SPECIAL EDITION
Commentary

By PETER HALT, M.D.

In the annual revels known as the radiology boards, 20 years of education are distilled to a single day in Louisville. The months of frantic preparation and the mounting dread leading up to the board exams have become a rite of passage for radiologists. I lived to tell the tale.

The road to Kentucky began for me with the first year of radiology residency, which I spent half-relaxing after a grueling internship and half-panicking about upcoming call. The second year was spent taking call and sleeping. In the third year, I took a little call and spent a lot of time worrying about written boards.

The written boards actually weren't too bad, especially after a lifetime of multiple-choice tests. The physics boards were annoying, but a rudimentary knowledge of radiation safety and radiology physics helps separate us from the cardiologists and surgeons who want to play with our equipment. I opted not to attend the weekly physics courses on the advice of my seniors, who assured me that reading and answering questions in Huda's Review of Radiological Physics would provide the basic information I needed to pass the exam. And my program offered a weeklong tutorial by Dr. Huda, which was the best-case scenario. Other, more complete physics texts and courses were available, but I thought Huda's were geared specifically to passing the radiology boards, and I didn't fall asleep during his course, as is the norm for me and physics.

I made the mistake of put-ting off the physics boards until third year, although the exam was available to second-year residents. Taking the test as early as possible makes sense because it requires little radiology experience, and getting it out of the way saves anxiety about it later when the written and oral exams are looming on the horizon.

OVERPREPARED

Preparing for and taking the written radiology boards was simply hellish. The questions are tough and seem to be a random compilation of the written boards of all medical subspecialties. I spent my third year reading textbooks because it seemed to be the right thing to do. I read Helms' Funda-mentals of Diagnostic Radiol-ogy cover to cover and managed to get through all of The Requisites series before I started looking at old questions. I found that all my preparation was of little help in answering most of the questions. It took a huge amount of time to look up the answers when they were not available. Thinking that I would save time, I frequently asked our staff for their opinions and found it was often difficult to get experts to agree on an answer.

The night before the test, I read a list of 500 old questions and answers. I would estimate that 75% of the test could be found in that final list of questions. I completed the test in 90 minutes and left certain that I had passed. In retrospect, I wish I had taken the written boards, as well as the physics boards, in my second year, especially knowing I could simply have spent two nights reading old questions and still would have passed. Instead, I spent several months worrying about it.

Preparation for oral boards began early. We residents took cases in conference in the first few years, but most of the fourth year was dedicated to passing that test. At my institution, there is an unspoken tradition that oral boards preparation is self-paced. We had months of elective time for study. We were a bit flaky about everything else, especially work. Fortunately, the residency directors in my program were beginning to see the light and were rebuilding the teaching curriculum. As a result, we had great conferences and teaching, but we were allowed to keep a huge block of elective time. Every noon conference after April was geared to quizzing fourth-years. We spent hours poring over ACR disks. The buildup was out of proportion. Despite assurances that the oral boards are a minimum-competency exam, people overprepared and overstressed.

We spent months lining up faculty for small-group board simulation sessions. I never liked taking cases in front of an audience; my brain empties in that setting. Small-group board simulations were even more horrifying. The mock examiner sat quietly, offering no help or feedback while I flailed for differential diagnoses in front of my very bright colleagues.

I spent a lot of time preparing on my own, reading case-based textbooks and studying the ACR disks. The best preparation for oral boards, however, was the time I spent moonlighting in small private practices. Oral boards seem designed with this in mind: the candidate sits down with another M.D., one-on-one, playing community radiologist. By the time I got to the exam room I was able, to some extent, to have fun.

USELESS RESIDENTS

The path leading to that point wasn't fun. Oral boards are stressful, expensive, and inconvenient. In the late fourth year of training, worry about them makes residents useless at a time when they should be most productive. Our predecessors had thoughtfully made sure we would have no call in that year so we could concentrate, but consider the result for the institution: First-year residents do the jobs of dozens of radiologists, while experienced fourth-years sit in a dark room with teaching CDs.

Old traditions die hard. Try to get fourth-years to take more call and you will hear whining about the boards. Future jobs depend on passing the test, board certification equals in-creased pay for moonlighting radiologists, and most important, failing means a long wait and another expensive and painful trip to Louisville.

The board exam itself is a reasonable and fair representation of real-world radiology, despite the occasional anecdotes about personality conflicts or the subjective nature of the exam. Most examiners go out of their way to make the test-takers feel comfortable. Not much is wrong that a few advances in technology and changes in timing wouldn't fix.

The written radiology exam, however, should be rethought. If I had not come from an institution with a tradition of memorizing old questions, I might not have been able to answer even 20% of the questions. Since lots of people fail, clearly not everyone has access to the type of preparation I had. Writing new questions every year is probably not feasible, but there has to be a better way than recycling old questions every three years.

Why offer a written exam at all? Do we need to know how much fluid makes an effusion visible on a chest x-ray? In the real world, referring physicians want to know if it is big or small. Is it loculated? Can they tap it or should they use ultrasound? This sort of material is covered nicely in the oral boards.

VIRTUAL ORALS

Finally, there must be a better way to conduct the orals than making hundreds of applicants and busy radiology staff travel to Louisville. If I have to go to Louisville, I want to sip a mint julep while watching the Kentucky Derby. I don't want to be sweating in my old interview suit in a room with 15 junior radiologists, waiting for those awful chimes to signal the start of the festivities.

Why not combine written and oral exams into a reasonable representation of what the profession requires? A computer-based exam could present cases that require the same thought processes, differential diagnoses, and recommendations without requiring a trip to Kentucky.

Present 100 mixed cases on a PACS queue-a moderately busy day in a private practice-and provide a voice dictation system in a private room, or multiple choice questions if the grading has to be more automated. Include normal exams, which are sometimes the hardest to read.

Most important, offer boards after residency, as many other specialties do. Let the fourth-years be radiologists, not test-takers. Let them moonlight in private practices or work in the lab. Make them take more call. Nothing makes a radiologist sharper than a busy night with a bookcase but no backup at 2 a.m.

In the fourth year, residents begin to synthesize the huge volume of information they have been force-fed. They are not overwhelmed by 100 cases in a pile. They are comfortable talking to a screaming cardiothoracic surgeon. They can do five right-upper-quadrant ultrasounds and still read all the plain films before sign-out in the morning. Above all, they can provide invaluable teaching to the second-year residents who are sleep-deprived and afraid of getting a call to rule out Budd-Chiari syndrome in the ICU at 4 a.m. By the end of the year, they will be ready for boards, because they will have been taking real-world exams all year.

Dr. Halt is a radiologist who survived the boards and practices in Mt. Shasta, CA.