ABPS Pass rates...

[347932]

From a reliable source:

The ABPS reports that 30% failed the Foot Surgery Exam Oral/CBPS. Repeat candidates had a 44% failure rate, and repeat>1 candidates had a failure rate of 68%.

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[amaprez]

What happens to those who fail? Unable to get on insurance panels --> unable to get a job?

 

[347932]

What happens to those who fail? Unable to get on insurance panels --> unable to get a job?

Depends where they are in the process. If you they reached their almost 7 year limit, they can sit for the written again and become Board Qualified again. You can only do that once, so ultimately, you have 14 years to submit your cases, be approved and pass the orals. You can only sit for the orals twice before having to go before the board to ask for another chance, if memory serves.

The more important question is why are all these people failing to begin with? Listen, it's not an easy test, but is designed to test basic competency. If it were a few %, I would say some just had a bad day. Almost a third though? And then that steadily increases again with retakes?

You have to start asking yourself if some of those failing should have ever been there to begin with. Sad and tough situation for sure.

 

[heybrother]

These individuals would have already completed the necessary student examinations and finished a 2-3 year residency? And this is for the more "generic" certification/qualification of foot as opposed to the less common rearfoot ankle exam?

The more I read this forum, the more I realize the process is intensively competitive throughout (ie. you have to have good grades to get the better externships, which allow you to get a better residency etc). What I'm not clear on is - what happens to an individual who isn't up to par in their residency? Are people eliminated or tossed?

http://www.abps.org/PDFHandler.ashx?pdf=ABPS/ABPS420.pdf
I thought this was interesting - its the study guide for the test (100 example questions).

 

[347932]

And this is for the more "generic" certification/qualification of foot as opposed to the less common rearfoot ankle exam?

Yep. I can't possibly imagine not passing the Forefoot oral examination. Once again, it is testing minimum competency and the questions, although challenging, are nothing that you shouldn't know at that point in your career.

The more I read this forum, the more I realize the process is intensively competitive throughout (ie. you have to have good grades to get the better externships, which allow you to get a better residency etc). What I'm not clear on is - what happens to an individual who isn't up to par in their residency? Are people eliminated or tossed?

Not eliminate or tossed, but helped along the way and possibly even held back to redo certain rotations. This is a big question mark in training for ALL medical specialties. What do you do with residents that you know won't cut it? I was involved with this big time at the institution where I was on faculty previously. It is a very hard situation. This happens in the MD world as well btw. Yes if an Ortho resident can't pass the Ortho boards, they can then try for the IM boards, right? WRONG. They haven't a prayer in you know what to pass those either unless they redo their entire residency. Food for thought.

http://www.abps.org/PDFHandler.ashx?pdf=ABPS/ABPS420.pdf
I thought this was interesting - its the study guide for the test (100 example questions).

The question to ponder is this. Should every one of our colleagues be surgeons? Is the ABPS examination our "natural selection" process?

 

[Dr Hurly MD]

The question to ponder is this. Should every one of our colleagues be surgeons? Is the ABPS examination our "natural selection" process?

Agreed. Not everyone can do surgery, but EVERYONE graduating from internship, residency and fellowship must practice MEDICINE

(Medicine first, Surgery second--Always--NEVER vice versa, and no exception). For all realms of Medicine in the 21st century: Osteopathic, Podiatric, Dental, and my realm Allopathic

 

[347932]

Agreed. Not everyone can do surgery, but EVERYONE graduating from internship, residency and fellowship must practice MEDICINE

(Medicine first, Surgery second--Always--NEVER vice versa, and no exception). For all realms of Medicine in the 21st century: Osteopathic, Podiatric, Dental, and my realm Allopathic

This is really the biggest issue in Podiatry atm. If you aren't certified by the ABPS, it is exceptionally hard to get hospital privileges and get on insurance panels as a young practitioner.

This is why some of the more progressive powers that be are pushing to consolidate the boards to allow EVERYONE access. Of course, there is major resistance to this, but change in this direction is virtually required for progression of our profession imo.

 

[RockyIV]

This is really the biggest issue in Podiatry atm. If you aren't certified by the ABPS, it is exceptionally hard to get hospital privileges and get on insurance panels as a young practitioner.

