APDR/APCR ABR UPDATE March 2010 Duane Mezwa MD William Beaumont Hospitals Past President, APDR GI Trustee, ABR

1. APDR/APCR ABR UPDATE March 2010Duane Mezwa MDWilliam Beaumont HospitalsPast President, APDRGI Trustee, ABR

2. Exam of the Future (EOF): Structure • Core examination • Certifying examination

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

4. 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

5. 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

6. EOF: Core Exam Blueprint minimum 45 questions per category

7. EOF: Examination Blueprint 0 25 15 90 Minimum of 45 questions if category is to be scored separately

8. EOF: Core Exam—Scoring • Each organ system • Each method • Patient safety, physics • Assuming sufficient breadth of content that a confident pass/fail decision is possible • Minimum 45 questions/category } Scored pass/fail

9. 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?

10. 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

11. 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 LearningJuly 2010.

12. Bloom’s Hierarchical Taxonomy of Educational Objectives 6. Evaluation Rank, Rate Oral 5. Synthesis Plan, Categorize Oral Identify, Analyze 4. Analysis Oral 3. Application Interpret, Solve Oral 2. Comprehension Distinguish, Convert “Written” Define, Describe, List 1. Knowledge “Written”

13. 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

14. EOF: Core Exam—Contrast With Oral Exam • Oral exam • Observation • Synthesis • Management • Communication • Core exam • 60% will test all of the above • Communication skills?

15. 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

16. EOF: Core Exam—Conditions of Contest • Pass all categories: Pass • Fail 5 categories: Condition • Fail > 5 categories: Fail • Conditioned candidates retake only the failed category(ies) • Failed candidates retake entire exam • Both will be offered in six months

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. Clinical Practice Areas Breast GENERAL Cardiac GI MSK Neuro Nuclear Pediatric Reproductive/Endo Thoracic Ultrasound Urinary Vascular-Interventional

24. 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 • CT enterography • MR enterography • Selective angiography • Enteroclysis Warning: Once you have made a selection, you may not return to this screen

25. What is the MOST likely diagnosis? • Carcinoid • GI stromal tumor • Adenocarcinoma • Metastatic melanoma

26. What is the MOST likely diagnosis? • Carcinoid • GI stromal tumor • Adenocarcinoma • Metastatic melanoma

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

28. 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

29. 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.

30. 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.

31. We are testing what the candidate feels is most important to his/her future practice, not what their past training has been.

32. 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 Modules General CAQ Core

33. 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

34. Recent Decisions

35. 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.

36. 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

37. 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.

38. 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

39. 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

40. 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

41. MQSA- Curently • "The interpreting physician shall have interpreted or multi-read at least 240 mammographic examinations within the 6-month 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."

42. 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"

43. 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 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 this residency, and 3) have passed their certifying board's core exam by the end of their residency are otherwise exempt."

45. 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

46. 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

47. 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

48. 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….

49. 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