Should the Oral Boards Be Delayed?

At the ACR Annual Meeting and Chapter Leadership Conference (AMCLC) this past May, the Oral Boards, or more specifically, their timing, were a lively topic of conversation.

In their meeting, the members of the Society of Chairmen in Academic Radiology Departments (SCARD) had recommended the boards be delayed for two years after residency, so that residents would be able to spend the entire fourth year of their training concentrating on their rotations, rather than in the library, studying, and so forth.

The Residents and Fellows Section of the Council disagreed and suggested such a change would make it difficult to obtain and concentrate on new jobs or fellowships, and that it would be more difficult to study for and pass the boards.

Add to this the concern of private practices — that the new recruits would be less available, would not have Board Certification, plus the issues surrounding Maintenance of Certification and Time Limited certificates — and you have quite a brew (and brouhaha).

Accordingly, the Council decided to empower a task force to study these issues. Chairman of the Board Dr. Arl Van Moore has asked me to chair that task force, and we will be preparing a report for the next annual meeting (May 2008).

Please give us your thoughts, and be sure to include your basic demographic data. Your voice will be important in clarifying the many attendant issues.

Barry D. Pressman, M.D., FACR
President
American College of Radiology

Comments

[Carol Rumack M.D.]

There is a precedent for lawyers who finish law school and spend 2 months studying before Law Exams. If it was true for all residents, it is certain that private and academic groups would adapt to the change.

In my opinion, 1 or 2 years later would also work. Since subspecialty readings are becoming in such demand, it is likely we will have 100% of residents taking fellowships and this could be planned into those fellowships.

Carol Rumack M.D.

[Matt Hayes M.D.]

Delaying oral boards would ultimately lead to less knowledgable radiologist and would be a diservice to our patients.

My residency has a beautiful library with endless board study material and videos. What private practice group or practing radiologis is going to have this or the time to use them.

In addition, I am doing an MSK fellowship and to be 2 years removed from Neuro, IR, mammo etc would make studying for the boards all the more difficult. I feel this plan to switch is motivated by one thing alone: MONEY.

The hospitals and residency programs are trying to get another year of CHEAP labor out of residents...PERIOD.

This is not about patient's but is entirely about money. A resident makes 45,000 senior year and the next year may increase this 10x or more. It amazing how much difference one year makes.

A resident can run the hospital at night and be payed less than a nurse...unbelievable. Yes the descision to delay is I'm sure based on patient care and not money, go figure.

Matt Hayes M.D.

[Mark J Adams, MD]

Barry,

As you know, this is a complex issue. Many of the arguments thus put forth are reasonable. Much of the 4th year of radiology residency is "lost" while studying for the boards.

Residents have been known to "disappear" from services. Often call, when a resident should be able to contribute the most, is foregone. This type of behavior is often counter productive to patient service as well as resident training.

On the other hand, the counter argument by the residents and fellows also carries considerable merit. The further one is beyond residency, the more difficult it is to pass all the required sections of the board exam.

Studying for the boards while trying to carry a full time job would be much more demanding than studying while in residency. Furthermore, if a resident sub specializes their training, they might be even at a greater disadvantage when sitting for the boards.

Radiology may be one of the few, if not the only medical subspecialty that schedules the boards while in training. The practical experience that is gained in the first few years of practice really demonstrates the ability of a radiologist, beyond that of the memorization of trivia.

I believe that if the format of the boards remains the same, it would be very difficult, if not unfair, to change the timing. If however, the format could be changed to reflect more of practical application of the knowledge, it might be reasonable to delay the timing of the boards for a year or two.

Let's not get the horse and cart mixed up. Any discussion of the timing of the boards must include the format as well.

Furthermore, there has been talk about completely changing the residency training requirements from one that is inclusive of all imaging subspecialties to one that is specialized.

For instance, the first two years may be general radiology and the final two specialized. With the ever increasing complexity of our specialty, we should be discussing this as well.

Thanks.

Mark Adams, M.D.

[David Poage, M.D.]

I think the timing of oral boards should not be changed.

The real problem is institutions allowing senior residents to disappear from their duties because of boards. If the seniors study and go to work like programs are designed they should do just fine and should not need excessive study time set aside for boards.

Maybe seniors could get a couple of weeks extra study time over several months prior to boards, but no more. Programs need to enforce an attendance policy if there is a problem.

David Poage, M.D.

[Philip Grimm]

This is an excellent question--it really goes to the crux of the problem of who is a Radiologist.

But the question is too big--too broad--to be answerable. It needs to be cut down into smaller, more easily digestable pieces...

I think this problem is also reflected in the questions that are asked in the ACR's Continuous Professional Improvement modules.

The more focused QUESTION that needs to be addressed is this: Who is the primary audience for the Radiologist? Who reads our reports, who is the group we most need to please?

I can think of at least a dozen audiences, and they all have different agendas and different criteria for assesment, all are valid, but not all will be pleased with the same report. Here is a brief grouping of potential audiences:

1. Accademic Radiologists
2. Other Accademic Physicians
3. Specialty and sub-specialty surgeons in tertiary referral centers.
4. Fellow Radiologists
5. Internist's and sub-specialty internist's in tertiary referral centes.
6. GP's hovering around the edges of tertiatry referral centers, but who do not have hospital privileges.
7. Surgeons, Internists and GP's who practice in non-referral centers.
8. Rural Surgeons, Internists and GP's
9. Non MD Health Care Providers
10. Hospital Administration
11. QA committee's-those who evaluate sentinal events.
12. State Boards of Medical Examiners
13. Patients
14. Non-medical alternative care providers
15. Plantif's lawyers

Each and every one of these people will read our reports and develop an opinion about them. A report directed at any one of those audiences could easily be dismissed or condemed by other audiences, for exactly the same reasons.

The the presentation of the findings of any given exam are dependent upon whom is the audience. But, even more than that, I believe the findings themselves will change depending upon whom is the audience...

In regard to the question about the timing and nature of Oral Board Exams, I think the primary audience should be #4 listed above.

And beyond that, I don't think that anyone coming out of any residency program is ready to step up to the plate alone, until they have been in private practice for at least five years. (I know this, because it took me ten years to get to be any good at this job.)

[Darryl Zuckerman, MD]

I have been involved in academic radiology for over 17 years and have been through the ritual of senior residents preparing for the oral exams over that time.

I am also an examiner for the ABR for the diagnostic radiology exam and the CAQs in IR. I am a fellowship program director. My residency in the 1980s was the first to go from a three year to four year program.

