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Commentary |
1 Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, 111 East 210th St., Bronx, NY 10467.
Received October 31, 2007; accepted after revision October 31, 2007.
Address correspondence to E. S. Amis, Jr.
(amis{at}aecom.yu.edu).
Keywords: diagnostic radiology • program requirements
In January 2007, the American Journal of Roentgenology published a commentary on proposed new diagnostic radiology program requirements [1] followed by a response from the leadership of the Radiology Residency Review Committee (RRC) [2]. Much has occurred since that time. By way of background, the Accreditation Council for Graduate Medical Education (ACGME) requires all RRCs to review program requirements for training programs every 5 years and revise them as necessary. The Radiology RRC did just that in 2005 during a special meeting devoted to the task. In developing the new program requirements, the RRC was motivated by both a desire to attain the ACGME goal of "exemplary accreditation" and by the awareness of its own fiduciary responsibility to residents and patients. The new program requirements were developed after careful deliberation.
The Radiology RRC leadership, wishing fully to inform its constituents of the proposed changes in program requirements, presented them at several national meetings and invited discussion. The RRC thoughtfully considered all comments received in these venues, but then reconfirmed its decision to proceed with the proposed changes. In keeping with ACGME policy, the proposed changes were posted on its Website along with a written justification for each change. This posting was widely publicized and comments were invited from interested parties. During the 6-week posting, comments were received from the American College of Radiology (ACR), the American Board of Radiology (ABR), and the American Medical Association (AMA), which are the three sponsoring organizations of the Radiology RRC. The Association of Program Directors in Radiology (APDR) also responded, as did others, including 13 radiology chairs, 19 independent radiologists, 46 program directors, and 87 residents. The collated comments filled 125 pages. Many of the comments expressed concern regarding the new requirement for 12 months of training in diagnostic radiology before a resident is allowed to stand independent in-house calls, while others supported the RRC on this controversial issue. The RRC prepared responses to all comments; a single response was prepared to groups of comments that were of a similar nature.
Based on the comments received regarding 12 months of training before residents are allowed to stand independent calls, the RRC revised the original wording of this requirement to clarify its intent that it indeed pertains only to independent call situations. It was not the intent of the RRC for this requirement to dictate policies regarding resident supervision during normal working hours when there presumably is a full complement of radiology faculty present. Furthermore, appreciating the difficulty that programs might experience in modifying call schedules given a July 2007 implementation date, the RRC opted to delay implementation of all the new requirements until July 1, 2008.
Minor changes also were made to a few other proposed requirements based on the comments received. The RRC had proposed that residents be allowed to rotate up to 15 months in a single subspecialty, but as that was noted to be in conflict with current ABR requirements, the requirement was rewritten to continue the current limitation of such rotations to 12 months. To clarify the requirement regarding the faculty member responsible for pediatric radiology, a statement in the current program requirements, which had been eliminated, was reinstated: "a pediatric radiologist may have a primary appointment at another institution and still be the designated faculty member supervising pediatric radiologic education." Finally, in response to some misunderstanding regarding how the requirement for teaching radiologic-pathologic correlation could be met, wording to the effect that resident participation in a formal external course fulfills this requirement was added, recognizing the fact that most residents receive this specific education by attending a course given by the Armed Forces Institute of Pathology (AFIP). It was not the intent of the RRC to disenfranchise the AFIP course.
A package consisting of the current program requirements, the proposed new program requirements (modified as noted above), the RRC justifications for the changes, all comments submitted by interested parties during the online posting, and the responses prepared by the RRC to those comments, then was submitted to the ACGME Committee on Requirements for its review and consideration. The chair of the Radiology RRC was invited to meet with the Committee on Requirements on February 12, 2007 to defend the proposed changes. At that meeting, the proposed program requirements were unanimously approved with only minor wording (but not substance) changes. The following day the ACGME Board of Directors voted final approval for the new program requirements without further question or comment.
Even after the requirements were approved, papers continued to be published questioning the need for the change from 6 to 12 months of training before standing independent call [3, 4]. An editorial on the topic titled "It's all over but the shouting," however, has clearly signaled an end to the debate [5]. It is hoped that program directors and residents will now devote their full attention toward complying with the new requirements.
Certainly 12 months of training will allow rotations of 1 month or longer in all the sub-specialties that will benefit residents as they begin independent call. While most residents do not yet realize it, even as trainees they may be at legal risk for missed diagnoses when rendering preliminary interpretations. This statement is underscored by a recent ruling in a New Jersey malpractice case that found that residents working under supervision must be held to the same standard of care as specialists in their fields [6]. Furthermore, in some hospitals the peer review process considers residents equally with faculty physicians when assigning responsibility for medical mishaps.