In my brief experience, I would say that not everyone should be doing surgery. The wonderful thing about Podiatry is that there are so many different types of "medicine" you can practice within the profession, that you can provide a valuable service to a large number of patients without going into an OR. But without hospital privileges and getting onto insurance panels you can be seriously handcuffed when providing even non-surgical services. Personally, I'm confident it will change but it is going to take some time and seriously affect a number of podiatrists until it does.

 

[PADPM]

Yep. I can't possibly imagine not passing the Forefoot oral examination. Once again, it is testing minimum competency and the questions, although challenging, are nothing that you shouldn't know at that point in your career.

The above is a quote from Kidsfeet, and includes a major pet peeve of mine. There IS NO such thing as a "FOREFOOT" oral exam or written exam. Sorry, does not exist. And how did you determine that it is testing "minimum competency"???????? Sorry, don't agree. The exam is not created to test "minimum competency", since I don't believe the board is designed around mediocrity.

There is certification in foot surgery. However, the last time I looked the "foot" included the forefoot, midfoot and rearfoot. As someone who was an examiner for the oral portion of the ABPS exam, and when I examined candidates, there were questions pertaining to the entire foot.

I also find it slightly pompous to state that you can't possibly imagine not passing the oral exam for foot surgery. There are a lot of factors involved, including candidate nerves, health status that day, mood of the examiner. I witnessed some bright candidates not pass the oral exam. Some try to make it too complicated, some over-think the question, some believe we were looking for some esoteric information, etc. So, I think saying you can't "possibly" imagine not passing seems just a little strong.

 

[NatCh]

I always figured that the state licensing exam was testing for minimal competency and the ABPS exam was testing for surgical knowledge.

 

[347932]

Yep. I can't possibly imagine not passing the Forefoot oral examination. Once again, it is testing minimum competency and the questions, although challenging, are nothing that you shouldn't know at that point in your career.

The above is a quote from Kidsfeet, and includes a major pet peeve of mine. There IS NO such thing as a "FOREFOOT" oral exam or written exam. Sorry, does not exist. And how did you determine that it is testing "minimum competency"???????? Sorry, don't agree. The exam is not created to test "minimum competency", since I don't believe the board is designed around mediocrity.

There is certification in foot surgery. However, the last time I looked the "foot" included the forefoot, midfoot and rearfoot. As someone who was an examiner for the oral portion of the ABPS exam, and when I examined candidates, there were questions pertaining to the entire foot.

I also find it slightly pompous to state that you can't possibly imagine not passing the oral exam for foot surgery. There are a lot of factors involved, including candidate nerves, health status that day, mood of the examiner. I witnessed some bright candidates not pass the oral exam. Some try to make it too complicated, some over-think the question, some believe we were looking for some esoteric information, etc. So, I think saying you can't "possibly" imagine not passing seems just a little strong.

You are correct. It is the Foot Surgery boards. I digress. I should have been more precise in my terminology.

As far as my slightly pompous comment, I think it is being taken out of context. It was not meant as a pinch to those who didn't pass, it is more a matter of "OMG, I can't believe I didn't pass!!!" , not "Why can't you pass this exam???". I don't know if that is coming across the way I intended, but I can see how that it can be seen as inflammatory. My apologies.

I do however disagree with your comment about it not being designed around mediocrity. The test is not designed to fail people. When I sat for the orals, that was clearly stated during our orientation. I think your assessment around "mediocrity" is misguided. Everyone finishing their residency and having their cases approved to sit for the oral boards should be able to pass them. If it's not designed around minimum competency, than what exactly it is designed around? If the board that writes the questions are saying to themselves that everyone at that point in their career SHOULD be able to pass the test (questions), that IS what a minimum competency exam is based on. If they are somehow factoring in a certain failure rate when compiling the questions, that implies biased towards the outcome, which I'm hoping is not the case. You are correct that there are external factors that affect the outcomes, but the test questions themselves should not be a factor if the examination is designed fairly. That is why some questions are ejected. They are "test" questions to see what the outcome on them are and if they are "fair".

 

[PADPM]

You are correct. It is the Foot Surgery boards. I digress. I should have been more precise in my terminology.

As far as my slightly pompous comment, I think it is being taken out of context. It was not meant as a pinch to those who didn't pass, it is more a matter of "OMG, I can't believe I didn't pass!!!" , not "Why can't you pass this exam???". I don't know if that is coming across the way I intended, but I can see how that it can be seen as inflammatory. My apologies.

