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    Panel Discussions in Radiology: Changes in Radiology Training ... Panel Discussions in Radiology: Changes in Radiology Training ... Document Transcript

    • Panel Discussions in RadiologyPanel Discussions in RadiologyAmis et al. Panel Discussions in Radiology: Changes in Radiology Training and New Examination FormatPanel Members: INTRoDuCTIoN. Change has been the mantra for diagnostic radiology during the lastE. Stephen Amis, Jr. decade. Prior to 2002, all radiology residents who passed the final oral examination held life-Stephen R. Baker time certificates in diagnostic radiology. Time-limited certificates began in 2002, requiringGary J. Becker newly certified radiologists to participate in Maintenance of Certification (MOC) and seek re-Patrick M. Colletti certification every 10 years. Changes in the training process began with discussions about the effectiveness of the clinical year and mechanisms to increase subspecialization during resi-N. Reed Dunnick dency training. These discussions were followed by expressed concerns about the timing andLawrence P. Davis content of the physics, clinical written, and final oral examinations in diagnostic radiology.Howard P. Forman The end result is newly proposed changes that will take effect beginning with the residencyScott A. Koss class of 2010. These changes affect both training and examinations. All core rotations will beCharles S. Resnik completed in the first 3 years of diagnostic radiology residency. The fourth year can be more focused with up to four areas of interest; meanwhile, fellowships remain unchanged. TheEditor in Chief: written examination will occur following the third year and include physics. The final certify-Thomas H. Berquist ing examination will occur 15 months following completion of the 4-year residency program. Both examinations will be image rich and computer based (visit www.theabr.org for further information). There will no longer be an oral examination for residents entering diagnostic radiology in 2010 and beyond. The proposed changes in training and the examination of the future have resulted in lively debates at national meetings and in numerous radiology journals. Strong concerns have been voiced regarding the impact that might occur to programs, institutions, and prac- tices throughout the United States. What will we gain from these changes? What are the potential consequences? The AJR has grasped this opportunity to bring together key stakeholders in order to address the questions and concerns expressed by all interested parties over the past several years. Panel participants (see bio sketches below) include Gary J. Becker, and N. Reed Dunnick (executive director and president, respectively, of the ABR), E. Stephen Amis, Jr. (past president of the ACR and chair of the Residency Review Committee for Diagnostic Radiology), Stephen R. Baker (president of the Society of Chairmen of Academic Radiology Departments), Charles S. Resnik (president of the Association of Program Directors in Radiology), Lawrence P. Davis (member of the ACR Board of Chancellors and chair of its Education Commission), Patrick M. Colletti (assistant editor for the cardiopulmonary section of AJR and author of the editorial “TheKeywords: CAQs, certification, maintenance of diagnostic radiology exam of the future: The law of unintended consequences meets the law ofcertification, radiology examinations, radiology training supply and demand,” Howard P. Forman (AJR section editor for health care policy and quality),DOI:10.2214/AJR.08.1936 and Scott A. Koss (a private practice radiologist from Waukesa, WI). The panel members will address 10 commonly asked questions based upon discussions andAddress correspondence to T. H. Berquist articles published over the last few years. The questions are listed below. Questions 1, 3, and(Berquist.Thomas@mayo.edu). 9 are included in the print journal; the remaining questions and responses can be found onlineWEB on the AJR’s Website (www.ajronline.org), where we also will provide the opportunity forThis is a Web exclusive article additional comments, questions, and discussion in a new online forum. We invite your comments on this new format and your suggestions for future panel discus-AJR 2008; 191:W217–W230 sion topics. 1) The new final examinations will be administered 15 months after completion of radiolo-0361–803X/08/1916–W217 gy residency. What impact will this have on private groups regarding recruitment, hospi-© American Roentgen Ray Society tal credentialing, and the practice of radiology?AJR:191, December 2008 W217
    • w217 11.05.08 Amis et al. 2) Why doesn’t a focused year in a certificate of added qualification prove the use of imaging techniques? (CAQ) specialty count towards our CAQ? 8) Will the new subspecialty emphasis in training diminish the 3) How can programs accommodate focusing in one to four areas value of today’s general radiologist? in the fourth year of training? 9) Are the changes in the training and the new examinations suffi- 4) How will training changes affect resident recruitment in pro- cient to enhance knowledge, and specialization, and to provide grams that can’t accommodate the focus options in the fourth added value to referring physicians? year of training? 10) Should the requirements for the clinical year be dropped or re- 5) Can the final exam of the future effectively replace the current oral one? structured? 6) Why can’t the final exam still be given at the end of training in- —Thomas H. Berquist stead of 15 months after the completion of radiology residency? Editor in Chief 7) Will changes in physics training enhance patient safety and im- AJR Question #1 The new final examinations will be administered 15 months after completion of radiology residency. What impact will this have on private groups regarding recruitment, hospital credentialing, and the practice of radiology?Amis next few years, is occurring for several reasons. First, other specialties Radiology groups don’t need to retool their recruitment processes. have introduced training curricula and their practitioners have gainedEven though after 2014 they will not be hiring a “finished product,” but some facility as image evaluators of cross-sectional studies. Until re-rather a “work in progress,” given the overall board pass rate of 90%+ cently, all radiologists, including general radiologists, were deemed es-there won’t be a significant increase in risk in taking in a new member sential, unique in their role as the sole proprietors of CT and MRI be-of the group from the pool of graduating residents or fellows. There will, cause they could interpret and explain 2D images in 3D terms to refer-however, be the need to assist the new member of the practice in satis- ring physicians. Now improvements in CT and MR displays have madefactorily completing the certification exam. There are many ways this 3D widely available. Some members of other disciplines can feel con-can occur, rather than simply giving him or her time away from the fident that they, too, can discern findings demonstrated by these stud-practice to study or attend review courses. Law firms actively assist their ies. Perhaps they may not be able to understand all the implications ofyoung lawyers to prepare for the Bar—and radiology practices should the abnormalities they perceive, but the presumption that their sense ofdo the same. Such an effort will likely improve the environment of heightened competence presents is causing a sea change in perceptionlearning within a practice. Once a system is developed, it can apply from and, ultimately, in practice initiatives. It is likely they will no longeryear to year as newly minted radiologists are added to the practice. seek to consult with a general radiologist who cannot hope to achieve Hospital-based practices will need to inform their hospital creden- an encyclopedic mastery of details in all subspecialties in radiology.tialing committees of the change in the board status of radiologists Given the sense of empowerment that some of our former referrers mayjust out of training. This should not result in problems with creden- have gained, we will have to contend with other specialists who willtialing of radiologists, as in most other specialties there are often one clamor for credentialing for imaging. And for some groups, i.e., cardi-or more years after training before the physician is eligible to take the ologists, they have already accomplished it in many institutions.final certifying exam. Hospitals likely will respond affirmatively to credentialing pro- There may be a few hiccups as radiology transitions from the old grams, validated by evidence of specialized training when sanctionedsystem to the new in 2014. It is doubtful that these will, however, affect by an “official body,” which will grant certificates of completionthe overall practice of radiology. The quality of training itself likely based upon a successful completion of a curriculum having desig-will not be significantly affected. Those who wish to become a general nated case numbers. The only defense against such initiatives is toradiologist will have that option. Those who wish to more clearly de- counter them with our own credentialing programs for which subspe-fine a subspecialty pathway will also be well-served. The real change cialization will be a prerequisite.will be experienced by referring specialists, who should find more At the same time, the job security of general radiologists in a par-value in their interactions with radiologists who are better trained in ticular practice will be confronted by challenges from North Ameri-the related subspecialty. can radiologists with subspecialty expertise who, through teleimag- ing, can provide image interpretation at all hours and perhaps, inBaker particular cases, even better than can a general radiologist. Hence, it The recent changes in board requirements were instituted in re- will become imperative that radiology groups to an increasing degreesponse to the emerging transformation of radiology practice, a phe- look to hire radiologists who possess subspecialty expertise. Failurenomenon that is already taking place, in an attempt to accommodate to do that will put such groups in a disadvantageous position withthe trends that are irrevocable and rapid with respect to the prospect respect to competition from distant radiologists who will seek andof the reallocation of responsibilities and opportunities to an expand- secure credentialing from hospitals and third-party payers on the ba-ing array of contenders for imaging interpretation work. sis of the quality and timeliness of their interpretations. In that regard, we are in danger of losing the “credentialing wars” to Thus the board changes, which in essence favor subspecialization, arethem. This challenge, which will become increasingly insistent in the not merely a realization of the goal of some special interest groups on theW218 AJR:191, December 2008
