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Challenges and Opportunities inRestructuring Radiology Residencies:The APDR Residency Restructuring
Committee ReportLori Deitte, MDa, Jocelyn D. Chertoff, MD, MSb, Martha B. Mainiero, MDc,
Janet L. Strife, MDd, Kristen K. DeStigter, MDe
Changes to the ABR certification process are imminent, with a core examination after 36 months of trainingand a certifying examination 15 months after the completion of training replacing the current examinationstructure for residents entering training in July 2010 and beyond. The Residency Restructuring Committee ofthe Association of Program Directors in Radiology was developed to analyze the challenges and opportunitiesof these upcoming changes and provide recommendations to programs. The guidelines included in this articlerepresent a summary of the work of this committee to date.
Key Words: Diagnostic radiology training program, Association of Program Directors in Radiology,ABR, radiology residency curriculum, radiology residency restructuring, core examination, certifyingexamination
J Am Coll Radiol 2010;7:507-511. Copyright © 2010 American College of Radiology
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ACKGROUND
ajor changes to the ABR certification process haveccurred over the past decade. Before 2002, lifetimeertificates were issued to radiology residents whoassed all required components of the board certifyingxaminations. Starting in 2002, 10-year time-limitedertificates were introduced, requiring newly certifiedadiologists to participate in the Maintenance of Cer-ification process.
These new requirements were followed by discussionsn ways to increase subspecialization training during ra-iology residency to reflect trends in clinical practice and
Department of Radiology, University of Florida College of Medicine, Gaines-ille, Florida.
Department of Diagnostic Radiology, Dartmouth-Hitchcock Medical Cen-er, Lebanon, New Hampshire.
Department of Diagnostic Imaging, Warren Alpert Medical School of Brownniversity, Rhode Island Hospital, Providence, Rhode Island.
Children’s Hospital Medical Center, Cincinnati, Ohio.
Department of Radiology, University of Vermont/Fletcher Allen Healthare, Burlington, Vermont.
Corresponding author and reprints: Kristen K. DeStigter, MD, University ofermont/Fletcher Allen Health Care, Department of Radiology, 111 Colchester
venue, Burlington, VT 05401; e-mail: [email protected].2010 American College of Radiology091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2010.01.016
o maximize the value of radiologists [1]. Changes to theontent and timing of the certifying examination wereroposed to mirror practice and to bring radiology in lineith other specialties. In October 2007, the ABR an-ounced that the following examinations would replacehe current physics, written, and oral board examina-ions, effective for residents entering diagnostic radiologyraining in July 2010 and beyond:
Residents will be eligible to take the core examinationafter completing 36 months of radiology residencytraining. This will be a comprehensive, computer-based, “image-rich” examination encompassing all ofdiagnostic radiology and radiologic physics. Catego-ries include organ systems, imaging methods, and fun-damental radiologic concepts. This examination willreplace the current written diagnostic and physics ex-aminations.The certifying examination will now be taken 15 monthsafter the completion of the 4-year radiology residencytraining program. This will be a computer-based, image-rich examination consisting of 5 modules, including non-interpretive skills, essentials of radiology, and 3 additionalmodules selected by candidates [2,3]. This examination
will replace the current oral board examination.507
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508 Journal of the American College of Radiology/Vol. 7 No. 7 July 2010
CGME REQUIREMENTS
ith the ABR announcement that it would changehe timing, content, and structure of the board exam-nations, it became evident that radiology trainingrograms would need to ensure that all residents re-eive adequate training in all specialty areas to preparehem for the new comprehensive, 36-month, image-ich core examination [4].
In response, the Diagnostic Radiology Residency Re-iew Committee of the ACGME revised the programequirements for radiology training programs. The re-ised program requirements for graduate medical educa-ion in diagnostic radiology, effective July 1, 2010, in-lude the following [5]:
“Residents entering diagnostic radiology training onJuly 1, 2010 or thereafter must be provided appro-priate clinical rotations and formal instruction in allsubspecialties of diagnostic radiology and in thecore subjects pertaining to diagnostic radiology (eg,medical physics, physiology of contrast media, etc.)before taking the ABR Core Examination (givenafter 36 months of diagnostic radiology training atthe end of PGY 4). During the final year of diagnos-tic training (PGY 5), these residents should be al-lowed, within program resources, to select and par-ticipate in rotations, including ‘general radiology,’that will reflect their desired areas of concentrationas they enter practice.”“Participation in on-call activities is essential for thedevelopment of radiologists who are expected to prac-tice independently upon completion of training, andshould occur throughout the second, third, and finalyears of diagnostic residency. Program directors mayexercise discretion in granting relief from call respon-sibilities for short periods before the oral board examfor residents entering diagnostic radiology training be-fore July 1, 2010 and before the ‘Core’ board exam forresidents entering diagnostic radiology training onJuly 1, 2010 or thereafter.”
