Core examination
Certifying examination

Core Exam Certifying
Exam
Internship
12 mos
R1 R2
12 mos 12 mos
R3
12 mos
R4
12 mos
Fellowship/ employment
12 mos 3 mos

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

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
CT
IR
MR
NM/Molecular
Rad/Fluoro
US
Physics
Safety
Q# 45 45 45 45 45 45 45 45 minimum 45 questions per category
45
Vascular
45
Q#
45
45
45
45
45
45
90
45
500

EOF: Examination Blueprint
CT
IR
MR
NM/Molec
Breast
0
Card GI MSK Neuro Peds Thorax Repr/endo GU Vasc Q#
45
45
45
45
Rad/Fluoro
US
Physics
Safety
Q#
45
25
45 45 45 45 45 45 45
Minimum of 45 questions if category is to be scored separately
15
45
45
90
45
45 45 500

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

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?

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

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.

6. Evaluation
5. Synthesis
4. Analysis
3. Application
Oral
Rank, Rate
Oral
Plan, Categorize
Oral
Identify, Analyze
Interpret, Solve
2. Comprehension
1. Knowledge
Oral
“Written”
“Written”
Distinguish, Convert
Define, Describe, List

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

Oral exam
– Observation
– Synthesis
– Management
– Communication
Core exam
– 60% will test all of the above
– Communication skills?

Entire spectrum of diagnostic radiology
Basic/intermediate level*
Probably at least 500 questions
Administered over 1 ½ days
*Clearly needed: a curriculum for every scorable category

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

ABR-RRC meeting yearly
All residents exposed to every clinical category to be tested
Board preparation displaced into 3 rd year
Structure of 4 th year
– Smaller programs—may be no change
– Larger programs—may be competition for highly sought clinical subspecialties

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

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

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

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, Vascular-
Interventional 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.

Breast
GENERAL
Cardiac
GI
MSK
Neuro
Nuclear
Pediatric
Reproductive/Endo
Thoracic
Ultrasound
Urinary
Vascular-Interventional

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) CT enterography
b) MR enterography
c) Selective angiography d) 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

“ The important thing is to make the lesson of each case tell on your education.”
William Osler

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.

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.

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

Restructured 4 th year
– Depends on size and orientation
– Will not include Boards frenzy
Effect on Fellowships
– Research-oriented
– Narrowly defined

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.

If a candidate plans to take the current
Orals then training must be completed by
Sept 30 th of that year.
Certificate will be held until completed.
Extenuating Circumstances
Exception must be attested by PD
Review by ABR

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.

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 3 rd week of June---probably

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

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

"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."

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"

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
Current MQSA Requirements, Before 2014
Year of Fellowship or Practice
No Exemption
R1
With Exemption
R1
R2
R2
R3
Oral Certifying Exam (Fail)

R4 F1/P F2/P P P
240 exams

960 exams in 24 months continuing experience

960 exams in 24 months continuing experience
Date qualifies as
Interpreting Physician
If not enough exams, must requalify etc.
240 exams
R3
or 240 exams
Oral Certifying Exam (Pass)

R4 F1/P F2/P P P
or 240 exams
or 240 exams

960 exams in 24 months continuing
Date qualifies as experience
960 exams in 24 months continuing experience

If not enough exams,
Interpreting Physician must requalify etc.
Proposed MQSA Requirements, After 2014
No Exemption (no change)
R1
With Exemption (proposed)
R1
R2
R2
Core Exam (Fail)

R3 R4
240
F1/P F2/P
960 exams in 24 months continuing
P P
960 exams in 24 months continuing experience exams

Date qualifies as
Interpreting Physician experience

If not enough exams, must requalify
Core Exam (Pass before residency end)

Certifying Exam
 etc.
240 exams
R3
or 240 exams
R4 F1/P F2/P P P
or 240 exams
or 240 960 exams in 24 months continuing exams

Date qualifies as experience

960 exams in 24 months continuing
If not enough exams, experience
Interpreting Physician must requalify etc.
Exams under Supervision

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

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 –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

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….

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

 Leadership meetings
 Discussions at ABR booth
 Trustee presentations at society meetings
 The Beam
 Email from ABR
 Web content, FAQs
 1-on-1 phone conversations in office
 “Open microphone”
 Pamphlet distribution
 Paper & electronic newsletters of societies
 Major journal articles
 Snail mail from ABR
 Responses to email questions (individual)
 Surveys
 Annual report
 Video
 Phone or Webex with practices

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

“One never notices what has been done, one can only see what remains to be done.”
Mdm Marie Curie
Contact : dmezwa@beaumont.edu