The Three and One-Half Year Radiology Residency

Robert I. Grossman; Georgeann McGuinness

It is increasingly clear that the radiology oral board examination fundamentally defines the framework of radiology education. Although it is generally acknowledged to be the minimum information necessary to be certified as a radiologist, an escalating amount of attention, energy, and focus in radiology residency is consumed in preparation for this examination. Many programs lament that residents spend a significant portion of their last year in board preparation, a situation that adversely impacts the entire training program, across all 4 classes (including the 3 junior classes).

Radiology is an ever-expanding specialty that is on the leading edge of medicine. The requisite knowledge to become a valued consultant in this challenging field has intensified. The radiologist is also scrutinized for the added value she or he brings to image interpretation and patient management, above and beyond that of the “clinician experts.” Accordingly, our educational endeavors must encompass a broad curriculum, including physics, anatomy, physiology, pathology, medical and surgical aspects of disease, procedural skills, applications of imaging modalities, radiation biology and patient safety issues, and expertise and experience with oral, intravenous, and intra-arterial contrast agents. In light of the rigors associated with successful assimilation of this expansive knowledge base and the required technical training, it is perplexing and, in our opinion, misguided that the American Board of Radiology (ABR) does not modify its credentialing schedule and move the oral board examination to follow completion of a residency by one or more years. This change would have a positive impact on the training and practical education of radiologists by allowing the resident the time required to become increasingly adept in all the critical areas of radiology. Furthermore, it would improve residency programs by decreasing the frenetic behavior exhibited by unnecessarily anxious residents during their final 6 months before board examination.

Residents should be expected to fulfill all of their educational requirements and responsibilities during this training period and have graduated from and completed the entire residency program before this final certifying examination. Moving the examination to a point a year or more postcompletion of the residency would fulfill that reasonable criterion. In addition, this postponement of the oral board examination until a year or more following graduation would encourage residents to pursue subspecialty training. Enhanced subspecialty expertise is essential for radiology as a field because it serves to boost our utility to clinicians and quell the arguments of those seeking to infringe on radiology “turf.”

No test can assess the depth of knowledge necessary to excel as a radiologist; however, it is disheartening to hear the commonly noted and glaringly irrelevant admonition, “You don’t have to know this, and it is not on the boards.” This wrongly reinforces the perception that what is important to know is only that which is deemed relevant by the ABR. We suspect that the ABR would not endorse this comment, yet by having an examination timed to certify residents even before the completion of their residency, the Board tacitly agrees with this supposition. Indeed, the atmosphere engendered by “board fever” inhibits exposition of innovative ideas and current science. Such reactionary thinking is generated when residents confront the diversity and quantity of material necessary for successful radiology training. A successful outcome at the boards is simply a consequence of such training. If one of our goals is to enhance the academic domain of radiology, an entire residency is necessary for trainees to fully engage in educational pursuits without the looming specter of the board examination.

Board examinations serve many essential purposes, including focusing educational programs and providing one metric to assess competence in trainees, but they are not an end in themselves. By attaching undue weight to this examination and by its suboptimal administration during the training period, complacent radiologists and the ABR inhibit the full educational process. Private practices and fellowship directors may argue that shifting the timing of the board examination would place additional burdens on them; however, the increased experience and knowledge generated by the last 6 months of a residency and an additional year of preparation would enhance the quality of training and improve the overall competency in radiology. To abbreviate educational opportunities and compromise fundamental training during the residency to placate concerns regarding the ability to prepare for boards when engaged in practice or fellowship is a hollow and flawed response. Virtually all other medical and surgical specialties have addressed this issue and believe education trumps the ability to be board-certified before beginning a job or fellowship; most specialties, including surgery, neurosurgery, neurology, pediatrics, orthopedics, otolaryngology, and ophthalmology, have their oral examinations one or more years following completion of residency training. Indeed, the aberration of a “during-training” board examination is a disservice to our specialty, but more significantly to our residents. We owe them an optimal approach to learning and acquiring competency in our shared field. The challenge to the ABR is to acknowledge this problem and to find creative solutions that enhance learning and improve, rather than erode, resident training. That, indeed, would be a legacy of the present trustees of the ABR.