It is apparent that adding the fourth year has done little to achieve its initial purpose: to provide additional exposure to the trainee to some of the emerging technologies and to make for a more comprehensive educational experience.

As is typical at most programs, the senior residents, for the last six months of their fourth year, are nowhere to be found, instead spending their time studying and reviewing for the exam in a variety of ways. Not only are they not involved in the learning process for this last 15% of their training, but they are not fulfilling their duties as a hospital employee. (At our institution, the residents are paid by the hospital, as I'm sure they are at many programs.)

In addition, radiology is one of the unique specialties that currently allows residents to sit for their exams during their training. We are, in that respect, an aberration, or anachronism. I see no good reason why surgery, medicine and other major specialties have little problem in administering their exam 1-2 years after the residency, but radiology remains reluctant to do the same. M

any med and surg trainees go on to the same pathways as radiologists (fellowship followed by private practice) and still seem to be able to successfully prepare for their exams.

As for the argument that the study materials, (teaching files, radiology library resources, conferences, etc.) are not available in private practice making it difficult to prepare for the exam after one has left their training, I would advise that residency programs make available their educational environment to those in the community who are studying for their boards. This shouldn't be that difficult.

Many are fully aware that changing the current schedule is unpopular with current residents and private practitioners whose primary focus is on clincial productivity and revenue generation; however, from my standpoint, I strongly believe that delaying the boards to after the residency is completed is simply the right thing to do.

Sometimes, that alone, should compel us to make these tough decisions.

[J. Andrew Hill, MD]

In the increasingly competitive market of health care, and radiology in particular, it is vital that practices become as efficient as possible.

In the academic centers this is especially true as attending physicians must balance such clinical productivity with the requirement to publish and their desire and opportunity to teach.

Residents are major contributors to efficiency in these practices, and that contribution is greatest as they near the end of their training.

Thus, it is not difficult to understand why the academic chairs voted to recommend pushing the oral board exam back two years from the completion of residency training and facilitate dedication of senior residents' time and energy to clinical productivity.

However, I believe that in so doing they have overlooked their primary responsibility to provide an education to their residents in favor of cost shifting to future employers, whether they be private practices or these same academic institutions, without considering other remedies.

My reason for that belief revolves around the question of the purpose of the board exam and its educational benefit, as well as experience with a board preparation process that works for everyone.

The board exam is a measure of competency. In the ABR's own words, its purpose is to certify "that its diplomats have acquired, demonstrated, and maintained a requisite standard of knowledge, skill and understanding essential to the practice of Diagnostic Radiology."

That skill set should be obtained during residency with the oversight of mentors and be most complete upon graduation, and therefore certified at the end of that training.

Delaying that certification would only allow those not meeting minimum requirements to be solely responsible for patient care during those two years, placing patients in danger.

Secondly, I believe the preparation for the board exam is a critical part of consolidating and firming up the residency education obtained over the last 3 & 1/2 years. Seniors ability to discuss cases, give a reasonable differential, and make recommendations, the primary skill we will use the remainder of our careers in interacting with our medical colleagues, grows remarkably during our board study and reviews.

Additionally, passage of the board exam is the one of the primary markers of the quality of education a residency provides. Removal of that institutional evaluation would only permit those programs whose highest priority is not resident education to slip workload and billing above their primary responsibility to their trainees.

Some argue that if delayed, the test would be designed differently from what we now know to compensate for the possible loss of general skills as we pursue and practice more specialized radiology and the concentrated learning environment of residency becomes more remote.

However, this again calls into question the purpose of the exam to certify a standard of knowledge. "Dumbing down" the test does not accomplish that purpose and would only erode the credibility of the board.

Lastly, it seems the impetuous for this recommendation comes from the physical or mental absence of residents during the winter and spring of their last year of training.

However, this is not the experience at all programs, and a revision of resident expectations and an evolution of resident behavior would address the problem directly.

At risk of jeopardizing the "good gig" many other residents may be experiencing, I'll share the experience at my institution. In my large and busy academic program, from February though May, senior residents are released from clinical services two hours early, two days per week, in addition to the routine residency-wide weekly didactic session occupying one late afternoon, for board reviews provided voluntarily by our excellent faculty.

These typically run into the early evening hours with the seniors as the only participants. With the exception of those 6 hours per week, seniors are on service, contributing to patient care, easing workload, and gaining additional valuable knowledge that they can incorporate into their intense learning during board preparation. The success of this process is evident in our exceptional pass rate.

Following the recommendation to push the oral board exam back two years while perhaps improving the department’s bottom line, would only serve to weaken the educational experience of residency and call into question the significance of board certification.

J. Andrew Hill, MD

[Mardjohan (John) Hardjasudarma, MD]

A Radiology residency program is four years long. Not 3 1/2, and certainly not 3. We could put those 'lost' months to good use, what with the profusion of new technologies, new equipment, new procedures, and dare I say, new science.

All other specialties examine after completion of the residency. If they can do it, surely so can we. There are enough bright and dedicated individuals amongst us to make this happen.

Will it be painful? Yes, the transition will not be very pleasant. But change we must, and sooner rather than later, for the benefit of most if not all.

Mardjohan (John) Hardjasudarma, MD

[John Reichle]

Delaying oral boards is possibly the most foolish thing the ACR has ever considered. No doubt it is driven solely by the academic radiologists who want resident labor to be more freely available.

Speaking from personal experience, residency staff radiologists on the whole are more focused on their own endeavors than teaching the residents, and as a result the residents to some degree are left to prepare for boards on their own.

At least residency programs have a wealth of material available to allow the residents to do so. This material is not nearly as available to private practice radiologists, who believe it or not have a lot more work responsibilities than a resident.

It is not realistic to expect a radiologist to spend his first 1-2 years in private practice studying for boards after working a 50-80 hour week, and especially when many are finally trying to give time to their families after all the years of training and telling the spouse "things will be better when I graduate and pass boards."

If everyone were honest, they would recognize that most radiologists are never "smarter" than the day the leave residency. Experience counts, true, but our boards aren't geared towards experience, but rather towards book knowledge. Let the residents take the oral boards when they're best prepared to do so.