    • w217 11.05.08 Panel Discussions in Radiologyboard and elsewhere, but rather are a response to changes that have al- should not be problematic, as it has been said that radiology will thenready taken place in the practice of radiology with regard to an expansion be aligned with other specialties that practice without board certifica-of opportunities for employment using sophisticated imaging for physi- tion. Presumably, the scope of practice without certification will becians situated beyond hospital borders or beyond the former barrier of limited to the 1% to 4% of all radiologists who have recently gradu-the preexisting specialty definition of radiology. ated and have joined a practice without (for 15 months) or after (for 3 months) completing a fellowship. Academic practices that have reliedBecker/Dunnick on board-certified fellows as participants will also need to assure ap- For decades in this country, physician recruitment, hospital creden- propriate modification of their practice by-laws as well.tialing, and practice have been ongoing in all clinical disciplines repre-sented by the 24 member boards of the American Board of Medical DavisSpecialties. Meanwhile, today in 22 of these disciplines, the paradigm Change is always scary, especially when a system that has been infor transition from training to practice includes a substantial delay of place for generations is undergoing radical change. I certainly under-1.5 to 36 months between the end of training and eligibility to take the stand the angst among residents, program directors (including my-certifying examination. Radiology and pathology stand alone in admit- self), private groups, and academic departments. We are all in thisting candidates still in training to the certifying examination. together and need to take a long-term perspective. With respect to the upcoming transition to the diagnostic radiology • Recruitment: Let’s remember that soon, all graduating residents(DR) certification examination at 15 months after the end of training, will be in the same boat. Departments in both private practicewe predict that community and academic radiology practices will ad- and academia that are looking to recruit entry-level radiologistsjust to the change. There is no reason to believe otherwise. There is no will be looking at the same 1,000+ manpower pool. All of theselogical reason to expect an impact on recruitment, hospital credential- graduates will be in the same position of having to take theiring, or the practice of radiology. Every diagnostic radiology trainee final certifying examination 15 months after they finish resi-will be a fully qualified radiologist with the same total time in training dency. I truly believe that groups and departments will adjustas those completing training today. The difference is that they will quickly, especially after the first year or two. Newly minted ra-have demonstrated their basic competence in the field at 36 months of diologists will be hired. Most groups and departments will givetraining and will have used the last year of training to focus in areas of them a fixed period of time to pass their certifying exam. Asanticipated practice emphasis. Will each trainee’s fourth year emphasis you know, the vast majority of U.S. trainees pass the ABR exambe the same as his/her practice emphasis 10 years after training? Prob- outright on the first attempt. I do not think this will change inably not. But that is the beauty of MOC. It is all about lifelong profes- the future despite the changes in the examination.sional development. Viewed in this way, the fourth year represents theremainder of a lifetime of practice in microcosm. Moreover, trainees • Hospital credentialing: I do not think this is a problem. Of the 24need not focus. They can still spend the fourth year in general diagnos- member boards of ABMS, only radiology and pathology cur-tic radiology, serving on a variety of clinical rotations. rently allow candidates still in training to sit for their certifying There is another point. The ACGME has undertaken an aggressive examination. The other 22 boards require postresidency clinicalchange agenda in residency training that features a decided emphasis experience of up to 36 months. Radiology is now moving to anon the six competencies: medical knowledge, patient care, interper- exam 15 months after residency training. Credentialing recentlysonal and communication skills, professionalism, practice-based graduated physicians who are “board eligible” has not been alearning and improvement, and systems-based practice. This out- problem for physicians in these other 22 specialties. Therefore, Icome project will advance training from the current time-in-service do not anticipate it will be a problem for radiology.model to a competency-based one underpinned by the achievement of • Practice of radiology: Will there be a change in the practice ofspecialty-specific milestones. When that happens, even more change radiology? Maybe towards a trend of more subspecialization. Iswill occur. Once again, community and academic practices will have that a bad thing? In my personal opinion, no! I think it could be ato adjust. As we move forward into the future of radiology—a future good thing. A survey performed by the ABR revealed that 94% ofin which accepted training milestones will include more quantitative the 2,756 responding radiologists indicated that their practice cur-imaging and informatics that will shape the imaging professional’s rently was limited to one to four subspecialty areas. (For those ofcontribution to personalized medicine—one thing is certain. The in- you that know me well, you know that my own clinical practicecreasing pace of change will force adaptations in DR training pro- has been limited to one area, nuclear radiology, unless you countgrams, certification processes, and systems of lifelong professional administration and paper pushing; then it would be two areas.)development. One such example will be the incorporation of simula- The new ABR exam will mirror that practice pattern, allowing thetion to render the training experience safer, more predictable, homo- examinee to take an exam focusing on one to four clinical areas asgeneous, and effective. Finally, we will have to embrace change more well as a general content module and a module of classic radio-quickly and more completely than ever before. There is absolutely no logic findings any radiologist might encounter while on call. Thefuture for the current model of training and certification. residency review committee (RRC) is allowing residency pro- grams, depending on department resources, to structure the R4Colletti year of training individualized to the practice pattern interests of With the insertion of a 15-month delay between the completion of each resident and allowing focused training in as many areas astraining and completion of the ABR certifying examination, a por- the resident wants with as few as one focused area for the entiretion of radiology practices will need to work with their privileging year. However, the ABR also has an option for examinees to take acommittees to allow such transitional radiologists to participate. This final certifying examination that covers all content areas in radiologyAJR:191, December 2008 W219
    • w217 11.05.08 Amis et al. if the trainee doesn’t want to focus his/her experience. The RRC amination. This will ultimately be up to each radiologist emerging obviously will still allow programs to accommodate this. from training, but the private sector will need to embrace the fact that Since no one yet really knows what to expect from the new exam, new radiologists will have this new challenge to prepare for boardsI think that for the first few years most graduating residents will do a during their early careers in private practice radiology.fellowship so that they can stay in a teaching environment for the first Hospital credentialing in the private sector should be a smooth12 of the 15 months as they prepare for the final certifying exam. I transition with this new examination method. Although new for radi-think that more fellowship-trained radiologists will improve the qual- ology, the majority of specialties begin their career without boardity of care we give to patients and show “added value” to our referring certification. Credentialing may become a problem, however, if aphysicians. This does not mean that I expect future radiologists to radiologist is unable to achieve board certification.just practice in the one subspecialty area in which they did their fel- I do not see too much impact on the practice of radiology, but thelowship. It does mean that I think most future radiologists will have a radiology training will be augmented with more time available in thefew areas in which they are truly experts in the midst of potentially fourth year of training for more intense subspecialization. Further-practicing in many different areas in radiology. more, if a trainee chooses to do so, he/she