EUROPE
Special Section: Building a better radiologist

Behind the united front in radiology education lies a small fault line: the European board exam. A voluntary board exam, according to some education leaders, would provide an objective means to measure training and education. Ultimately open to residents in all European countries, it could smooth the way for radiologists to work anywhere in the continent by certifying mastery of knowledge in standard imaging areas.

The most likely scenario is a multiple-choice, computer-based exam that would be given partway through training. Such an exam is not without critics, however.

"There is a lot of talk about a European board exam in radiology, but it is by no means a fait accompli. There is a lot of resistance to it," said Prof. Helen Carty, who is due to become president of the European Congress of Radiology in 2004.

At a July meeting of the European Association of Radiology's executive board in Lund, Sweden, leaders decided to proceed cautiously by exploring options for a computerized test. But Prof. Iain McCall, chair of the EAR professional organization committee, stressed that no go-ahead has been given.

"The European diploma is in a very early stage of development. A number of countries are not in support, while others are prepared to support it. It is not universally accepted," he said.

Detractors say such an exam could never be comprehensive enough to fully assess a radiologist's skill and competency. Many radiologists, however, are enthusiastic about the concept.

"If you have a larger number of people sitting for an exam, which would be possible on the European level, the results are bound to be more statistically significant and less prone to bias on the part of examiners," said Prof. Dr. Gustav von Schulthess, director of nuclear medicine at University Hospital Zurich in Switzerland.

"When it comes to harmonizing education, the most important thing would be to have an identical board exam across Europe. If you have one board exam, all programs must be geared so that people can pass this test," he said.

REGIONAL VARIATIONS

While training has been standardized in many key areas of radiology education, exam structure remains varied. U.K. residents take a mandatory national board exam midway through training. In Poland and Austria, radiologists undergo a comprehensive compulsory exam at the time of exit. France has no board examination at all. German radiology trainees face a fairly short oral exam, with variable content depending on the training center.

Austria had a voluntary national board for many years, which became mandatory this year. Other national radiology associations are considering changes to their exam regimes. In Italy, for example, each university holds its own annual tests throughout the course of training, in addition to an exit test. At an April meeting, Italian radiology professors decided to create a national test that could be developed as early as next year.

CHAMPIONING EUROPEAN CAUSE

One of the most vocal and prominent supporters for the exam is Prof. Rolf Guenther, EAR past president. A proposal for a European board first surfaced 15 years ago and failed to gain ground, but the time may finally be right, according to Guenther.

"It has taken some time to realize the need for a standardized exam on the European scale to improve quality. I think it stands a real chance now," he said.

Aside from the need to ease professional passage of radiologists across borders and to set standards for countries in East Europe seeking to enter the European Union, there are political factors behind the exam initiative. There is a growing concern that the EU politicians favor European board exams. Many specialties-including anesthesiology, vascular surgery, and nuclear medicine-have already created some form of European diploma.

"For the time being, it is a national privilege to hold exams, but sooner or later a European diploma will be recognized," Guenther said. "It will be better for us to define aims by ourselves and not be forced by a supranational authority to implement something we do not want. It is important for us to submit an exam to the EU and say there is no need for the polity to become involved."

But some say such an exam could be difficult to administer, considering the likely multiple-choice format and need for translation.

"Have you ever tried to set up a multiple-choice question and remove ambiguity? It is an exceedingly difficult task," Carty said.

The growth of Eurorad, the Internet image database project, could have implications for development of a pan-European diploma, according to Prof. Dr. Roberto Passariello, chair of the EAR's committee on information technology and leader of Eurorad. Eurorad's base doubled to 1002 images at the end of 2001, and organizers believe it will grow even more quickly in the next two years.

"When we reach 3000 or 4000 cases, it will be large enough to be used as basis of an automatic test and scoring system. We are already considering this possibility. We hope to be ready in a few years for a European diploma," Passariello said.