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]