could have focused spe- cialty training in one area and continue with a fellowship toward aForman CAQ in a different field. This would certainly enhance his/her educa- It may cause a short-term hiring deficit, while the transition oc- tion and improve marketability.curs, but the equilibrium should be the same. More important is thatthese groups have several years to prepare for this transitional period, Resniklikely making it a zero-sum game. I don’t believe we can accurately predict the effect that the new ABR exam structure will have on recruitment for private radiology groups.Koss There is a definite potential for many more residents to pursue fellow- This paradigm shift for board certification will certainly have an ships in order to stay in the academic environment for most of the timeimpact on the diagnostic and interventional radiology groups in the preceding the final examination. On the other hand, there will likely beprivate sector. I would expect that fellowship training would determine many residents who pursue 12 months of subspecialty training duringhow the private sector handles recruitment and contract negotiation the fourth year of residency, perhaps obviating the need to do a tradi-given the new board certification after residency. If a private practice tional fellowship. Once the first year or two of this process has passed,group hires a neuroradiologist, for example, directly out of fellowship, recruitment should normalize regardless of the number of residentsI would expect negotiation for a delay in start date (i.e., 3 months off to pursuing fellowship. Overall, this will likely result in more radiologistsprepare for boards) or a “no call” period for 3 months leading up to the with subspecialty training, although how this will affect the practice ofexamination. The more difficult scenario is the new radiologist who is radiology remains unknown. In any event, credentialing should not behired without fellowship training. Although it would be difficult to take an issue, since hospitals already credential board-eligible physicians inoff for large blocks of time, one could certainly orchestrate call and other specialties and will have several years to accommodate thisvacation schedules to optimize time off to prepare for the board ex- change in radiology. Question #2 Why doesn’t a focused year in a CAQ specialty count towards our CAQ?Amis Baker CAQs were developed to document added qualifications gained dur- It would appear logical and justifiable that if one spent 12 monthsing accredited subspecialty training beyond residency. Under the new pursuing training in one particular subspecialty area, either in thesystem, there will be more opportunity for residents to focus their fourth year of residency or in the year beyond residency, then thattraining during the final year of training. However, this is not new to should count towards qualification for a CAQ. The CAQ is a measuresome programs. For example, at Massachusetts General Hospital the of added competence and as such is an important expedient in the questfinal year has long been used by residents to gain subspecialty exper- to prevail in the upcoming interspecialty credentialing wars. CAQ re-tise during two 6-month “mini-fellowships.” CAQs should not be is- quirements should be liberalized to allow the qualifications affordedsued in addition to the standard board certificate for learning that oc- by a 12-month course of study within the interval of training, even ifcurred during the final year of residency training. If they are to have that training occurs before the end of residency or before the schedul-any validity at all, CAQs should reflect ACGME-accredited additional ing of the certifying board examination.subspecialty training capped by an additional exam. One can argue theneed for continuing the CAQ process. They only apply to less than half Becker/Dunnickof subspecialty programs, and there is no CAQ for ACGME-accredited First, the term “Certificate of Added Qualification” or “CAQ” isprograms in musculoskeletal radiology and abdominal radiology. Ac- no longer an accepted term of the ABMS or its member boards, in-creditation for chest radiology programs has recently been withdrawn cluding the ABR. The proper term is “subspecialty certificate.” Thereby the Radiology RRC due to lack of interest. Bottom line: A CAQ are a number of features that distinguish the subspecialty certificateshould still reflect subspecialty fellowship training beyond residency if holder from an individual who has just completed a residency, re-the ABR decides to continue the program. gardless of training emphasis. First, the subspecialist has alreadyW220 AJR:191, December 2008
    • w217 11.05.08 Panel Discussions in Radiologycompleted his/her ACGME-accredited DR residency training before on upcoming boards. This medical knowledge focus may be positiveundertaking additional training in the subspecialty. Second, how for fellowship programs, as presumably fellows will opt to be testedmuch of the subspecialty training experience obtained prior to com- in the area of their fellowship for the certifying exam.pletion of the DR training requirements is “lost” on the unprepared or Analysis of the perceived importance of CAQ certification will bepartially prepared trainee? Third, the subspecialty training curricu- interesting, as many radiology specialty areas, including body imag-lum in an ACGME-accredited fellowship is a rigorous experience ing, abdominal imaging, musculoskeletal imaging, and breast imag-imparted by qualified subspecialists in accordance with the require- ing currently do not have such CAQ opportunities. Another potentialments set forth and overseen by the radiology RRC. Fourth, the indi- trend may be for radiologists completing CAQ fellowships to bypassvidual who has completed this rigorous training must still complete CAQ examinations, perhaps based on potentially difficult-to-achievean additional year in subspecialty practice before qualifying to take posttraining requirements, such as participating in a 50% neuroradi-the subspecialty examination. Finally, the individual must pass a ology practice. Alternatively, participation in the CAQ process mayseparate subspecialty certifying examination. increase as a response to the MOC program.Colletti Forman It should not matter whether training occurs during residency or This is a question for the Board itself.postresidency fellowship. Perhaps the rationale for not counting thefocused resident year is related to protecting the recruitment pools for ResnikCAQ fellowships. Fellowship program directors realized that in the The intent of any changes should not be to shorten the durationpast, senior residents were less mature than the board-certified fel- of training but rather to enhance that training. Allowing the fourthlows. Delaying the certifying examination might level the field, as year of residency to serve also as a qualifying year for CAQ wouldnow there will be little difference between senior residents and fel- only decrease the overall expertise of the trainee and thus shouldlows. Seniors will have less experience; fellows may be more focused be avoided. Question #3 How can programs accommodate focusing in one to four areas in the fourth year of training?Amis lead faculty member in each of the traditional nine subspecialties that This will be relatively easy for large programs with faculty depth together encompass the four areas of possible concentration a resi-and large workloads in each subspecialty area, assuming that the resi- dent will choose in his or her fourth year of training.dents in those programs have at least some divergence of subspecialtyinterest. When there is oversubscription of one subspecialty area in a Becker/Dunnicktraining program, the program will have to develop a system for ensur- It has been suggested that the new training and certification para-ing an equitable distribution of residents during the final year of resi- digm will adversely affect small training programs that will find them-dency. The new system may pose a problem for small programs with selves unable to provide a full range of fourth-year options to residents.little subspecialty expertise and differentiation. Such programs will Hall and Janower (Hall FM, Janower ML. The new requirements andhave to appeal from the beginning to those candidates who wish to testing for American Board of Radiology certification: a contrary opin-become “generalists” and plan to enter small, and often rural, practic- ion. Radiology 2008; 248:710–712) feel that this is particularly true ines. Alternatively, graduates of such programs who wish to subspecial- regard to the ability of said programs to offer subspecialty training.ize will seek subspecialty training during a fellowship year, just as they However, this notion has been countered by a different logic from thedo now. Either way, I don’t see the new order of things disenfranchising ABR. The ABR’s diagnostic radiology primary certification examina-smaller programs. tions will continue to cover the entire domain of diagnostic radiology. Candidates will have the option to select a generalist track. SomeBaker smaller programs themselves perceive a competitive disadvantage ow- I believe that this question is, in essence, a straw man that has been ing to their relative inability to offer a full range of subspecialty train-raised by fretful program directors. If, according to RRC regulations, ing rotations. The ABR maintains that under the new training and cer-a program has adequate personnel in all of the areas that encompass tification paradigm, the total duration of training will be unchangeda radiology training program, including the faculty that meet that test and the subspecialty offerings a given institution is able to provide willqualitatively and quantitatively, then that program should be able to be unaffected. In other words, if that ability is limited now, it will beprovide focused training in each of the four areas. The new board limited then. There is no reason to expect a difference. Therefore, it isrequirements do not mandate that there should be training in new highly likely that small and large programs will each continue to at-specialties in radiology not previously encompassed by the RRC tract the same resident pools that they are attracting today.training criteria, but rather that there could be a reorientation of theintervals allotted each existing subspecialty area to allow for a pro- Collettilonged period of focused study in one deemed “concentration area.” It would seem possible for all programs to create 3-month, 4-month,In order to be accredited by the RRC, a diversified faculty should al- 6-month, or 12-month specialized rotations. As some subspecialty fo-ready be on-site and in place. Specifically there must be a designated cus areas may be more attractive to residents, the key will be to developAJR:191, December 2008 W221
