To the Editor.—We read with interest the manuscript “Fellowship Board Pass Rates Rising: Analysis of Pathology Subspecialty Examination Performance.”1  Foremost, we congratulate the authors on this work, and appreciate the opportunity to comment and expand. We agree that it is an important time to reemphasize the importance of certification as a means of assuring competency. The American Board of Pathology (ABPath) has several ongoing initiatives to ensure that certification and continuing certification are valuable and relevant for our diplomates and the patients they serve. We also agree with the authors that board pass rates remain an important quality metric for the assessment of training programs by the Accreditation Council for Graduate Medical Education.

The ABPath for many years has made a consistent and concerted effort to emphasize practical, need-to-know information on the certification examination; reduce simple recall items; and eliminate minutia.2  Additionally, the ABPath, in conjunction with subspecialty societies in hematopathology, cytopathology, and molecular pathology, has worked to harmonize training requirements, certification expectations, and the knowledge and skills necessary for clinical practice.3–5  The ABPath continues to use criterion-referenced standard setting that relies heavily on the modified Angoff method for cut-score determination, which is likely the most common practice for high-stakes exams. More recently, however, the ABPath has expanded the number of content experts who participate in the standard-setting process, since the inclusion of a greater number of participants has been demonstrated to improve standard setting precision.6  Currently, the ABPath is developing a comprehensive content outline that will provide more detailed guidance to candidates and educators with respect to the knowledge, judgment, and skills important to achieve certification. This initiative has and will continue to seek input from the broader pathology community.

Jacobs and colleagues1  interestingly propose that the higher subspecialty board-pass rates may be due to continually improving and more readily available preparatory material, such as question banks and web- or social media–based materials. In this current era, trainees are no longer restricted to the faculty expertise and resources located in their residency program, but can now access a wide variety of resources, much of it free of charge. The ABPath encourages the development of high-quality material that may be electronically accessed by trainees and believes this contributes to equity in medical education. Whenever free material is available the question of quality and validity should arise. Therefore, we encourage our recognized cooperating societies to develop and offer high-quality resources for trainees that are free of charge, and we thank those who already have. This is a great way to introduce pathology trainees to our pathology societies.

The existence of practice material, such as question banks, is highly encouraged, as the use of practice exams has been shown to increase test performance.7  Not only are practice tests and question banks important tools for learning new material, but they also provide opportunities for the recall of previously learned material, which strengthens the associated memory and interrupts forgetting.8  Finally, the use of practice tests allows the candidate to become accustomed to test taking, which decreases the associated stress, which may improve performance.8  The ABPath website offers a virtual microscopy sample exam and practice tutorial that candidates are encouraged to review (https://vmdemo.abpath.org/ and https://abpath.org/practice-tutorial-for-certification-exams/).

Jacobs and colleagues1  also noted a significant difference in pass rates between candidates who took a certification examination for the first time and those who were initially unsuccessful and made a repeat attempt. This is a common occurrence for both primary and subspecialty certification examinations and is not unique to ABPath. This finding has also been described by the American Board of Physical Medicine and Rehabilitation (ABPMR).9  The ABPMR undertook a 5-year retrospective review of their 2-part certification examination. They demonstrated that for Part I of the examination the pass rate dropped from 90% on the first attempt to 58% on the second attempt, then to 41% on the third attempt, and finally to 17% on the fourth or greater attempts. Similarly, for Part II of their certification examination, the pass rate for the initial attempt was 87%, which dropped to 65% for the second attempt, then 41% on the third attempt, and finally to 20% for the fourth or greater attempts. The ABPath currently provides feedback to individuals who were unsuccessful in their attempt at certification to help guide their future studies. We also intend to undertake a regression analysis study based on scaled scores with the hope of providing more detailed predictive analytics to individuals who were initially unsuccessful in their certification, so that they may even better address gaps in a more focused manner.

In conclusion, we appreciate this study, and Nayar is the immediate past president of ABPath. study, and the previous manuscript, which assessed primary certification pass rates.10  External reviews of certification data such as these afford the opportunity for the exchange of information regarding certification and continuing certification, which we hope assures our colleagues of the vigilance of the ABPath in maintaining the highest quality in certification available in our field, as well as in our ongoing continuous improvement efforts.

1.
Jacobs
JW,
Booth
GS,
Usmani
A,
Burner
J,
Adkins
BD.
Fellowship board pass rates rising: analysis of pathology subspecialty board examination performance
.
Arch Pathol Lab Med
.
2023
;
147
(
8
):
964
968
.
2.
Johnson
RL.
American Board of Pathology examination pass rates
.
Arch Pathol Lab Med
.
2020
;
144
(
12
):
1447
.
3.
Swerdlow
SH,
Monaghan
SA,
Douglas
AR,
Johnson
K,
Johnson
RL.
Harmonization of training, training requirements, board certification, and practice of hematopathology
.
Am J Clin Pathol
.
2019
;
152
(
5
):
625
637
.
4.
Nayar
R,
Chute
D,
Douglas
A,
Sandersfeld
T,
Johnson
R.
Harmonization of training, training program requirements, board certification, and the practice of cytopathology: data from the American Board of Pathology surveys
.
J Am Soc Cytopathol
.
2021
;
10
(
5
):
447
458
.
5.
Velu
PD,
Cushman-Vokoun
A,
Ewalt
MD,
et al.
Alignment of fellowship training patterns for molecular pathologists
.
J Mol Diagn
.
2022
;
24
(
8
):
825
840
.
6.
Shulruf
B,
Wilkinson
T,
Weller
J,
Jones
P,
Poole
P.
Insights into the Angoff method: results from a simulation study
.
BMC Med Educ
.
2016
;
16
:
134
.
7.
Yang
BW,
Razo
J,
Persky
AM.
Using testing as a learning tool
.
Am J Pharm Educ
.
2019
;
83
(
9
):
7324
.
8.
Brown
PC,
Roediger
HL
III,
McDaniel
MA.
Make It Stick: The Science of Successful Learning
.
Cambridge, MA
:
The Belknap Press of Harvard University Press
;
2014
.
9.
Robinson
LR,
Sabharwal
S,
Driscoll
S,
Raddatz
M,
Chiodo
AE.
How do candidates perform when repeating the American Board of Physical Medicine and Rehabilitation certification examinations? Am
J Phys Med Rehabil
.
2016
;
95
(
10
):
718
724
.
10.
Adkins
BD.
Recent advances in anatomic and clinical pathology board examination pass rates
.
Arch Pathol Lab Med
.
2020
;
144
(
12
):
1448
1450
.

Competing Interests

Procop is the chief executive officer for the American Board of Pathology (ABPath), and Nayar is the immediate past president of ABPath. The authors have no relevant financial interest in the products or companies described in this article.