John L. Reichle MD

[Philip Grimm MD]

Another series of comments about why Board Exams should be delayed, from the perspective of private practice:

1. Newly fledged radiologists are hired at near full partner wages, but it is the exceptional rookie radiologist who can pull his/her share of the work load. And, simply put the rookie radiologist (and by this I mean that the rookie year can actually last many years) who is the one who is making the most mistakes. It's just like driving a car, it is the young driver who makes the most errors. No big deal, it gets better.. But Passing The Boards does not make you a good radiologist--experience does.

2. Too many young radiologists who joined our group had an arrogance that was difficult to understand. Not all, but a large percentage of them thought they knew more about this stuff specialty than the older guys do. This is not true, and by putting another real world hurdle in front of them, it may keep their eyes open. By delaying boards, it may force these newby's into choosing a mentor.

3. Our group suffered from Modality Cliques. Many guy's coming out of a fellowship were too good at what they do, to see what the entire practice was like. All of our interventionalists hung together, all of the MR guys hung together, and almost everyone thought they were more important than anyone else... and no one, NO ONE wanted to do barium...

If a newby has to wait a few years before taking his/her boards, that delay will force them not to ignore the rest of radiology.

By forcing new partners to 'stay current' in the entire specialty, if only for a few years, they will not be so short sighted as to ignore the rest of the business. They will also be less isolated.

4. Many radiologists keep reading and learning, but many don't. Some create the impression that they can't even read a book--all they can do is look at pictures. Having someone in the group who is actually studying for the boards, would be an incentive for the older partners to keep reading so they won't be embarrassed, so they can keep up, current, or whatever, the older guys could re-introduce themselves to things they didn't get the first time around...

5. There is an amazing avoidance of case conferences in private practice.

There is always the excuse of time constraints, but it frequently seems that there is a real avoidance of the learning experience, especially since the learning is frequently done via the group 'correcting' someone's particular mistake. By delaying boards for several years into private practice, it would make these conferences have a sense of purpose, they would be driven by the new guys, who could use it as both a teaching and a learning experience.

6. By having the person who is taking the boards actually know what private practice is all about, will tone down the academic stuff that can creep into the specialty.

If enough board candidates tell the board examiners: "In five years I've never seen this pathology" or " If I put that phrase into a report, the chief of vascular surgery at our hospital would serve my head on a plate at grand rounds." or "At our tumor board, the oncologists think we are overcalling abdominal uptake on PET/CT's and here you are showing me another case exactly like the one that caused a fight at tumor board just last week"

Delaying a specialty wide board makes sense. but how long of a delay is an interesting question. Unfortunately, I don't think that anyone could pass a board exam that covered the entire specialty, if it was given ten years after residency. Five year delay would be the max.

[Alan Kaye]

This is a complex issue that cannot be analyzed in isolation. The entire structure of radiology training must bo open to evaluation, including the timing, format and emphasis of the Boards.

Numerous factors must be considered, including radiology manpower needs, technological advances, external demands on and threats to radiologists. I have written formally and informally on this. A column I wrote in the January, 2007 issue of Imaging Economics is copied below, along with the link.

In short:

1. Keep the required total training period at 5 years.
2. Keep the residency at 4 years, so that residents leaving training have a broad enough base to enter general radiology practice.
3. Eliminate the requirement of a clinical internship.
# Require a subspecialty fellowship in either clinical radiology or research.
4. Restructure and postpone the Boards and recapture half the fourth year.

http://www.imagingeconomics.com/issues/articles/2007-01_11.asp

General Radiologists: Necessary But Not Sufficient

by Alan Kaye, MD

The author argues for eliminating the 1-year internship and mandating specialty training to ensure that radiologists can be competitive

Radiology residency training guidelines are increasingly the topic of scrutiny and discussion. On October 26, 2006, the radiology Residency Review Committee (RRC) issued proposed changes to the program requirements for diagnostic radiology resident education. These are significant, but they dealt mostly with revisions to documentation, oversight, support systems, and minor curriculum changes. In July 2005, the Intersociety Conference (ISC), sponsored by the American College of Radiology (ACR), meets to consider a selected issue in our specialty: how to best design training programs to meet future needs.1

The primary recommendations of the conferees were to reduce the time for training in general radiology to 3 years; shift the "clinical" training to a required 3-year subspecialty/research fellowship; and consider delaying the oral boards examination until at least 1 year after completion of training. These, in turn, have engendered much discussion and alternative proposals, some of which further reduce the general diagnostic radiology exposure; increase the subspecialty training and/or research; and even substitute nonradiology training for general radiology, thereby opening subspecialty radiology certification to nonradiologists. Indeed, the ISC raised the specter of abandonment of the notion of a general radiologist. "The underlying theme is that our field has become so complex that no one individual can maintain the level of expertise needed to practice the entire field of radiology. Because no one practices the entire field, why do we insist that radiologists become at least ‘minimally competent' in the entire field?"

The latest round of public discussion of potential changes to radiology training programs was publicly heralded in the Chairman's column in the ACR Bulletin in May 2003 by E. Stephen Amis, MD. Amis wrote, "Some feel that cutting residency training from 4 years back to 3 might be the answer; others maintain this would ‘dumb down' the specialty. Many other options were considered, but each one had significant flaws."

Six months prior to the publication of Amis' column, I had hosted the second of two informal symposia on the topic of "The Future of Interventional Radiology." Fifteen department chairmen and interventional radiologists from seven hospitals in Connecticut (five of which have residency programs) addressed the issue of radiology training in the era of turf battles, subspecialization, and radiologist shortages, among other subtopics. We, too, lamented a "dumbing down" of our specialty, but felt that it was already at risk as a result of the flight from subspecialty fellowship training engendered by the hot job market for radiologists. This has prompted many overburdened radiology groups to forego longstanding policies to hire only fellowship-trained radiologists and to dangle offers before graduating residents that these debt-burdened trainees cannot resist. Unfortunately, with the incursions of nonradiologists performing imaging procedures, these general-only radiologists may be less well-trained in the specific subspecialty than the nonradiologists. Now that is dumbing down. Radiology practices and departments need the subspecialists who are familiar with advanced imaging and the specific clinical issues, both of which can be garnered only through advanced experience and/or training. The economic imperatives will dictate the loss of fellowship training and will change radiology irreversibly and for the worse.