    • w217 11.05.08 Amis et al.a plan that allows for appropriate whole academic practice coverage. FormanMethods of allocating specialty focus opportunities include competi- I think programs will learn, as with other training areas wheretive selection, assignment, and lottery. some specialty areas are in more demand than others (business schools, as a good example) that they can use auction theory to allotDavis rotations in a fair manner. It may then be the case that a resident who As a program director, I personally have some concerns about this. desires a large amount of training in musculoskeletal imaging willMy program is a medium-sized program with 18 residents, three fel- have to accept additional service to his/her residency in an undesir-lowships, 25 faculty, and about 200,000 cases. If all of my five senior able area.residents wanted to do a full-focused year in musculoskeletal radiol-ogy, I would have a problem. I would not have enough MSK volume Resnikto accommodate all of them and also provide appropriate training for Individual programs will develop their own best ways of structur-my R1–R3 residents, even if we combined forces with our sister insti- ing the fourth year of residency training based on subspecialty casetution in our large health care system. My plan is to start a discussion volume and faculty expertise. There will no doubt be many programswith each resident, as early as the beginning of the R2 year but cer- that will have difficulty accommodating the exact requests of all se-tainly no later than the beginning of the R3 year, and concerning nior residents. Multiple residents focusing in the same subspecialtywhat their subspecialty interests are. We already give our R4 resi- has a potential to overburden the teaching resources, while subspe-dents elective time to have some focused training in their areas of cialties that attract no residents in a given year may have difficultychoice. This can be expanded to accommodate several months of fulfilling service obligations. We must all remember that it is the ob-training in each of several focused areas. It will take some flexibility ligation of a training program to consider resident education a higheron the part of the program to make schedule changes, but we must do priority than clinical service, while still recognizing that clinical ser-this because as the RRC reminds us, residency is about education and vice is indeed an integral part of resident education. The delicate bal-training and not service obligations. The seniors will have to coordi- ance of these priorities will be a challenge to all residency programnate among themselves to distribute the clinical time on the most directors. It is anticipated that they will be provided some guidancepopular rotations. In our program, there is a unique camaraderie by the APDR in order to remain in compliance with program require-amongst the residents so this should not be a problem. Finally, I think ments mandated by the ACGME Residency Review Committee.that APDR will play a key role in suggesting innovative curriculumchanges and popularizing best practices, which individual programscan adopt if they wish. Question #4 How will training changes affect resident recruitment in programs that can’t accommodate the focus options in the fourth year of training?Amis areas, then it is deficient and it must cover the deficiency or risk losing See response to question #3. As long as radiology retains its current its accreditation. The curricular demands consequent to the newlypopularity among medical students selecting specialties, there will be instituted timing modification and other program changes require nono problem. There will be more candidates for training than there are new training focus, only a rearrangement of time spent within pres-training positions and good candidates will be available to fill all ac- ent curricular confines. Thus, these changes do not compel a programcredited slots. However, in the early to mid 1990s, there were far more to add to what it provides now. Yet if a program can make only aradiologists than positions. This prompted medical students to not opt marginal attempt to accommodate a year-long assignment, it mayfor radiology training. As a result, we woke up to the perfect storm in partner in a complementary way with another program. For example,1999–2000 when there were far more positions than radiologists. The if two programs that sense this threat have separate deficiencies thenmedical students have been responding to this situation ever since by they might want to combine their training for the fourth year so thatflocking to radiology. What if the situation reverses again, which could some individuals may pursue instruction in an area in which a pro-occur since many workforce issues over the years have proven cyclical gram is excellent and not remain in that program if it is less thanin nature? One can argue that students are now opting for radiology good. Accordingly a sharing agreement may be established for thestrictly on the basis of the desirable characteristics of our specialty transfer of residents as long as it is done reciprocally. An inevitable(e.g., more flexible lifestyle and high-tech toys for the “wired genera- result of the board changes will be that some weaker programs willtion”), but it is more likely that students will vote with their feet if the close, just as they are doing now and better ones will expand. Thatjob market changes drastically. If that is the case, the smaller, less sub- has always been true. The board changes should encourage weak pro-specialty-differentiated programs will likely be the first to go unfilled. grams to improve and not just try to persist.Baker Colletti As currently configured, a program must meet the requirements of A 15-month delay in ABR certification will likely increase par-training in all areas as specified by the ACGME-Radiology RRC ticipation in fellowships. It is not intuitive that this should increaseregulations. If a program cannot provide education in any of these demand for a focused residency fourth year. The majority of resi-W222 AJR:191, December 2008
    • w217 11.05.08 Panel Discussions in Radiologydency applicants may not consider focus accommodations to be as way, I bet that most of these medical students will change their areaimportant as overall program excellence, educational environment, of subspecialty interest several times before they enter their R4 year.faculty, technical access, and location. Most programs can offer I know that many of my residents, as they go through their residency,3-month rotations in areas appropriate for radiology practice. With change areas of interest.increasingly talented applicant pools, radiology resident recruitmentwill not be a problem for any qualified program. Forman There are always opportunities to outsource or subcontract. Per-Davis haps, though, smaller programs may be forced to merge in order to I am not yet convinced that this is as big an issue as many think. I achieve sufficient scale.have been a program director for about 20 years and have been in-volved in resident recruitment for this amount of time. It has been my Resnikobservation that the vast majority of senior medical students whom The “focus options” are not specifically limited by the ABR or bywe interview don’t really know in which subspecialty area in radiol- the RRC. They may, however, be limited by the resources of a spe-ogy they have an interest. I have always asked the candidates when I cific residency program. Residents within the program will be famil-interview them what they see for themselves after they complete res- iar with these resources and will adapt accordingly. While most ap-idency and what type of fellowship, if any, they might pursue. The plicants to radiology residency do not have a clear and sustainablevast majority of them don’t know! What attract students to the pro- desire to pursue a specific subspecialty, they will no doubt be influ-gram are its name and reputation, as well as its location. The inter- enced by the number of options available at each program. Thoseview day is vitally important as the interviewees respond to the look applicants with a defined subspecialty desire will likely highly rankand feel of the program and the department, as well as the obvious programs with that as a defined strength. It will be up to individualcamaraderie of the residents, faculty, and staff. I do not anticipate any programs to highlight their strengths and their options for diversifica-of this changing. However, the occasional senior medical student tion during the recruitment process. Other important factors such aswho already knows that he/she wants to do 12 dedicated months of, program location and resident camaraderie will continue to play asay, MSK radiology in the R4 year, may not rank us as highly. By the dominant role in the decisions of applicants. Question #5 Can the final exam of the future effectively replace the current oral one?Amis Becker/Dunnick I’ve been a guest examiner at the oral board exams for 24 years. The