| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Commentary |
1 Department of Radiology, University of Colorado Health Sciences Center, 4200 E
Ninth Ave., Denver, CO 80262.
2 Department of Radiology, The University of Pennsylvania Health System,
Philadelphia, PA.
Received March 14, 2008; accepted after revision March 16, 2008.
Address correspondence to D. B. Larson
(david.larson{at}uchsc.edu).
Keywords: ABR • radiology board certification process
On October 26, 2007, the American Board of Radiology (ABR) posted on its Website (www.theabr.org) plans to change the primary radiology board certification process:
The clinical examination modules are expected to be graduated. In other words, if an examinee chooses a given subspecialty for 25% of the examination, he or she will be tested on basic elements in that area, whereas if he or she chooses 50–100% of a given specialty, he or she will be given more advanced subspecialty questions. Although the content of the examinations will become more specialty-specific, the Board still plans to certify graduates broadly as diagnostic radiologists. The Board is currently not planning to publish the specific makeup of each individual's tailored examination.
This policy brief examines how these changes—specifically those of (1) content and (2) timing of the oral board examination—may impact the major radiology stakeholders in the certification process: training programs, academic centers, private groups, and individual radiologists.
Examination Content
In its announcement, the ABR indicated that the decision to modify the content of the board examination was based on evolving practice models that are increasingly emphasizing radiologist subspecialty expertise. The Board states that this expertise is necessitated by rapid advancements in medical imaging applications, scientific knowledge, and the subspecialization of referring colleagues. This is supported by findings that indicate that most practicing radiologists, including those in private practice, focus on four or fewer areas of concentration. Some believe that the changes in the examination may encourage increased subspecialization as well.
Because the makeup of each individual examination is not to be disclosed by the Board, the effect of the examination changes on the field of radiology might be minimized. However, it is likely that potential employers, hospital credentialing committees, and perhaps even juries will ask future graduates the makeup of their examinations. If this occurs, then radiologists would be faced with significant pressure to disclose this information or potentially imperil their employment prospects, which would in turn have essentially the same effect as if the Board released the contents of the examination.
Regardless of whether the Board's decision serves as a catalyst or as a response to new practice realities, the decision signals a shift from a generalist model toward a subspecialist model of radiology practice.
Implications for Training Programs
While the ABR does not hold direct jurisdiction over the structure and
curriculum of residency training programs, the current training model will be
significantly impacted by the new examination options. The changes will
encourage residency programs to allow residents to focus more intensely on a
few subspecialty areas in their last 12 months of training, rather than on a
wider, more superficial base of generalized knowledge. To accomplish this,
senior residents will likely wish to tailor their education toward their
desired areas of concentration. It is unclear whether this could be
accomplished with only minor adjustments to current residency programs or
would require major re structuring of the entire radiology residency
curriculum. These changes will likely be more easily accommodated by larger
academic programs, which tend to have wider resources and greater flexibility
and will probably pose greater challenges for smaller community-based
programs. If residency programs make no accommodations for residents
who wish to focus on four or fewer areas of concentration in the finalyear,
such programs may be viewed as less desirable to resident candidates and place
them at a competitive disadvantage.
Implications for Academic Centers
The announced changes reinforce the subspecialty practice model that most
academic centers have embraced for many years. The changes will at least
allow, and likely encourage, more radiologists to subspecialize earlier in
their training, potentially providing larger candidate pools from which
academic centers can recruit. More sub specialty-focused residency/fellow ship
training may also allow more time for research and other academic endeavors
during this period—potentially bolstering current research efforts and
possibly encouraging more recent graduates to continue academic pursuits after
graduation. Furthermore, increased emphasis on subspecialty expertise may
present new business opportunities for academic centers to provide
consultative or supplemental services to smaller or more generalized
practices.
However, the pressure to allow senior residents to focus on subspecialty areas of concentration may put a greater strain on residency programs. Furthermore, academic groups will still need to compete for staffing with private practice groups—many of which are also highly subspecialized—by offering attractive benefits in terms of salary, protected time, opportunities for career development, etc. In addition, increased subspecialty emphasis will not help academic groups overcome certain challenges ubiquitous to radiology, such as providing quality after-hours emergency radiology coverage, maximizing practice workflow efficiency, and compensating for temporary and long-term workforce shortages.
Implications for Private Practice Groups
Since the announced changes have the potential to influence the structure
of the entire field of radiology, they are likely to open up a debate that has
been smoldering for many years—that is, the proper balance between
general and subspecialty radiology practice. Many radiologists, especially
those in smaller, rural, and more generalist practices, fear that the
decreased flexibility that comes with increased specialization will pressure
them to either join with larger regional groups or turn to teleradiology
companies to provide the requisite subspecialty expertise. This would likely
serve to further stimulate the growth of these teleradiology companies and,
some would argue, hasten the overall "corporatization" and
"commoditization" of radiology services. On the other hand, many
radiologists feel that the announced changes will have a positive effect on
private practices, especially those that are relatively large and
subspecialized. The difference between private practice and academic groups in
terms of subspecialty expertise is becoming increasingly blurred. As the
subspecialized radiologist candidate pool increases, these groups may be
better able to provide the "value-added services" demanded by
special ist referrers. This may help provide rad iology practices overall with
a greater competitive advantage relative to nonradiologist special ists or
subspecialist teleradiology companies.
Implications for Individual Radiologists
The announced changes may decrease the requisite time spent training in
activities that are unlikely to be used in practice, but may come at the
expense of decreased flexibility in terms of breadth of practice, career path,
and geographic location. Trainees may unwittingly restrict their future
opportunities by focusing their efforts on certain areas of concentration at
the expense of others during their training, only to discover later that the
practice they wish to join has needs that do not match the radiologists'
preparation. On the other hand, allowing for multiple areas of concentration
may increase radiologists' marketability, in that the radiologist may be
considered a subspecialist in up to four areas without additional fellowship
training. The market will likely decide which of these forces will
predominate.