In addition to the need for providing state-of-the-art clinical and scientific education in our discipline, the appropriate structure for radiology training programs must address the aforementioned issues. I propose several possible measures to the American Board of Radiology (ABR):

1. Keep the required total training period at 5 years. Lengthening the time would have two drawbacks: diminishing the flow of new practitioners into radiology at a time when a small workforce is detrimental to the future of our specialty; and reducing the relative attractiveness of our specialty for medical graduates.
2. Keep the residency at 4 years. There is much to learn in the not-yet-mature fields of ultrasound, CT, MRI, and PET, and much more is coming in molecular imaging. There remains a need for general radiology training, and shorter or fewer rotations in the broader specialty will weaken just as many departments and practices as will be strengthened by additional subspecialty training.
3. Eliminate the requirement of a clinical internship. The absolute requirement of a clinical internship has not always been the case. When it was not required by the ABR, many excellent programs either made it optional or reserved PGY-1 radiology slots for top candidates. The residency program in my department was one of those, and we were able to attract excellent candidates, many of whom turned out to be among our best residents and are now successful private and academic radiologists. As pointed out in the ISC report, the required PGY-1 clinical year "has little value in today's practice."
4. Require a subspecialty fellowship in either clinical radiology or research. Aside from enhancing the expertise of the entrants into the workforce and the quality of the practices they join, this has numerous indirect benefits. By raising the overall expertise of radiologists, it presents a more formidable defense in turf issues with other specialists whose training may include specific exposure to imaging in their specialties. Academic departments will benefit by the assured supply of fellows, the enhanced likelihood that exposure to research will lead to choices of academic careers, and the increased supply of subspecialists. The supply of new radiologists would not be interrupted because the PGY-1 clinical year would no longer be required.
5. Alternatively, if eliminating the internship year is not acceptable, we should still require subspecialty training. One way of including the subspecialty training while minimizing the loss of general training would be to move the oral boards examinations to a year or more after completion of residency. This would restore the training portion of the second half of the fourth year of the radiology residency and allow it to be used for mandatory subspecialty training.

Radiology has thrived on change. We have adopted new technology, adapted to socioeconomic trends, and had a profound effect on health care. The current discussion of training requirements is a healthy exercise.

[Erik Strom, MD]

It is possible that some large private radiology practices might be able to absorb a newly-hired young radiologist into their work schedule for a year or so (or however long it takes) to study for the boards.

However, a very small one-, two-, or three-person practice could not do this, as they depend on a new hire to "hit the ground running" from day one, providing service to patients and revenue to the practice, and would simply not have the resources to "red shirt" a radiologist for a year.

Additionally, many small practices are in smaller cities and towns, without the resources of an academic department to draw upon, which would likely limit a new radiologist's choices of where to (start) practice. Also, there would be credentialling problems when a hospital or imaging center owner requires that all radiologists be board certified.

Our oral boards (at least in their present form) are not like the surgical specialties, which require performance of a certain number of cases in practice before taking their boards. Perhaps interventional radiology boards could be structured along similar lines, but not diagnostic radiology, which requires detailed familiarity of the entire knowledge base of the specialty - and a lot of studying to attain that familiarity.

Our academic radiology departments exist for the primary purpose of teaching and research, and are the "bedrock" upon which our specialty has flourished so spectacularly in the past few decades. This is the best place for residents to complete their training, and it's up to the department chairs and residency directors to find (and enforce) the proper balance between studying and "work" as their fourth year residents complete their training.

Maybe one partial solution would be for academic departments to hire one or two general radiologists to "read the stacks", thereby freeing up the academic staff for more research and the resident staff for more study time.

Erik Strom, MD

[Ted Fogarty, MD]

Simply want to second Dr. Poage's statement. Smaller programs do not have as much of a problem with this issue. If anything the large program mentality of letting residents shirk their clinical duties for the sake of studying is further placing the small program residents at a disadvantage for passing boards.

The crisis needs to be rectified by program directors at those places where this is a problem which will give a fair playing field for those who still took call and showed up every day until just before boards (and afterwards). Furthermore, as this potential change dovetails with an enticement of specialization it will be a disservice to our profession to have everyone fellowship trained; observations of cross-disciplinary nature often come from those who remain unspecialized; sometimes these are quantum leaps in medicine and science.

Being in several "boxes" at once as a generalist allows those observations to occur and advance the science of imaging.

Ted Fogarty, MD

[Alan Kaye M.D.]

More:

When the Boards are moved out 2 years, the senior residents will have the opportunity to attend the ACR Annual meeting and represent trainees.

As with night call and other responsibilities, it is something from which senior residents can perhaps benefit and contribute more than their junior colleagues.

As a physician who hires many recent trainees, I have a high level of confidence that the character of the Boards will change, and, like our colleagues in other specialties, our practices will not be imapcted negatively by preparation for Boards.

Lastly, recent articles have expressed concerns that trainees come to practice with many limitations, including several that would be addressed by residents having opportunities to take on more responsibilities at the end of their fourth years.

Alan Kaye M.D.

[William A. Ladd]

I am a radiologist in full-time private practice in a 24 person group. I also am on the clinical faculty of the local medical school and I teach neuroradiology to radiology residents one full day per month via readout sessions.

When I was a resident 1982-85, we didn't miss any days or even hours of rotations due to studying for the boards.

I think it would be silly to change the timing of the boards. The idea that 4th year residents need to "disappear" for much of the year is absurd. If someone is capable and pays attention well during an entire residency, that should in itself be sufficient to pass the boards.

The performance of the work on the rotations is supposed to be a learning experience, and in fact prepares you for practicing radiology much better than factoid cramming does. Some evening and/or weekend studying during the 4th year is inevitable, due to the importance, not the difficulty of the exam.

It sounds like the problem is that some program chairpersons don't have the courage or whatever it takes to make the residents do what they are supposed to do.

The failings of these administrators should not be used as a reason to change the timing of the exam. If the residents don't show up for rotations they should be dropped from the program. In fact, if they don't show up, I don't think they qualify to sit for the board exam, nor do they qualify to graduate from the program. They should be required to spend an extra year.

Bottom line: Absolutely no need to change the timing of the boards, and it would be a very bad thing to do.

Just tell the residents to stop their truancy.

Sincerely,

William A. Ladd

[Timothy J Miller, MD]

It's a simple question of passing the buck.
Academic programs are struggling and want the private practice groups to shoulder some of the burden for Resident Education which traditionally and properly rests with the Universities.

The type of intensive learning required for the Boards is best done in a formal training program. Who's going to teach you about Lhermitte-Duclos disease in private practice? Who's going to let you practice your cerebral angio techniques on their patients?

It won't happen. If you push the Boards experience off to private practice, your just going to dumb-down specialty.