I do however disagree with your comment about it not being designed around mediocrity. The test is not designed to fail people. When I sat for the orals, that was clearly stated during our orientation. I think your assessment around "mediocrity" is misguided. Everyone finishing their residency and having their cases approved to sit for the oral boards should be able to pass them. If it's not designed around minimum competency, than what exactly it is designed around? If the board that writes the questions are saying to themselves that everyone at that point in their career SHOULD be able to pass the test (questions), that IS what a minimum competency exam is based on. If they are somehow factoring in a certain failure rate when compiling the questions, that implies biased towards the outcome, which I'm hoping is not the case. You are correct that there are external factors that affect the outcomes, but the test questions themselves should not be a factor if the examination is designed fairly. That is why some questions are ejected. They are "test" questions to see what the outcome on them are and if they are "fair".

1) I don't know of any legitimate test that is specifically designed to FAIL people, but on the other hand they never create an exam with an expected pass rate of 100%. So although it's not specifically designed to fail people, it's also not designed to pass all candidates.

2) I don't agree at all with your belief about minimum competency. The ability to pass an examination based on experience and knowledge does not equate with minimum competency. I believe the ABPS has set the bar higher than that level. Testing for EXPECTED knowledge and the ability to think and problem solve does not equate with minimum competency.

3) Would YOU go to a surgeon who is "minimally competent"????

4) The board is testing for expected knowledge and the ability to apply and think. The thought of minimum competency in this process is beyond scary and in my mind way off base.

 

[347932]

1) I don't know of any legitimate test that is specifically designed to FAIL people, but on the other hand they never create an exam with an expected pass rate of 100%. So although it's not specifically designed to fail people, it's also not designed to pass all candidates.

2) I don't agree at all with your belief about minimum competency. The ability to pass an examination based on experience and knowledge does not equate with minimum competency. I believe the ABPS has set the bar higher than that level. Testing for EXPECTED knowledge and the ability to think and problem solve does not equate with minimum competency.

3) Would YOU go to a surgeon who is "minimally competent"????

4) The board is testing for expected knowledge and the ability to apply and think. The thought of minimum competency in this process is beyond scary and in my mind way off base.

What does this testing process mean then? Whether I am minimally competent or not, there are minimum standards by which we are expected to perform as Podiatric Surgeons. You've mentioned you've seen excellent candidates fail the examination based on non empiric test related issues and that it also has somewhat to do with the examiner's mood.

I passed the examination and am now Board Certified. How does my competency rate against those that aren't? Am I deemed more competent? Am I more competent than the others who are also Board Certified?

My point is that there are minimum standards by which we are expected to perform. That is what the examination is trying to distinguish. Do we know the basics? Or are we below that standard? Maybe the terminology is skewed. I don't know.

To answer your question 3). How would I know if the surgeon was minimally competent or not? By their Board status, no? Does non Board status imply incompetence?

Ultimately, what does Board status actually mean? To me it is a badge of honor. I went through school, did my residency, passed a very challenging written examination, submitted and had approved a host of cases that allowed me to then sit for the oral examination, and ultimately made it through the examination and attained Board Certified Status. To me personally, that was a big achievement. To me personally, I don't rate my competency by the diplomas on my wall. We have to have a standard however, don't we?

Ultimately, I think we'll have to agree to disagree on this.

 

[PADPM]

What does this testing process mean then? Whether I am minimally competent or not, there are minimum standards by which we are expected to perform as Podiatric Surgeons. You've mentioned you've seen excellent candidates fail the examination based on non empiric test related issues and that it also has somewhat to do with the examiner's mood.

I passed the examination and am now Board Certified. How does my competency rate against those that aren't? Am I deemed more competent? Am I more competent than the others who are also Board Certified?

My point is that there are minimum standards by which we are expected to perform. That is what the examination is trying to distinguish. Do we know the basics? Or are we below that standard? Maybe the terminology is skewed. I don't know.

To answer your question 3). How would I know if the surgeon was minimally competent or not? By their Board status, no? Does non Board status imply incompetence?

Ultimately, what does Board status actually mean? To me it is a badge of honor. I went through school, did my residency, passed a very challenging written examination, submitted and had approved a host of cases that allowed me to then sit for the oral examination, and ultimately made it through the examination and attained Board Certified Status. To me personally, that was a big achievement. To me personally, I don't rate my competency by the diplomas on my wall. We have to have a standard however, don't we?

