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  • 1. AJR:191, December 2008 W217 Panel Discussions in Radiology: Changes in Radiology Training and New Examination Format Panel Members: E. Stephen Amis, Jr. Stephen R. Baker Gary J. Becker Patrick M. Colletti N. Reed Dunnick Lawrence P. Davis Howard P. Forman Scott A. Koss Charles S. Resnik Editor in Chief: Thomas H. Berquist Keywords: CAQs, certification, maintenance of certification, radiology examinations, radiology training DOI:10.2214/AJR.08.1936 Address correspondence to T. H. Berquist (Berquist.Thomas@mayo.edu). WEB This is a Web exclusive article AJR 2008; 191:W217–W230 0361–803X/08/1916–W217 © American Roentgen Ray Society Panel Discussions in Radiology Introduction. Change has been the mantra for diagnostic radiology during the last decade. Prior to 2002, all radiology residents who passed the final oral examination held life- time certificates in diagnostic radiology. Time-limited certificates began in 2002, requiring newly certified radiologists to participate in Maintenance of Certification (MOC) and seek re- 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- dency training. These discussions were followed by expressed concerns about the timing and content of the physics, clinical written, and final oral examinations in diagnostic radiology. The end result is newly proposed changes that will take effect beginning with the residency class of 2010. These changes affect both training and examinations. All core rotations will be 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. The written examination will occur following the third year and include physics. The final certify- 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 “The diagnostic radiology exam of the future: The law of unintended consequences meets the law of supply and demand,” Howard P. Forman (AJR section editor for health care policy and quality), and Scott A. Koss (a private practice radiologist from Waukesa, WI). The panel members will address 10 commonly asked questions based upon discussions and articles published over the last few years. The questions are listed below. Questions 1, 3, and 9 are included in the print journal; the remaining questions and responses can be found online on the AJR’s Website (www.ajronline.org), where we also will provide the opportunity for 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- sion topics. 1) The new final examinations will be administered 15 months after completion of radiolo- gy residency. What impact will this have on private groups regarding recruitment, hospi- tal credentialing, and the practice of radiology? Panel Discussions in Radiology Amis et al.
  • 2. W218 AJR:191, December 2008 Amis et al. w217 11.05.08 Amis Radiology groups don’t need to retool their recruitment processes. Even though after 2014 they will not be hiring a “finished product,” but rather a “work in progress,” given the overall board pass rate of 90%+ there won’t be a significant increase in risk in taking in a new member of the group from the pool of graduating residents or fellows. There will, however, be the need to assist the new member of the practice in satis- factorily completing the certification exam. There are many ways this can occur, rather than simply giving him or her time away from the practice to study or attend review courses. Law firms actively assist their young lawyers to prepare for the Bar—and radiology practices should do the same. Such an effort will likely improve the environment of learning within a practice. Once a system is developed, it can apply from year to year as newly minted radiologists are added to the practice. Hospital-based practices will need to inform their hospital creden- tialing committees of the change in the board status of radiologists just out of training. This should not result in problems with creden- tialing of radiologists, as in most other specialties there are often one or more years after training before the physician is eligible to take the final certifying exam. There may be a few hiccups as radiology transitions from the old system to the new in 2014. It is doubtful that these will, however, affect the overall practice of radiology. The quality of training itself likely will not be significantly affected. Those who wish to become a general radiologist will have that option. Those who wish to more clearly de- fine a subspecialty pathway will also be well-served. The real change will be experienced by referring specialists, who should find more value in their interactions with radiologists who are better trained in the related subspecialty. Baker The recent changes in board requirements were instituted in re- sponse to the emerging transformation of radiology practice, a phe- nomenon that is already taking place, in an attempt to accommodate the trends that are irrevocable and rapid with respect to the prospect of the reallocation of responsibilities and opportunities to an expand- ing array of contenders for imaging interpretation work. In that regard, we are in danger of losing the “credentialing wars” to them. This challenge, which will become increasingly insistent in the 2) Why doesn’t a focused year in a certificate of added qualification (CAQ) specialty count towards our CAQ? 3) How can programs accommodate focusing in one to four areas in the fourth year of training? 4) How will training changes affect resident recruitment in pro- grams that can’t accommodate the focus options in the fourth year of training? 5) Canthe final exam ofthefuture effectively replace thecurrent oralone? 6) Why can’t the final exam still be given at the end of training in- stead of 15 months after the completion of radiology residency? 7) Will changes in physics training enhance patient safety and im- 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? next few years, is occurring for several reasons. First, other specialties have introduced training curricula and their practitioners have gained some facility as image evaluators of cross-sectional studies. Until re- cently, all radiologists, including general radiologists, were deemed es- sential, unique in their role as the sole proprietors of CT and MRI be- cause they could interpret and explain 2D images in 3D terms to refer- ring physicians. Now improvements in CT and MR displays have made 3D widely available. Some members of other disciplines can feel con- fident that they, too, can discern findings demonstrated by these stud- ies. Perhaps they may not be able to understand all the implications of the abnormalities they perceive, but the presumption that their sense of heightened competence presents is causing a sea change in perception and, ultimately, in practice initiatives. It is likely they will no longer seek to consult with a general radiologist who cannot hope to achieve an encyclopedic mastery of details in all subspecialties in radiology. Given the sense of empowerment that some of our former referrers may have gained, we will have to contend with other specialists who will clamor for credentialing for imaging. And for some groups, i.e., cardi- ologists, they have already accomplished it in many institutions. Hospitals likely will respond affirmatively to credentialing pro- grams, validated by evidence of specialized training when sanctioned by an “official body,” which will grant certificates of completion based upon a successful completion of a curriculum having desig- nated case numbers. The only defense against such initiatives is to counter them with our own credentialing programs for which subspe- cialization will be a prerequisite. At the same time, the job security of general radiologists in a par- ticular practice will be confronted by challenges from North Ameri- can radiologists with subspecialty expertise who, through teleimag- ing, can provide image interpretation at all hours and perhaps, in particular cases, even better than can a general radiologist. Hence, it will become imperative that radiology groups to an increasing degree look to hire radiologists who possess subspecialty expertise. Failure to do that will put such groups in a disadvantageous position with respect to competition from distant radiologists who will seek and secure credentialing from hospitals and third-party payers on the ba- sis of the quality and timeliness of their interpretations. Thus the board changes, which in essence favor subspecialization, are not merely a realization of the goal of some special interest groups on the prove the use of imaging techniques? 8) Will the new subspecialty emphasis in training diminish the value of today’s general radiologist? 9) Are the changes in the training and the new examinations suffi- cient to enhance knowledge, and specialization, and to provide added value to referring physicians? 10) Should the requirements for the clinical year be dropped or re- structured? —Thomas H. Berquist Editor in Chief AJR
  • 3. AJR:191, December 2008 W219 Panel Discussions in Radiology w217 11.05.08 board and elsewhere, but rather are a response to changes that have al- ready taken place in the practice of radiology with regard to an expansion of opportunities for employment using sophisticated imaging for physi- cians situated beyond hospital borders or beyond the former barrier of the preexisting specialty definition of radiology. Becker/Dunnick For decades in this country, physician recruitment, hospital creden- tialing, and practice have been ongoing in all clinical disciplines repre- sented by the 24 member boards of the American Board of Medical Specialties. Meanwhile, today in 22 of these disciplines, the paradigm for transition from training to practice includes a substantial delay of 1.5 to 36 months between the end of training and eligibility to take the certifying examination. Radiology and pathology stand alone in admit- ting candidates still in training to the certifying examination. With respect to the upcoming transition to the diagnostic radiology (DR) certification examination at 15 months after the end of training, we predict that community and academic radiology practices will ad- just to the change. There is no reason to believe otherwise. There is no logical reason to expect an impact on recruitment, hospital credential- ing, or the practice of radiology. Every diagnostic radiology trainee will be a fully qualified radiologist with the same total time in training as those completing training today. The difference is that they will have demonstrated their basic competence in the field at 36 months of training and will have used the last year of training to focus in areas of anticipated practice emphasis. Will each trainee’s fourth year emphasis be the same as his/her practice emphasis 10 years after training? Prob- ably not. But that is the beauty of MOC. It is all about lifelong profes- sional development. Viewed in this way, the fourth year represents the remainder of a lifetime of practice in microcosm. Moreover, trainees need not focus. They can still spend the fourth year in general diagnos- tic radiology, serving on a variety of clinical rotations. There is another point. The ACGME has undertaken an aggressive change agenda in residency training that features a decided emphasis on the six competencies: medical knowledge, patient