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Why Are Our Board Certification Pass Rates So Low?

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. They are scheduled to take the American Board of Podiatric Medicine (ABPM) qualification exams in May. I will not delve into a detailed explanation of their feelings toward the exam but I will briefly say 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.

Board certification is a way of demonstrating our competence to our patients. Most hospitals accept ABPM certification in regard to granting privileges. For residents completing a 36-month residency with or without rearfoot certification, the requirements are passing the qualifying exam (part 1) and passing the certifying exam (part 2). No case submission is required.

As our profession has transitioned to becoming highly surgical, having ABFAS board certification can demonstrate surgical competence. There are various parts to this exam that are scheduled to change in 2020. As of now, we are required to take part 1, which consists of four parts: foot didactic, foot CBPS, rearfoot didactic and rearfoot CBPS.

There is also the issue of the ABFAS pass rate. 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. So 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 factor in the cost of taking exams repeatedly, this can be an expensive process.
There is a failure in our system somewhere. Is it in our training? One should assume the majority of first-time test takers are fresh out of a three-year surgical residency so these are residency graduates highly trained in surgery. I find it hard to believe residents at the peak of their surgical training should be failing their board exam at a 70 percent or lower 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 itself 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 residents are to choose the best answer. This becomes an opinion-based question rather than one of evidence-based medicine.

An example of this was at the American College of Foot and Ankle Surgeons Scientific Conference this year. At a panel discussion, four or five of the biggest names in podiatry discussed a case and gave their opinion on what they would do. There was no instance when all of them agreed. The cases were 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 hallux valgus but the question is written by someone who prefers an Austin, then what is the correct answer?

The board qualification road is long, confusing and rather expensive. All of these expenses are due while we are still in residency, which is a tough ask for someone living on a minimal salary with little to no expendable income. Also, all of these prices are based on the fact that the individual passes these exams on the first try. As the statistics for ABFAS show, this is very, very often not the case.

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, then it is embarrassing. If we as a profession are barely able to pass our own minimum competency surgical boards, then how do outsiders, including our patients, view us?

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

Dr. Bishop is a second-year resident at Alliance Community Hospital in Alliance, Ohio.

This column was adapted from two DPM Blogs at and .


1.     American Board of Foot and Ankle Surgery. Newsletter Fall 2018. Available at .

By David Bishop, DPM



One answer to Dr. Bishop's question is that the pass rate on ABFAS exams is low because not all podiatrists are alike. In a recent survey of podiatric residents, over 30 percent did not intend to be advanced foot and ankle surgeons. They do intend to be general practice podiatrists. There is diversity among podiatrists and this diversity is an asset to the profession, and helps us to best serve the public health needs in America.

We all need to acknowledge that there is ample room for diversity in podiatry and that such diversity is an advantage for us as a profession. We are so used to believing that the more we all do surgery, the more respect we deserve and will get. That’s nonsense. We will get respect as a profession in proportion to how well we serve all of the public health foot care needs of the population, and we don’t do that best with only surgery.…

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