Ultimately, I think we'll have to agree to disagree on this.

Can't disagree or agree, because I have no idea what your comments above actually are saying, they're all over the place. I don't feel any of your comparisons are valid, and if you dissect your comments, you'll see that you completely missed my point.

Bottom line is that the ABPS exam is not testing for minimum competency. Period. Give them a call and ask if that's their ultimate goal. Because there are as you say, minimum standards at which we are expected to perform, doesn't mean the exam is testing for those minimum standards. Additionally, the ABPS exam is no indicator on actually surgical performance. It's simply an academic test based on knowledge, not surgical performance.

 

[NatCh]

What does this testing process mean then? Whether I am minimally competent or not, there are minimum standards by which we are expected to perform as Podiatric Surgeons. You've mentioned you've seen excellent candidates fail the examination based on non empiric test related issues and that it also has somewhat to do with the examiner's mood.

I passed the examination and am now Board Certified. How does my competency rate against those that aren't? Am I deemed more competent? Am I more competent than the others who are also Board Certified?

My point is that there are minimum standards by which we are expected to perform. That is what the examination is trying to distinguish. Do we know the basics? Or are we below that standard? Maybe the terminology is skewed. I don't know.

To answer your question 3). How would I know if the surgeon was minimally competent or not? By their Board status, no? Does non Board status imply incompetence?

Ultimately, what does Board status actually mean? To me it is a badge of honor. I went through school, did my residency, passed a very challenging written examination, submitted and had approved a host of cases that allowed me to then sit for the oral examination, and ultimately made it through the examination and attained Board Certified Status. To me personally, that was a big achievement. To me personally, I don't rate my competency by the diplomas on my wall. We have to have a standard however, don't we?

Ultimately, I think we'll have to agree to disagree on this.

Ummm...Wernicke's aphasia much? Kidding...

I also had trouble understanding what you were trying to articulate here.

 

[347932]

Wow,

That'll teach me to try to write anything coherent while hoped up on Nyquil. Sincerest apologies.

All I was trying to say was that I think every test out there has a standard by which it measures the test taker. By "minimally competent" all I'm saying is that if you passed the test you are considered "standard". That's all.

 

[PADPM]

Wow,

That'll teach me to try to write anything coherent while hoped up on Nyquil. Sincerest apologies.

All I was trying to say was that I think every test out there has a standard by which it measures the test taker. By "minimally competent" all I'm saying is that if you passed the test you are considered "standard". That's all.

Ha, I guess that Nyquil is still having lingering effects..

BTW, how do you have time at 9:15 am to be hanging out on the internet I want to work where YOU do!!

 

[347932]

Ha, I guess that Nyquil is still having lingering effects..

BTW, how do you have time at 9:15 am to be hanging out on the internet I want to work where YOU do!!

I can type blazing fast in between patients!

 

[FACN]

1) I don't know of any legitimate test that is specifically designed to FAIL people, but on the other hand they never create an exam with an expected pass rate of 100%. So although it's not specifically designed to fail people, it's also not designed to pass all candidates.

2) I don't agree at all with your belief about minimum competency. The ability to pass an examination based on experience and knowledge does not equate with minimum competency. I believe the ABPS has set the bar higher than that level. Testing for EXPECTED knowledge and the ability to think and problem solve does not equate with minimum competency.

3) Would YOU go to a surgeon who is "minimally competent"????

4) The board is testing for expected knowledge and the ability to apply and think. The thought of minimum competency in this process is beyond scary and in my mind way off base.

Does passing a written test make you are skilled surgeon? I know of many people that are very book smart and I would not got to for surgery.

I realize that you have to test one's knowledge, I'm just playing devils advocate.

 

[PADPM]

Does passing a written test make you are skilled surgeon? I know of many people that are very book smart and I would not got to for surgery.

I realize that you have to test one's knowledge, I'm just playing devils advocate.

You're absolutely not playing devil's advocate, because I don't believe that I stated in any of my posts above that passing the written or oral examination makes anyone a skilled surgeon. I DID say that it tests knowledge and the ability to think.

Look over my posts again and you'll read that I did not equate passing any exam with being a skilled surgeon. That's intuitively obvious.