SSOCIATION OF PROGRAM DIRECTORSN RADIOLOGY RESPONSE
n response to the new ABR and ACGME changes, thessociation of Program Directors in Radiology (APDR)reated the Residency Restructuring Committee. Pro-ram directors from both large and small programs fromround the country, as well as representatives from theBR and the Diagnostic Radiology Residency Reviewommittee, are members of this committee.1 The com-
The members of the APDR Residency Restructuring Committee are Kristen
eStigter, MD (chair), Janet E. Bailey, MD, Jocelyn D. Chertoff, MD, uittee’s mission and focus is to examine and evaluate thepcoming changes, solve potential challenges, and com-unicate recommendations that will help all programs
dapt to the changing circumstances.The initial goals set forth by the committee included
nalyzing the upcoming changes and the developing op-ions for schedule and curricular adjustments for theesidency core curriculum (R1-R3) and the fourth yearR4). To anticipate what changes the new examinationsnd program requirements might have on residencyraining, separate surveys were developed and sent to thePDR membership and to current radiology residents.he survey results are summarized below.The APDR program director survey summary yielded
he following findings [6]:
One hundred six members of the APDR responded tothe survey.Survey respondents agreed that the length of time in agiven area of “focused training” for fourth-year resi-dents will be mainly determined by program resources.There was a consensus that fourth-year residents arelikely to take more call.Program directors concurred that the changes will bet-ter position fourth-year residents to serve as leaders andeducators on their services.The majority of program directors stated that theyplan to allow fourth-year residents to use some of theirfocused training time for research if they so desire.Concern was expressed that the fourth-year focusedtraining may have a negative educational impact onthe training of core residents (R1-R3) and fellows.
The APDR resident survey summary yielded the fol-owing findings [7]:
One thousand ninety-eight radiology residents re-sponded to the survey.Residents generally preferred smaller blocks (eg, 12weeks) of focused training in different subspecialtyareas to a larger block (eg, 36 weeks) in a single sub-specialty during the fourth year.The subspecialty areas of greatest interest for focusedtraining were neuroradiology, musculoskeletal radiol-ogy, and MRI, followed by abdominal imaging.Thirty percent of resident respondents stated that theywould be highly or moderately interested in pursuingresearch during the fourth year.
awrence P. Davis, MD, Lori A. Deitte, MD, Spencer B. Gay, MD, Darel E.eitkamp, MD, Charles F. Lanzieri, MD, Martha B. Mainiero, MD, Duane. Mezwa, MD, Mark D. Murphey, MD, Melissa Myers, MD, Charles S.esnik, MD, Ali Shirkhoda, MD, Eric M. Spickler, MD, Janet L. Strife, MD,noop S. Wattamwar, MD (American Alliance of Academic Chief Residents
n Radiology representative), and Mark S. Rzeszotarski, PhD (guest contrib-
tor).
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Deitte et al/Restructuring Radiology Residencies 509
Current residents predicted that 85% of future resi-dents will undergo fellowship training after residencygraduation and before taking the ABR certifying ex-amination 15 months later.
It is evident that program directors are faced withhallenges and opportunities in developing schedule andurriculum changes for the core curriculum and for theourth year. During the core curriculum, radiology train-ng programs are required to teach their residents theundamentals of diagnostic radiology, safety, and radio-ogic physics. Challenges include managing the integra-ion of physics education during all 4 years of training,cheduling the Armed Forces Institute of PathologyAFIP) away rotation, determining how scholarly activitynd research fit in, and satisfying US FDA and Mam-ography Quality Standards Act training requirements
nd the Nuclear Regulatory Commission’s radioactiveaterials training requirements. The 36-month ABR
ore examination will encompass anatomy, physiology,afety, and clinically relevant physics. What modifica-ions to the current curriculum will be necessary to pre-are our residents for this examination? How will physicse integrated into the curriculum? Will the AFIP rota-ion need to be scheduled in the second and fourth yearso accommodate board preparation in the spring of thehird year? Will residents have time to pursue researchnd scholarly activities during the core training years?rogram directors will need to examine the strengths andeaknesses of their own programs and make schedule
nd curricular adjustments within the constraints of theirwn program resources [7].
