Transcript 45 - The American Board of Radiology

APDR/APCR ABR UPDATE
March 2010
Duane Mezwa MD
William Beaumont Hospitals
Past President, APDR
GI Trustee, ABR
Exam of the Future (EOF):
Structure
Core examination
Certifying examination
Core Exam
Internship
12 mos
R1
R2
R3
R4
12 mos
12 mos
12 mos
12 mos
Certifying
Exam
Fellowship/
employment
12 mos
3 mos
EOF: Core Examination
Given at 36 months
Covers all of diagnostic radiology
– Only comprehensive exam in EOF
– Candidate must pass every category to
qualify for certifying examination
– Level of knowledge expected:
basic/intermediate
EOF: Core Exam Categories
Organ Systems* (10):
– Breast, Cardiac, Endocrine/Reproductive,
Gastrointestinal, Musculoskeletal, Neuro, Pediatric,
Thoracic, Urinary, Vascular
Modalities (6):
– Rad/fluoro, CT, MR, Nuclear/Molecular, US,
Interventional
Fundamentals (2):
– Physics, patient safety
* Clinically relevant anatomy, pathophysiology, etc
EOF: Core Exam Blueprint
Breast
Cardiac
GI
MSK
Neuro
Peds
Thorax
Repro /
Endo
Urinary
Vascular
Q#
CT
45
IR
45
MR
45
NM/Molecular
45
Rad/Fluoro
45
US
45
Physics
90
Safety
45
Q#
45
45
45
45
45
45
45
45
minimum 45 questions per category
45
45
500
EOF: Examination Blueprint
Breast
CT
Card
GI
MSK
Neuro
Peds
Thorax
Repr/endo
GU
Vasc
0
Q#
45
IR
45
MR
45
NM/Molec
45
Rad/Fluoro
45
25
US
15
90
45
Physics
Safety
Q#
45
45
45
45
45
45
45
45
45
Minimum of 45 questions if category
is to be scored separately
45
45
500
EOF: Core Exam—Scoring
}
Each organ system
Each method
Patient safety, physics
Scored pass/fail
Assuming sufficient breadth of content that
a confident pass/fail decision is possible
Minimum 45 questions/category
EOF: Core Exam - Physics
Content
Minimum of 90 questions
Each item writing organ system-based category
has a physicist
Questions: “Clinically relevant” physics
– How can image quality be improved?
– What is the source of this artifact?
– How would you design this examination to minimize
excessive radiation exposure?
EOF: Core Exam—Example
Physics Question
Repeat CT is requested
to determine whether
the CBD lesion is a
tumor or a stone. What
is the most appropriate
maneuver?
a) Decrease kVp
b) Increase kVp
c) Decrease mas
d) Increase mas
e) Buy new unit
Update on Physics Activities
Curriculum
– Revision completed: www.aapm.org
– Teaching objectives: spring 2009
– Questions matched to curriculum
Web-based modules – RSNA Website
– Phase 1 (completed - RSNA 2009)
X-ray, CT, Nucs, US, MR, Biology
32 modules developed by radiologist/physicsist
– Phase 2 (target June ’10 or so)
Processing, display, quality, perception, PACS
30 additional modules
AAPM Summer School on Teaching Medical Physics:
Innovations in Learning July 2010.
Bloom’s Hierarchical Taxonomy of
Educational Objectives
6. Evaluation
5. Synthesis
4. Analysis
3. Application
2. Comprehension
1. Knowledge
Oral
Rank, Rate
Oral
Oral
Oral
“Written”
“Written”
Plan, Categorize
Identify, Analyze
Interpret, Solve
Distinguish, Convert
Define, Describe, List
EOF: Core Exam—Contrast with
Current Written Exam
Written exam
– Fact retrieval only
– Individual organ systems and imaging methods not
separately evaluated
– ? Relevance of some physics questions
Core exam
– Roughly 40% fact retrieval
– Comprehensive, all systems/methods scored
– Questions based on specific images
EOF: Core Exam—Contrast With
Oral Exam
Oral exam
– Observation
– Synthesis
– Management
– Communication
Core exam
– 60% will test all of the above
– Communication skills?
EOF: Core Exam—Content
Entire spectrum of diagnostic radiology
Basic/intermediate level*
Probably at least 500 questions
Administered over 1½ days
*Clearly needed: a curriculum for every
scorable category
EOF: Core Exam—Conditions of
Contest
Pass all categories:
Fail 5 categories:
Fail > 5 categories:
Pass
Condition
Fail
Conditioned candidates retake only the
failed category(ies)
Failed candidates retake entire exam
Both will be offered in six months
EOF: Core Exam—Effects on
Training Programs
ABR-RRC meeting yearly
All residents exposed to every clinical
category to be tested
Board preparation displaced into 3rd year
Structure of 4th year
– Smaller programs—may be no change
– Larger programs—may be competition for
highly sought clinical subspecialties
EOF: Core Exam—What We Need
Written curricula for all categories
About 100 item-writers
About 2000 questions before 2013
Sage advice from all of you
Goodwill of the radiology community
EOF: Certifying Exam— 2015
Underlying Duality
Conceived as the first MOC exam, but
also
Final certifying exam given by ABR
– Must pass test of public scrutiny
– Must test competencies
– Need not test entire breadth of radiology
EOF: Certifying Exam
Given 15 months after residency graduation
Will contain 5 modules
– Noninterpretive skills (common to physicians)
– Essentials of radiology (common to radiologists)
– 3 modules chosen by candidate
General radiology
Subspecialty radiology
EOF Certifying Exam—Content
Emulate practice of radiologist at work
– Some normal exams
– Many “real-life” decisions
Differential (not single) diagnoses
Management decisions
More complicated question types
– Many possible right answers
– Layout mimicking real patient workups
What are the clinical practice areas on the
certifying examination?
The clinical practice area choices will reflect current
radiology practice: Breast, Cardiac, GI, MSK, Neuro, NM,
Peds, Repro/Endo, Thoracic, Ultrasound, Urinary, VascularInterventional and General Diagnostic Radiology.
The ABR will monitor the numbers of candidates taking
each module and modify this list as seems appropriate
after 3 years depending on the choices made by
candidates.
Clinical Practice Areas
Breast
GENERAL
Cardiac
GI