care, interper- sonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. This out- come project will advance training from the current time-in-service model to a competency-based one underpinned by the achievement of specialty-specific milestones. When that happens, even more change will occur. Once again, community and academic practices will have to adjust. As we move forward into the future of radiology—a future in which accepted training milestones will include more quantitative imaging and informatics that will shape the imaging professional’s contribution to personalized medicine—one thing is certain. The in- creasing pace of change will force adaptations in DR training pro- grams, certification processes, and systems of lifelong professional development. One such example will be the incorporation of simula- tion to render the training experience safer, more predictable, homo- geneous, and effective. Finally, we will have to embrace change more quickly and more completely than ever before. There is absolutely no future for the current model of training and certification. Colletti With the insertion of a 15-month delay between the completion of training and completion of the ABR certifying examination, a por- tion of radiology practices will need to work with their privileging committees to allow such transitional radiologists to participate. This should not be problematic, as it has been said that radiology will then be aligned with other specialties that practice without board certifica- tion. Presumably, the scope of practice without certification will be limited to the 1% to 4% of all radiologists who have recently gradu- ated and have joined a practice without (for 15 months) or after (for 3 months) completing a fellowship. Academic practices that have relied on board-certified fellows as participants will also need to assure ap- propriate modification of their practice by-laws as well. Davis Change is always scary, especially when a system that has been in place for generations is undergoing radical change. I certainly under- stand the angst among residents, program directors (including my- self), private groups, and academic departments. We are all in this together and need to take a long-term perspective. • Recruitment: Let’s remember that soon, all graduating residents will be in the same boat. Departments in both private practice and academia that are looking to recruit entry-level radiologists will be looking at the same 1,000+ manpower pool. All of these graduates will be in the same position of having to take their final certifying examination 15 months after they finish resi- dency. I truly believe that groups and departments will adjust quickly, especially after the first year or two. Newly minted ra- diologists will be hired. Most groups and departments will give them a fixed period of time to pass their certifying exam. As you know, the vast majority of U.S. trainees pass the ABR exam outright on the first attempt. I do not think this will change in the future despite the changes in the examination. • Hospital credentialing: I do not think this is a problem. Of the 24 member boards of ABMS, only radiology and pathology cur- rently allow candidates still in training to sit for their certifying examination. The other 22 boards require postresidency clinical experience of up to 36 months. Radiology is now moving to an exam 15 months after residency training. Credentialing recently graduated physicians who are “board eligible” has not been a problem for physicians in these other 22 specialties. Therefore, I do not anticipate it will be a problem for radiology. • Practice of radiology: Will there be a change in the practice of radiology? Maybe towards a trend of more subspecialization. Is that a bad thing? In my personal opinion, no! I think it could be a good thing. A survey performed by the ABR revealed that 94% of the 2,756 responding radiologists indicated that their practice cur- rently was limited to one to four subspecialty areas. (For those of you that know me well, you know that my own clinical practice has been limited to one area, nuclear radiology, unless you count administration and paper pushing; then it would be two areas.) The new ABR exam will mirror that practice pattern, allowing the examinee to take an exam focusing on one to four clinical areas as well as a general content module and a module of classic radio- logic findings any radiologist might encounter while on call. The residency review committee (RRC) is allowing residency pro- grams, depending on department resources, to structure the R4 year of training individualized to the practice pattern interests of each resident and allowing focused training in as many areas as the resident wants with as few as one focused area for the entire year. However, the ABR also has an option for examinees to take a final certifying examination that covers all content areas in radiology
  • 4. W220 AJR:191, December 2008 Amis et al. w217 11.05.08 if the trainee doesn’t want to focus his/her experience. The RRC obviously will still allow programs to accommodate this. Since no one yet really knows what to expect from the new exam, I think that for the first few years most graduating residents will do a fellowship so that they can stay in a teaching environment for the first 12 of the 15 months as they prepare for the final certifying exam. I think that more fellowship-trained radiologists will improve the qual- ity of care we give to patients and show “added value” to our referring physicians. This does not mean that I expect future radiologists to just practice in the one subspecialty area in which they did their fel- lowship. It does mean that I think most future radiologists will have a few areas in which they are truly experts in the midst of potentially practicing in many different areas in radiology. Forman It may cause a short-term hiring deficit, while the transition oc- curs, but the equilibrium should be the same. More important is that these groups have several years to prepare for this transitional period, likely making it a zero-sum game. Koss This paradigm shift for board certification will certainly have an impact on the diagnostic and interventional radiology groups in the private sector. I would expect that fellowship training would determine how the private sector handles recruitment and contract negotiation given the new board certification after residency. If a private practice group hires a neuroradiologist, for example, directly out of fellowship, I would expect negotiation for a delay in start date (i.e., 3 months off to prepare for boards) or a “no call” period for 3 months leading up to the examination. The more difficult scenario is the new radiologist who is hired without fellowship training. Although it would be difficult to take off for large blocks of time, one could certainly orchestrate call and vacation schedules to optimize time off to prepare for the board ex- amination. This will ultimately be up to each radiologist emerging from training, but the private sector will need to embrace the fact that new radiologists will have this new challenge to prepare for boards during their early careers in private practice radiology. Hospital credentialing in the private sector should be a smooth transition with this new examination method. Although new for radi- ology, the majority of specialties begin their career without board certification. Credentialing may become a problem, however, if a radiologist is unable to achieve board certification. I do not see too much impact on the practice of radiology, but the radiology training will be augmented with more time available in the fourth year of training for more intense subspecialization. Further- 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 a CAQ in a different field. This would certainly enhance his/her educa- tion and improve marketability. Resnik I don’t believe we can accurately predict the effect that the new ABR exam structure will have on recruitment for private radiology groups. There is a definite potential for many more residents to pursue fellow- ships in order to stay in the academic environment for most of the time preceding the final examination. On the other hand, there will likely be many residents who pursue 12 months of subspecialty training during the fourth year of residency, perhaps obviating the need to do a tradi- tional fellowship. Once the first year or two of this process has passed, recruitment should normalize regardless of the number of residents pursuing fellowship. Overall, this will likely result in more radiologists with subspecialty training, although how this will affect the practice of radiology remains unknown. In any event, credentialing should not be an issue, since hospitals already credential board-eligible physicians in other specialties and will have several years to accommodate this change in radiology. Amis CAQs were developed to document added qualifications gained dur- ing accredited subspecialty training beyond residency. Under the new system, there will be more opportunity for residents to focus their training during the final year of training. However, this is not new to some programs. For example, at Massachusetts General Hospital the final year has long been used by residents to gain subspecialty exper- tise during two 6-month “mini-fellowships.” CAQs should not be is- sued in addition to the standard board certificate for learning that oc- curred during the final year of residency training. If they are to have any validity at all, CAQs should reflect ACGME-accredited additional subspecialty training capped by an additional exam. One can argue the need for continuing the CAQ process. They only apply to less than half of subspecialty programs, and there is no CAQ for ACGME-accredited programs in musculoskeletal radiology and abdominal radiology. Ac- creditation for chest radiology programs has recently been withdrawn by the Radiology RRC due to lack of interest. Bottom line: A CAQ should still reflect subspecialty fellowship training beyond residency if the ABR decides to continue the program. Baker It would appear logical and justifiable that if one spent 12 months pursuing training in one particular subspecialty area, either in the fourth year of residency or in the year beyond residency, then that should count towards qualification for a CAQ. The CAQ is a measure of added competence and as such is an important expedient in the quest to prevail in the upcoming interspecialty credentialing wars. CAQ re- quirements should be liberalized to allow the qualifications afforded by a 12-month course of study within the interval of training, even if that training occurs before the end of residency or before the schedul- ing of the certifying board examination. Becker/Dunnick First, the term “Certificate of Added Qualification” or “CAQ” is no longer an accepted term of the ABMS or its member boards, in- cluding the ABR. The proper term is “subspecialty certificate.” There are a number of features that distinguish the subspecialty certificate holder from an individual who has just completed a residency, re- gardless of training emphasis. First, the subspecialist has already Question #2 Why doesn’t a focused year in a CAQ specialty count towards our CAQ?