The APDR Residency Restructuring Committee pro-oses the following guidelines for program directors toonsider for the core curriculum (R1-R3) [5]:
Structured scheduling with required core rotations isproposed for the first through third years of radiologyresidency (R1-R3). It is unlikely that programs will beable to offer electives during these years.Proposed guidelines for the core curriculum (R1-R3)include 3 rotations in each of the core subspecialties(or equivalent, depending on the unique features ofeach training program): neuroradiology, vascular andinterventional radiology, musculoskeletal radiology,cardiothoracic radiology, abdominal radiology, pedi-atric radiology, ultrasonography (including obstetricand vascular ultrasonography), and nuclear radiology(including PET and nuclear cardiology). The R1-R3curriculum should also include 2 rotations of breastradiology with the third required breast rotationscheduled during the R4 year.Some programs might provide limited (pending indi-
vidual program resources) relief from in-house call for Fthird-year residents 3 to 4 months before the 36-month core examination.Residents may prefer to be scheduled for AFIP rota-tions from January through June of the second year(R2), July through December of the third year (R3),or during the fourth year (the rationale being thatthe physics curriculum is likely to become morefocused during the 6 months leading up to the coreexamination).Adjustments should be made to the physics curricu-lum to transition into an integrated, clinically relevantcurriculum with clinical case scenarios supplementedwith online resources.The general radiology curriculum should be revised toincrease the focus on anatomy, physiology, and medi-cal management. Because the future radiology corecurriculum will consist of 3 years rather than 4 years,programs might consider repeating the core curricu-lum lecture series every 18 months instead of every 24months.In the future, the specialty societies may need to helpdefine the “core rotations.”The documentation of the ACGME case logs will berequired only for the R1 to R3 years.
The APDR Residency Restructuring Committee pro-oses the following guidelines for program directors toonsider for the fourth year (R4):
Structure the schedule to include one rotation each inmammography (the Mammography Quality Stan-dards Act’s minimum residency training requirementis 12 weeks) and nuclear medicine (the US NuclearRegulatory Commission’s minimum residency train-ing requirement is 16 weeks) during the fourth year.Include a requirement that fourth-year residents takein-house call. This helps provide call relief for the R3residents and is integral to the professional develop-ment and maturity of our future leaders.Consider offering 2-month to 3-month blocks of fo-cused training during the fourth year. Many programsprefer this option.Some programs may offer 6 to 9 months of focusedtraining within the constraints of program resources.The fourth-year educational experience will need to beadjusted so that it does not have a negative educationalimpact on the training of core residents.
On the APDR resident survey, residents agreed thathey generally prefer smaller blocks of focused training inifferent subspecialty areas to a larger block of time in aingle subspecialty area. This model should be a morettractive option for programs with limited resources.
or some small programs, a fourth year with more diverse
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510 Journal of the American College of Radiology/Vol. 7 No. 7 July 2010
raining that resembles the R1 to R3 years will be theorm.For programs that will offer larger blocks of focused
raining, the discussion with individual residents regard-ng desired areas of concentration will likely take placeuring the latter part of the second year or early in thehird year, and the fourth-year schedule will be adjustedccordingly. It is important to keep in mind that the newuly 2010 radiology program requirements purposely al-ow for flexibility in scheduling the fourth-year rotationswithin program resources” to include “general radiol-gy” [5]. Maintaining flexibility will be a key factor inptimizing the transition from the current curriculumnd schedule to the new curriculum and schedule withintraining program. It is important to remember that thectual delegation of specific rotations during the fourthear falls under the jurisdiction of the program directorsnd depends not only on resident interests but on theeeds of the clinical services and the availability of pro-ram resources.
HE ABR EXAMINATIONS
he ABR initially planned to schedule both the last ABRral examination for fourth-year residents and the firstore examination for third-year residents at the end of thecademic year in 2013. Early on, the APDR Residencyestructuring Committee identified this timing as a tre-endous challenge for programs and petitioned the ABR
o move the first core examination to the fall of 2013. Athis time, the ABR has agreed to move the date of the firstore examination to accommodate the unique challengesf 2013.
The American Association of Physicists in MedicineAAPM) and the Radiological Society of North AmericaRSNA) are developing Web-based physics resources de-igned to supplement radiologic physics education inesidency programs. These resources include a revisedhysics curriculum syllabus and online modules. Theecently approved curriculum in medical physics for di-gnostic radiology residents can be accessed via a link onhe APDR’s Web site [8] or directly on the AAPM’s Webite [9]. The initial set of 16 physics Web modules waseleased at the RSNA’s 2009 annual meeting and is avail-ble to any RSNA or AAPM member. Additional mod-les are nearing completion, and a second phase of mod-le development is planned for 2010. Approximately 40o 45 total modules are anticipated. These modules aremage rich and were written by teams of radiologists andhysicists to help bridge the gap between physics andlinical radiology. These modules will also enhance edu-ational opportunities for programs lacking physicist ex-ertise in one or more areas of study. In addition, the
odules can be assigned during clinical rotations so that rhe physics training is concurrent with the clinical train-ng. Posttests are provided with each module and can besed by program directors to document successful com-letion of the modules. It is hoped that additional radi-logy resources will become available to aid programsnd trainees in preparing for the computerized image-ich core and certifying ABR examinations of the future.