Timothy J Miller, MD

[Larry Liebscher, MD]

One of the key assumptions made in proposing to change the timing to 1-2 years after residency is that the board exams would undergo significant change and be tailored to the actual practice experience of the individual.

This is a significant departure from the current situation where the assumption is that someone who has passed their boards has demonstrated competence over the breadth of the specialty.

The ACR Guidelines and Standards frequently use this fact as a base for recommending privileging for a wide variety of exams. Most of our Guidelines state that certification by the ABR is a sufficient condition to prove competence to perform the exam.

My sense is that with a change to a later testing period and a tailored exam to reflect actual practice patterns, this would no longer be the case. As radiologists would no longer be tested in detail over the entire range of the specialty, board certification would reflect competence only in those areas tested.

Certainly there are, and would continue to be, alternative pathways to prove competence to perform or interpret exams for which the radiologist had not been examined under the ABR boards. But board certification alone would not suffice.

This leads me to believe that such a process would further the subspecialization of Radiology.

That is not to say that such a change is not good or desirable. It is only the observation that I think this would be one more factor in the move to greater subspecialization.

Larry Liebscher, MD

[Bernard G. Maristany]

I am a private practice radiologist with a CAQ in NeuroRadiology and I am about 8 years removed from the board process. I feel strongly that the boards should not be moved for several reasons.

Learning at the viewbox with the attending is the first and most important aspect of learning radiolgy in training. But it is in those last few months of intense study that putting it all together occurs.

It is at that time that many residents "catch up" in knowledge base and experience. Radiology is different from other specialties in that the breadth of knowledge is so great, this intense study time is necessary to provide well rounded radiologists to the community.

The ABR seems to assume that all training programs are created equally, they are not. It is during this independent and group study that any perceived weak areas can be improved.

The academic radiologists appear to be upset that the residents are off studying and skirting clinical responsibilities. I agree with the above comments that the program directors should address this issue in their department. But please, how can the attendings be that upset when the residents are STUDYING so hard and LEARNING so much.

In order to pass the boards the way they are currently administered, a resident significantly benefits from being a part of a "group" going through the experience. That includes case reviews with other residents as well as with subspecialty attendings. None of this would be available in a private practice setting.

I have worked over the years with a couple of board eligible radiologists who I have witnessed trying to study for the boards in private practice. Frankly, I don't feel that they have a very good chance. Not because they aren't smart, but because the time and machinery required to pass the boards are not there. I am sure the ABR has data on those Post residency examinees and their poor performance.

Finally, if the boards were delayed a couple of years, as a private practice radiologist I would not want to hire a new graduate. The board preparation (not necessarily passing)is a real equalizer, raising the bar of quality in new graduates across the board.

Bernard G. Maristany, M.D.

[Alfonso Gay, Jr., M.D.]

It is curious that the idea of delaying oral boards happens to coincide with the shortage of radiologists, especially in academia.

Is this idea really looking out for the best of our new graduates or simply an attempt at "tapping into" an underutilized workforce (i.e. senior residents)?

Clearly the problem as I see it rests on the shoulders of program directors. During my residency our senior residents did not disappear from clinical duties. We spent many hours after the regular day studying for boards individually and as a group.

As an institution we performed well on our boards and the ability to study with your fellow residents enhanced our weaknesses as we lifted each other up where needed. This of course would not have been possible in private practice.

During my fellowship at a different institution it was clear that the focus was for their residents to pass oral boards. I did not know the senior residents well as I hardly ever saw them as they were off studying. This was in sharp contrast to how my residency functioned. I suspect they had an easier time with the boards than we did but they were less prepared for private practice. I was fully prepared to hit the ground running when I joined private practice.

Delaying the oral boards will definitely negatively affect the smaller private practice groups as they need the full FTE, otherwise they would hire a part time employee. Not only would there be a disincentive for private practice groups, especially smaller practices, to hire new grads who have yet to pass the boards, there would be a disincentive for new grads to join any practice that does not have access to the learning resources afforded by teaching programs.

In other words, if you're a graduating resident don't join any practice not near a teaching hospital as you will be at a distinct disadvantage compared to your peers.

End result: Megagroups centered in large cities, extinction of rural groups, vacuum filled by non-radiology specialties, further degradation in radiology turf etc. Keep the boards as is.

Alfonso Gay, Jr., M.D.

[Stephen Miller, MD]

Keep the timing and content of the ABR exam as is, and require the senior residents to stay on their daily and call rotations - simple.

There is no need to reinvent the wheel. It would be nearly impossible to pass the ABR exam as it stands while in practice - the exam would have to be modified.

Stephen Miller, MD

[Thomas A. Kavic, M.D.,RPVI, RVT, RDMS, RDCS]

Make the oral boards optional - at completion of residency or one year later or two years later.

Thomas A. Kavic, M.D.,RPVI, RVT, RDMS, RDCS

[Amy Kirby]

There are a few issues that should be considered regarding this issue.

The first is patient care. Is it in the best interest of the patient to have radiologists interpreting films for two years who then fails the boards, conveying some lack of competency?

The second is that without curriculum changes, this cannot happen. THose of us who are in fellowship are too far removed from all the aspects of radiology two years out, and it is not reasonable to expect us to demonstrate proficiency in areas that we have not had exposure to after two years have passed.

Unless the boards are changed in regards to content, to reflect the practice of that particular physician, this will never work, nor will it be adequate to truly determine what is the "competency" of the graduated radiologist.

Amy Kirby, MA, MD

[Philip Araoz, MD]

One argument for delaying the oral boards is that 4th year residents are off studying and therefore aren't learning by being on clinical rotations.

If studying for the oral boards isn't learning (or at least isn't "real learning" or "useful learning") then why have oral boards at all?

Or maybe the oral boards should be changed so that studying for them is "real learning." How about instead we dispense with this silly argument that putting off the oral boards will help the residents learn and is somehow doing them a favor.

Let's just have the program directors be up front and say that they want more productivity out of their cheap workforce.

Philip Araoz, MD

[Justin Phillpott, M.D.]

I learned more my 4th year BECAUSE of boards than the other three years combined. Boards make you study because of the fear of failing (at the time I took them, 30% conditioned and 5-10% failed).

Did we disappear from some services to study? Yes. But, only after the work was done and our faculty let us leave. Also, we had over 100 mock board drills my senior year with more than a dozen faculty (four of which were current board examiners). This would not be possible if you were in private practive or in fellowship.

