APDR/APCR ABR UPDATE March 2010

APDR/APCR ABR UPDATE APDR/APCR ABR UPDATE March 2010March 2010

Duane Mezwa MDDuane Mezwa MDWilliam Beaumont HospitalsWilliam Beaumont Hospitals

Past President, APDRPast President, APDRGI Trustee, ABRGI Trustee, ABR

Exam of the Future (EOF): Exam of the Future (EOF): StructureStructure

Core examinationCore examination

Certifying examinationCertifying examination

R1 R2 R3 R4 Fellowship/employment

Internship

12 mos 12 mos 12 mos 12 mos 12 mos 12 mos 3 mos

Core Exam CertifyingExam

EOF: Core ExaminationEOF: Core Examination

Given at 36 monthsGiven at 36 months

Covers Covers allall of diagnostic radiology of diagnostic radiology– Only comprehensive exam in EOFOnly comprehensive exam in EOF– Candidate must pass every category to Candidate must pass every category to

qualify for certifying examinationqualify for certifying examination– Level of knowledge expected: Level of knowledge expected:

basic/intermediatebasic/intermediate

EOF: Core Exam CategoriesEOF: Core Exam Categories

Organ Systems* (10):Organ Systems* (10):– Breast, Cardiac, Endocrine/Reproductive, Breast, Cardiac, Endocrine/Reproductive,

Gastrointestinal, Musculoskeletal, Neuro, Pediatric, Gastrointestinal, Musculoskeletal, Neuro, Pediatric, Thoracic, Urinary, VascularThoracic, Urinary, Vascular

Modalities (6):Modalities (6):– Rad/fluoro, CT, MR, Nuclear/Molecular, US, Rad/fluoro, CT, MR, Nuclear/Molecular, US,

InterventionalInterventional

Fundamentals (2)Fundamentals (2)::– Physics, patient safetyPhysics, patient safety

* Clinically relevant anatomy, pathophysiology, etc

BreastBreast CardiacCardiac GIGI MSKMSK NeuroNeuro PedsPeds ThoraxThoraxRepro / Repro / EndoEndo UrinaryUrinary VascularVascular Q#Q#

CTCT 45

IRIR 45

MRMR 45

NM/MolecularNM/Molecular 45

Rad/FluoroRad/Fluoro 45

USUS 45

PhysicsPhysics 90

SafetySafety 45

Q#Q# 45 45 45 45 45 45 45 45 45 45 500

minimum 45 questions per category

EOF: Core Exam Blueprint

BreastBreast CardCard GIGI MSKMSK NeuroNeuro PedsPeds ThoraxThorax Repr/endoRepr/endo GUGU VascVasc Q#Q#

CTCT 4545

IRIR 4545

MRMR 4545

NM/MolecNM/Molec 4545

Rad/FluoroRad/Fluoro 4545

USUS 4545

PhysicsPhysics

SafetySafety 4545

Q#Q# 4545 4545 4545 4545 4545 4545 4545 4545 4545 4545 500500

0

25

90

Minimum of 45 questions if categoryis to be scored separately

EOF: Examination Blueprint

15

EOF: Core Exam—ScoringEOF: Core Exam—Scoring

Each organ systemEach organ system

Each methodEach method

Patient safety, physicsPatient safety, physics

Assuming sufficient breadth of content that Assuming sufficient breadth of content that a confident pass/fail decision is possiblea confident pass/fail decision is possible

Minimum 45 questions/categoryMinimum 45 questions/category

} Scored pass/fail

EOF: Core Exam - Physics EOF: Core Exam - Physics ContentContent

Minimum of 90 questionsMinimum of 90 questions

Each item writing organ system-based category Each item writing organ system-based category has a physicisthas a physicist

Questions: “Clinically relevant” physicsQuestions: “Clinically relevant” physics– How can image quality be improved?How can image quality be improved?– What is the source of this artifact?What is the source of this artifact?– How would you design this examination to minimize How would you design this examination to minimize

excessive radiation exposure?excessive radiation exposure?