MSK
Neuro
Nuclear
Pediatric
Reproductive/Endo
Thoracic
Ultrasound
Urinary
Vascular-Interventional
EOF: Certifying Exam—Example
Case
A 43 year old man experienced intermittent episodes
of hematochezia. Capsule endoscopy showed
angiodysplastic changes in the ileal mucosa. Which
of the following radiologic examinations is MOST
appropriate for further evaluation
a)
b)
c)
d)
CT enterography
MR enterography
Selective angiography
Enteroclysis
Warning: Once you have
made
a selection, you may not
return
to this screen
What is the MOST likely
diagnosis?
a) Carcinoid
b) GI stromal tumor
c) Adenocarcinoma
d) Metastatic melanoma
What is the MOST likely
diagnosis?
a) Carcinoid
b) GI stromal tumor
c) Adenocarcinoma
d) Metastatic melanoma
Exam Philosophy
“The
important thing is to make the lesson of
each case tell on your education.”
William Osler
Certifying Exam- 2015
How will the exam be graded?
5 modules: Noninterpretive skills,
essentials, three candidate-selected
modules
Each will be graded with own passing
standard
Candidate must pass all 5 components
No “condition” status
Rationale:
*Both psychometric and “face” validity are necessary
to our various stakeholders. We are currently the only
board with a condition category at this time.
*Elimination of “condition” is reasonable because we
have narrowed the scope of the exam and eliminated
subjectivity of an oral exam.
Assuming that the examination is available in testing
centers every six months, additional preparation by
candidates and prompt reexamination will be feasible.
Certifying Exam:
Of the three clinical modules, how many can be chosen in the
same category?
All 3. Candidates allowed free choice to construct their exam
among General or Subspecialty Category
Rationale: The clinical modules will comprise only 60% of the
exam. Allowing free choice permits early subspecialization, while
still testing all of DR.
It is expected that candidates selecting more modules in a given
subject will be answering questions of higher difficulty.
We are testing what the candidate
feels is most important to his/her
future practice, not what their past
training has been.
EOF: Certifying Exam—What We
Need
Even more help!
Sufficient material and question-writing
expertise to create graded spectrum of
sophistication within every category
Example: Neuroradiology content
Increasing sophistication
Core
General
Modules
CAQ
EOF: Certifying Exam—Effect on
Training Programs
Restructured 4th year
– Depends on size and orientation
– Will not include Boards frenzy
Effect on Fellowships
– Research-oriented
– Narrowly defined
Recent Decisions
Orals Results
Distribution of Orals results
Beta tested in Louisville last October
Very successful
Results were available on line quicker than
US mail
Will do this for upcoming exam in May.
PD to get results very close in time to
release of results to residents.
September 30 Rule
If a candidate plans to take the current
Orals then training must be completed by
Sept 30th of that year.
Certificate will be held until completed.
Extenuating Circumstances
Exception must be attested by PD
Review by ABR
Enough is Enough Rule
Applies to candidates that repeatedly try to pass
the Exam
Currently 10 years
In EOF it will be 5 years to pass Core after
becoming eligible ( 36 months of training).
In EOF it will be 5 years to pass Certifying after
first qualifying to take exam. (15 mos)
Additional year of training if not able to meet the
requirement.
No need to take Core again once passed.
2013
Last year of full Orals June 2-5, 2013
First year of Core Exam
Week of September 30-October 4, 2013
Following year will move Core earlier to 3rd
week of June---probably
Transition Plan
What happens to those in process who do not
finish Written or Orals when we convert in 2013?
Elaborate timing diagram with every permutation
with Condition and Fail
Fail Written 3 times  Core
Fail Orals 3 times  Core
Condition Orals 3 times  Certifying Module
Plus Essentials and Non-Interpretative
Louisville and Beyond
After 2015 will go on
RP and RO plan on continuing their Oral
exams for the future
Now assessing the sites available to give
the future exams: computer storage, ability
to show our exam material etc
Simulation possibilities
MQSA- Curently
"The interpreting physician shall have
interpreted or multi-read at least 240
mammographic examinations within the 6month period immediately prior to the date
that the physician qualifies as an
interpreting physician. This interpretation
or multi-reading shall be under the direct
supervision of an interpreting physician."
Exemption- Currently
But if you pass your Boards first time:
"Physicians who have interpreted or multi-read
at least 240 mammographic examinations under
the direct supervision of an interpreting
physician in any 6-month period during the last
2 years of a diagnostic radiology residency
and who become appropriately board
certified at the first allowable time, as defined
by an eligible certifying body, are otherwise
exempt"
MQSA- EOF
Works in progress -Awaiting final FDA
Graduates after 2014
"Physicians who 1) successfully complete a
diagnostic radiology residency program in
2014 (or later), 2) have interpreted or multiread at least 240 mammographic
examinations under the direct supervision of
an interpreting physician in any 6-month
period during the last 2 years of this
residency, and 3) have passed their
certifying board's core exam by the end of
their residency are otherwise exempt."
Initial and Continuing Experience Requirements for New Interpreting Physicians Under MQSA
Year of Residency
Year of Fellowship or Practice
Current MQSA Requirements, Before 2014
No Exemption
R1
Oral Certifying Exam (Fail)