 

[347932]

You're absolutely not playing devil's advocate, because I don't believe that I stated in any of my posts above that passing the written or oral examination makes anyone a skilled surgeon. I DID say that it tests knowledge and the ability to think.

Look over my posts again and you'll read that I did not equate passing any exam with being a skilled surgeon. That's intuitively obvious.

So once again, what does the test really mean?

How does passing this test make anyone "better" than someone who fails the test?

Brilliant mind, horrible hands or Skilled hands and meh mind? Which would you pick?

 

[FACN]

The test represents the best effort to standardized the quality of a specialist. That is how I see it. While it has limitations the two parts, one written the second oral/with case submission is the Boards attempt to find surgeons that are educate and skilled.

I would pick neither. A skilled hand that does the wrong procedure is just as damaging as one who knows the procedure but can't do it.

 

[PADPM]

So once again, what does the test really mean?

How does passing this test make anyone "better" than someone who fails the test?

Brilliant mind, horrible hands or Skilled hands and meh mind? Which would you pick?

Once again I fail to see your point. I never stated nor implied that someone who passes in any "better" than someone who fails.

It is testing knowledge and the ability to think. I don't believe it's intended to test for "minimum" competency, nor did I agree with one of your original comments that you could not possibly imagine who anyone could not pass the ABPS oral exam for foot surgery.

So my comments were really in dispute of your two comments above. However, no where did I EVER state that someone board certified is "better" or more skilled than someone who is not certified.

And I agree with FACN, I would not choose either of the doctors you've mentioned in your example. There is no reason to, since a hypothetical question like that is not relevant. There are plenty of smart and skilled surgeons. Why would I settle?

 

[347932]

Would YOU go to a surgeon who is "minimally competent"????

Please explain this comment.

Also, it seems like you're trying to take another stab at my "I can't believe" comment when I clearly explained my intention behind the comment. You want me to digress and apologize for it again?

 

[PADPM]

Please explain this comment.

Also, it seems like you're trying to take another stab at my "I can't believe" comment when I clearly explained my intention behind the comment. You want me to digress and apologize for it again?

1) Chill out, your tone is starting to tick me off.

2) I can easily explain the comment, which once again had NOTHING to do with equating someone passing the exam with being a better surgeon. It is/was a tongue in cheek comment made after you kept saying that the exam tests for "minimal competency". I obviously disagreed and as a result asked you if you would want to be treated by anyone considered "minimally competent".

3) You are the one that inferred I said something that I never did and used some examples.
As I've already stated too many times, I never equated passing the boards with making someone a better surgeon, yet you attempted to use that in an argument against me.

4) You've proven already that what you write isn't always what you mean, so let's end this now before it gets ugly. I assure you that's the best answer.

 

[347932]

1) Chill out, your tone is starting to tick me off.

4)...so let's end this now before it gets ugly. I assure you that's the best answer.

Whoa. We are all on equal ground here and are all friends having a discussion. I think we all have an equal amount to offer.

If WE can't have a heated discussion about our opinions here, then where else?

 

[Ferocity]

 

[347932]

Butter or plain?

 

[347932]

Deleting since it refers to a post that was removed.

 

[Ferocity]

Butter or plain?

Why would I waste time with plain? Medicine is only advancing and someday a good cardiologist will keep me ticking. I dip each kernel into butter for maximum profit.

 

[347932]

Why would I waste time with plain? Medicine is only advancing and someday a good cardiologist will keep me ticking. I dip each kernel into butter for maximum profit.

You might change your mind when you get a little older and have a family to support.

 

[Ferocity]

You might change your mind when you get a little older and have a family to support.

I'm hoping I won't be cornered into such a situation. You see, if everything goes as planned, I am hoping to find a millionaire wife and then retire around age 35 so I can focus on eating.

 

[Ferocity]

Now you might be thinking, why even waste time going to podiatry school then? Well quite simply it's because I don't have the looks so getting the whole Dr. title thing is all part of my intricate plan.

 

[Ferocity]

Dude, you're going to be a podiatrist. Women won't be flocking to the guy with the foot fetish. Be nice to the nurses at your residency program when you get to that point in your career.

 

[dyk343]

Another waste of 5 min.

 

[Ferocity]

Deleting since it refers to a post that was removed.

Damn, my posts are completely out of context now.

