Remaking the grade

December 1, 2008

During the annual meeting of the American College ofRadiology in May, several radiologists peppered thegroup's leadership with concerns over controversialplans for a sweeping overhaul of the certification examinationprocess.

During the annual meeting of the American College of Radiology in May, several radiologists peppered the group's leadership with concerns over controversial plans for a sweeping overhaul of the certification examination process.

Dr. Steve Koller, chief of radiology for Middlebury's Porter Medical Center and president of the Vermont Radiological Society, was one of many practicing members of the ACR who spoke up during an open-microphone segment to register misgivings about the revisions.

Asserting the changes could "destroy the heart of radiology," Koller, a generalist, said he has observed almost an active campaign to stamp out the concept of general radiology.

"Which would be a terrible loss for the profession," he said.

The new exam has two major modifications: Residents will be able to choose subspecialty areas in which they will be tested, and it will be given a full 15 months after training is completed instead of during the final year of residency.

Interviews with academics, practicing radiologists, and residents reveal a range of concerns and opinions. Some criticized the exam's delay, saying it simply transfers the problem of cramming from residency into the workplace, while others think the revisions will produce better trained radiologists.

An ACR task force, in a white paper published in the November issue of the Journal of the American College of Radiology (2008;5[11]:1112-1117), claimed that the decision to revise the oral board examination "raises more questions than it answers."

Koller asserts the changes unnecessarily pressure radiologists into specialized fields, insisting this does not reflect real-world practices that either don't need or can't support widespread specialization except in large, urban hospitals.

The revised focus of the exam will only hasten the commoditization of radiology, effectively mandating subspecialization, he said.

"We might all end up in a windowless warehouse someday, sitting among the many rows of cubicles in front of monitor banks reading the same exam all day long-proud employees, one and all, of Chest Films*R*Us," he said.

ACR president Dr. Barry Pressman, however, stressed in his keynote speech the importance of specialization, telling the Washington, DC, gathering that radiologists must elevate their practices through subspecialization. "Distinction will prevent extinction," he said.

Pressman challenged the idea that public costs will soar without generalists.

"I say only subspecialist radiologists can stem the tide of imaging by self-referring nonradiologists, 50% of which is unnecessary and already costs the American healthcare system $16 billion a year," he said.

Koller disputes this.

"There certainly is no preponderance of reliable research proving that subspecialization elevates anything other than egos," he said. "When a small cadre of insiders takes this assumption and tries to reshape all of radiology practice in the image of academic radiology, it feels to me that the tail is wagging the dog."

Doubtless the underlying motivation for the revisions is to avert the "disappearing resident" phenomenon, in which most fourth-year students largely retreat from their training programs to study for the oral boards. The problem is viewed as a major issue by many radiology department chairs.

A key change in the new "Exam of the Future" is that the oral grilling now done by a board of examiners in Louisville, KY, will be discontinued altogether, to be replaced with an image-rich computer-based test that can be taken in test centers across the country.

The revised certification exam, which will focus on general radiology or subspecialty tracks chosen by residents, should replace the current binge-and-purge approach to exam preparation, according to the American Board of Radiology, which administers the test.

The certification exam will be preceded by a core exam, to be given at the end of the third year of residency, that will cover all aspects of diagnostic radiology, including organ systems, technical methodologies, and clinical subjects like oncologic and emergency imaging. It will replace the two computer-based exams now taken during the second, third, or fourth years of residency, which cover physics and diagnostics.

According to the ABR, the revision simply mirrors the certification process used by nearly every other medical specialty board, which test only after residency is finished.

Currently, only radiology and pathology still give board-certifying exams before the end of residency training. Most medical boards also have replaced oral exams with computer-based tests.

Dr. Dennis Balfe, a radiology professor at Washington University and chair of the ABR certification committee, said the new, focused certification exam will better prepare radiologists for their areas of interest.

"Right now, residents cram for everything, take the exam, and don't think about it anymore," he said. "We think it will reduce their anxiety, because they can select what they're going to be tested in. This will ensure that we stay current in our areas of expertise."

And even though the certification exam will emphasize subspecialties, candidates must first pass the core exam, which will cover 11 categories.

The new exam will be much less expensive for both residents and the ABR, Balfe said. In the current oral exam, which is given 39 months into residency, 300 examiners and approximately 1000 residents must pay to travel to Louisville and stay in hotels.

CHANGING PRACTICE PATTERNS

ACR vice president Dr. N. Reed Dunnick said one of the primary goals was to tailor the revised test with an eye toward students' anticipated practices.

"We're requiring them to be competent in the entire field of radiology when many do not plan to practice significant portions of the field," he said.

The 15-month gap between completion of training and administration of the new certification exam doesn't pressure residents into fellowships but simply reflects the growing trend toward subspecialization, Dunnick said. By his estimate, as many as 80% of residents now go into fellowships anyway, a pattern that will better prepare them for the new test, which will be administered three months after fellowships are completed.

Dr. Ron Arenson, chair of the radiology department at the University of California, San Francisco, supports the changes.

"To take [so] much time because of fear of failing a board exam is just too much," he said. "The idea is to push it outside of the window of the training program. In this way, they will have already gained experience during their practice or fellowship. And the most important concept is [that] the exam they take at the end of this period will be tailored to their practice."

The number of radiology fellowships has fluctuated during the last decade, with vascular and interventional fellowships attracting the most applicants, followed by neuroradiology and pediatric fellowships, according to the American Board of Medical Specialties (ABMS).

Dr. Allen Elster, chair of the radiology department at Wake Forest University in North Carolina, supports the change but agrees there are drawbacks, including the possibility that fewer people may choose to become generalists. It's a trade-off, he said, a choice between taking time from individuals' academic training or from their practices to prepare for the exam.