  • 5. AJR:191, December 2008 W221 Panel Discussions in Radiology w217 11.05.08 completed his/her ACGME-accredited DR residency training before undertaking additional training in the subspecialty. Second, how much of the subspecialty training experience obtained prior to com- pletion of the DR training requirements is “lost” on the unprepared or partially prepared trainee? Third, the subspecialty training curricu- lum in an ACGME-accredited fellowship is a rigorous experience imparted by qualified subspecialists in accordance with the require- ments set forth and overseen by the radiology RRC. Fourth, the indi- vidual who has completed this rigorous training must still complete an additional year in subspecialty practice before qualifying to take the subspecialty examination. Finally, the individual must pass a separate subspecialty certifying examination. Colletti It should not matter whether training occurs during residency or postresidency fellowship. Perhaps the rationale for not counting the focused resident year is related to protecting the recruitment pools for CAQ fellowships. Fellowship program directors realized that in the past, senior residents were less mature than the board-certified fel- lows. Delaying the certifying examination might level the field, as now there will be little difference between senior residents and fel- lows. Seniors will have less experience; fellows may be more focused on upcoming boards. This medical knowledge focus may be positive for fellowship programs, as presumably fellows will opt to be tested in the area of their fellowship for the certifying exam. Analysis of the perceived importance of CAQ certification will be interesting, as many radiology specialty areas, including body imag- ing, abdominal imaging, musculoskeletal imaging, and breast imag- ing currently do not have such CAQ opportunities. Another potential trend may be for radiologists completing CAQ fellowships to bypass CAQ examinations, perhaps based on potentially difficult-to-achieve posttraining requirements, such as participating in a 50% neuroradi- ology practice. Alternatively, participation in the CAQ process may increase as a response to the MOC program. Forman This is a question for the Board itself. Resnik The intent of any changes should not be to shorten the duration of training but rather to enhance that training. Allowing the fourth year of residency to serve also as a qualifying year for CAQ would only decrease the overall expertise of the trainee and thus should be avoided. Amis This will be relatively easy for large programs with faculty depth and large workloads in each subspecialty area, assuming that the resi- dents in those programs have at least some divergence of subspecialty interest. When there is oversubscription of one subspecialty area in a training program, the program will have to develop a system for ensur- ing an equitable distribution of residents during the final year of resi- dency. The new system may pose a problem for small programs with little subspecialty expertise and differentiation. Such programs will have to appeal from the beginning to those candidates who wish to become “generalists” and plan to enter small, and often rural, practic- es. Alternatively, graduates of such programs who wish to subspecial- ize will seek subspecialty training during a fellowship year, just as they do now. Either way, I don’t see the new order of things disenfranchising smaller programs. Baker I believe that this question is, in essence, a straw man that has been raised by fretful program directors. If, according to RRC regulations, a program has adequate personnel in all of the areas that encompass a radiology training program, including the faculty that meet that test qualitatively and quantitatively, then that program should be able to provide focused training in each of the four areas. The new board requirements do not mandate that there should be training in new specialties in radiology not previously encompassed by the RRC training criteria, but rather that there could be a reorientation of the intervals allotted each existing subspecialty area to allow for a pro- longed period of focused study in one deemed “concentration area.” In order to be accredited by the RRC, a diversified faculty should al- ready be on-site and in place. Specifically there must be a designated lead faculty member in each of the traditional nine subspecialties that together encompass the four areas of possible concentration a resi- dent will choose in his or her fourth year of training. Becker/Dunnick It has been suggested that the new training and certification para- digm will adversely affect small training programs that will find them- selves unable to provide a full range of fourth-year options to residents. Hall and Janower (Hall FM, Janower ML. The new requirements and testing for American Board of Radiology certification: a contrary opin- ion. Radiology 2008; 248:710–712) feel that this is particularly true in regard to the ability of said programs to offer subspecialty training. However, this notion has been countered by a different logic from the ABR. The ABR’s diagnostic radiology primary certification examina- tions will continue to cover the entire domain of diagnostic radiology. Candidates will have the option to select a generalist track. Some smaller programs themselves perceive a competitive disadvantage ow- ing to their relative inability to offer a full range of subspecialty train- ing rotations. The ABR maintains that under the new training and cer- tification paradigm, the total duration of training will be unchanged and the subspecialty offerings a given institution is able to provide will be unaffected. In other words, if that ability is limited now, it will be limited then. There is no reason to expect a difference. Therefore, it is highly likely that small and large programs will each continue to at- tract the same resident pools that they are attracting today. Colletti It would seem possible for all programs to create 3-month, 4-month, 6-month, or 12-month specialized rotations. As some subspecialty fo- cus areas may be more attractive to residents, the key will be to develop Question #3 How can programs accommodate focusing in one to four areas in the fourth year of training?
