Fellowship Board Pass Rates Rising: Analysis of Pathology Subspecialty Board Examination Performance

To the Editor.—The findings reported by Jacobs et al,¹  who studied American Board of Pathology board performance data for anatomic and clinical pathology and the pathology subspecialties over the past 15 years, are both exciting and encouraging. The authors highlight an increasing pass rate across the board for subspecialty fellowship examinations.¹  I would like to use this opportunity to highlight the trend in pediatric pathology.

Historically, pediatric pathology subspecialty board pass rates have been the lowest among pathology subspecialities. As a matter of fact, according to Jacobs et al,¹  pediatric pathology experienced the absolute worst board scores amongst all subspecialties for the first 2 time periods assessed, namely 2007–2011 and 2012–2016.¹  The significant improvement made in the third period (2017–2021) is likely a direct result of a new criterion-referenced standard applied in 2014. More specifically, a change in grading system from separate practical and written exam scoring, with the need to pass each component, immediately yielded more positive results, with a pass rate of 91% in 2014 and 84% in 2015 compared to 61% and 57% in 2013 and 2012, respectively.²  In addition, the switch from in-person examinations to remote testing may have influenced those scores. The second application of the new criterion standard in 2018 was followed by the highest consecutive exam results of the previous 16 years, with pass rates of 96%, 89%, and 91% in 2019, 2020, and 2021, respectively.²  Per Jeffrey Goldstein, MD, 2022 president of the American Board of Pathology, via email interview on Friday, December 8, 2023, other factors that may have contributed to improved test scores in the latter part of the period include the expansion of the number of content experts on standard exam setting panels and the reduction in the percentage of strict knowledge-recall questions to increase the relative proportion of questions that focus more on interpretation and judgment, the result of conscious decisions by the Committee on Examinations. The former likely gave the committee a better perception of the capabilities of pediatric pathology fellows and what a minimally competent pathologist should be expected to know. In the report by Jacobs et al,¹  for the 3 periods combined, however, the pass rate of 78.9% is still the lowest among all specialties. These traditionally poor board scores have plagued the minds of the leaders of the field so much that they worried that it may play a role in the less than optimal recruitment suffered by pediatric pathology fellowship programs.

A number of pediatric pathologists, including myself, have pondered the possible role of low pediatric pathology board scores on the decision of residents to pursue the subspecialty. Testament to that uncomfortable notion, the 2017 Pediatric Pathology Recruitment Survey, in its questionnaire to residents, included a question that read “Has the pass rate of examinees taking the American Board of Pathology’s subspecialty exam influenced your choice of fellowship?” Much to my relief, the responses did not indicate that the poor pass rates influenced a decision against a fellowship in pediatric pathology.³  Still, the question was not very intentional about performance on the pediatric pathology board exam per se. It will be interesting to determine whether the new trend of much better pediatric board scores is accompanied by improved recruitment. The study does highlight other important factors that contribute to the difficulties in recruitment to pediatric pathology fellowship programs. The survey results showed that a significant proportion of respondents were not attracted to a career in pediatric pathology because they did not want to be restricted to pediatric diseases or deal with pediatric autopsies. Some trainees were averse to the idea of being restricted to a geographic area where children’s hospitals are located, and a minority perceived pediatric pathology as complex, demanding, commanding a low income, or associated with limited job opportunities.³  The survey also revealed that the majority of pathology residents have already decided upon their choice of fellowship at the postgraduate year 2 and 3 levels. It also found that 45% of pathology residents had made their subspecialty selection without having rotated through pediatric pathology.³  Additionally, a 2012 study by Bernacki et al⁴  found that 91.3% of residents had decided on fellowship choice before the end of their third year. Singh et al³  suggested that if pediatric pathology is introduced early in pathology residency training, it might help with recruitment. Board pass rates may not play a significant role in pediatric pathology recruitment woes after all.

The aforementioned pediatric pathology experience highlights the importance of continued reassessment of board examinations, including content, with the ultimate goal of facilitating trainees with more manageable yet meaningful examinations, without compromising the established standards. With that said, I would like to urge administrators of pathology and pathology subspecialty examinations to continue to prioritize the constant review of their exams with the best interest of pathology trainees, training programs, and the broader field of pathology at heart.