ABR Board of Trustees firmly believes that the computer-basedThe one-on-one contact, no matter how diligently I try to create a certifying examinations can and will replace the current oral examina-low stress milieu, reduces some candidates to quivering hulks who tions, and in some respects surpass them. By way of explanation, it iscan barely remember their own names. The argument can be made, clear that the current time-tested oral examination is successful, well-of course, that these are the less well-prepared candidates. That regarded, efficient, valid, and reliable. It also manages to assess thesaid, the oral exam has served our specialty well over the years. candidate at cognitive levels that exceed knowledge and comprehen-However, I strongly believe that an appropriately designed comput- sion, including application, analysis, and management, for example.er-based interactive examination can appropriately determine ade- The latter levels are notoriously difficult to achieve with the multiple-quate training, including the ability to integrate imaging physics, choice-item format. Thus, it is clear that the ABR has work to do.overall medical knowledge, and clinical appropriateness into imag- However, it is equally clear that there are problems with the existinging decisions and can reasonably simulate the consultative nature of examination, most of which will eventually be mitigated by the comput-radiology practice. er-based approach. Examples include the cuing that comes from the simple knowledge that one is being examined in a specific category eachBaker 25 minutes, lack of normal studies on the examination, limited image Certainly! The oral examination is an example of “hazing” in which display unlike today’s expanded menu of renderings and post-processingan unnatural situation is presented to the stressed test taker who must options at the imaging workstation, absence of procedure reporting, andperform well on the first two image examples shown lest he/she fear more. In short, the examination has begun to lack face validity.failing that section. This mode of presentation does not replicate cus-tomary radiology practice. Immediate performance on difficult cases Collettiis in essence a melodramatic construct. In common practice one delib- Contemporaneous radiology residents are selected from the top 75therates on challenging cases without the added burden of having a dis- percentile and above based on results of national board exams. It ispassionate examiner sitting close by. A computer-based exam provides likely that they will be adept at approaching multiple-choice examina-a more accurate simulation of radiology practice than the intimidating, tions. Future computerized examinations may be hierarchically craftedperformance-oriented oral exam. Inasmuch as almost every other spe- to identify critical judgment errors by automatic refocusing of ques-cialty has abandoned the oral exam, there is no reason why radiology tions in areas identified as potentially deficient. As an example, candi-should retain it. dates might be given a multiple-choice scenario in which one may de-AJR:191, December 2008 W223
    • w217 11.05.08 Amis et al.cide to perform thrombolysis in a hypothetical patient with a sub- But did the oral exam really assess the examinees’ communicationarachnoid bleed. The programmed exam may then automatically offer skills? I think not! In my many years of being an oral board examiner, Iquestions specific to the safety aspects of the proposed intervention. have seen normally verbal and articulate people become barely able toAll responses would receive an appropriate positive or negative value. utter a word because of fear—fear of the oral exam process, fear of theThe electronic exam system would value specified unacceptable candi- dark hotel rooms, and fear of the unknown, or even worse, fear of thedate responses in a manner similar to that of an ABR examiner or known and world-famous oral board examiner. In fact, and this is a truepanel. Developing, quality assuring, securing, and maintaining such a story, in my first year as an examiner, I went to pay my respects to acomputerized program will have substantial initial expenses. These world-famous MSK radiologist standing in the corridor as we wereexpenses should be offset over time by substantial savings related to waiting for the day’s exam to begin. He mistook me for an examinee andthe discontinuance of the oral board operations. started to drag me into the room to take the MSK section of the exam. Potential advantages include: My pulse suddenly tripled and I could barely speak. I only got out of the • Uniform, fair, highly disciplined examination process room alive by showing him my examiner’s ID badge. There is nothing like fear to destroy good communication skills! The new computer • Rapid reporting of meaningful results to candidates, programs, exam will not have this same element of fear and panic and I don’t think and the ABR that the examinees will miss that. I do think that the new computer • Multiple opportunities to reschedule or repeat examinations as exam can replace the current oral exam and can be a better exam. needed • Applicability to the MOC recertification process Forman There has never been an assertion that the current oral examina-Davis tion is ideal. It has been somewhat successful over the years in estab- I think the planned image-rich, computer-based exam that the ABR lishing a baseline of competency. We should not be looking to a fu-is planning as the final certifying exam can replace the current oral ture exam to “replace” the current exam. We should be looking for aexam. I understand that the current oral exam allows us to assess the future standard that will further establish our profession as the idealcandidate’s communication and management skills as well as his/her specialty to interpret images for our patients.knowledge base. The future computer exam will allow a much morestandardized exam experience for the examinees, which I think, is im- Resnikportant. The new computer exam will mirror everyday clinical practice I believe the content of the new exam can easily replace, and evenmuch better than the current oral exam. Cases will be presented in a exceed, that of the current exam. However, the testing of the organiza-random pattern potentially with normals included instead of in discrete tion of thought skills and communication skills of the candidate is25-minute packets in a known content area. The candidates will be able likely to be lost. These skills are, of course, critical to the developmentto view complete data sets like they do every day at work instead of a of a competent radiologist. The pressure of an upcoming oral exam is afew preselected images. Questions will be “story boarded” as they are strong motivator for residents to refine these skills. Residency pro-in the current MOC exams, which will uniquely allow assessment of grams will presumably need to develop mechanisms to assess thesepatient management. I am not concerned about the exam’s loss of as- skills, including objective structured clinical exams and what we cur-sessment of communication skills. All program directors know that rently call “mock oral boards.” Program directors will need to deter-their training programs are required by the RRC to assess their resi- mine how the results of these assessment tools will be used to ensuredents’ communication skills as part of the six general competencies. that all graduating residents achieve necessary competence. Question #6 Why can’t the final exam still be given at the end of training instead of 15 months after the completion of radiology residency?Amis by scheduling it 15 months after residency or 3 months after a fellow- The obvious answer is that it could. However, I think we all know the ship year, the trainee can develop specialized knowledge in a particularreasoning behind this change. First, we are in a very small minority of area that will be valuable for his/her career and for his/her opportuni-specialties offering the final certifying exam before training is complet- ties to be attractive to a group practice. Incidentally, in a survey that weed. And second, giving the oral exam at the end of residency has reduced have done of senior residents taking our review course, fully 90% willthe final year of training, or at least the last few months, to a prolonged be entering a fellowship program. Although examples can be found ofboard review (“board mania” or “board frenzy”) in many institutions. individuals going directly into practice, this has become increasingly a choice of a shrinking minority as residents recognize the need for spe-Baker cific training beyond residency in one particular area. The certifying should be given at the end of an interval after resi-dency so that an individual can effectively gain subspecialty training in Becker/Dunnickone or two areas. Such training may be a 2-year term encompassing the After years of debate among the academic societies and within thefourth year of residency followed by 1 year of fellowship in a particular ABR, the decision to move the examination to 15 months after trainingarea or 1 year of training in each of two different areas over the same was made. However, this decision occurred only after the ABR real-24 months. If the exam would be given after the fourth year of resi- ized that it was not concerned primarily with the timing of examina-dency there would be no time to develop subspecialty expertise. Rather tion, but rather with the transformation of the training-and-certificationW224 AJR:191, December 2008