The new specialty-focused examination will likely better accommodate those radiologists with time-limited certificates than would the current general oral board examination, given that most radiologists tend to specialize to some degree after training. It is anticipated that the first administration of the new testing format will coincide with the first wave of maintenance of certification (MOC) examinations for those with time-limited certificates, beginning in 2012, though this has yet to be determined.
Examination Timing
A subset of the radiology community, most strongly represented by The Society for Chairmen in Academic Radiology Departments (SCARD), has advocated for the oral board exam ination to be administered after resi den cy training, as is the case with many other medical specialties. For example, Dr. Stephen Baker [1], in a recently published article, states that residents spend excessive time and effort during the last few months of training on preparing for an overly comprehensive and superficial oral exam ination, often at the expense of their clinical duties and other educational opportunities. Efforts to delay the oral board examination traditionally have been met with strong disapproval by the residents, who feel that preparation for the oral boards is a valuable "capstone" learning experience at the end of their training. Residents against the delay have argued that since resident labor is essentially free to the training hospitals (their salaries and administrative costs are offset by reimbursement from government and other entities), it is not unreasonable for residents to finish the last few months of training rounding out their education.
Implications for Training Programs
By delaying the primary certification examination, residency programs hope
that fourth-year residents will turn their focus from oral board preparation
to increased participation in clinical, call, and educational activities. With
the new Residency Review Committee (RRC) requirements, which do not allow
first-year residents to take unsupervised call, it is hoped that fourth-year
residents, including those in the last 6 months of their residency (which is
not currently mandated by the RRC program requirements) will be able to make
up the difference in oncall staffing. Furthermore, delaying the primary
certification examination to 15 months following the completion of residency
training will place the examination at the earliest possible time that would
minimally interfere with fellowship training, as it is currently structured.
Traditional "board review" sessions provided by local faculty, as
well as resident group study sessions, will likely be curtailed since the
examination will be removed from the end of training and each resident will
likely be studying for different, tailored examinations.
Implications for Academic Centers
Delaying the final board examination will likely benefit academic radiology
programs, with anticipated increased productivity from senior radiology
residents, though such gains may be offset by the difficulty in accommodating
senior residents' potential desires to focus on a few areas of concentration.
Delaying the examination may also encourage more residents to pursue
fellowships, especially in the setting of a more specialty-focused
examination.
Implications for Private Practice Groups
It is less clear how delaying the certification examination will affect
private practice groups. Some fear that delaying the examination will shift
the burden of preparation time from training programs to practices—which
will disproportionately impact private practice. Others point out that since
most private practices provide a relatively large amount of vacation time,
such groups will not be impacted by examination preparation. Those in favor of
the delayed examination also argue that the combination of a delayed and more
specialized examination may allow new graduates to better establish their
career path and better tailor their examination preparation based on
individual preferences and group needs.
Implications for Individual Radiologists
The burden of preparing for primary certification is most likely to shift
from academic centers to the recently graduated individuals themselves. If
months of preparation are still required for passing the new examination, then
recent graduates will need to sacrifice more personal time after graduation to
compensate for time formerly spent during training, with decreased access to
libraries, exposure to academic radiologists, group-study with colleagues,
etc. Further more, practices would likely view recent graduates as a greater
risk as they will not yet have proven themselves by passing the boards and as
requiring a greater investment as they may need extra time to prepare for the
boards. Thus, recently graduated board-eligible radiologists are likely to be
at even more of a disadvantage relative to more experienced board-certified
radiologists than they currently are. Recent graduates may face decreased
starting salaries and delayed time until partnership.
Allowing trainees to focus less on acquiring skills they are unlikely to use in practice may diminish the overall time burden required to prepare for the examination. Furthermore, it is hoped that activities in fellowship and more focused training potentially granted to senior residents will naturally better prepare new graduates in those areas, lessening the need for board reviews, group study, time spent in the libraries, etc. In addition, while new graduates' attractiveness as general radiologists might be diminished, their attractiveness as subspecialists may be enhanced.
Going Forward
While the ABR has announced its plans to go forward with these changes, the details of these changes continue to evolve. Input has been provided in varying degrees by different radiology organizations. In addition, an invitation for written comments was posted on the ABR Website, ending January 31, 2008.
As input from external organizations and individuals is offered, it should be borne in mind that the ABR Board of Trustees is an independent body. While it consists of members nominated by medical societies including the ACR, ARRS, AUR, RSNA, and AMA, as well as AAPM, ARS, and ASTRO, candidates are elected by the ABR Board of Trustees and are not expected specifically to represent the interests of their specialty organizations; rather, ABR board of trustees members consider the interests of all of the various stakeholders, including the profession of radiology.
We have not discussed the implications for other vital stakeholders, including regulators, payers, and, most importantly, patients. While this is outside the scope of our discussion, the benefit to patients should remain the primary consideration throughout what we hope will be an ongoing healthy dialogue within the radiology profession of how to best structure residency training, board certification, and practice organization.
Regardless of whether the recently announced changes in the primary cert ification process represent the effect or the cause, the announcement portends a shift toward a more subspecialist model of radiology practice. Given simultaneous changes in technology, reimbursement, and increasing demand for evidence of quality, we are likely to witness a momentous trans formation of the organization and practice of radiology in the coming years.
References
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  S. R. Baker Rounding Out Their Education Am. J. Roentgenol., December 1, 2008; 191(6): W319 - W319. [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 |