R2
R3
R4
240
exams
F1/P
F2/P
960 exams in 24 months continuing
experience

Date qualifies as
Interpreting Physician
With Exemption
R1
R2
or 240
exams
or 240
exams
or 240
exams
F2/P
960 exams in 24 months continuing
experience

Date qualifies as
Interpreting Physician
P

If not enough exams,
must requalify
Oral Certifying Exam (Pass)

R4
F1/P
R3
240
exams
P
960 exams in 24 months continuing
experience
etc.
P
P
960 exams in 24 months continuing
experience
etc.

If not enough exams,
must requalify
Proposed MQSA Requirements, After 2014
No Exemption (no change)
R1
Core Exam (Fail)

R2
R3
R4
240
exams
F1/P

Date qualifies as
Interpreting Physician
With Exemption (proposed)
Core Exam (Pass
before residency end)
R2
R3
240
exams
or 240
exams
R4
or 240
exams
or 240
exams
P

If not enough exams,
must requalify
F1/P
F2/P
960 exams in 24 months continuing
experience

Date qualifies as
Interpreting Physician
Exams under Supervision
P
960 exams in 24 months continuing
experience
etc.
Certifying Exam


R1
F2/P
960 exams in 24 months continuing
experience
P
P
960 exams in 24 months continuing
experience
etc.

If not enough exams,
must requalify
IMG Policy
Most candidates from India.
India advisory committee to ABR.
Must have completed training and certification .
Chair is PD. Hired as junior faculty.
All 4 years MUST be in same institution.
If they switch the 4 years start over again.
Can take Certifying Exam after 4 years of
training. Do not have to wait the 15 months
Practice Analysis
Survey instruments finalized
Could add question about focused practice
Will be distributed electronically
Results to be discussed by October, 2010
Recognized not most scientific way to
gather data
Should look at feasibility of obtaining
CTP/ICD-9 codes from sample practices
ABRF Proposal
ABRF –President Bill Hendee
New venture to help Residents and PDs
RFP to go out soon
14 Ethics and Professionalism modules
Modeled after the Physics modules
ETA: April 2011
Volunteerism
EOF Committees all formed
BUT…..
Terms of service on these committee
range from 2-4 years
Still need 1000s of items for the exams,
both Core and Certifying
Orals still around for a few more years….
MIRC
Medical Imaging Resource Center
A simple way to identify, index and retrieve images,
teaching files and other radiology information
The ability to search multiple imaging libraries as if they
were a single library organized by medically important
categories
An authoring tool that makes it easy to create radiology
teaching files and other electronic documents in flexible
formats with a common underlying structure
Tools to enable sites to manage and exchange images
and research data sets for imaging clinical trials
17 Ways ABR Communicates

Pamphlet distribution

Paper & electronic
newsletters of societies

Leadership meetings

Discussions at ABR booth

Trustee presentations at
society meetings

Major journal articles

The Beam

Snail mail from ABR

Email from ABR

Responses to email
questions (individual)

Web content, FAQs

Surveys

1-on-1 phone
conversations in office

Annual report

Video

Phone or Webex with
practices

“Open microphone”
EOF: Final Thoughts
ABR mission, to protect the public, is vital
No part of its mission is possible without the work of
hundreds of volunteers
Thanks to everyone who has or will contribute their
cases and writing expertise to continue our mission
If we are to survive, we must establish the culture
of lifelong learning in each of our diplomates
Concluding Thought
“One never notices what has been done, one
can only see what remains to be done.”
Mdm Marie Curie
Contact :
[email protected]