| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
colletti{at}usc.edu
The product of our Accreditation Council for Graduate Medical Education (ACGME) radiology training programs and the American Board of Radiology (ABR) is excellent. Our newly certified radiologists are qualified to independently practice highquality modern radiology. Potential limitations of the current system of radiology resident training and written and oral board examinations are well known. Unlike the majority of medical specialties, radiologists in training currently take their written physics and clinical examinations in the second and third years and complete their oral examination in Louisville in June of their fourth year before graduation. Because these examinations occur during residency training, in the months immediately pre ceding each of these examinations, residents are focused on assuring their medical knowledge, even at the expense of the other five general competencies: patient care, interpersonal and communication skills, professionalism, practice-based learning, and systems-based learning.
The oral examination in Louisville has much to offer [1]. Candidates are challenged by 10 respected experts in the areas tested. Standardized unknown cases are presented as they might be in clinical practice and the candidates' medical knowledge and communication skills are examined in a manner that no multiple choice examination can possibly offer.
If the board format is not broken, then why fix it? Difficulties with the current system include:
The hypothesis is that a series of computer-based examinations can replace the current system. Required maintenance of certification (MOC) will ensure continued competence [2]. Such a system is or will be the basis for most medical specialty boards. Thus, it is reasonable for radiology to move in this direction. There is no doubt that changes in the ABR examinations plus MOC will achieve the excellence our specialty demands.
Scientists know that we should vary conditions one at a time. Leaders, on the other hand, develop global policies that present best as a single package. The ABR certification restructuring [3] includes:
MOC and computer-based examinations make sense for the 21st century. As always, the devil is in the details. By moving the final certifying examination to a period 15 months after completion of training, a delay of 15 months in releasing new board-certified radiologists is introduced.
Perhaps we might recall Le Chatelier's principle [4] from our chemistry class:
If a chemical system at equilibrium experiences a change in concentration, temperature, volume, or total pressure, then the equilibrium shifts to partially counteract the imposed change.
The principle is used by chemists to manipulate the outcomes of reversible reactions, often to increase the yield of reactions [4]. Perhaps here, we have reduced the pressure and turned up the heat. Delaying board certification for new radiologists may have predictable and possibly profound effects on our specialty. For the purposes of analysis, consider the following steady state:
Assuming: Radiologist Supply < Radiologist Demand (there are current vacant positions); Assuming: Radiologist Supply + Radiologist Shortfall = Radiologist Demand; and, Graduating Radiologists – Retiring Radiologists = Active Radiologist Change; For the steady state with a stable Radiologist Demand,Active Radiologist Change = 0, and Graduating Radiologists = Retiring Radiologists
The exact numbers of Active Radiologists and Retiring Radiologists and Radiologist Shortfalls are not known with certainty [5–8]. For the purposes of this discussion, let us assume that:
Active Radiologists = 25,000, and Graduating Radiologists = Retiring Radiologists = 1,200
Let us also assume that currently 75% of Graduating Radiologists participate in 1-year fellowships [9], so that each year 900 Fellowship-Trained and 300 Non–Fellowship Trained graduates enter our steady-state balanced equation, matching the 1,200 Retiring Radiologists. How might a 15-month delay in board certification (and board eligibility, for that matter) affect our steady state?
Graduating Radiologists without board certification will have substantially reduced options for employment [8, 9]. It is reasonable to expect 100% applying for fellowship positions. Interventional and musculoskeletal imaging and MRI programs will be even more competitive, and applications for neuroradiology, nuclear radiology, and breast imaging fellowships will increase. This trend will likely also increase applications for abdominal imaging and body imaging fellowships. This may be good news for academic departments, but again there is a potential problem: few of these fellows will be board certified or board eligible. Results are predictable: Fellows in non-ACGME programs will be no more able to function as junior faculty than will those protected by ACGME regulations. Coverage for academic practices may no longer be enhanced by unsupervised board-certified fellows. Depending on ACGME interpretation, fellows without board certification may not be considered in resident–faculty ratios.
To some extent, the phenomenon of senior residents perseverating on the acquisition of medical knowledge may be reduced. Many may realize that residency is the best time to prepare for examinations, but the intensity will be reduced substantially. Just as Le Chatelier's principle would predict, candidates will of course need to prepare at some time. When will that be? Most will use the 3 months after completion of fellowship. Many will focus on board preparation during their fellowship. As many fellowship directors can attest, fellows without boards are less focused on their fellowship program.
Policy experts may remember recent rapid variations in the demand for
radiologists' services. In the 1980s and 1990s, there was an oversupply of
radiologists. Reduction of the number of residency positions was considered.
By 2000, a number of factors led to a prominent shortage of radiologists,
including population growth and increasing demand for rapid access to medical
imaging. Methods for increasing the number of residents were considered.
Reducing the length of radiology training to 3 years was proposed
[6]. This would inject 1,200
extra radiologists by the end of the first-year cycle, with about 300 extra
radiologists each year to follow. Paradoxically, we are in the process of
creating a virtual fifth year of residency. This will permanently reduce the
number of Active Radiologists by 300 to 400 (remember, the delay is 1
years). Here we must assume that results of electronic examinations will be
officially reported to the candidates and recorded within the week of the
event. Up to this point, we have assumed that all candidates will successfully
pass the examination. In the past, approximately 15% "conditioned"
one or more examination sections
[10]. Most of these candidates
were successful on reexamination in November of the same year of the initial
examination. Let us assume that 90%+ will successfully pass a final
computerized examination.
What will the postfellowship radiologists do during the 3 months after they complete their training? Well, that will be a good time for them to complete their preparation for the board examination. It is unfortunate that they may be unemployed at that time. As they are no longer residents or fellows, they will likely participate in relatively expensive general and topic-focused board review courses. Perhaps if the shortage of available radiologists is significant, practicing groups will recruit graduating fellows with a stipend to help with this posttraining transition.
If ABR certification delay becomes policy, radiologists would do well to begin working to amend their practice guidelines to allow the practice and billing for the services of trained but not certified radiologists.
The 15-month delay between the end of residency training and the administration of the examination will now have radiology in conformance with many of the other specialties in the American Board of Medical Specialties (ABMS) [1]. Perhaps we are endorsing an "everyone else is doing it" argument for our specialty that we would not accept from our children. We must ask what it is about the certification processes of other specialties that we aspire to.
Look for this future commentary: 2013—The Year No One Certified in Radiology.
 Top References |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  D. J. Wester Jr. The Diagnostic Radiology Examination of the Future Am. J. Roentgenol., December 1, 2008; 191(6): W317 - W317. [Full Text] [PDF]
|
|
|
|
|
|
P. M Colletti Reply Am. J. Roentgenol., December 1, 2008; 191(6): W318 - W318. [Full Text] [PDF]
|
|
|
|
|
|
G. J. Becker and N. R. Dunnick Intended Consequences of Computer-Based Core and Certifying Exams in Diagnostic Radiology Am. J. Roentgenol., November 1, 2008; 191(5): 1302 - 1305. [Full Text] [PDF]
|
|
|
|
 |
|
 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]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