  • 6. W222 AJR:191, December 2008 Amis et al. w217 11.05.08 a plan that allows for appropriate whole academic practice coverage. Methods of allocating specialty focus opportunities include competi- tive selection, assignment, and lottery. Davis As a program director, I personally have some concerns about this. My program is a medium-sized program with 18 residents, three fel- lowships, 25 faculty, and about 200,000 cases. If all of my five senior residents wanted to do a full-focused year in musculoskeletal radiol- ogy, I would have a problem. I would not have enough MSK volume to accommodate all of them and also provide appropriate training for my R1–R3 residents, even if we combined forces with our sister insti- tution in our large health care system. My plan is to start a discussion with each resident, as early as the beginning of the R2 year but cer- tainly no later than the beginning of the R3 year, and concerning what their subspecialty interests are. We already give our R4 resi- dents elective time to have some focused training in their areas of choice. This can be expanded to accommodate several months of training in each of several focused areas. It will take some flexibility on the part of the program to make schedule changes, but we must do this because as the RRC reminds us, residency is about education and training and not service obligations. The seniors will have to coordi- nate among themselves to distribute the clinical time on the most popular rotations. In our program, there is a unique camaraderie amongst the residents so this should not be a problem. Finally, I think that APDR will play a key role in suggesting innovative curriculum changes and popularizing best practices, which individual programs can adopt if they wish. Forman I think programs will learn, as with other training areas where some specialty areas are in more demand than others (business schools, as a good example) that they can use auction theory to allot rotations in a fair manner. It may then be the case that a resident who desires a large amount of training in musculoskeletal imaging will have to accept additional service to his/her residency in an undesir- able area. Resnik Individual programs will develop their own best ways of structur- ing the fourth year of residency training based on subspecialty case volume and faculty expertise. There will no doubt be many programs that will have difficulty accommodating the exact requests of all se- nior residents. Multiple residents focusing in the same subspecialty has a potential to overburden the teaching resources, while subspe- cialties that attract no residents in a given year may have difficulty fulfilling service obligations. We must all remember that it is the ob- ligation of a training program to consider resident education a higher priority than clinical service, while still recognizing that clinical ser- vice is indeed an integral part of resident education. The delicate bal- ance of these priorities will be a challenge to all residency program directors. It is anticipated that they will be provided some guidance by the APDR in order to remain in compliance with program require- ments mandated by the ACGME Residency Review Committee. Amis See response to question #3. As long as radiology retains its current popularity among medical students selecting specialties, there will be no problem. There will be more candidates for training than there are training positions and good candidates will be available to fill all ac- credited slots. However, in the early to mid 1990s, there were far more radiologists than positions. This prompted medical students to not opt for radiology training. As a result, we woke up to the perfect storm in 1999–2000 when there were far more positions than radiologists. The medical students have been responding to this situation ever since by flocking to radiology. What if the situation reverses again, which could occur since many workforce issues over the years have proven cyclical in nature? One can argue that students are now opting for radiology strictly on the basis of the desirable characteristics of our specialty (e.g., more flexible lifestyle and high-tech toys for the “wired genera- tion”), but it is more likely that students will vote with their feet if the job market changes drastically. If that is the case, the smaller, less sub- specialty-differentiated programs will likely be the first to go unfilled. Baker As currently configured, a program must meet the requirements of training in all areas as specified by the ACGME-Radiology RRC regulations. If a program cannot provide education in any of these areas, then it is deficient and it must cover the deficiency or risk losing its accreditation. The curricular demands consequent to the newly instituted timing modification and other program changes require no new training focus, only a rearrangement of time spent within pres- ent curricular confines. Thus, these changes do not compel a program to add to what it provides now. Yet if a program can make only a marginal attempt to accommodate a year-long assignment, it may partner in a complementary way with another program. For example, if two programs that sense this threat have separate deficiencies then they might want to combine their training for the fourth year so that some individuals may pursue instruction in an area in which a pro- gram is excellent and not remain in that program if it is less than good. Accordingly a sharing agreement may be established for the transfer of residents as long as it is done reciprocally. An inevitable result of the board changes will be that some weaker programs will close, just as they are doing now and better ones will expand. That has always been true. The board changes should encourage weak pro- grams to improve and not just try to persist. Colletti A 15-month delay in ABR certification will likely increase par- ticipation in fellowships. It is not intuitive that this should increase demand for a focused residency fourth year. The majority of resi- Question #4 How will training changes affect resident recruitment in programs that can’t accommodate the focus options in the fourth year of training?
  • 7. AJR:191, December 2008 W223 Panel Discussions in Radiology w217 11.05.08 dency applicants may not consider focus accommodations to be as important as overall program excellence, educational environment, faculty, technical access, and location. Most programs can offer 3-month rotations in areas appropriate for radiology practice. With increasingly talented applicant pools, radiology resident recruitment will not be a problem for any qualified program. Davis I am not yet convinced that this is as big an issue as many think. I 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 observation that the vast majority of senior medical students whom we interview don’t really know in which subspecialty area in radiol- ogy they have an interest. I have always asked the candidates when I interview them what they see for themselves after they complete res- idency and what type of fellowship, if any, they might pursue. The vast majority of them don’t know! What attract students to the pro- gram are its name and reputation, as well as its location. The inter- view day is vitally important as the interviewees respond to the look and feel of the program and the department, as well as the obvious camaraderie of the residents, faculty, and staff. I do not anticipate any of this changing. However, the occasional senior medical student who already knows that he/she wants to do 12 dedicated months of, say, MSK radiology in the R4 year, may not rank us as highly. By the way, I bet that most of these medical students will change their area of subspecialty interest several times before they enter their R4 year. I know that many of my residents, as they go through their residency, change areas of interest. Forman There are always opportunities to outsource or subcontract. Per- haps, though, smaller programs may be forced to merge in order to achieve sufficient scale. Resnik The “focus options” are not specifically limited by the ABR or by the RRC. They may, however, be limited by the resources of a spe- cific residency program. Residents within the program will be famil- iar with these resources and will adapt accordingly. While most ap- plicants to radiology residency do not have a clear and sustainable desire to pursue a specific subspecialty, they will no doubt be influ- enced by the number of options available at each program. Those applicants with a defined subspecialty desire will likely highly rank programs with that as a defined strength. It will be up to individual programs to highlight their strengths and their options for diversifica- tion during the recruitment process. Other important factors such as program location and resident camaraderie will continue to play a dominant role in the decisions of applicants. Amis I’ve been a guest examiner at the oral board exams for 24 years. The one-on-one contact, no matter how diligently I try to create a low stress milieu, reduces some candidates to quivering hulks who can barely remember their own names. The argument can be made, of course, that these are the less well-prepared candidates. That said, the oral exam has served our specialty well over the years. However, I strongly believe that an appropriately designed comput- er-based interactive examination can appropriately determine ade- quate training, including the ability to integrate imaging physics, overall medical knowledge, and clinical appropriateness into imag- ing decisions and can reasonably simulate the consultative nature of radiology practice. Baker Certainly! The oral examination is an example of “hazing” in which an unnatural situation is presented to the stressed test taker who must perform well on the first two image examples shown lest he/she fear failing that section. This mode of presentation does not replicate cus- tomary radiology practice. Immediate performance on difficult cases is in essence a melodramatic construct. In common practice one delib- erates on challenging cases without the added burden of having a dis- passionate examiner sitting close by. A computer-based exam provides a more accurate simulation of radiology practice than the intimidating, performance-oriented oral exam. Inasmuch as almost every other spe- cialty has abandoned the oral exam, there is no reason why radiology should retain it. Becker/Dunnick The ABR Board of Trustees firmly believes that the computer-based certifying examinations can and will replace the current oral examina- tions, and in some respects surpass them. By way of explanation, it is clear that the current time-tested oral examination is successful, well- regarded, efficient, valid, and reliable. It also manages to assess the candidate at cognitive levels that exceed knowledge and comprehen- sion, including application, analysis, and management, for example. The latter levels are notoriously difficult to achieve with the multiple- choice-item format. Thus, it is clear that the ABR has work to do. However, it is equally clear that there are problems with the existing examination, most of which will eventually be mitigated by the comput- er-based approach. Examples include the cuing that comes from the simple knowledge that one is being examined in a specific category each 25 minutes, lack of normal studies on the examination, limited image display unlike today’s expanded menu of renderings and post-processing options at the imaging workstation, absence of procedure reporting, and more. In short, the examination has begun to lack face validity. Colletti Contemporaneous radiology residents are selected from the top 75th percentile and above based on results of national board exams. It is likely that they will be adept at approaching multiple-choice examina- tions. Future computerized examinations may be hierarchically crafted to identify critical judgment errors by automatic refocusing of ques- tions in areas identified as potentially deficient. As an example, candi- dates might be given a multiple-choice scenario in which one may de- Question #5 Can the final exam of the future effectively replace the current oral one?
