Preparation Starts Now: The Plastic Surgery In-Service Training Exam

by Gianfranco Frojo, MD
St. Louis, MO

The Plastic Surgery In-Service Training Exam (PSITE) is designed to objectively assess fundamental plastic surgery knowledge in five competency sections: core surgical principles, comprehensive, cosmetic/breast,  craniomaxillofacial, and hand/extremities. The American Society of Plastic Surgeons In-Service committee consists of five subcommittees who oversee the creation of exam questions. The National Board of Medical Examiners administers the exam, and in combination with the In-Service Written Exam Committee, analyze the performance on each question and of each examinee before releasing individual scores and normalized scores for each post graduate year.

Residents each year are able to examine their performance on this exam as well as their performance relative to their peers, and gauge their knowledge level and readiness for the written plastic surgery board exam. Recent studies in general surgery have shown that in-service training exam scores can be predictive of success on written board examinations.However, within the plastic surgery literature, only one study has demonstrated that scoring at a lower percentile compared to peers on the PSITE correlates with higher risk of failing the plastic surgery written board exam.2

As would be expected, ambitious plastic surgery residents nationwide spend hours of individual study and structured learning geared towards performing well on this exam, along with the assumed complementary knowledge gained through daily clinical learning and preparation. The transparent nature of the exam’s annual syllabus with detailed explanation and sources for each question along with performance reports is a valuable educational resource for plastic surgery education. In fact, the ASPS re-brands the In-Service Examination as a continued medical education (CME) product for practicing attending plastic surgeons. This has also led to multiple studies and publications on the sources of citations and the frequency of tested subjects, specifically craniomaxillofacial, lower extremity, craniomaxillofacial, and aesthetic surgery.3-6

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 Reconstructive Surgery (38.5%), Clinics in Plastic Surgery (5.6%), Journal of Hand Surgery (5.1%), and Annals of Plastic Surgery (3.8%).Textbook citations included Plastic Surgery (2nd edition edited by Stephen J. Mathes) (7.1%), Green’s Operative Hand Surgery (7%), and Grabb & Smith’s Plastic Surgery (6.7%).Similar studies have been conducted for three popular subsections of the PSITE, and are summarized in the chart below.

Topic (Total questions) Years examined Most Frequently Cited Journals Most Frequently Cited Textbooks
Lower Extremity (107) 2008-2013 PRS (54.9%)

Annals (4.2%)

Mathes Plastic Surgery (21.9%)Grabb and Smith (14.1%)
Aesthetic (301) 2008-2013 PRS (58%)Clinics (7%)

ASJ (6%)

Art of Aesthetic Surgery (13%)

Mathes Plastic Surgery (13%)

Pediatric Craniofacial (1174) 2010-2015 PRS (34%)

JCFS (10.2%)

Grabb and Smith (17.6%)

Mathes Plastic Surgery  (14.3%)

A 2015 study examined 107 lower extremity PSITE questions over a five year period (2008-2013). Questions were derived from 263 citations from 66 separate journals. Of these 263 citations, 144 (54.9%) came from Plastic and Reconstructive Surgery followed by Annals of Plastic Surgery (4.2%).The most frequently referenced textbooks were Plastic Surgery 2nd Edition by Stephen J. Mathes (21.9%) and Grabb & Smith’s Plastic Surgery (14.1%).4

Another study from the same group reviewed 301 aesthetics-related questions (26% of all questions) over a six year period (2008-2013). Similar to the lower extremity subset, Plastic and Reconstructive Surgery (58%), Clinics in Plastic Surgery (7%), and Aesthetic Surgery Journal (6%) were the most frequently cited journals.5 The most frequently referenced textbooks were both the Art of Aesthetic Surgery by Nahai (13%) and Plastic Surgery 2nd Edition by Stephen J. Mathes (13%).5

Finally, another group examined 1174 pediatric craniofacial questions over a six year period (2010-2015). Once again, Plastic and Reconstructive Surgery (34.5%) was the most frequently cited journal, followed by Journal of Craniofacial Surgery (10.2%).The most frequently referenced textbook was Grabb & Smith’s Plastic Surgery (17.6%) followed by Plastic Surgery 2nd Edition by Stephen J. Mathes (14.3%).6

Knowledge of the most commonly referenced resources utilized for in-service examination questions helps guide preparation. Publications analyzing the content of the examination may also provide specific high yield topics to review prior to the examination date. Analyses of the PSITE reflect the need for early initiation of contemporary literature analysis and a didactic curriculum that parallels both established principles and evolving trends in plastic surgery. Preparation for the PSITE should include review of landmark articles and current publications in select plastic surgery journals, supplemented with core plastic surgery textbooks.


  1. James AT, Biester TW, Buyske J, Lewis FR, Malangoni MA. Using the American Board of Surgery In-Training Examination to predict board certification: a cautionary study. J Surg Educ. 2014 Nov-Dec;71(6):e144-8. doi: 10.1016/j.jsurg.2014.04.004. Epub 2014 Jun 7
  2. Girotto JA, Brandt K, Janis JE, Cullisen T, Slezak S. Abstract: Saw It Coming: The Correlation Between Poor Performance on the Plastic Surgery in Service Exam and Failure on the American Board Written Exam. Plastic and Reconstructive Surgery Global Open. 2017;5(9Suppl):70
  3. Silvestre J, Zhang A, Lin SJ. Analysis of References on the Plastic Surgery In-Service Training Exam. Plast Reconstr Surg. 2016 June; 137(6):1951-7. doi: 10.1097/PRS.0000000000002191. PubMed PMID: 26895583
  4. Silvestre J, Basta MN, Serletti JM, Chang B. Evaluation of the Plastic Surgery In-Service Training Exam: Lower Extremity Questions. J Surg Educ. 2015 Sep-Oct;72(5):875-81. doi: 10.1016/j.jsurg.2015.04.025. Epub 2015 Jun 24. PubMed PMID: 26117077
  5. Silvestre J, Taglienti AJ, Serletti JM, Chang B. Analysis of Cosmetic Topics on the Plastic Surgery In-Service Training Exam. Aesthet Surg J. 2015 Aug;35(6):739-45. doi: 10.1093/asj/sju151. PubMed PMID: 26229130
  6. Silvestre J, Chang B, Taylor JA. Analysis of an In-Service Examination for Core Pediatric Craniofacial Surgery Knowledge. J Surg Educ. 2016 May-Jun;73(3):375-80. doi: 10.1016/j.jsurg.2015.12.008. Epub 2016 Feb 6. PubMed PMID: 26861580

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