Programs should set their own policies about studying during working hours. This should not be manipulated by the ABR by moving oral boards. If boards are delayed, it would take two years worth of higher failer rates to realize that it was a bad idea.

Justin Phillpott, M.D.

[Robert Jaffe, MD]

Our hospital has a fixed rule that you must be board certified at the end of 2 years on staff. Any associate that failed or even conditioned the boards would lose their privileges and their jobs. It is a lot of pressure to put on someone.

As for the workplace issues, I am afraid you will be replacing absentee resident for absentee fellows. Given that fellows are more useful than residents I am not sure this is a good trade for academic programs.

[Chad Williams]

Another vote for NOT delaying oral boards.

Andrew Hill's well thought out comments and analysis are right on.

I am asst. pgm director at a community training program and so have perspective from both private practice and academic worlds. I also actually remember what it was like to be a resident.

In a nutshell:

It would be easier on program faculty if they did not have to worry about boards prep for their seniors. A delay or change would be worse for everyone else: private practices, fellowships, patients and residents for all the reasons discussed above.

I don't mind if we prepare radiologists differently than other specialties. I think we do a better job. Saying we have to delay our boards because that's the way other professions do it doesn't make sense to me.

Programs are getting squeezed from both sides trying to stay competitive and efficient while generation X'er residents want to study at work instead of at home.

Programs, expect more from your residents and keep them on task. Residents, give service back to your programs so that they can be sustained and not drained.

The boards are good. Keep them the same.

Chad Williams, MD

[ashni behal md]

why dont we just get rid of the oral boards. Residents study about rare and esoteric cases for the boards--cases one would probably not see in a lifetime.

The oral board exams are an uneccessary stress on trainees.in community practice we need well rounded general radiologists and passing oral boards does not gurantee that.

Ashni Behal MD

[Negar G. Knowles, MD]

I am opposed to moving the exam for a few reasons:

Radiology differs from many specialties which take their boards after graduating from residency in that a substantial portion of our knowledge base comes from studying out of books and case review series.

This is because so much of what we need to know is rare enough that we are not guaranteed to see it at the viewbox during a four year residency, but common enough that we need to know it.

The longer you are in training, the less often you see cases with which you are unfamiliar. Spending a few more hours during the last 6 months looking at cases with the same attendings whose pearls you have been soaking up for 3 years will not fill in the gaps in your knowledge base.

Studying is an important part of residency. The argument that we are wasting time learning about irrelevant zebras is flawed. If you have mastery of a body of knowledge at some point, and forget some of it, at least you will know when you need to look something up. If you never achieve familiarity with the entire body of knowledge, you will not know what you don't know, and that is dangerous.

Another reason why radiology is different from other specialities is that it is entirely possible to practice in a setting where you get little or no feedback on your mistakes. The clinicians do not always come back to tell you if your read was correct or not. Unless you diligently follow-up on your cases, you could be providing erroneous reads on a regular basis and never know it. This is all the more reason why it is imperative that a radiologist meet some criteria of competency prior to practicing.

Last, if a radiologists can practice for two years without having passed the boards, doesn't that beg the question of whether the exam is necessary at all? Why should you have to pass it if you are safe to practice without it?

Negar G. Knowles MD

[Lee Woldenberg, MD]

As a program director of a 16 resident program, I strongly oppose moving the oral boards.

1. We do not lose our residents the fourth year. we let them take their call during the first half of the year: the full amount they owe.

2. Residents are required to work regardless of year. Our fourth year residents are present and taking part as the leaders of the residency program during their fourth year. They get four weeks off at the end to study. we impress on them from the beginning that they need to study 15-20 hours a week for four years, and not wait until the end. It is up to the program to require their residents to take part.

3. The materials and time to review, with fewer social complications and smaller families at that stage of the game allow for greater concentration at home for studying. Young families have enough stress on them already.

4. Private groups want to know that the resident is board certified and capable. if someone were functioning well but not boarded, what is the point of the boards in the first place. and if board certification is required and they flunk the exam, what happens to them then? transfer? new job? retrain? lost money, dislocation. A terrible idea.

5. As stated above, the main reason this is being promoted is that large programs are short faculty, and somehow are requiring residents to get work done for them. they should concentrate on having the residents report when they are supposed to, instead of changing the rules of the game.

6. There is no better environment for study than the academic atmosphere, and the presence of two or more other residents going through it with you.

Keep it the same and quit dictating rules changes to the majority of the positions that are producing radiologists 3-5 per year, and are important in the production of well-trained radiologists.

Lee Woldenberg, MD

[Harvey Lefkowitz, MD]

I was in the first group of three year residents to take the boards prior to completing the residency in 1975. I believe that the five senior residents and four junior attendings all passed.

Ten years later two of my partners were in four year residencies at the same program and they both completed their board exams after the third year and devoted the full fourth year to clinical matters. They were both strong clinical radiologists from the start.

As a non academic radiologist with office and hospital based practice experience for over thirty plus years, I have always thought that the boards rewarded and recognized basic competence and did not award "gold medals" for academic "know-it-alls." performances. I do not understand why there is a need for such intensive study before these exams. We all managed to find time to review. As radiologists we are examined everyday of our lives. We are being examined with every case that we read. It never ends!

Radiologists must study their entire careers. It appears to me that the board examiners are able to discern who is functioning at the level that they have achieved, and recognize that they know the basics to go out practice and continue to learn.

My answer is to demphasize "acing" the boards and spend more time on preparation for becoming knowledgeable, practical and contributing members of the health care delivery system. Unlike other specialities where patient chooses you, in Radiology you are examined daily by the referring physicians and nowadays, the other health care providers(sic.)

Keep the boards timing as is, but develop a reasonable rationale, expectation and decrease the associated anxiety.

Harvey Lefkowitz, MD

[Charles Medbery MD]

Is there any reason for moving the boards other than wanting the senior residents to work more in the department? If that is the only reason then moving boards only shifts who gets this academics or private practice. Having been staff in military and academic departments as well as now in PP, I can tell you that you do not have to "lose" the seniors, and they will get no help once they are out.

I and my partners have no time to teach and no desire to. If I wanted to teach, I would go back to academics. We also expect all new recruits to put in full day working and take equal call. If we were told that new graduates would need time off to study we wouldn't hire them. This means that all the learning would have to be after normal work hours. If that ccould be done in private practice it could be done in training.