These facts aside, it is recognized that some programs, particularly smaller ones, will face temporary difficulties in revising the resident call schedule. Current program requirements state that full-time participation by the residents in call responsibilities is expected at all levels of training. This has been interpreted by program directors in varied ways. The new requirement regarding senior resident call is more stringent and clearly states that "all residents must participate in taking call during the first six months of the final year of diagnostic radiology residency." It is the intent of the RRC that the new requirement will give programs the mandate necessary to assign call to senior residents. Certainly, patients will benefit from the experience and accuracy of senior residents standing call. Furthermore, the American Board of Radiology has consistently supported the concept that preparation for the oral examination is enhanced by the involvement of residents in interpretation and management of difficult cases encountered from the emergency department and intensive care services.
Aside from the issue of independent call, there are other changes in the program requirements warranting further discussion. These include designation of training institutions, required faculty complement, case logs, further integration of the competencies into resident training, resident learning portfolios, and the board pass rate.
The designation of hospitals and other training sites as integrated or affiliated, as has been the case for many years, has been confusing. The new requirements simplify the issue by indicating that the program should be based at a primary hospital and that all rotations outside that hospital occur at "participating sites." Each participating site must offer significant educational opportunities to the program. There must be a formal letter of agreement between the program and each participating site to which residents are required to rotate. The required contents for letters of agreement are clearly listed in the common (bolded type) program requirements.
The required faculty complement currently is based on a faculty-to-resident ratio of one to one. This has resulted in creative thinking on the part of program directors and chairs, who have on occasion elected to include not only radiologists but also a wide assortment of other professionals who may or may not interact regularly with residents. The new requirement simply accepts the common program requirement for faculty that applies to all specialties and which states that "at each participating site, there must be a sufficient number of faculty with documented qualifications to instruct and supervise all residents at that location." The RRC does not plan to create further formulas for determining faculty size. However, it will likely be quite evident during review of a program when the number of supervising faculty is deficient. The minimum number of faculty in a program under the new requirements is determined by the necessity of having one full-time equivalent (FTE) physician faculty in each of the nine subspecialty areas.
The requirement for participation in the ACGME Case Log System actually began this past summer (initial data were to be entered by August 1, 2007), yet only slightly more than one half of programs complied. This is an important initiative as the RRC eventually plans to use aggregate data on resident experiences during training to set benchmarks that can guide accreditation decisions. At least annually, data for each resident indicating his/her direct involvement (i.e., dictated the case) with a selected group of imaging examinations and procedures, as defined by CPT procedure codes, must be entered into the Case Log System online via the ACGME Website. Programs are responsible for gathering these data, typically found on the departmental Radiology Information System (RIS), and program directors are required to review each resident's data annually. Who enters the data and how frequently it is entered (monthly, quarterly, yearly) are departmental decisions. The Case Log System is different from the resident procedure log. A procedure log is required to be maintained by each resident and must document all invasive procedures in which the resident directly participates. Procedure logs may be paper-based or maintained in an electronic database such as HI-IQ (developed by the Society of Interventional Radiology), and must be available for review by the site surveyor during accreditation visits.
Probably no single change in residency training over the past few decades has generated more anxiety among all specialties than the concept of the six basic competencies. The RRC is committed to the ACGME timeline for making the competencies a mainstay in residency training, and during program reviews will be looking for full integration of the competencies and their assessment in resident learning and clinical care. To this end, there are new radiology program requirements related to the competencies. To assist program directors in meeting what at first glance seems to be a rather daunting goal, the RRC has prepared sample outcome measures for each competency and submitted them to the APDR, which has posted them on its Website (www.apdr.org). Compliance with at least one of these measures for each competency will satisfy the requirements for accreditation in this area, though programs are strongly urged to develop their own innovative outcome measures. Following are examples of new requirements and measures as they apply to the competencies.
For Patient Care, the required training in nuclear medicine is even more prescriptive than in the past so graduating residents will be eligible to qualify for Nuclear Regulatory Commission (NRC) Authorized User (AU) status. Mammography requirements remain well defined, again for regulatory reasons (MQSA standards). The RRC will be looking for an outcome measure that documents the quality of care, or improvement in the care, rendered by residents to patients. One such measure might be documentation showing reduction in the discrepancy rate over time, or a consistently low discrepancy rate between preliminary interpretations rendered by the resident while on independent call and the final faculty interpretation. Another method of compliance could be documentation of competence in performing specific procedures (e.g., barium enema) or adequacy of resident treatment of a simulated contrast reaction.
