery, 2nd Edition (Mathes) (14.3 percent).5 Knowledge of the most commonly referenced resources used for in-service questions helps guide preparation. Analyses of Plastic Surgery In-Service Training Exam questions reflects the need for early initiation of frequent literature analysis and a curriculum that parallels established principles and contemporary trends. Preparation should include review of landmark articles and current publications in select plastic surgery journals supplemented by core textbooks. DISCLOSURE Authors have no known conflicts of interest associated with this article. Gianfranco Frojo, M.D.Kashyap K. Tadisina, M.D.Sumesh Kaswan, M.D.Aaron Doston, B.S.Alexander Y. Lin, M.D.Division of Plastic SurgerySaint Louis University School of MedicineSt. Louis, Mo.