    • w217 11.05.08 Panel Discussions in Radiologyprocess. With this perspective, it should be understood that the practice senior resident emphasis on medical knowledge to enhance their focusyear is considered an essential step in rendering the newly minted on medical practice, practice-based learning, and professionalism.trainee finally ready for board certification and a professional lifetime There may be no radiologists certified in 2014, but the sun will con-of education, self-assessment, and practice quality improvement. tinue to rise each morning on the great specialty of radiology.Colletti Davis Of course the final ABR exam can be given as always in the final The new certifying exam will test practical clinical experience,June of training. The 15-month ABR certification delay was added to which will be gained during the 15 months after residency. It will alsoreduce the annual intense senior resident medical knowledge board align the ABR with the other ABMS specialties.preparation learning effort to a period after residency and fellowshipare completed. This essentially moves the exam preparation energycost from the academic program to the candidate and the candidate’s Formaninitial practice. This is a question for the ABR. We have been a long-standing out- It would seem likely that the pass rate will be lower for the new lier among specialties. By changing the timing, we are entering the“core” exam offered for third-year residents as opposed to the de- mainstream of medical subspecialty training.layed “certifying” exam. It will be interesting to watch for “binge andpurge” behavior in third-year core candidates. Perhaps we can run, Resnikbut we can’t hide from predictable human behavior. There has been much debate regarding the timing of the ABR Continued discussion on the advantages and potential pitfalls of re- examinations for over a decade. Numerous surveys of varied con-assigning the ABR exam to a time 15 months after the completion of stituents failed to provide any consensus. The ABR believes that theresidency may be counterproductive after the decision to proceed with changed format is in the best interest of the future of the specialtythe current proposal has been made. Given this reality, we must move of radiology. It is up to all of us to embrace this belief and to provideon to adjust our practices appropriately. Residency training programs our residents with the tools to pass the exams and to practice out-should take advantage of these ABR changes to refocus the current standing radiology. Question #7 Will changes in physics training enhance patient safety and improve the use of imaging techniques?Amis Becker/Dunnick Changes in physics training, driven by the new content and se- In order to answer this question, one must be clear about the “changesquencing of the board exams, are essential in today’s world where in physics training.” The short answer is “yes,” but the truth is that sub-there is increasing awareness of radiation exposure related to medi- stantive change is on a longer timeline to implementation. The AAPMcal imaging and more sophisticated equipment requiring radiolo- curriculum committee (for DR) chaired by Phil Heintz has produced itsgist input to optimize image quality. In 1987, only 15% of back- curriculum that spans all content areas of physics for DR trainees. Billground radiation for the general public came from medical imag- Hendee is currently serving as editor-in-chief of a new project compris-ing; in 2008, the majority of background radiation is due to medical ing the creation of a modular physics series for diagnostic radiologists.imaging. Radiologists must be aware of this increasing public safe- Each of about 35 modules will be produced by a pair of contributors thatty issue and know how to minimize radiation exposure. Facility includes a diagnostic radiologist and a physicist. Ultimately, the AAPMwith the physics of MRI is also essential in order to obtain quality curriculum and the training course will have to map to the ABR coreimages in a reasonable time. The learning and testing of physics examination. Dr. Hendee is passionate about the online training project,knowledge can no longer be a “binge and purge” phenomenon, as it and it is on schedule. Insofar as patient safety in imaging is concerned,is under the current certification system. Rather, an awareness of there is currently an intense focus on the topic, and numerous radiationthe physical principles underlying imaging must drive decisions re- reduction practice quality improvement (PQI) projects are in variousgarding choice of modality as well as image quality. stages of development and implementation.Baker Davis I would hope so. The integration of physics into practice is key I think the new structure of the ABR exams as well as the newfor a better understanding of the nature of radiation exposure to RRC requirements will enhance physics training and patient safety.caregivers, radiation dose to patients, and the establishment of Currently the residents cram and study physics in the summer, 3–4proper technique for both diagnostic and therapeutic imaging pro- months before they take the current physics exam in the fall. All ofcedures. Separating it from the remainder of training by allowing my residents do this in the beginning of the R2 year. The day after thethe exam to be taken after the first year makes physics seem like exam, they never look at or think about this material again. Stevean outlier. Integration of physics within the diagnostic curriculum Amis has termed this “binge and purge” and I agree since this is ex-should be imposed to place physics at a central position, not mere- actly what I did as a resident. There is now a multiorganizational re-ly something to be studied only to pass an exam. Thus, I believe newed interest in revamping and improving training in radiologythat the proposed changes in physics instruction are salutary for physics and an increased concern and awareness on the part of theour specialty. public concerning radiation exposure and radiation safety. There isAJR:191, December 2008 W225
    • w217 11.05.08 Amis et al.nothing like an exam to motivate residents to study and learn a par- Resnikticular content area. The new 36-month core exam and potentially the The evolution in physics training has already begun with thefinal certifying exam and MOC exams will have applied physics 2007 publication of the Diagnostic Radiology Residents Physicsquestions integrated into the appropriate portions of each exam. The Curriculum developed by the American Association of PhysicistsRRC’s radiology program requirements also require physics training in Medicine Education Council and the Radiology Academic Coun-as part of the general core didactic content throughout all 4 years of cil (http://www.aapm.org/pubs/reports/Curriculum.pdf). This cur-training. I think this will make physics issues seem real, practical, riculum should prove to be an outstanding knowledge base for resi-and patient centric instead of being something abstract, to be learned dents and practicing radiologists alike. If the new ABR examina-for the exam and then forgotten. tion tests an understanding of these physics principles, it is bound to enhance patient safety and to reinforce the need to optimize imag-Forman ing techniques. I certainly hope so, but have no evidence either way. Question #8 Will the new subspecialty emphasis in training diminish the value of today’s general radiologist?Amis survey indicated that the vast majority of radiologists already focus I don’t foresee this as being an issue. Residents will still be able to their practice in one to four areas. The exam and training process willchoose a “general radiology” focus during their final year of residency mirror this pattern. For those who want to practice across all areas ofand their certifying exam will then test across the spectrum in radiolo- radiology and be a true “general radiologist,” the training and examgy, though not to the depth it will test when limited to only a few sub- process will accommodate that.specialty areas. The new structure of the board exams will not, in myestimation, limit the opportunities for training in general radiology. FormanFor those planning to practice in small groups or in rural areas, this The definition of “general” radiologist is already changing. Histori-will be the preferred option. A well-trained general radiologist will cally, general radiologist was applied to someone who had no subspe-continue to provide optimum value to primary care physicians. What cialty training. More recently, general radiologist refers to someonethe new structure does allow, however, is the ability to more signifi- who reads multiple modalities. The training changes are unlikely tocantly subspecialize. These folks will likely be planning to practice in lead to any further shift.a large radiology group with significant subspecialization or in an aca- Teleradiology, on the other hand, has a far greater possible effect indemic radiology department. Either way, general radiology or subspe- moving toward greater subspecialization.cialized radiology, the appropriately trained radiologist should be ableto offer the most relevance to the clinical community served. Koss Although there is a role for the general radiologist in privateBaker practice, the depth and complexity of radiology and new technolo- Absolutely it will. But it already is being diminished by forces be- gies place tremendous emphasis on subspecialization. It is para-yond radiology. The changes in the board exam accommodate to devel- mount that radiologists continue to move toward subspecializationopments that actually exist or will soon occur. The notion that a gen- to strive for a high level of radiologic and clinical knowledge ineral radiologist will be important in the years to come is increasingly their chosen field to provide the best quality diagnostic or inter-doubtful. Even now the assertion of its continuing essentiality is still an ventional services for the patient. This strategy also suppresses turfidea that fails to reckon with ineluctable forces already in play. battles with other specialties who may believe they can perform ra- diology services to a higher standard. With all that said, residencyBecker/Dunnick programs will need to continue to produce high-quality, well- No, but accelerating obsolescence will. See the answer to Question #1. rounded radiologists, capable of providing diagnostic services across the board in the private sector.Colletti Talented general radiologists will always be appreciated. This is par- Resnik All radiology residents will continue to be trained and examinedticularly so for the 22% of practices with fewer than five radiologists, and in all aspects of diagnostic radiology. Whether or not they becomefor emergency coverage in larger groups where subspecialists may be “subspecialists” will depend on the specific practice situation theyless available after hours. Over time, radiology practice will morph in an are in. This is likely to be market-driven—if local referring physi-orderly manner into more focused subspecialization, supported by mod- cians or the public demand subspecialty expertise, radiologists willifications in training programs and the MOC process. have to adapt accordingly. It is unlikely that all referrers will need or want the complexities of this expertise, so there will still be aDavis place for radiologists with diverse general skills. I do not think that the new exam process and residency programchanges will diminish the value of the general radiologist. The ABRW226 AJR:191, December 2008
