Dermatopathology Learning Needs Identified Through Continuing Certification Program Assessments of the American Board of Dermatology

The American Board of Dermatology (ABD) recently developed a Continuing Certification Program (CCP) for board-certified dermatologists to help advance excellence in dermatologic care and improve outcomes for all patients [1]. This program includes quarterly longitudinal knowledge assessments accessed on a web-based testing platform called CertLink, where assessments are individually designed by participants. Assessments include 23% “concentration” questions (from selectable percentages of medical, surgical, pediatric, and cosmetic dermatology, and dermatopathology questions; board-certified dermatopathologists are automatically assigned 23% dermatopathology questions) and 31% article-based questions. There are various choices of high-impact articles, eight of which must be chosen annually. In 2024, 5% of participating dermatologists chose to receive dermatopathology concentration questions, accounting for 2% of total assigned concentration questions. Analysis of knowledge gaps from these assessments may potentially help dermatopathologists and specialty societies who help address knowledge gaps in practicing physicians. All CertLink articles selected by diplomates and all assigned multiple-choice questions and their performance between October 1, 2021 and September 30, 2023 were included for assessment. Prior to this study, all questions had key validation performed through standard ABD processes. Questions that appeared to be too difficult or had low-to-poor discrimination using standard ABD criteria [2] were manually reviewed by ABD question writing experts. If a significant deficiency was identified, the question was eliminated from further analysis. Multiple choice questions were grouped by subspecialty area and question category (core, concentration, and article-based). All concentration questions and articles designated as “dermatopathology” by ABD test-writing committees were included for analysis. Title and count of articles selected by diplomates were recorded. A knowledge gap was defined as a valid question that was answered incorrectly. Validated questions were ranked in order of the greatest number of incorrect first responses by diplomates. Question themes were generated by ABD testing experts. When multiple questions identified the same theme, those totals were combined and sorted so each topic or theme was listed only once when compiling a top 10 list. ABD assessed 551 495 diplomate responses to 344 test questions and 152 588 selected article reviews from 138 articles during the study period. There were 24 928 diplomate responses to 72 dermatopathology concentration items. These responses came from 1364 dermatologists without dermatopathology subspecialty certification and 573 board-certified dermatopathologists. These dermatopathology questions were tested between 64 and 537 times each and incorrectly answered between 3 and 255 times. Rates of incorrect responses for dermatopathology items ranged from 1% to 53% incorrect, with an overall incorrect rate of 11.6%. In comparison, the mean incorrect scores for cosmetic dermatology, medical dermatology, pediatric dermatology, and surgical dermatology were 15.0%, 14.9%, 15.8%, and 12.3%, respectively. Table 1 summarizes the top 10 themes from the most frequently incorrectly answered items. There were 21 articles tagged as “dermatopathology” that were selected for review 8706 times. Table 2 summarizes the most frequently chosen dermatopathology articles. Board-certified dermatopathologists answered 67.0% of all dermatopathology questions assigned. In comparison, 15.4% of assigned pediatric dermatology questions were answered by board-certified pediatric dermatologists, and 55% of assigned surgical dermatology questions were answered by those board-certified in micrographic dermatologic surgery. The CCP of the ABD includes a subset of questions specifically related to dermatopathology. Dermatopathology questions experienced the highest mean correct score of any of the subspecialty concentration question sets during 2022–2023. These questions also had the highest rate of any subspecialty question set being answered by board-certified subspecialists. This suggests general dermatologists do not often choose dermatopathology questions when designing their assessments compared with other subspecialty areas. The ABD identified themes of its top dermatopathology knowledge gaps from its ABD CCP knowledge assessments in 2022–2023. Top dermatopathology knowledge gap themes included the recognition of distinguishing histopathologic features and staining of tumors, fibrosing disorders, papulosquamous diseases, and various skin infections, including deep fungal infections. The tumors providing the greatest challenges were mucinous and glandular tumors, vascular tumors, and tumors associated with syndromes. The most frequently selected dermatopathology articles for article-based questions addressed ancillary testing to better assist in the accurate diagnosis of melanocytic tumors and autoimmune disease detected with immunofluorescence. Organizations that plan dermatopathology educational activities may find it useful to review the thematic knowledge gaps and areas of dermatopathology interests identified by this review. This work complements previous reports on self-selected exploration of various dermatopathology performance gaps when fulfilling ABD CCP performance improvement requirements [13]. This study has limitations. Question topics, articles to select, and themes are only from 2 years of data, do not represent all possible relevant topics, and do not robustly assess every theme identified. Themes listed may only represent a solitary question missed frequently. Dermatopathology questions did not have equal testing frequency. A question's poor performance might be due to aspects of the question itself (confusing stem, poor photo, plausible distractors, etc.) not discovered during key validation rather than a true knowledge gap. For questions assigned to both dermatopathologists and non-dermatopathologists, we cannot distinguish question performance by subspecialty status. We are not able to ascertain the participation rates or dermatopathology question performance of dermatologists who sign out their own dermatopathology cases but who are not board certified in dermatopathology. Finally, articles attributed to dermatopathology may have overlapping subspecialty appeal and not represent a dermatopathology-specific motivation to select. The ABD CCP identifies potential knowledge gaps and areas of interest in dermatopathology that can serve as needs assessment data for the planning of future dermatopathology educational activities. All authors had full access to the data and take full responsibility for the integrity and accuracy of the data. All authors took part in drafting the article, critically revising it, and approving it for final submission. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from American Board of Dermatology. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of American Board of Dermatology.