With regard to medical knowledge, there is now a requirement for residents to be exposed to a well-defined didactic core curriculum containing both subspecialty and general components. The core curriculum should contain lecture series that are updated and repeated at least every 2 years. In this section there are even more specific requirements for training in nuclear medicine, again reflecting the NRC regulations. The general components of the core curriculum include, among other topics, medical physics, patient safety, appropriate imaging utilization, fundamentals of molecular imaging, the socioeconomics of radiologic practice, the pharmacology of contrast media, professionalism, and ethics. In addition to the core lecture series, there should be interactive case conferences and resident participation in interdepartmental conferences. All told, there must be at least 5 hours of conference/lectures each week. Attendance at all conferences should be monitored, and time for residents to attend conferences must be protected. Compliance with outcomes for the medical knowledge competency can be very straightforward: There should be evidence of satisfactory performance annually on some type of objective examination, such as the ACR In Service Examination.
For Practice-Based Learning, residents will need to perform an annual self-assessment and then develop and follow an individual learning plan designed to correct any identified deficiencies in knowledge. For example, a resident might feel deficient in interpreting cases of congenital heart disease, and results on the In Service Examination might confirm this weakness. Adherence to a defined plan for in-depth reading and case review, developed in conjunction with a pediatric or cardiothoracic radiologist, should lead to documentation of improved performance in handling such cases. In addition to self-assessment, residents will need to demonstrate the integration of radiation safety principles into their everyday practice of radiology.
For Interpersonal and Communication Skills, programs must document resident competence in oral communication and the quality and timeliness of their written reports. The latter could be accomplished by documentation of resident participation in a departmental seminar on how to prepare appropriate written radiology reports followed by sampling of reports for each resident to confirm the effectiveness of the initiative.
Professionalism generally is assessed by faculty evaluations and 360° evaluations performed on a regular basis. In addition, one measure of the quality of professionalism could be documentation of resident compliance with specific departmental and institutional policies (e.g., dress code, infection control, HIPAA, Joint Commission, etc.). Finally, Systems-Based Practice requirements indicate that residents must participate in some process to identify and help resolve systems problems at any level from the department to nationally. Documentation of this process will satisfy the outcome measure requirement.
Another ACGME initiative, the Resident Learning Portfolio, has been endorsed by the RRC and figures heavily in the new program requirements. A portfolio will have to be maintained for and by each resident and, like the procedure logs, can be in manila file folders or in an electronic database. They must be separate and distinct from resident personnel files. Required contents of these portfolios are clearly defined in the new program requirements.
The RRC has long required that during the most recent 5-year period, at least 50% of a program's graduates should pass, without condition, the written and oral ABR examinations on the first attempt. In reality, this requirement has been applied primarily to the pass rate on the oral examination. The APDR and others have advocated for a 50% pass or condition rate, as opposed to a first-time pass rate, as the accreditation criteria. Respecting the validity of that request, the RRC asked the ABR to research the issue and, based on the data obtained, changed the requirement to read as follows: "During the most recent five-year period, at least 50% of a program's graduates should pass the oral examination either on the first attempt or, if only one section is failed, should pass that section at the first opportunity." The reasoning for this change is that even well-trained residents from excellent programs occasionally stumble and fail one section. Allowing the 50% pass rate to include failure of two or even three sections, even though a candidate may pass those sections at the first opportunity, proved not to be a discriminatory accreditation criterion. In defining this new requirement, it was the clear view of the RRC that the board pass rate remains one of the only truly objective criteria available on which a program can be judged.
The above discussion should in no way be considered an exhaustive review of all the new program requirements. It is imperative that program directors peruse the new requirements and the exhaustive list of FAQs addressing them, which are available on the ACGME Website (www.acgme.org), and seek to attain full compliance with each requirement. Attention to detail in this process is necessary for a successful site visit and a satisfactory accreditation decision. Furthermore, department chairs, radiology faculty members, and residents are all also strongly encouraged to become familiar with the new requirements. Questions regarding any facet of the accreditation process can be addressed via e-mail to the executive director of the RRC (mfleming{at}acgme.org).
References
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F. M. Hall and M. L. Janower The New Requirements and Testing for American Board of Radiology Certification: A Contrary Opinion Radiology, September 1, 2008; 248(3): 710 - 712. [Full Text] [PDF]
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