  • 8. W224 AJR:191, December 2008 Amis et al. w217 11.05.08 cide to perform thrombolysis in a hypothetical patient with a sub- arachnoid bleed. The programmed exam may then automatically offer questions specific to the safety aspects of the proposed intervention. All responses would receive an appropriate positive or negative value. The electronic exam system would value specified unacceptable candi- date responses in a manner similar to that of an ABR examiner or panel. Developing, quality assuring, securing, and maintaining such a computerized program will have substantial initial expenses. These expenses should be offset over time by substantial savings related to the discontinuance of the oral board operations. Potential advantages include: • Uniform, fair, highly disciplined examination process • Rapid reporting of meaningful results to candidates, programs, and the ABR • Multiple opportunities to reschedule or repeat examinations as needed • Applicability to the MOC recertification process Davis I think the planned image-rich, computer-based exam that the ABR is planning as the final certifying exam can replace the current oral exam. I understand that the current oral exam allows us to assess the candidate’s communication and management skills as well as his/her knowledge base. The future computer exam will allow a much more standardized exam experience for the examinees, which I think, is im- portant. The new computer exam will mirror everyday clinical practice much better than the current oral exam. Cases will be presented in a random pattern potentially with normals included instead of in discrete 25-minute packets in a known content area. The candidates will be able to view complete data sets like they do every day at work instead of a few preselected images. Questions will be “story boarded” as they are in the current MOC exams, which will uniquely allow assessment of patient management. I am not concerned about the exam’s loss of as- sessment of communication skills. All program directors know that their training programs are required by the RRC to assess their resi- dents’ communication skills as part of the six general competencies. But did the oral exam really assess the examinees’ communication skills? I think not! In my many years of being an oral board examiner, I have seen normally verbal and articulate people become barely able to utter a word because of fear—fear of the oral exam process, fear of the dark hotel rooms, and fear of the unknown, or even worse, fear of the known and world-famous oral board examiner. In fact, and this is a true story, in my first year as an examiner, I went to pay my respects to a world-famous MSK radiologist standing in the corridor as we were waiting for the day’s exam to begin. He mistook me for an examinee and started to drag me into the room to take the MSK section of the exam. My pulse suddenly tripled and I could barely speak. I only got out of the room alive by showing him my examiner’s ID badge. There is nothing like fear to destroy good communication skills! The new computer exam will not have this same element of fear and panic and I don’t think that the examinees will miss that. I do think that the new computer exam can replace the current oral exam and can be a better exam. Forman There has never been an assertion that the current oral examina- tion is ideal. It has been somewhat successful over the years in estab- lishing a baseline of competency. We should not be looking to a fu- ture exam to “replace” the current exam. We should be looking for a future standard that will further establish our profession as the ideal specialty to interpret images for our patients. Resnik I believe the content of the new exam can easily replace, and even exceed, that of the current exam. However, the testing of the organiza- tion of thought skills and communication skills of the candidate is likely to be lost. These skills are, of course, critical to the development of a competent radiologist. The pressure of an upcoming oral exam is a strong motivator for residents to refine these skills. Residency pro- grams will presumably need to develop mechanisms to assess these skills, including objective structured clinical exams and what we cur- rently call “mock oral boards.” Program directors will need to deter- mine how the results of these assessment tools will be used to ensure that all graduating residents achieve necessary competence. Amis The obvious answer is that it could. However, I think we all know the reasoning behind this change. First, we are in a very small minority of specialties offering the final certifying exam before training is complet- ed. And second, giving the oral exam at the end of residency has reduced the final year of training, or at least the last few months, to a prolonged board review (“board mania” or “board frenzy”) in many institutions. Baker The certifying should be given at the end of an interval after resi- dency so that an individual can effectively gain subspecialty training in one or two areas. Such training may be a 2-year term encompassing the fourth year of residency followed by 1 year of fellowship in a particular area or 1 year of training in each of two different areas over the same 24 months. If the exam would be given after the fourth year of resi- dency there would be no time to develop subspecialty expertise. Rather by scheduling it 15 months after residency or 3 months after a fellow- ship year, the trainee can develop specialized knowledge in a particular area that will be valuable for his/her career and for his/her opportuni- ties to be attractive to a group practice. Incidentally, in a survey that we have done of senior residents taking our review course, fully 90% will be entering a fellowship program. Although examples can be found of individuals going directly into practice, this has become increasingly a choice of a shrinking minority as residents recognize the need for spe- cific training beyond residency in one particular area. Becker/Dunnick After years of debate among the academic societies and within the ABR, the decision to move the examination to 15 months after training was made. However, this decision occurred only after the ABR real- ized that it was not concerned primarily with the timing of examina- tion, but rather with the transformation of the training-and-certification 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?