    • w217 11.05.08 Panel Discussions in Radiology Question #9 Are the changes in the training and the new examinations sufficient to enhance knowledge, specialization, and provide added value to referring physicians?Amis hanced ability to distribute image data to appropriately trained ex- The ABR and the RRC certainly hope that these changes are at least perts, strongly encourages specialization. All of this will add value toa step in the right direction. It will certainly help if there is no drop off, our patients and referring colleagues.and hopefully an increase, in the number of graduating residents who optfor fellowship training. Fellowship on top of subspecialty emphasis dur- Davising the final year of residency should provide an improved level of sub- Since no one yet really knows what to expect from the new exam, Ispecialty expertise for those radiologists who plan to serve clinical spe- think that, at least for the first few years, most graduating residents willcialists. For those radiologists whose general practice serves a primary do a fellowship so that they can stay in a teaching environment for thecare clinical community, there should be little change in the training and first 12 of the 15 months as they prepare for the final certifying exam.therefore the level of expertise brought to the practice. The missing in- More fellowship-trained radiologists, I think, will improve the qualitygredient is relevant clinical exposure for subspecializing radiologists. of care we give our patients and show “value added” to our referring(See response to Question #10 for why this is not currently feasible.) physicians. This does not mean that I expect future radiologists to just practice in the one subspecialty area in which they did their fellowship.Baker It does mean that I think most future radiologists will have a few areas I would hope so. The training period cannot be prolonged any further in which they are truly experts in the midst of potentially practicing inas trainees are now, in many instances, deeply in debt and have been many different areas in radiology.saddled with financial burdens often for over a decade. The emphasis on Formanfurther specialization is absolutely essential. One would hope that it can I believe that these changes are unlikely to have any real effect onbe accommodated by the redirection of the board’s content and context our value to our patients and referring physicians.during a term of study no longer than the present 6-year interval, includ-ing a preliminary year, a 4-year residency, and a 1-year fellowship. Koss The coming changes in radiology training and board examinationBecker/Dunnick timing will certainly offer more value to referring physicians given Yes, they are. And we would argue that in the absence of these that there will be more time in residency for subspecialty training.changes, contemporary radiologists will find themselves diminish- This should not underscore the fact that fellowship training will ulti-ingly valuable to referring physicians. mately be the training ground for subspecialty radiologists. The up- coming changes in training will certainly augment fellowship train-Colletti ing, but are by no means a replacement. Driven by ACGME and RRC guidelines and the competitive resi-dents our specialty attracts, the quality of radiology training has pro- Resnikgressed steadily. Residents are exposed to hundreds of computerized The added value of radiology services to referring physicians is theimages, and correlative imaging and clinical correlation are greatly accurate interpretation of correctly performed necessary imagingsimplified. Access to medical knowledge via the Internet and gener- studies and the conveyance of these results in a timely fashion. Anal- and radiology-specific Websites such as http://goldminer.org is excellent knowledge base, whether subspecialty or not, is only oneinstantaneous. MOC will extend this process to lifelong learning. component of this. Our training, and perhaps our examination, willThe complexity of our technology and related procedures, with en- need to address the other components, both now and in the future. Question #10 Should the requirements for the clinical year be dropped or restructured?Amis was rejected out of hand. It is simply politically impossible at the cur- The ABR and the RRC, working together, have tried in the past few rent time to significantly revamp the clinical experience for radiologyyears to restructure the clinical experience during radiology training. residents. Further, there is survey evidence that radiologists value high-The goal was to fold the clinical rotations into the last 2 years of an ly the clinical training they received. So best leave well enough alone.overall 5-year radiology training program. Also, the clinical rotationswere envisioned as structured to reflect the interests of the resident, Bakerrather than just being a general exposure to clinical medicine, surgery, We have completed a study on the attitudes of residents and fellowspediatrics, etc. For example, a resident choosing to focus training in toward their clinical year. It was published in Academic Radiology inneuroradiology and musculoskeletal radiology would benefit most September 2008. We found that despite strong opinions on both sides offrom rotations in neurology, neurosurgery, orthopedics, and rheuma- the issue, the majority of trainees favored the continuance of the clinicaltology. A pilot project featuring this concept, when proposed to CMS, year although some wished it could be shortened to 6 months. This wasAJR:191, December 2008 W227
    • w217 11.05.08 Amis et al.especially the view of residents completing a transitional internship in may require specific time periods of general medical practice trainingwhich the level of satisfaction about training content and working condi- typical of at least a portion of the PPG1 year experience.tions was less than with a medical or surgical internship. While digital imaging may isolate us, patients benefit from direct Should the training period be shortened? Well, that is an interesting interaction with radiologists. This means consulting with patients,question, but it is really only idle speculation because Medicare man- performing hands-on procedures, and perhaps admitting and treat-dates that a 12-month period of preliminary clinical experience be pur- ing patients on our services. It is not clear that radiology wouldsued by every resident. Because the establishment of a truncated pre- benefit from the elimination of the clinical year.liminary experience will not happen anytime soon, one must work toimprove existing internships, not eliminate them, even though radical Davisrestructuring will probably be helpful for the many transitional programs I do not think the clinical year should be dropped. I stated that pub-(but not for the majority of traditional preliminary year programs in licly at an APDR meeting 2 years ago as part of a roundtable discus-medicine or surgery). In any event, discussions about the clinical year are sion. My goal as a radiology program director is to provide the bestlargely irrelevant in relation to changes in the board exam and also with possible radiology training for our future colleagues. However, as aregard to prospects for radiology. Unless subspecialization is allowed to medical educator, it is my primary responsibility to produce the bestflourish, our specialty will be placed in great jeopardy in terms of its possible caring and compassionate physicians. Although we do empha-germaneness in the face of changes in imaging as a whole and changes size the six general competencies in our radiology residency program,in credentialing in particular. Restructuring to meet these challenges I think the trainees best learn compassion and communication withshould take place toward the end of training, not at its beginning. patients and families one on one at the bedside. For me personally as a radiologist, this occurred during my medical internship. My personalBecker/Dunnick feeling is that the clinical year should be restructured. We should drop Dropped? No. Restructured? Possibly. One potential opportunity the fluff and stress core rotations in medicine, surgery, ICU, and ED.that may derive from restructuring would be improved timing andappropriateness of the selection of clinical training. In other words, Formanthe selection would occur at a later point in training when the clinical My personal opinion is that the year should be optional. I haveemphases are known and the experience more robust. seen no evidence that it has any long-lasting effects on being a good radiologist. I do, however, believe that there are some advantages toColletti training programs in having someone further out of medical school. While