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Examining what led to record low BB/TM ABPath certification examination pass rates in 2022

Recently, over the course of just two years, pass rates for the American Board of Pathology (ABPath) Blood Banking/Transfusion Medicine certification examinations saw an unprecedented decline.1 What caused it? And what does this trend mean for the subspecialty going forward?

Plummeting pass rates?

First offered in 1973, the examination in Blood Banking/Transfusion Medicine (BB/TM) is one of 11 pathology subspecialty certificates ABPath offers.2 A one-day, computer-based exam featuring 280, combined written and practical, single-best-answer multiple-choice questions, the examination is designed to assess a candidate’s breadth of knowledge and problem-solving ability across a number of subject areas including blood, plasma, and components practices, consultation and criteria; transfusion practices and sequelae; and the history, administration, management, and regulation of the field.

As a criterion-referenced test, to pass the BB/TM exam, candidates must perform above a cut-off score —as opposed to norm-referenced tests that compare and rank examinees on the curve—making it a non-comparative individual assessment of mastery of the subject matter. This means that it is theoretically possible for an entire cohort of candidates to either pass or fail.3 Although the examination grading itself does not compare between test-takers, looking at the differences in the yearly pass rate, detailed in ABPath’s annual report, can highlight trends within groups of candidates taking the BB/TM exam, and potentially those regarding the wider discipline.

A 2023 study analyzed ABPath annual reports in five-year increments from 2007 to 2021 to evaluate the board’s subspecialty examination pass rates and identify trends. The authors found that, although the overall pass rate trended upward over time, the five-year average pass rate for BB/TM was consistently among the lowest and never rose above 90 percent—a bar that the majority of the other subspecialties cleared, especially in the five years between 2017-2021.4 However, these averages conceal some of the story. Looking closer at this period shows it to be one of great fluctuation. In 2019, the pass rate peaked at 96 percent overall.5 Although still high, the rate declined somewhat in 20206 before falling to the second-lowest among pathology subspecialties in 20217 and the absolute lowest in 2022. At that point, the BB/TM pass rate sat at 62 percent, a record low for the discipline.8

Behind the decline

What caused this drop-off in pass rates? In an editorial piece, a group of authors, including some from the 2023 study, outlined several factors they believed might have influenced the number of candidates passing the exam—first and foremost among them the COVID-19 pandemic and its accompanying stressors.1 Despite relatively high BB/TM pass rates in 2020, the pandemic led to major disruption across healthcare and medical education, with the virus’ highly contagious nature halting in-person teaching and training in favor of virtual alternatives.9

The authors highlighted a study in which less than half of respondents to a cross-sectional international survey conducted in 2021 had e-learning modules for transfusion medicine available to them via their institutions—and, of those who did, one-third were using courses that had been created during the pandemic.10 From this, they hypothesized that the rapid shift in educational strategies resulted in an abundance of e-learning resources of varying quality, effectiveness, and intended audience. They also pointed to increased BB/TM clinical service volume, new indications for apheresis, and cellular therapy collections by apheresis services as signs that this cohort of fellows may have had higher volumes of clinical patients than their predecessors, making it more difficult to balance work and education in the leadup to certification exams.

Although experts agree that these causes should be investigated further, not all are convinced that the 2022 BB/TM examination cohort’s pass rate is cause for laboratory professionals, especially those in the discipline, to be concerned. ABPath themselves take this view, emphasizing that the 2022 pass rate is not part of a larger trend and was the only one outside the range of previously reported values.11

“Advanced training in BB/TM is already compressed into a single year of training; this is the minimum time period deemed acceptable for a trainee to gain the knowledge, judgment, and skills necessary to perform competently in the workplace,” ABPath representatives wrote in a response to the earlier editorial. “Interruptions in this training, whether it be from the redistribution of the trainee workforce (e.g. trainees collecting or processing specimens), personal illness, or working from home, are reasonable explanations, in part, for the inadequate preparation of some individuals in the training period most severely affected by the COVID-19 pandemic.”11

Back on track

In response to 2022’s unexpected pass rate, ABPath conducted an investigation into that year’s examination, verifying that the low pass rate occurred not as a result of issues with standard-setting or increased difficulty, but instead because—likely as a result of the previously mentioned contributing factors—this cohort was less prepared to take the exam than previous ones.11 Given that medical education has largely returned to in-person delivery, trainees taking the BB/TM exam in future years—just like those taking it before 2020—should be able to prepare themselves for success.

ABPath CEO Gary Procop and his colleagues point to 2023’s exam as a final piece of evidence to alleviate worries. “We were pleased to report that the BB/TM board pass rate in 2023 registered at an all-time high of 97 percent, with no change in standard setting, examination construction, or administration,” they stated. “We are hopeful that this is another indicator of a return to normalcy.”11

Although this may not be the last time a major event disrupts medical education, outcomes like the 2022 BB/TM pass rates are not inevitable. There are several steps lab leaders can take to better weather storms in the face of unforeseen circumstances—including making trainee education a priority; ensuring that teaching resources are high-quality, up-to-date, and accessible; and preparing for the potential impact of outlier events by creating and maintaining policies and plans for educational continuity. As a stress test, COVID-19 highlighted many areas of medical education in need of fortification. Now, institutions, program directors, and clinical laboratory professionals must work together to strengthen those systems and ensure that every lab trainee can prepare themselves for success no matter what may come.


  1. Adkins BD et al. The devil’s in the details: exploring historically low board pass rates in Blood Banking/Transfusion Medicine. Am J Clin Pathol. 2024;161(2):108–110. doi:10.1093/ajcp/aqad127.
  2. American Board of Pathology. Subspecialty Exam Descriptions. July 6, 2023. https://abpath.org/subspecialty-certification/blood-banking-transfusion-medicine/.
  3. American Board of Pathology. Blood Banking/Transfusion Medicine Exam Description. January 31, 2024. https://abpath.org/subspecialty-certification/.
  4. Jacobs JW et al. Fellowship board pass rates rising: analysis of pathology subspecialty board examination performance. Arch Pathol Lab Med. 2023;147(8):964–968. doi:10.5858/arpa.2022-0129-OA.
  5. American Board of Pathology. Annual Report 2019. June 17, 2020. https://abpath.org/wp-content/uploads/2023/03/ABPath-Annual-Rpt-2019_Final.pdf.
  6. American Board of Pathology. Annual Report 2020: Adapting in Response to the Global Pandemic. June 22, 2021. https://abpath.org/wp-content/uploads/2023/03/ABPath-2020-Annual-Report-final.pdf.
  7. American Board of Pathology. Annual Report 2021. June 21, 2022. https://abpath.org/wp-content/uploads/2023/03/ABPath-Annual-Report-2021_final-3.pdf.
  8. American Board of Pathology. Annual Report 2022: Year in Review Highlighting Program Enhancements. July 06, 2023. https://abpath.org/wp-content/uploads/2023/07/ABPath-2022-Annual-Report_.pdf.
  9. Lucey CR et al. The transformation effects of COVID-19 on medical education. JAMA. 2020; 324(11):1033–1034. doi:10.1001/jama.2020.14136.
  10. Al-Riyami AZ et al. E-learning/online education in transfusion medicine: a cross-sectional international survey. Transfus Med. 2022; 32(6):499–504. doi:10.1111/tme.12920.
  11. Procop GW et al. Low board pass rates in Blood Banking/Transfusion Medicine. Am J Clin Pathol. 2024; online ahead of print. doi:10.1093/ajcp/aqae028.

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