 

[Organically]

Another waste of 5 min.

Agreed!

 

[bobdolerson]

I like cheese.

We're supposed to discuss anything but the original point, right? I'm trying to figure out the purpose of this thread...

 

[bobdolerson]

Also, I heard Rex Ryan was going to be a podiatrist.

 

[STLFeetdoc]

What does this testing process mean then? Whether I am minimally competent or not, there are minimum standards by which we are expected to perform as Podiatric Surgeons. You've mentioned you've seen excellent candidates fail the examination based on non empiric test related issues and that it also has somewhat to do with the examiner's mood.

I passed the examination and am now Board Certified. How does my competency rate against those that aren't? Am I deemed more competent? Am I more competent than the others who are also Board Certified?

My point is that there are minimum standards by which we are expected to perform. That is what the examination is trying to distinguish. Do we know the basics? Or are we below that standard? Maybe the terminology is skewed. I don't know.

To answer your question 3). How would I know if the surgeon was minimally competent or not? By their Board status, no? Does non Board status imply incompetence?

Ultimately, what does Board status actually mean? To me it is a badge of honor. I went through school, did my residency, passed a very challenging written examination, submitted and had approved a host of cases that allowed me to then sit for the oral examination, and ultimately made it through the examination and attained Board Certified Status. To me personally, that was a big achievement. To me personally, I don't rate my competency by the diplomas on my wall. We have to have a standard however, don't we?

Ultimately, I think we'll have to agree to disagree on this.

Agree but we shouldn't only have one board association that's accepted. ABFAS has a complete monopoly on the podiatry world and I don't feel that is fair. Do you only have 1 cell phone company to choose from? Do you only have 1 cable company to choose from? They all give you services that you need and get to the same place. No different with surgery boards.

 

[Weirdy]

Agree but we shouldn't only have one board association that's accepted. ABFAS has a complete monopoly on the podiatry world and I don't feel that is fair. Do you only have 1 cell phone company to choose from? Do you only have 1 cable company to choose from? They all give you services that you need and get to the same place. No different with surgery boards.

5 years ago.

 

[Cranjis McBasketball]

Also, I heard Rex Ryan was going to be a podiatrist.

 

[diabeticfootdr]

I find even more impressive is that DPMs get surgical privileges at hospitals with the ABPM board and the host of other random boards. It appears that is coming to a close now.

You shouldn't be that impressed. ABPM is one of only 2 boards recognized by JCRSB/CPME (under the authority of APMA).

Surgical privileges are based on one's education, training, and experience. All Podiatric education and training is now standardized. Experience is proving, via case logs, that one has enough cases in any procedure category to be proficient. Just because you're board certified in anything, doesn't automatically get you surgical privileges.

ABPM intervenes when any diplomate reports BC discrimination for hospital privileges, and we're generally successful.

ABPM also tests on surgical principles. Look at the content outline on the website. https://www.abpmed.org/files/General Examination Information.pdf

We test 550 podiatrists a year now.



Sent from my iPhone using SDN mobile

 

[bunNfxr]

Yes but did you know that NONE of the podiatry boards (ABPM or ABFAS) are recognized by the American Board of Medical Specialties?

All this posturing and neither of our boards are recognized. Every other medical specialty is. ABFAS and ABPM should collaborate their efforts to get the American Board of Medical Specialties approval rather than fighting each other.

Just saying...


Sent from my iPhone using SDN mobile

Meh!! They don't regulate oral surgeons, optometrists or pharmacist either. They are not divinely inspired to oversee specialty boards. They do what they do and most MDs are fighting them over MOC requirements. So its not like referring docs look down on non-ABMS credentials. if They look down on you its because your not an MD.

 

[diabeticfootdr]

Yes but did you know that NONE of the podiatry boards (ABPM or ABFAS) are recognized by the American Board of Medical Specialties?

All this posturing and neither of our boards are recognized. Every other medical specialty is. ABFAS and ABPM should collaborate their efforts to get the American Board of Medical Specialties approval rather than fighting each other.

Just saying...


Sent from my iPhone using SDN mobile

No, not every medical specialty board is a member of ABMS. Also, no non-MD (or DO) boards are members.

But I do agree with you that the 2 DPM boards shouldn't be arguing and instead they should be working toward a single, stronger board process with subspecialty certificates.