Also I agree that the help that we got(after hours) to prepare for boards with staff and fellow residents was invaluable. Because of my training I felt fully prepared for boards and actually found them enjoyable. On the other hand when I took my Peds boards(former pediatrician), I had no idea of what to expect and no idea of how I did because they were done 2 years after residency.

What I saw in Peds was that a significant number didn't bother with boards. They had jobs and saw no need to take them. This may well occur in radiology if boards are moved.

Charles Medbery MD

[Arun Krishnaraj, MD, MPH]

The proposal by the Society of Chairman of Academic Radiology (SCARD) and the creation of the task force to study the impact of moving the oral board examinations 2 years back, spurred by a resolution issued by the ACR RFS (Resident and Fellows Section) at the most recent AMCLC meeting, has brought to light an issue that has been brewing for the past few years.

The arguments for moving the boards have centered around the fact that chairman of academic radiology departments have become frustrated to lose their "most valuable residents", those in their final years of training, to what Dr. Steven Baker has called "the most accelerated seniority system in the history of employment". The solution to this "problem" has been to postpone the board exam by 2 years thereby salvaging the fourth year of residency.

The main argument against moving the oral boards, supported by the ACR RFS, is that this would place an undue burden on residents to study for boards while in their first years of private practice or as junior faculty without the resources, intellectual stimulation and discussion afforded by daily conferences and interactions with academic attendings. Moreover, the oral boards are by their nature comprehensive examinations testing the skills and knowledge acquired in all aspects of Radiology.

Due to the fact that most current residents are pursuing fellowship training in a particular field, this would make it much more difficult to review topics not within one's subspecialty. The process of studying for oral boards also allows senior residents to finally see the "forest for the trees" and consolidate the knowledge acquired during the previous years of training.

Often during this period residents approach attendings in their department with questions that help round out their knowledge, an opportunity which would not be available in private practice. The other looming issue is that a fundamental restructuring of residency training is needed which also complicates matters in regards to the timing and content of oral boards.

In this period of flux, where the field of Radiology is at a cross roads regarding specialization versus generalization, in addition to the growing workloads in academic and private practice groups altering the timing of oral boards is unwarranted.

Arun Krishnaraj, MD, MPH

[M.L. Janower M.D.]

The APDR through its Board Review Committee has studied the problem of Board frenzy for several years and has not been able to come up with a solution, and many people feel that it never will.

Be that as it may, the Committee has been frustrated by many program directors and department chairpeople who feel that they are powerless to insure that the senior residents remain full participants in the Department's activities such as providing clinical service, attending conferences, performing research, etc.

Obviously. the program information forms submitted by them do not specify that the senior residents will spend months away from the department to study. Furthermore the site inspectors have a specific question about the senior residents full participation and I am not aware of any program director, department chief, or resident answering in the negative.

Is this fraud?

I leave the answer up to your judgement.

[M.L. Janower M.D.]

Failure of senior residents to fully participate in their training programs represents a failure of the program directors and department chiefs to fully train their residents.

[SIRAM SATYANATH]

Exams should not be delayed.
If a resident is learning , as designed by college,should be able to take the exam without problem on time.
If a delay is requested, it only speaks poor of the faculty training them.
To get in to residency in radiology is very very competitive.
If a brilliant student ia joining the residency why shold he ever request for delay?

[Shailendra Chopra, MD, MRCP, FRCR]

Having trained in England and in the USA, and being a board examiner and on the MOC committee, let me introduce a different perspective on this. In Britain, radiology training is FIVE years long. That is after two years of mandatory clinical training. Majority of the trainees in Radiology already have passed a post graduate exam in a medical or surgical specialty. The final exam in Radiology (also called the Fellowship exam because the degree is called the Fellowship of the Royal College of Radiologists FRCR) is completed at the end of the THREE years in Radiology. Following that, there is a mandatory two year post Fellowship training period before the trainee gets the final accreditation from the college, necessary to be employed as a staff radiologist. Part of this training can be a fellowship in the USA.

Final exam, two years before you finish the training! Unbelievable? Believe me, the learning during that period of time is tremendous. You have already gotten all the basic facts under your belt. Now you are learning how to apply them. There is no anxiety. Call is not a problem. You rotate through the various subspecialties in 3 month rotations. You are given increasingly more independent responsibility over that period so that by the end of it you have eased into your role as a staff radiologist. In short, in those two years you learn how to practice independently. You make your mistakes in supervised, supportive environment and learn from independent experience.

Let us examine the advantages to our system of a policy where the exam is taken at the end of three years and the fourth and possibly a fifth year is spent in a mandatory fellowship like setting rotating through all or a choice of various subspecialties. Part of the rotation may even be through participating private practices.

1. The senior radiology residents have no incentive to shun the call.

2. In the final year/two, the resident who has already passed the exam is given more independent duties, thus reducing the burden on the academic faculty.

3. The radiologist coming out of such a program has the degree as well as the experience, something missing in the current training as brought out by many of the posts on this site.

4. It gives more time and a perspective of experience to a new radiologist to decide what type of practice he/she likes.

So, to finish the exam after three years rather than postponing it may be a solution to many of the points raised in this thread and prove to be a win-win-win situation for the residents, academic departments and community practice.

[Timothy Davis]

After residency at Mallinckrodt and a faculty stint at MGH, I am frankly shocked at the ABR decision.

Mallinckrodt will (or should) lose much of its draw if it no longer is responsible for preparing its residents for Boards.

Radiology will lose by not having teams of board-takers working hard together learning early morning and late evening for 5 months.

This is not general sugery. This is a cerebral, information-intensive physician-to-physician consultation specialty that needs trained, not almost-trained physicians in private practice, and indeed in academics. We are not interested or equipped to finish the training process for new hires after they start their jobs. It will fall on the individual, at home late at night, and be done less well than in a group setting. Don't worry, they can afford the study materials, but will be sad and lonely for them. And with bad results.

Board-takers are some of the most-teachable people. Why not do your job and teach them during this teachable moment?

I realize that academic radiology is in deep trouble. I left my "dream job" at MGH because it was in the wrong state for me (I had family who needed us in Indiana) and it paid less than half of my earning potential. Each grant I got constrained my pay further, because of NIH caps. And believe it or not, the daily patient care opportunities now give me an even better daily sense of success than I had teaching and doing researchin the more "rich" environment of the academic institution.

Who is left in academic radiology? Those who didn't figure out the difference before it was too late, those who love it too much to leave, the independently wealthy, and those who are not easily employed otherwise. I was almost one of the above. It would be a great job, if you could figure out how to get paid.