Residents who apply to sit for the ABR certifyingxamination may have missed no more than 120 daysrom the total 4 years of residency training. This policyill remain after the new examination structure is in
ffect. It is the current understanding of this committee,fter discussion with the ABR, that activities in the fourthear of training that are part of the training curriculum orre electives that promote the educational experience ofhe resident in the program will not count against the20-day requirement.
ONSEQUENCES: INTENDED ANDNINTENDED
ne of the most challenging aspects of these changes wille to provide both core teaching and focused subspe-ialty experiences within existing department resourcesithout compromising the learning experiences of resi-ents or fellows and while maintaining the positive as-ects of residency culture. Some programs have proposedcompetitive approach to the assignment of the mostighly sought focused rotations in the fourth year. Arogram that chooses this approach will have to definehe selection process and criteria and monitor the out-ome of this approach. Unintended consequences couldnclude a devaluing of the less desired rotations and aompetitive rather than cooperative attitude among theesidency group, possibly leading to less collegiality (eg,ess willingness to trade calls or to help one another).
The suggested timing of AFIP from January to June ofhe R2 year and July to December of the R3 year mayecome another source of stress among the residents be-ause they are likely to perceive AFIP to be a criticalotation in the R3 year before the core examination.rograms may need to manage this scheduling by lotteryr competition. Programs could begin adjusting theirFIP schedule now in preparation for 2012 to 2013
before the last oral examination and the first core exam-nation), when there is expected to be significant compe-ition for these slots. In addition, it has been suggested byembers of this committee that AFIP consider integrat-
ng physics into its curriculum, creating a modern modelf radiology education that can be replicated at the pro-ram level.
The flexibility of the fourth year introduces the possi-ility of truly different and exciting opportunities. A
esearch elective of several months’ duration would have
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Deitte et al/Restructuring Radiology Residencies 511
he potential for accommodating basic science research asell as clinical research. Academic institutions may be
ble to take advantage of the educational resources withinheir systems and facilitate projects with their depart-ents or in associated graduate programs of engineering,
usiness, law, sociology, and health policy. Some pro-rams may choose to offer electives focused in teaching,eadership, quality improvement, informatics, or inter-ational outreach. For nonclinical or off-site electives,here will be reimbursement challenges, and residentsay need to look at other funding sources for innovative
rograms. Certainly, the upcoming changes will providemple opportunity for programs to be creative and inno-ative as we mold our future leaders.
ONCLUSIONS
he field of radiology is in a period of intense scrutiny.ow is the time for us to determine how to educate our
esidents to take leadership roles in creating the newaradigm. As we prepare for the changes that will occurn our diagnostic radiology training programs broughtorth by the new ABR examination process, we have thepportunity to manage these changes in a way that max-mizes the benefit to our profession. The APDR Resi-ency Restructuring Committee has attempted to iden-ify and address the challenges and opportunities that willesult from these changes. Our recommendations willikely be modified as the requirements put forth by theegulatory, accreditation and certification bodies con-
inue to evolve. This committee will continue to assessutcomes of the restructuring process, communicatingdeas and best practices as we go forward.
EFERENCES
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. Amis ES Jr, Baker SR, Becker GJ, et al. Panel discussions in radiology:changes in radiology training and new examination format. AJR Am JRoentgenol 2008;191:W217-30.
. American Board of Radiology. ABR exam of the future: update RSNA2008. Available at: http://www.theabr.org/present/eof_update_dec08.pdf.Accessed October 31, 2009.
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. Deitte LA, Dravid VS, Heitkamp DE, Shirkhoda A. The new 4th year:challenges and opportunities. 2009 annual AUR meeting presentation.Available at: http://www.apdr.org/documents/2009_meeting_materials.cfm. Accessed October 19, 2009.
. Deitte LA, DeStigter KK, Heitkamp DE. Update from the APDR Resi-dency Restructuring Committee: options for program directors. 2009 an-nual AUR meeting presentation. Available at: http://www.apdr.org/documents/2009_meeting_materials.cfm. Accessed October 19, 2009.
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