evidence for the efficacy of the clinical year may be limited,the inclusion by the July 1, 2008 Residency Review Committee Com- Kossmon Requirements would seem to ensure continuation of this legacy. The requirements for the clinical year should not be dropped, but a Modifying the clinical year would be a politically difficult, expen- creative restructuring of the clinical year is certainly worth entertaining.sive undertaking that is perhaps beyond the potential of organized Diagnostic radiologists are fundamentally a clinical consultant. To re-academic radiology. Radiology training budgets might require up to move all clinical training from radiology residency programs would ef-a 25% increase if an additional year of clinical training is to be add- fectively diminish the role of the radiologist to technician. There areed. Presumably, this would be at the expense of current PPG1 organi- certainly unique and creative ways that the clinical year could be restruc-zation budgets. It is reasonable to assume that current PPG1 programs tured to maximize the clinical experience. Integration of a clinical yearwould be reluctant to yield 1,000+ positions to radiology. throughout the radiology residency and serving as a radiology consultant Eliminating the RRC requirement for the clinical year will create a to clinical specialties linked to the trainee’s subspecialty interests, wouldchallenging transition scenario. Having recruited for positions 15 serve as a more efficient and effective clinical training model.months in advance, programs would need to recruit for positions 15and 30 months in advance simultaneously. This might mean interview- Resniking both third- and fourth-year medical students in the same period. The requirements for the clinical year are intended to enhance theOnce a procedure for direct recruitment of to residency is established, basic understanding of clinical medicine for all radiologists and, asfourth-year students may be matched 3 months prior to beginning their such, they are necessary. Any restructuring that retains this objectiveradiology training. Beyond these logistical changes, state licensure could be given future consideration.W228 AJR:191, December 2008
    • w217 11.05.08 Panel Discussions in RadiologyPanel Members E. Stephen Amis, Jr. years and served at the National Institutes of E. Stephen Amis, Jr. has interests in both academic Health for a year and a half. In 2005, he moved to uroradiology and service to organized radiology at the University of Arizona College of Medicine in the national level. Having trained in both urology Tucson, where he joined the faculty as a professor and diagnostic radiology, and holding board certi- in the interventional section of the Department of fication in both specialties, he combined expertise Radiology. Beginning in January 2006, he spent in these two fields during his fellowship at Massa- one third of his time as associate executive director chusetts General Hospital, 1980–1981. He is coau- for diagnostic radiology and subspecialties at the thor of Essentials of Uroradiology and Textbook of ABR in Tucson, AZ, and assumed the full-time Uroradiology. He has multiple publications in the role as ABR executive director in January 2008. peer-reviewed literature, has served as president of Becker is the author or coauthor of one text, 205 the Society of Uroradiology, and is a fellow and articles, 36 book chapters, and 175 published ab- gold medal recipient of the society. Amis is a past stracts and he has delivered more than 300 lectures president of the ACR and completed a 2-year term and scientific presentations. as chair of the ACR Board of Chancellors. In May 2007 he was awarded the ACR’s gold medal. Amis is interested in radiation dose and recently chaired Patrick M. Colletti a Blue Ribbon Panel on Radiation Dose in Medi- Patrick M. Colletti is professor of radiology, med- cine convened by the ACR. A white paper on radi- icine, biokinesiology, and pharmaceutical scienc- ation dose in medicine resulted from the delibera- es at the University of Southern California. He tions of that panel, and was published in JACR in has worked with MRI for 22 years since he be- May 2007. came chief of MRI at the USC Imaging Science Center. With 120 peer-reviewed papers and 17 book chapters to his credit, Colletti’s expertise in- Stephen R. Baker cludes imaging science. He is on the editorial Stephen R. Baker is a graduate of Wesleyan Uni- board of Current Concepts in Cardiology, and is versity and the Albert Einstein College of Medi- associate editor of Radiology, and assistant editor cine. He completed his radiology residency at Ein- of the American Journal of Roentgenology. Col- stein and there rose through the ranks to become letti has two active NIH-funded studies of 3-T professor and acting chair. In 1990 he was recruit- MRI of carotid artery plaque and he is currently ed to New Jersey Medical School to serve as pro- studying MRI of cartilage in knees treated with fessor and chair of radiology, a position he still stem cells. Colletti is past president of the Los maintains and where he also serves as the associ- Angeles Radiological Society. ate dean for Graduate Medical Education. The au- thor of 10 books and 450 contributions to the radi- ologic literature, his medical interests include radi- N. Reed Dunnick ology management, the assessment of the plain ab- N. Reed Dunnick is the Fred Jenner Hodges Pro- dominal film—on which he has written the defini- fessor and chair of the Department of Radiology at tive textbook—and emergency radiology. Baker the University of Michigan. Dunnick has investi- has given 500 lectures both in the United States gated functional adrenal diseases, hypertension, re- and in 30 foreign countries and is currently presi- nal masses, and the percutaneous approach to uro- dent of the Society of Chairmen of Academic Ra- lithiasis. He has served on the editorial boards of diology Departments in the United States. 12 peer-reviewed journals and as the chair of the ACR’s Intersociety Committee. He is a past presi- dent of the Society of Uroradiology, the Society of Gary J. Becker Computed Body Tomography, the Society of Gary J. Becker completed his education and train- Chairmen of Academic Radiology Departments, ing at Indiana University where he earned his B.A. the Michigan Radiological Society, the ARRS, the with high distinction in biological sciences in 1974 Academy for Radiology Research, and the found- and his MD from the Indiana University School of ing president of the Radiology Research Alliance. Medicine in Indianapolis in 1977. After an internal He serves as president of the ABR and is vice pres- medicine internship and diagnostic radiology resi- ident and a member of the ACR Board of Chancel- dency at Indiana, he joined the faculty in 1981 and lors. Dunnick serves as the board liaison for sci- rose to the rank of professor and chief of the vas- ence for the RSNA and is a frequently invited cular section. He was Assistant Medical Director guest speaker at academic institutions and interna- at the Miami Cardiac and Vascular Institute for 14 tional specialty society meetings.AJR:191, December 2008 W229
    • w217 11.05.08 Amis et al.Panel Members Lawrence P. Davis ing emergency/trauma radiologist, he is involved in Lawrence P. Davis is a medical school graduate of patient care and issues related to financial adminis- SUNY Downstate. He did his medical internship tration, health care compliance, and contracting. and radiology residency at North Shore University He has worked in the U.S. Senate, as a legislative Hospital on Long Island and a Nuclear Medicine fellow, on Medicare legislation. Forman also serves Fellowship at Albert Einstein College of Medicine as treasurer of the ARRS and is Section Editor for in the Bronx, NY. He is currently vice chair of ra- Health Care Policy and Quality for the AJR. diology at Long Island Jewish Medical Center and North Shore University Hospital and radiology res- idency program director at Long Island Jewish Scott A. Koss Medical Center. Davis is chair of the Commission Scott A. Koss is director of cardiovascular imaging on Education of the American College of Radiology for Radiology Waukesha, S.C., a predominantly and is a member of the ACR Board of Chancellors. hospital-based, private practice in Waukesha, WI. He is a member of the Radiology Residency Review He attended the Medical College of Wisconsin for Committee (RRC) as well as secretary-treasurer medical school and residency and received his for- and board member of the Association of Program mal training in cardiac and vascular CT/MRI at Directors in Radiology (APDR). Davis also serves the Brigham and Women’s Hospital in Boston. He as the chair of the Nuclear Medicine Maintenance currently serves on the ARRS Publication Com- of Certification Examination Committee of the ABR. mittee, as well as the ACR Appropriateness Crite- ria Committee for vascular imaging. Howard P. Forman Howard P. Forman is a health services researcher Charles S. Resnik focusing on diagnostic radiology, health policy, Charles S. Resnik is a Professor of Radiology at and health care leadership. His most recent publi- the University of Maryland School of Medicine. cations address teleradiology, international out- He has been the residency program director at the sourcing, the incentives that medical students re- University of Maryland Medical Center for 19 spond to in choosing a specialty, and ensuring years and is currently the president of the Associa- quality in imaging services. Forman teaches health tion of Program Directors in Radiology. His an- care policy in the Yale School of Public Health and swers to these questions are strictly his personal Healthcare Economics in Yale College. He is the views and not an official representation of the faculty founder and director of the Yale MD/MBA views of APDR. program and co-director of the School of Manage- ment’s MBA for Executives program. As a practic-W230 AJR:191, December 2008