Why Are Our Board Certification Pass Rates So Low?

1. American Podiatric Medical Licensing Examination. About the exam. Available at:https://www.apmle.com/about-the-exam/ . Accessed March 23, 2021.
2. American Board of Foot and Ankle Surgery. Pathway to certification. Available at:https://www.abfas.org/become-board-certified/pathway-to-certification . Accessed March 23, 2021.

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Our third-year residents recently took their American Board of Foot and Ankle Surgery (ABFAS) part 1 didactic and computer-based patient simulation (CBPS) exams. I will not delve into a detailed explanation of their feelings toward the exam but I will briefly say that it was not positive. This opinion is not new nor is this confined to residents. Many attendings I have spoken to about this test and process have had nothing positive to say.

I think this discussion needs to begin with the basics. What is this exam for? This board certification process is meant to determine the minimum competence of the podiatric foot and ankle surgeon. Keep in mind the idea of minimal competence. This process is broken into a didactic exam and a CBPS portion for qualification. Then there is a case review and CBPS exam for certification. These exams are meant to test the basic knowledge of podiatric surgery as well as review the surgeon’s cases to ensure he or she can properly manage surgical cases.

Consider the first time pass rates for all portions of the qualification and certification exams and reviews. I do find it important to recognize that these are first time attempts at passing these exams. In 2017, the first time pass rates for the ABFAS fall qualification exam were 29 percent for the foot didactic portion, 50 percent for the foot CBPS portion, 31 percent for the reconstructive rearfoot/ankle (RRA) didactic portion and 46 percent for the RRA CBPS portion.¹

In 2018, the spring qualification exam first time pass rates were as follows: 71 percent for foot didactic, 77 percent for foot CBPS, 57 percent for reconstructive rearfoot/ankle (RRA) didactic and 59 percent for RRA CBPS.¹ In 2018, the certification first time pass rates were as follows: 59 percent for foot case review, 60 percent for foot CBPS, 66 percent for RRA case review and 75 percent for RRA CBPS.¹

In podiatry school, anything below a 70 percent was considered failing. By those standards, we are essentially failing our own surgical certification process. I know of no other specialty that has such a low pass rate for their certification exams. When you calculate in the cost of taking exams repeatedly, this can be an expensive process.

Aside from the cost, we have to look at this objectively. There is a failure in our system somewhere.

Is it in our training? One may assume that the majority of first-time test takers are fresh out of a three-year surgical residency. These are recent residency graduates who are highly trained in surgery. They take this test either during their third year of residency or just after graduating, and we still have a failing grade in most sections. I find it hard to believe that residents at the peak of their surgical training are failing a board exam at a 70 percent or less pass rate overall. At this stage, residents have been living, breathing, and constantly studying surgery for almost three years, and we have a 70 percent or less pass rate? That seems ridiculous.

Is the exam the problem? A common report from those who have taken the test is that the questions often have more than one right answer and that they are to choose the best answer. This becomes an opinionated question rather than one based on evidence-based medicine. My example of this was at the American College of Foot and Ankle Surgeons annual scientific conference this year. There was a panel discussion in which four to five of the biggest names in podiatry discussed a case and gave their opinion on how they would handle it. There was no instance where all of them agreed. It was open to each surgeon’s interpretation.

So is this type of question fair? If a resident is trained that a Scarf procedure is the optimum procedure for HAV but the question is written by someone that prefers an Austin, then what is the correct answer?

I want to be objective as possible but there is a flaw in the system somewhere. Our profession is struggling for relevance all the time. I feel that if our MD and DO competitors look at us from a board certification standpoint, it is embarrassing. If we as a profession are barely able to pass our own minimum competency surgical boards, then how are we viewed to outsiders including our patients?

We are all well trained capable surgeons. We just can’t give ourselves extremely high standards that we cannot achieve.

Reference

1. American Board of Foot and Ankle Surgery. Newsletter Fall 2018. Available at https://issuu.com/abfas1/docs/abfas_fall_2018_newsletter .