Academic radiology programs such as Mallinckrodt claim to work independent of residents ("I'm so much faster than the residents, they actually slow us down," I heard many times.) While not completely true, those who rely on residents to actually produce the bulk of work are not doing their jobs. Teaching them is more time consuming than actually doing the work, often. Hospitals are paid to train these residents, last I checked over $30k/yr/resident. They are not expected, according to the usual system, to be overly productive. And a my institution, we were given only about 1/2 day for a month off of service to study, less than double vacation that year. We scrunched our call earlier into residency. We didn't "disappear", rather our workday was extended by 2 hours every morning and and hour every other evening or so, for review sessions given by volunteers. And IT WAS GREAT!!!! We all passed, of course, all 19 of us. But that wasn't all. We learned how to learn best, how to teach each other, how to be a collegial group of excellent radiologists.

I am not interested in hiring any non-board-certified radiologists. We never have, and probably never will. I want them to spend that 5 months at Mallinckrodt or other top institution before I have to work next to them and trust them with my patients and my company's reputation. Indeed, before I trust them to uphold the reputation of the Discipline of Radiology.

Perhaps the length of residency or final-year focus could be changed. I'm not opposed to change. But I am opposed to the concept that residency directors shouldn't be responsible for the board study system.

If the ABR asks radiology residencies to abrogate their responsibility to get their residents through boards, then I think we will have to have a "board-study fellowship" crop up, effectively to extend the residency or fellowship educational process through boards, a stop-gap measure until we can convince the residencies themselves to start doing their job again.

[Kerri Kirchhoff, MD]

Dear Colleagues,

I am writing to express my grave concern over the proposed Revised Program Requirements which are projected to become effective July 1, 2010. Specifically,
I am strongly opposed to the requirement that “the final year of radiology training is to be devoted to a number of subspecialty rotations of the resident’s choosing in order to better prepare him/her for a desired practice pattern.”

There is no doubt that our specialty is changing rapidly. Every day, we see new technologies, new applications of established technologies, new understandings of clinical syndromes and their implications for imaging. We have seen exponential growth in the number of imaging studies as well as the number of images per study. We can see anatomy in detail unimaginable even 10 years ago. Newer imaging modalities move beyond depiction of anatomy to imaging of physiology. These exciting trends will assuredly continue. Having an elite group of highly trained subspecialists is necessary to fully exploit the strengths of these new technologies. However, the place for subspecialty training is in fellowship, not residency.

The actual practice of radiology in the real world requires skilled imagers who have a solid working knowledge of general radiology. A quick review of recent advertisements of job openings reveal that while some subspecialties such as mammography and interventional are in high demand, approximately half of the positions available are for radiologists with general skills. Most radiologists with subspecialty training still devote a considerable portion of their practice to general radiology. This is entirely appropriate. It is not necessary to have a thoracic imaging fellowship to read a chest radiograph or a gastrointestinal imaging fellowship to perform a barium enema. As radiology moves toward round the clock service, it is essential for practices to have radiologists who can competently interpret general radiology studies to ensure access of radiology services to our patients and quick turn around times. At a time when radiology is becoming ever more sophisticated and complex, this cannot be accomplished by reducing core radiology training to three years.

Under the new proposed requirements, one could easily envision a scenario in which a resident would elect to devote the entire last year of residency to a specific subspecialty area, then a fellowship year to the same area. That means that once that physician enters practice, he or she may have gone two years (or longer) without doing basic radiology except, perhaps, some exposure during call in the final year of residency. This is not a service to the physician who would then be seeking a job (given the openings available), the practices in the community looking to hire new radiologists, or importantly, our patients.

The new proposed requirements will also be devastating to smaller and non-university residencies. The vast majority of radiology resident applicants have not decided upon a subspecialty at the time they interview at residency programs. This is desirable, because it is through exposure to the various subspecialties in residency that a resident can make an informed decision about where their passions lie. As most applicants do not have a firm decision to go into a specific subspecialty at the time they enter a residency, most will want to go to residencies with robust subspecialty departments in multiple areas so as to keep their future career options open. Smaller residency programs and non-university programs will be at a distinct disadvantage in this regard. If these programs experience difficulty recruiting residents the very survival of these programs could be in jeopardy. At a time when there is an ongoing national shortage of radiologists, decreasing the number of programs training radiologists is not in the best interests of our specialty or our patients.

The new proposed requirements could also have negative unintended consequences for fellowship programs as well. If a resident can spend 15 months of training in a specific subspecialty area, spending another 12 months in fellowship in that same area may seem unnecessary, especially if the subspecialty area the resident has chosen is in high demand. Also, as residents and fellows compete for studies in training programs, it is likely that -the educational experience will be diluted for both.

Finally, the proposed requirements will have negative consequences for our specialty as a whole. As radiology residents are driven into subspecialty areas, it is likely they will preferentially chose high paying subspecialties or subspecialties that are considered exciting or lifestyle friendly. This could leave other less lucrative or otherwise less attractive subspecialties fewer applicants. As the amount of core training in some of these “less attractive” subspecialties is slashed by the new requirement, and the number of people entering these subspecialties dwindles, paradoxically, the rush to sub specialization could actually decrease the overall level of competency in those subspecialty areas. This may also lead to increasing loss of “turf” to other non-radiology clinicians. For example, decreased radiologist interest in gastrointestinal imaging could lead to gastroenterologists performing CT colonoscopy. Or, imagine an oncologist wishing to review bone, chest and abdominal images of a patient. Would the oncologist have to consult with three radiologists? Would chest studies need to sit unread if the designated thoracic radiologist is unexpectedly absent because the radiologists in the department are so specialized they no longer have basic chest skills? These are some of the potential problems of overemphasis on sub specialization. We as a profession need to ensure that sub specialization does not come at the expense of solid general radiology skills or become a barrier to care.

In summary, sub specialization is an important trend in radiology which is necessary to fully exploit new imaging techniques. However, in this age of ongoing radiologist shortages, increasing demand for imaging, and increasing complexity of imaging studies, it is absolutely imperative that residency programs continue to provide strong general radiology training to their residents. This most important goal will be severely compromised by the new proposed requirements which will decrease the time residents spend developing these general radiology skills. We should reject the new proposed requirements and recommit to promoting the development of strong foundational radiology skills in residency and subsequent sub specialization in fellowships.

Sincerely,

Kerri J. Kirchhoff, MD