Reconsidering Percentile Reporting in Plastic Surgery In-service Examinations: Insights From the Trainee Perspective

The Plastic Surgery In-service Training Examination (PSITE) is administered annually to evaluate resident knowledge and guide program curricula. The American Board of Surgery In-service Training Examination (ABSITE) is used in general surgery for similar purposes. Recently, percentile score reporting was removed from the ABSITE due to concerns over its use in high-stakes decisions and limitations in interpreting percentile data.1 These concerns also apply to plastic surgery and warrant reevaluation of PSITE percentile reporting. The PSITE currently provides 3 performance metrics: percentage correct, raw score (based on distribution around the mean), and percentile rank relative to all plastic surgery residents within the same training year. With only 221 residents in the 2025 integrated intern class, the small sample size limits the reliability of percentile-based comparisons.2 Clustering of scores can exaggerate percentile shifts with only minimal changes in raw score.1 The 2025 PSITE normative table data reveal that scoring 78% versus 77% correct as a fifth-year resident increases the percentile rank from the 83rd to 94th percentile. This is problematic given the lack of evidence linking PSITE performance to clinical competence. A multi-institutional survey of plastic surgery faculty found PSITE performance ranked low among indicators of resident excellence, whereas bedside manner, personality, operative case preparation, leadership, and technical ability were ranked highest.3 Tying percentile scores to rewards may also foster unhealthy competition, detract from collaboration, and worsen burnout. Despite these limitations, percentile-based metrics offer a normalized score that compensates for examination variability, helping to guide curricular interventions. One study by Girotto et al4 reported that PSITE scores below the 24th percentile are associated with a 7.5-fold increased risk of failing the American Board of Plastic Surgery written examination. As a result, programs often use percentiles to assess readiness for board examinations. However, the study analyzed data from 2009 to 2015 and should be replicated in more recent cohorts. Despite the presence of this metric, first-time pass rates for the written boards have continued to decline.5 Moreover, using imprecise metrics as a proxy for clinical readiness can foster a false sense of confidence or exacerbate stress and burnout, especially given the differences in plastic surgery exposure in early training years across programs. Alternative options such as the Bayesian Score Predictor used in family medicine should be considered. In fellowships (such as hand surgery) with applicants from multiple specialties, percentile scores may help compare candidates with diverse training backgrounds. However, limited evidence and a lack of clarity around their use raise doubts about their reliability for applicant evaluation. Additionally, the inclusion of PSITE scores in many fellowship applications may suggest their use in applicant selection and warrants further transparency from fellowship directors. The removal of percentile scores from the ABSITE presents a timely opportunity for reevaluation of this metric and its utility in plastic surgery residency. As such, we advocate for increased transparency in how PSITE scores are used and call for the elimination of percentile score reporting as a meaningful step toward restoring the PSITE to its original intent as a formative educational tool. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.