When young surgeons step into the operating room for the first time — or when seasoned surgeons encounter a technology they never trained on — their sense of competence can feel crumble.
For Charles Nelson, MD, chief of the joint replacement service and professor of orthopedic surgery at the Philadelphia-based Hospital of the University of Pennsylvania, and president of the American Board of Orthopaedic Surgery, that breakdown has never been acceptable.
Across his clinical, academic and leadership roles, Dr. Nelson is working to build a more connected, transparent system of education, assessment and lifelong learning — one that adapts as quickly as the field itself and protects both patients and the profession.
A board built to protect the public — and the profession
The American Board of Orthopaedic Surgery formed in 1934 on a straightforward premise: establish a national standard for orthopedic training and practice. Before that, requirements varied wildly by state, Dr. Nelson told Becker’s.
“There was really no type of requirement, no standardization … so you had significant differences in quality and education,” Dr. Nelson said. “This board was established with a purpose of protecting the public — and by protecting the public, you’re really also protecting the profession.”
Pursuant to that mission is a rigorous written exam after residency and a practice-based oral exam once surgeons have been in independent practice for several years. The oral component, he emphasized, reflects real surgical decision-making.
“We’re not expecting somebody who’s a shoulder expert to be a spine expert,” he said. Instead, the board evaluates surgeons based on their own cases to ensure safe, context-specific judgment.
Beyond testing, ABOS also investigates credentialing concerns, including license actions or felony convictions, and can revoke certification if necessary. It is not a regulatory body, he clarified, but rather a certifying one: states grant licensure; ABOS determines whether a surgeon meets a national standard of excellence.
Where training meets accountability
ABOS routinely partners with the Accreditation Council for Graduate Medical Education to ensure residents receive comprehensive exposure across orthopedic subspecialties, such as trauma, pediatrics, hand, spine and oncology.
One initiative Dr. Nelson highlighted is ABOS’ Knowledge, Skills and Behavior platform, which enables real-time feedback between residents and faculty.
“It’s a platform that allows residents and faculty to send brief evaluations right after a case, providing immediate feedback on what was understood and how well the procedure was performed, so trainees can track and improve their skills over time,” he said.
The behavioral component comes via 360-degree evaluation — by faculty, peers, nurses and staff — whcih identifies early professionalism concerns and supports trainees who need mentorship. It is, he said, one of the few ways the board touches residents before they complete training.
Building fairness into the exam process
Amid increasing scrutiny of bias in testing, ABOS’ DEI committee evaluates exam questions to detect unintended disparities.
“We review all of our questions to see whether certain groups perform differently on them,” Dr. Nelson said. “If we find, for example, that men do better on some questions and women do better on others, we evaluate those items to make sure they’re not unintentionally favoring any group.”
Examiners complete bias training as well.
“We want to make sure that the exam is as fair as possible for everybody,” he said.
AI: a powerful tool — and a real challenge
Few topics loom as large as artificial intelligence. ABOS has been discussing AI for years, consulting national experts to stay ahead of its opportunities and risks.
Today, the board is investing heavily in upgrading its IT infrastructure to manage the massive data volumes generated through exams, case uploads and the KSB program. The goal, Dr. Nelson said, is to use data to improve public protection without compromising exam integrity.
Making lifelong learning realistic for surgeons
One of the most meaningful shifts at ABOS has been the transition from high-stakes, once-a-decade testing to a more flexible, continuous model known as web-based longitudinal assessment.
“It’s basically people demonstrating that they’re keeping up with their education,” he said.
Surgeons choose articles to read and complete open-book questions at regular intervals — a format designed to reduce stress while maintaining accountability.
Diplomates asked for it, he said, and the board listened. The challenge? Some subspecialties are so small that maintaining separate psychometrically valid exams is becoming impossible. But overall adoption has been strong.
“We wanted to meet the goals and the wishes of our diplomates,” he said. “But still make certain that people are continuing to do lifelong learning.”
For Dr. Nelson, the logic is straightforward: the field evolves at incredible speed.
“When I was training, robotic surgery didn’t exist,” he said, adding that some of his mentors practiced before hip replacement was even common. With that pace of change, ongoing education becomes a necessity, not a choice.
Joint replacement today: the shift to outpatient care
Dr. Nelson, a joint replacement specialist, has witnessed a dramatic change in how patients experience surgery.
“When I was an early resident, patients came to the hospital the day before surgery. They stayed … four or five days, and then they went to rehab for at least a week,” he said.
Now, many leave the same day.
He credits improvements in multimodal pain management, anesthesia, prehabilitation, patient education and less invasive surgical techniques — as well as technology like robotics and navigation.
While evidence hasn’t yet proven that robotic surgery leads to better outcomes, Dr. Nelson believes the long arc of innovation points toward wide adoption, similar to how smartphones rapidly became indispensable.
“You can’t survive without your cell phone these days,” he said. Surgical tools, he believes, may follow a similar trajectory toward ubiquity.
Teaching the next generation: the hidden curriculum
When asked what he tries to instill early in residents and fellows, he didn’t hesitate.
“There’s always what’s called the hidden curriculum,” he said. “Trainees watch how you behave — not just what you say.”
Role modeling professionalism, humility and respect — especially in high-stress surgical environments — is part of the ethical responsibility of training.
But the core message is even simpler.
“The main thing I try to get across to trainees is the patient comes first,” he said. “If you keep that principle, the other things fall into place.”
What comes next
As ABOS prepares for 2026, Dr. Nelson’s priorities revolve around modernization of data systems, testing methodologies, training partnerships and fairness — all while safeguarding the public trust that underpins the profession.
It’s a balance between honoring a legacy nearly a century old and preparing surgeons for technologies that didn’t exist even a decade ago. But to Dr. Nelson, that evolution is not only necessary — it’s an obligation.
“As surgeons,” he said, “we have a responsibility to behave in a way that reflects well on the profession and sets a good example. It’s about the patients.”