  • 9. AJR:191, December 2008 W225 Panel Discussions in Radiology w217 11.05.08 process. With this perspective, it should be understood that the practice year is considered an essential step in rendering the newly minted trainee finally ready for board certification and a professional lifetime of education, self-assessment, and practice quality improvement. Colletti Of course the final ABR exam can be given as always in the final June of training. The 15-month ABR certification delay was added to reduce the annual intense senior resident medical knowledge board preparation learning effort to a period after residency and fellowship are completed. This essentially moves the exam preparation energy cost from the academic program to the candidate and the candidate’s initial practice. It would seem likely that the pass rate will be lower for the new “core” exam offered for third-year residents as opposed to the de- layed “certifying” exam. It will be interesting to watch for “binge and purge” behavior in third-year core candidates. Perhaps we can run, but we can’t hide from predictable human behavior. Continued discussion on the advantages and potential pitfalls of re- assigning the ABR exam to a time 15 months after the completion of residency may be counterproductive after the decision to proceed with the current proposal has been made. Given this reality, we must move on to adjust our practices appropriately. Residency training programs should take advantage of these ABR changes to refocus the current senior resident emphasis on medical knowledge to enhance their focus on medical practice, practice-based learning, and professionalism. There may be no radiologists certified in 2014, but the sun will con- tinue to rise each morning on the great specialty of radiology. Davis The new certifying exam will test practical clinical experience, which will be gained during the 15 months after residency. It will also align the ABR with the other ABMS specialties. Forman This is a question for the ABR. We have been a long-standing out- lier among specialties. By changing the timing, we are entering the mainstream of medical subspecialty training. Resnik There has been much debate regarding the timing of the ABR examinations for over a decade. Numerous surveys of varied con- stituents failed to provide any consensus. The ABR believes that the changed format is in the best interest of the future of the specialty of radiology. It is up to all of us to embrace this belief and to provide our residents with the tools to pass the exams and to practice out- standing radiology. Amis Changes in physics training, driven by the new content and se- quencing of the board exams, are essential in today’s world where there is increasing awareness of radiation exposure related to medi- cal imaging and more sophisticated equipment requiring radiolo- gist input to optimize image quality. In 1987, only 15% of back- ground radiation for the general public came from medical imag- ing; in 2008, the majority of background radiation is due to medical imaging. Radiologists must be aware of this increasing public safe- ty issue and know how to minimize radiation exposure. Facility with the physics of MRI is also essential in order to obtain quality images in a reasonable time. The learning and testing of physics knowledge can no longer be a “binge and purge” phenomenon, as it is under the current certification system. Rather, an awareness of the physical principles underlying imaging must drive decisions re- garding choice of modality as well as image quality. Baker I would hope so. The integration of physics into practice is key for a better understanding of the nature of radiation exposure to caregivers, radiation dose to patients, and the establishment of proper technique for both diagnostic and therapeutic imaging pro- cedures. Separating it from the remainder of training by allowing the exam to be taken after the first year makes physics seem like an outlier. Integration of physics within the diagnostic curriculum should be imposed to place physics at a central position, not mere- ly something to be studied only to pass an exam. Thus, I believe that the proposed changes in physics instruction are salutary for our specialty. Becker/Dunnick In order to answer this question, one must be clear about the “changes in physics training.” The short answer is “yes,” but the truth is that sub- stantive change is on a longer timeline to implementation. The AAPM curriculum committee (for DR) chaired by Phil Heintz has produced its curriculum that spans all content areas of physics for DR trainees. Bill Hendee is currently serving as editor-in-chief of a new project compris- ing the creation of a modular physics series for diagnostic radiologists. Each of about 35 modules will be produced by a pair of contributors that includes a diagnostic radiologist and a physicist. Ultimately, the AAPM curriculum and the training course will have to map to the ABR core examination. Dr. Hendee is passionate about the online training project, and it is on schedule. Insofar as patient safety in imaging is concerned, there is currently an intense focus on the topic, and numerous radiation reduction practice quality improvement (PQI) projects are in various stages of development and implementation. Davis I think the new structure of the ABR exams as well as the new RRC requirements will enhance physics training and patient safety. Currently the residents cram and study physics in the summer, 3–4 months before they take the current physics exam in the fall. All of my residents do this in the beginning of the R2 year. The day after the exam, they never look at or think about this material again. Steve Amis has termed this “binge and purge” and I agree since this is ex- actly what I did as a resident. There is now a multiorganizational re- newed interest in revamping and improving training in radiology physics and an increased concern and awareness on the part of the public concerning radiation exposure and radiation safety. There is Question #7 Will changes in physics training enhance patient safety and improve the use of imaging techniques?
  • 10. W226 AJR:191, December 2008 Amis et al. w217 11.05.08 Amis I don’t foresee this as being an issue. Residents will still be able to choose a “general radiology” focus during their final year of residency and their certifying exam will then test across the spectrum in radiolo- gy, though not to the depth it will test when limited to only a few sub- specialty areas. The new structure of the board exams will not, in my estimation, limit the opportunities for training in general radiology. For those planning to practice in small groups or in rural areas, this will be the preferred option. A well-trained general radiologist will continue to provide optimum value to primary care physicians. What the new structure does allow, however, is the ability to more signifi- cantly subspecialize. These folks will likely be planning to practice in a large radiology group with significant subspecialization or in an aca- demic radiology department. Either way, general radiology or subspe- cialized radiology, the appropriately trained radiologist should be able to offer the most relevance to the clinical community served. Baker Absolutely it will. But it already is being diminished by forces be- yond radiology. The changes in the board exam accommodate to devel- opments that actually exist or will soon occur. The notion that a gen- eral radiologist will be important in the years to come is increasingly doubtful. Even now the assertion of its continuing essentiality is still an idea that fails to reckon with ineluctable forces already in play. Becker/Dunnick No, but accelerating obsolescence will. See the answer to Question #1. Colletti Talented general radiologists will always be appreciated. This is par- ticularly so for the 22% of practices with fewer than five radiologists, and for emergency coverage in larger groups where subspecialists may be less available after hours. Over time, radiology practice will morph in an orderly manner into more focused subspecialization, supported by mod- ifications in training programs and the MOC process. Davis I do not think that the new exam process and residency program changes will diminish the value of the general radiologist. The ABR nothing like an exam to motivate residents to study and learn a par- ticular content area. The new 36-month core exam and potentially the final certifying exam and MOC exams will have applied physics questions integrated into the appropriate portions of each exam. The RRC’s radiology program requirements also require physics training as part of the general core didactic content throughout all 4 years of training. I think this will make physics issues seem real, practical, and patient centric instead of being something abstract, to be learned for the exam and then forgotten. Forman I certainly hope so, but have no evidence either way. Resnik The evolution in physics training has already begun with the 2007 publication of the Diagnostic Radiology Residents Physics Curriculum developed by the American Association of Physicists in Medicine Education Council and the Radiology Academic Coun- cil (http://www.aapm.org/pubs/reports/Curriculum.pdf). This cur- riculum should prove to be an outstanding knowledge base for resi- dents and practicing radiologists alike. If the new ABR examina- tion tests an understanding of these physics principles, it is bound to enhance patient safety and to reinforce the need to optimize imag- ing techniques. Question #8 Will the new subspecialty emphasis in training diminish the value of today’s general radiologist? survey indicated that the vast majority of radiologists already focus their practice in one to four areas. The exam and training process will mirror this pattern. For those who want to practice across all areas of radiology and be a true “general radiologist,” the training and exam process will accommodate that. Forman The definition of “general” radiologist is already changing. Histori- cally, general radiologist was applied to someone who had no subspe- cialty training. More recently, general radiologist refers to someone who reads multiple modalities. The training changes are unlikely to lead to any further shift. Teleradiology, on the other hand, has a far greater possible effect in moving toward greater subspecialization. Koss Although there is a role for the general radiologist in private practice, the depth and complexity of radiology and new technolo- gies place tremendous emphasis on subspecialization. It is para- mount that radiologists continue to move toward subspecialization to strive for a high level of radiologic and clinical knowledge in their chosen field to provide the best quality diagnostic or inter- ventional services for the patient. This strategy also suppresses turf battles with other specialties who may believe they can perform ra- diology services to a higher standard. With all that said, residency programs will need to continue to produce high-quality, well- rounded radiologists, capable of providing diagnostic services across the board in the private sector. Resnik All radiology residents will continue to be trained and examined in all aspects of diagnostic radiology. Whether or not they become “subspecialists” will depend on the specific practice situation they are in. This is likely to be market-driven—if local referring physi- cians or the public demand subspecialty expertise, radiologists will have to adapt accordingly. It is unlikely that all referrers will need or want the complexities of this expertise, so there will still be a place for radiologists with diverse general skills.
