Understanding Discordant Board Outcomes: Why Top Part I Performers Fail Part II of the ABPMR Certification Examination.

It is unexpected when initial certification examinees pass the American Board of Physical Medicine and Rehabilitation (ABPMR) Part I Examination with a top score and subsequently fail the Part II Examination. This study aims to determine individual and residency program factors associated with this outcome. A retrospective, observational review of ABPMR data between 1999 and 2025 identified 161 individuals (1.6% of all examinees) who passed Part I with top quartile performance but subsequently failed one or more attempt at Part II. Multinomial logistic regression models demonstrated a lower odds ratio for Part II failure among female physicians (OR=0.60, P=0.016) and those enrolled in fellowship training (OR=0.53, P=0.006). A higher odds ratio was found for physicians aged >40 years (OR=3.80, P<0.001), non-white ethnicity (OR=1.80, P=0.004), and those who completed newer (<10 years, OR=3.13, P=0.026) and smaller (2-4 and 5-7 residents per year, OR=1.98 and 2.13, P=0.009 and 0.001) residency programs. Awareness of this potential outcome should prompt rigorous preparation for the Part II Examination, even for the highest performing Part I examinees.