"I would argue the benefits to society are to train the person better to spend the maximum time [and] optimally utilize their education and training on those things rather than to study for a test," he said.

The options aren't pretty, according to Elster. If the exam's delayed timeline means more people go right into general practice, less research will be done by those in fellowships and there will be fewer subspecialists; if more go into fellowships, the already small pool of generalists will dry up even further.

But he considers encouraging subspecialties a legitimate priority.

"Medicine is getting so complicated already, it's hard enough to keep up within your own discipline," Elster said. "How can you keep up in 10 different disciplines? There's no way you can do that if you don't go into fellowships."

Radiology residents coming in a year from now will be the first to take the new certification exam in 2015, after they finish training. The new exam will include five modules. One will cover radiology fundamentals, and another will deal with noninterpretive skills like patient safety and ethics. The other three modules, general radiology or as many as three subspecialties, may be chosen by each candidate. The first core exam will be given in 2013.

MIXED FEELINGS

Other academics have decidedly mixed feelings about the modifications, among them Dr. Robert Suh, director of the residents' program at the University of California, Los Angeles Medical Center's radiology department.

The current qualifying written exam is given in two segments, allowing residents to study for one exam before gearing up for another test the following year.

"The planned changes will simply push all this frenzy earlier in residency," Suh said.

He also concurred with the view that there is little evidence for promoting subspecialization; a majority of the specialists with whom Suh works still do a substantial amount of general radiology, he said.

"It just depends on the makeup of your group, the personnel and their expertise," he said. "If you join a small group, you may have only one neuroradiologist, but he can't read every neuroradiology study. So everyone has to pitch in."

In Southern California, there appeared to be a decline in the demand for subspecialists during the last decade. "Groups were finding it very hard to maintain subspecialist expertise in all areas as people left over the years," Suh said. "You must have some people who can switch over and do more than just their subspecialty. It just became too costly."

Three of Suh's residents had varying views on the changes, but all agreed that more people will go into fellowships in order to be better prepared and a computerbased exam will be easier than the current oral questioning before live examiners.

Willis Huang, a third-year resident at UCLA, said the new computer-based exam will certainly be easier. "Oral exams allow the examiner to divert you from your test-taking strengths and focus more on your true ability," he said.

Dr. January Lopez, a fourth-year UCLA resident, agreed that the computer-based exam will be easier than the orals she will face in June. She also expects the new core exam to be more difficult because it will be more comprehensive than the current tests, which are staggered over different years.

Dr. Adrienne Bean, a third-year resident at UCLA and a board-certified pediatrician, calls the new exam format a disaster because it does away with a key component in assessing a radiologist's capabilities: oral questioning. "We are a consultant service, so much of what we do is communicating," she said. "We need to make sure clinicians understand not only what we see but what they can do with what we see."

So much of the consultant part of a radiologist's job is making sure the referring physicians know the strengths and limitations of imaging so they can correlate findings appropriately, according to Bean.

"I know plenty of people who can work a multiple choice test, but when I hear them take cases in class, they're abysmal," she said.

Dr. Ben Greenspan, associate program director of nuclear medicine and a radiologist at Washington University, echoes Bean's view. Radiologists are consultants, and the only way to really gauge this essential capability is through oral questioning, he said.

"It determines if they can synthesize findings and reach a diagnosis that makes sense to the clinician," Greenspan said. "Computer exams just test recall."

Nearly two-thirds of the 24 medical specialty boards currently give oral exams, according to the ABMS. Most medical specialties administer their board exams soon after the end of residency, usually within a couple of months. Greenspan, who also attended the ACR meeting, said he sympathizes with residents' dilemma of trying to juggle the demands of studying for exams while still participating in training programs.

"I've seen programs where they disappeared as early as mid-February and didn't read cases-just went off and studied," he said.

But Greenspan disagrees with the ABR's decision to postpone the certification exam as a solution.

A better solution is to designate a month-long period, probably in March of their final year, during which residents can spend half the day working and half studying, Greenspan said. He implemented such a program when he oversaw the radiology training program at the University of Missouri–Columbia, with notable success.

Dr. Douglas Beall, a professor of orthopedic surgery at the University of Oklahoma in Oklahoma City and chief of services at Clinical Radiology of Oklahoma, said the revisions will only transfer the problem of studying from residency programs into private practice.

"I think it's mostly a downside, but the upside is this will probably drive more people into fellowships and increase their level of subspecialty expertise, which I view strongly as a positive," he said.

The orthopedic surgery residents Beall works with have to wait two years for board certification. They are envious of radiologists who can go to work as certified right after they finish training, he said.

Beall acknowledged the current system has advantages and drawbacks.

"When you cram for boards, you have a chance to apply your knowledge in a clinical environment as they do now," he said. "But the bottom line is, residents are not much use when they're studying for their boards." Employers will be understandably concerned that their new hires will need time to study for the exam, he said.

"If a guy has to take boards in 15 months, I know he'll be under great pressure to study, and he won't be as productive as he would be otherwise," he said. "There're only a certain number of hours in the day."

Dr. Leonard Berlin, chair of the radiology department at Rush North Shore Medical Center in Skokie, IL, was also at the ACR meeting. He agreed that it's a controversial issue.

"There was a feeling among certain parts of the membership that this is not a good idea," he said.

There was a time in radiology when certification exams were given after the end of training. Berlin said he had to wait for a year before taking his orals in the 1960s. In the end, everyone will adjust to the revisions.

"Employers may be concerned that new employees won't come to work as much because they'll need to take a lot of time from their chores to study," he said. "But I have a feeling it's all going to work out."