Neuroradiology after 2012 – The effect of new structure of the ABR certifying examination structure on neuroradiology training of residents and fellows and the future of Neuroradiology subspecialty certification (CAQ).
The American Board of Radiology is radically changing the initial certification and recertification examination process for radiology trainees. Beginning with residents entering training in 2010 the written ABR exam and the oral exam in Louisville will be history. In their place will be two new computer based image rich exams. The first exam (“Core exam”) will be given after 36 months of training and will cover all aspects of radiology including radiation physics and radiation biology. The second exam (“Initial Certifying exam”) will be given 15 month after the completion of residency training. The Certifying Exam will have 5 parts. There will be one part on non-diagnostic topics such as radiation safety, MR safety, contrast reactions, ethics etc. One section will concern diagnoses that all radiologists should be able to make with an emphasis on emergent conditions such as pneumothorax, free abdominal air aneurismal subarachnoid hemorrhage and acute infarction. The radiologist determines the remaining three parts of the examination based on his or her practice pattern. An individual may choose to be examined in 3 two or one area. Therefore in theory an individual could choose to have all three self-determined exam sections in neuroradiology. When the candidate takes the recertifying in 10 years he/she will once again choose areas that they wish to be examined in. These may be the same areas chosen on the initial certifying exam or they may be different if the radiologist’s practice pattern has changed.
So why is the ABR doing this now and why is it doing it in this manner? Changing the exam structure has been “on the table” for years. We are all familiar with the arguments concerning the timing of the certifying exam. Board psychosis consumes 4th year residents distracting them from the task of “finishing off” their training in preparation for entering practice. Radiology is the only specialty that gives its certifying exam during rather than after training. So why not bite the bullet and just move the oral exam to one year after training? Over the years there has been major push back to moving the exam from radiology residents the private practice community and even from academic departments. All of these groups (basically everyone except radiology program directors who have had to deal with having their most experienced residents rendered clinically useless) liked the fact that having the exam at the end of training got certification “out of the way”.
The impetus to change the board has come from a different source. There has been a growing realization in the radiology community that our current training programs are not preparing our residents to function in the current medical environment. Care is increasingly supplied by physicians with subspecialty training and expertise. The imaging needs of these referring doctors may not be met by radiologists trained to everything adequately but nothing well. In order to improve the training of radiologists we must allow residents to gain expertise in a few areas and in order to do this we must allow residents to have focused learning and clinical experiences during the 4th year of the residency. The current ABR exam structure with its consequent effects on the 4th year of training makes focused training impractical except in a few elite training programs.
The new ABR exam structure is meant to facilitate the process of increased practice specialization. The core exam at 36 month will cover all areas of radiology. Following passage of the exam the resident can devote his or her 4th year to developing expertise in one or a few areas of radiology. Following completion of residency and a year of practice or fellowship the candidate takes the certifying exam. 60% of the content of this exam will be chosen by the candidate to reflect their actual practice experience. This eliminates the need to study of all of radiology and encourages the candidate to study those things that have actual practical import for their own practice. At the time of recertification the radiologist will once again choose to be examined in those aspects of radiology that pertain to his or her practice. Thus the radiologist may choose to be examined on the recertification exam in different areas if his or her practice changes.
How will these changes affect neuroradiology training and practice? I have heard concerns that the institution of the 4th year of focused training will eliminate the need (perceived or real) for a post graduate year of neuroradiology training thus seriously damaging the ACGME approved fellowship training of which we are so justly proud. Others believe that candidates who take all three of their test modules in neuroradiology will be able to claim that they are board certified neuroradiology destroying the value of the Subspecialty Certification (CAQ).
Let me deal with the “easy” questions first.
1) Regardless of the areas a candidate chooses to be examined in, the ABR Diagnostic Radiology Certification will be in radiology with no indication of areas of specialized knowledge or skill. Therefore a candidate who chooses all of his/her modules in neuroradiology will not be able to claim to have documented expertise in neuroradiology.
2) The CAQ (or Subspecialty Certification) exam will be given,as it is now, 15 months after completion of an ACGME fellowship. The exam will be a computer-based exam with the same general format of the current recertification exam. The exam will have fewer items than the recertification exam but the questions will have the same format and degree of difficulty. It is likely that the ABR will replace the oral CAQ exam with computerized exam in 2011 or 2012.
3) So what are the differences in the neuroradiology modules used for the Certifying exam for Diagnostic Radiology and those used for the initial or recertifying exams used for the CAQ exam? The modules will have different levels of difficulty. This may involve using different cases or asking more or less complex questions about the cases. An individual taking one or two modules as part of the Diagnostic Radiology Certifying (or recertifying)Exam will take “basic modules”. If an individual chooses all three modules in one discipline he/she will be given at least one “advanced” module. All of the modules used for the initial or recertification CAQ exam will all be “advanced”. Note that all of the modules used for the current recertification exam are “advanced”. What will be new are basic modules developed for the Diagnostic Radiology Initial certification and recertification exams.
4) Once an individual passes the CAQ exam the first recertification exam is taken after 10 years and this exam will result in recertification in both Diagnostic Radiology and subspecialty certification in Neuroradiology. Resetting” the recertification clock means that individuals will not have to take two different exams at two different 10 year cycles
And now for hard part: How will this affect our training programs and the practice of neuroradiology? First a caveat: Everything from here on out is speculation. Major changes often have unpredictable and/or unforeseen consequences and this is certainly a major change. What follows is my opinion but believe it or not I have been wrong in the past. We all need to think about these questions and try to figure out what will happen and what we will do about it.
It is certainly possible that the ability to obtained focus training during residency may decrease the number of residents seeking fellowships in all radiology specialties. Factors outside of our control including economic pressures and changes in health care will undoubtedly affect residents’ career decisions. However there is every reason to believe that the changes in training will not have a significant impact on the number of residents entering neuroradiology fellowships. We all know that neuroradiology is the coolest specialty in the world and I am sure it will continue to attract our best residents. The practice of neuroradiology is changing and we need to train our fellows in advanced imaging techniques and invasive procedures such as spine interventions if we are to maintain our leadership in neuroimaging and intervention. Other groups are anxious to perform and interpret neuroimaging exams. Since we do not “control” patients (a truly abhorrent notion if one thinks about it) our only option is to take high road. We must maintain the highest levels of practice skill and in order to do this we must constantly improve and update our training programs.
I believe that the change in radiology residency programs can actually strengthen neuroradiology training. We all struggle to provide everything our fellows need to learn in the one year ACGME fellowship. Several years ago Dave Yousem lead an ASNR retreat that concluded that 18 months was the ideal amount of time for neuroradiology training. At the time there was no way to get a significant number of training programs to provide residents with dedicated time in the 4th year to begin training in neuroradiology. With the new structure of residency training dedicated time in neuroradiology should be available in many programs. It might even be possible in the future to formally incorporate this time into the ACGME fellowship training program.
I hope that this blog will clear up confusion surrounding the changes in ABR exam structure and that it will stimulate discussion of how this will affect training and practice of neuroradiology
Bob Zimmerman