  • 11. AJR:191, December 2008 W227 Panel Discussions in Radiology w217 11.05.08 Amis The ABR and the RRC certainly hope that these changes are at least a step in the right direction. It will certainly help if there is no drop off, and hopefully an increase, in the number of graduating residents who opt for fellowship training. Fellowship on top of subspecialty emphasis dur- ing the final year of residency should provide an improved level of sub- specialty expertise for those radiologists who plan to serve clinical spe- cialists. For those radiologists whose general practice serves a primary care clinical community, there should be little change in the training and therefore the level of expertise brought to the practice. The missing in- gredient is relevant clinical exposure for subspecializing radiologists. (See response to Question #10 for why this is not currently feasible.) Baker I would hope so. The training period cannot be prolonged any further as trainees are now, in many instances, deeply in debt and have been saddled with financial burdens often for over a decade. The emphasis on further specialization is absolutely essential. One would hope that it can be accommodated by the redirection of the board’s content and context 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. Becker/Dunnick Yes, they are. And we would argue that in the absence of these changes, contemporary radiologists will find themselves diminish- ingly valuable to referring physicians. Colletti Driven by ACGME and RRC guidelines and the competitive resi- dents our specialty attracts, the quality of radiology training has pro- gressed steadily. Residents are exposed to hundreds of computerized images, and correlative imaging and clinical correlation are greatly simplified. Access to medical knowledge via the Internet and gener- al- and radiology-specific Websites such as http://goldminer.org is instantaneous. MOC will extend this process to lifelong learning. The complexity of our technology and related procedures, with en- hanced ability to distribute image data to appropriately trained ex- perts, strongly encourages specialization. All of this will add value to our patients and referring colleagues. Davis Since no one yet really knows what to expect from the new exam, I think that, at least for the first few years, most graduating residents will do a fellowship so that they can stay in a teaching environment for the first 12 of the 15 months as they prepare for the final certifying exam. More fellowship-trained radiologists, I think, will improve the quality of care we give our patients and show “value added” to our referring physicians. This does not mean that I expect future radiologists to just practice in the one subspecialty area in which they did their fellowship. It does mean that I think most future radiologists will have a few areas in which they are truly experts in the midst of potentially practicing in many different areas in radiology. Forman I believe that these changes are unlikely to have any real effect on our value to our patients and referring physicians. Koss The coming changes in radiology training and board examination timing will certainly offer more value to referring physicians given that there will be more time in residency for subspecialty training. This should not underscore the fact that fellowship training will ulti- mately be the training ground for subspecialty radiologists. The up- coming changes in training will certainly augment fellowship train- ing, but are by no means a replacement. Resnik The added value of radiology services to referring physicians is the accurate interpretation of correctly performed necessary imaging studies and the conveyance of these results in a timely fashion. An excellent knowledge base, whether subspecialty or not, is only one component of this. Our training, and perhaps our examination, will need to address the other components, both now and in the future. Amis The ABR and the RRC, working together, have tried in the past few years to restructure the clinical experience during radiology training. The goal was to fold the clinical rotations into the last 2 years of an overall 5-year radiology training program. Also, the clinical rotations were envisioned as structured to reflect the interests of the resident, rather than just being a general exposure to clinical medicine, surgery, pediatrics, etc. For example, a resident choosing to focus training in neuroradiology and musculoskeletal radiology would benefit most from rotations in neurology, neurosurgery, orthopedics, and rheuma- tology. A pilot project featuring this concept, when proposed to CMS, was rejected out of hand. It is simply politically impossible at the cur- rent time to significantly revamp the clinical experience for radiology residents. Further, there is survey evidence that radiologists value high- ly the clinical training they received. So best leave well enough alone. Baker We have completed a study on the attitudes of residents and fellows toward their clinical year. It was published in Academic Radiology in September 2008. We found that despite strong opinions on both sides of the issue, the majority of trainees favored the continuance of the clinical year although some wished it could be shortened to 6 months. This was Question #9 Are the changes in the training and the new examinations sufficient to enhance knowledge, specialization, and provide added value to referring physicians? Question #10 Should the requirements for the clinical year be dropped or restructured?
  • 12. W228 AJR:191, December 2008 Amis et al. w217 11.05.08 especially the view of residents completing a transitional internship in which the level of satisfaction about training content and working condi- tions was less than with a medical or surgical internship. Should the training period be shortened? Well, that is an interesting question, but it is really only idle speculation because Medicare man- dates that a 12-month period of preliminary clinical experience be pur- sued by every resident. Because the establishment of a truncated pre- liminary experience will not happen anytime soon, one must work to improve existing internships, not eliminate them, even though radical restructuring will probably be helpful for the many transitional programs (but not for the majority of traditional preliminary year programs in medicine or surgery). In any event, discussions about the clinical year are largely irrelevant in relation to changes in the board exam and also with regard to prospects for radiology. Unless subspecialization is allowed to flourish, our specialty will be placed in great jeopardy in terms of its germaneness in the face of changes in imaging as a whole and changes in credentialing in particular. Restructuring to meet these challenges should take place toward the end of training, not at its beginning. Becker/Dunnick Dropped? No. Restructured? Possibly. One potential opportunity that may derive from restructuring would be improved timing and appropriateness of the selection of clinical training. In other words, the selection would occur at a later point in training when the clinical emphases are known and the experience more robust. Colletti While evidence for the efficacy of the clinical year may be limited, the inclusion by the July 1, 2008 Residency Review Committee Com- mon Requirements would seem to ensure continuation of this legacy. Modifying the clinical year would be a politically difficult, expen- sive undertaking that is perhaps beyond the potential of organized academic radiology. Radiology training budgets might require up to a 25% increase if an additional year of clinical training is to be add- ed. Presumably, this would be at the expense of current PPG1 organi- zation budgets. It is reasonable to assume that current PPG1 programs would be reluctant to yield 1,000+ positions to radiology. Eliminating the RRC requirement for the clinical year will create a challenging transition scenario. Having recruited for positions 15 months in advance, programs would need to recruit for positions 15 and 30 months in advance simultaneously. This might mean interview- ing both third- and fourth-year medical students in the same period. Once a procedure for direct recruitment of to residency is established, fourth-year students may be matched 3 months prior to beginning their radiology training. Beyond these logistical changes, state licensure may require specific time periods of general medical practice training typical of at least a portion of the PPG1 year experience. While digital imaging may isolate us, patients benefit from direct interaction with radiologists. This means consulting with patients, performing hands-on procedures, and perhaps admitting and treat- ing patients on our services. It is not clear that radiology would benefit from the elimination of the clinical year. Davis I do not think the clinical year should be dropped. I stated that pub- licly at an APDR meeting 2 years ago as part of a roundtable discus- sion. My goal as a radiology program director is to provide the best possible radiology training for our future colleagues. However, as a medical educator, it is my primary responsibility to produce the best possible caring and compassionate physicians. Although we do empha- size the six general competencies in our radiology residency program, I think the trainees best learn compassion and communication with patients and families one on one at the bedside. For me personally as a radiologist, this occurred during my medical internship. My personal feeling is that the clinical year should be restructured. We should drop the fluff and stress core rotations in medicine, surgery, ICU, and ED. Forman My personal opinion is that the year should be optional. I have seen no evidence that it has any long-lasting effects on being a good radiologist. I do, however, believe that there are some advantages to training programs in having someone further out of medical school. Koss The requirements for the clinical year should not be dropped, but a creative restructuring of the clinical year is certainly worth entertaining. Diagnostic radiologists are fundamentally a clinical consultant. To re- move all clinical training from radiology residency programs would ef- fectively diminish the role of the radiologist to technician. There are certainly unique and creative ways that the clinical year could be restruc- tured to maximize the clinical experience. Integration of a clinical year throughout the radiology residency and serving as a radiology consultant to clinical specialties linked to the trainee’s subspecialty interests, would serve as a more efficient and effective clinical training model. Resnik The requirements for the clinical year are intended to enhance the basic understanding of clinical medicine for all radiologists and, as such, they are necessary. Any restructuring that retains this objective could be given future consideration.
  • 13. AJR:191, December 2008 W229 Panel Discussions in Radiology w217 11.05.08 E. Stephen Amis, Jr. E. Stephen Amis, Jr. has interests in both academic uroradiology and service to organized radiology at the national level. Having trained in both urology and diagnostic radiology, and holding board certi- fication in both specialties, he combined expertise in these two fields during his fellowship at Massa- chusetts General Hospital, 1980–1981. He is coau- thor of Essentials of Uroradiology and Textbook of Uroradiology. He has multiple publications in the peer-reviewed literature, has served as president of the Society of Uroradiology, and is a fellow and gold medal recipient of the society. Amis is a past president of the ACR and completed a 2-year term 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 a Blue Ribbon Panel on Radiation Dose in Medi- cine convened by the ACR. A white paper on radi- ation dose in medicine resulted from the delibera- tions of that panel, and was published in JACR in May 2007. Stephen R. Baker Stephen R. Baker is a graduate of Wesleyan Uni- versity and the Albert Einstein College of Medi- cine. He completed his radiology residency at Ein- stein and there rose through the ranks to become professor and acting chair. In 1990 he was recruit- ed to New Jersey Medical School to serve as pro- fessor and chair of radiology, a position he still maintains and where he also serves as the associ- 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- ology management, the assessment of the plain ab- dominal film—on which he has written the defini- tive textbook—and emergency radiology. Baker has given 500 lectures both in the United States and in 30 foreign countries and is currently presi- dent of the Society of Chairmen of Academic Ra- diology Departments in the United States. Gary J. Becker Gary J. Becker completed his education and train- ing at Indiana University where he earned his B.A. with high distinction in biological sciences in 1974 and his MD from the Indiana University School of Medicine in Indianapolis in 1977. After an internal medicine internship and diagnostic radiology resi- dency at Indiana, he joined the faculty in 1981 and rose to the rank of professor and chief of the vas- cular section. He was Assistant Medical Director at the Miami Cardiac and Vascular Institute for 14 Panel Members years and served at the National Institutes of Health for a year and a half. In 2005, he moved to the University of Arizona College of Medicine in Tucson, where he joined the faculty as a professor in the interventional section of the Department of Radiology. Beginning in January 2006, he spent one third of his time as associate executive director for diagnostic radiology and subspecialties at the ABR in Tucson, AZ, and assumed the full-time role as ABR executive director in January 2008. Becker is the author or coauthor of one text, 205 articles, 36 book chapters, and 175 published ab- stracts and he has delivered more than 300 lectures and scientific presentations. Patrick M. Colletti Patrick M. Colletti is professor of radiology, med- icine, biokinesiology, and pharmaceutical scienc- es at the University of Southern California. He has worked with MRI for 22 years since he be- 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- cludes imaging science. He is on the editorial board of Current Concepts in Cardiology, and is associate editor of Radiology, and assistant editor of the American Journal of Roentgenology. Col- letti has two active NIH-funded studies of 3-T MRI of carotid artery plaque and he is currently studying MRI of cartilage in knees treated with stem cells. Colletti is past president of the Los Angeles Radiological Society. N. Reed Dunnick N. Reed Dunnick is the Fred Jenner Hodges Pro- fessor and chair of the Department of Radiology at the University of Michigan. Dunnick has investi- gated functional adrenal diseases, hypertension, re- nal masses, and the percutaneous approach to uro- lithiasis. He has served on the editorial boards of 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 Computed Body Tomography, the Society of Chairmen of Academic Radiology Departments, the Michigan Radiological Society, the ARRS, the Academy for Radiology Research, and the found- ing president of the Radiology Research Alliance. He serves as president of the ABR and is vice pres- ident and a member of the ACR Board of Chancel- lors. Dunnick serves as the board liaison for sci- ence for the RSNA and is a frequently invited guest speaker at academic institutions and interna- tional specialty society meetings.
  • 14. W230 AJR:191, December 2008 Amis et al. w217 11.05.08 Lawrence P. Davis Lawrence P. Davis is a medical school graduate of SUNY Downstate. He did his medical internship and radiology residency at North Shore University Hospital on Long Island and a Nuclear Medicine Fellowship at Albert Einstein College of Medicine in the Bronx, NY. He is currently vice chair of ra- diology at Long Island Jewish Medical Center and North Shore University Hospital and radiology res- idency program director at Long Island Jewish Medical Center. Davis is chair of the Commission on Education of the American College of Radiology and is a member of the ACR Board of Chancellors. He is a member of the Radiology Residency Review Committee (RRC) as well as secretary-treasurer and board member of the Association of Program Directors in Radiology (APDR). Davis also serves as the chair of the Nuclear Medicine Maintenance of Certification Examination Committee of the ABR. Howard P. Forman Howard P. Forman is a health services researcher focusing on diagnostic radiology, health policy, and health care leadership. His most recent publi- cations address teleradiology, international out- sourcing, the incentives that medical students re- spond to in choosing a specialty, and ensuring quality in imaging services. Forman teaches health care policy in the Yale School of Public Health and Healthcare Economics in Yale College. He is the faculty founder and director of the Yale MD/MBA program and co-director of the School of Manage- ment’s MBA for Executives program. As a practic- Panel Members ing emergency/trauma radiologist, he is involved in patient care and issues related to financial adminis- tration, health care compliance, and contracting. He has worked in the U.S. Senate, as a legislative fellow, on Medicare legislation. Forman also serves as treasurer of the ARRS and is Section Editor for Health Care Policy and Quality for the AJR. Scott A. Koss Scott A. Koss is director of cardiovascular imaging for Radiology Waukesha, S.C., a predominantly hospital-based, private practice in Waukesha, WI. He attended the Medical College of Wisconsin for medical school and residency and received his for- mal training in cardiac and vascular CT/MRI at the Brigham and Women’s Hospital in Boston. He currently serves on the ARRS Publication Com- mittee, as well as the ACR Appropriateness Crite- ria Committee for vascular imaging. Charles S. Resnik Charles S. Resnik is a Professor of Radiology at the University of Maryland School of Medicine. He has been the residency program director at the University of Maryland Medical Center for 19 years and is currently the president of the Associa- tion of Program Directors in Radiology. His an- swers to these questions are strictly his personal views and not an official representation of the views of APDR.

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