EOF: Core Exam—Example EOF: Core Exam—Example Physics QuestionPhysics Question

Repeat CT is requested Repeat CT is requested to determine whether to determine whether the CBD lesion is a the CBD lesion is a tumor or a stone. What tumor or a stone. What is the most appropriate is the most appropriate maneuver?maneuver?

a) Decrease kVpa) Decrease kVpb) Increase kVpb) Increase kVpc) Decrease masc) Decrease masd) Increase masd) Increase mase) Buy new unite) Buy new unit

Update on Physics ActivitiesUpdate on Physics ActivitiesCurriculumCurriculum– Revision completed: Revision completed: www.aapm.org– Teaching objectives: spring 2009Teaching objectives: spring 2009– Questions matched to curriculumQuestions matched to curriculum

Web-based modules – RSNA WebsiteWeb-based modules – RSNA Website– Phase 1 (completed - RSNA 2009)Phase 1 (completed - RSNA 2009)

X-ray, CT, Nucs, US, MR, BiologyX-ray, CT, Nucs, US, MR, Biology32 modules developed by radiologist/physicsist32 modules developed by radiologist/physicsist

– Phase 2 (target June ’10 or so)Phase 2 (target June ’10 or so)Processing, display, quality, perception, PACSProcessing, display, quality, perception, PACS30 additional modules30 additional modules

AAPM Summer School on Teaching Medical Physics: AAPM Summer School on Teaching Medical Physics:

Innovations in LearningInnovations in Learning July 2010.July 2010.

Bloom’s Bloom’s HierarchicalHierarchical Taxonomy of Taxonomy of Educational ObjectivesEducational Objectives

1. Knowledge

2. Comprehension

3. Application

4. Analysis

5. Synthesis

6. Evaluation

“Written”

“Written”

Oral

Oral

Oral

Oral

Define, Describe, List

Distinguish, Convert

Interpret, Solve

Identify, Analyze

Plan, Categorize

Rank, Rate

EOF: Core Exam—Contrast with EOF: Core Exam—Contrast with Current Written ExamCurrent Written Exam

Written examWritten exam– Fact retrieval onlyFact retrieval only– Individual organ systems and imaging methods not Individual organ systems and imaging methods not

separately evaluatedseparately evaluated– ? Relevance of some physics questions? Relevance of some physics questions

Core examCore exam– Roughly 40% fact retrievalRoughly 40% fact retrieval– Comprehensive, all systems/methods scoredComprehensive, all systems/methods scored– Questions based on specific imagesQuestions based on specific images

EOF: Core Exam—Contrast With EOF: Core Exam—Contrast With Oral ExamOral Exam

Oral examOral exam– ObservationObservation– SynthesisSynthesis– ManagementManagement– CommunicationCommunication

Core examCore exam– 60% will test all of the above60% will test all of the above– Communication skills?Communication skills?

EOF: Core Exam—ContentEOF: Core Exam—Content

Entire spectrum of diagnostic radiologyEntire spectrum of diagnostic radiology

Basic/intermediate level*Basic/intermediate level*

Probably at least 500 questionsProbably at least 500 questions

Administered over 1Administered over 1½ days½ days

*Clearly needed: a curriculum for every *Clearly needed: a curriculum for every scorable categoryscorable category

EOF: Core Exam—Conditions of EOF: Core Exam—Conditions of ContestContest

Pass all categories:Pass all categories: PassPass

Fail 5 categories:Fail 5 categories: ConditionCondition

Fail > 5 categories:Fail > 5 categories: FailFail

Conditioned candidates retake only the Conditioned candidates retake only the failed category(ies)failed category(ies)

Failed candidates retake entire examFailed candidates retake entire exam

Both will be offered in six monthsBoth will be offered in six months

EOF: Core Exam—Effects on EOF: Core Exam—Effects on Training ProgramsTraining Programs

ABR-RRC meeting yearlyABR-RRC meeting yearly

All residents exposed to every clinical All residents exposed to every clinical category to be testedcategory to be tested

Board preparation displaced into 3Board preparation displaced into 3rdrd year year

Structure of 4Structure of 4thth year year– Smaller programs—may be no changeSmaller programs—may be no change– Larger programs—may be competition for Larger programs—may be competition for

highly sought clinical subspecialtieshighly sought clinical subspecialties

EOF: Core Exam—What We NeedEOF: Core Exam—What We Need

Written curricula for all categoriesWritten curricula for all categories

About 100 item-writersAbout 100 item-writers

About 2000 questions before 2013About 2000 questions before 2013

Sage advice from all of youSage advice from all of you

Goodwill of the radiology communityGoodwill of the radiology community

EOF: Certifying Exam— 2015 EOF: Certifying Exam— 2015 Underlying DualityUnderlying Duality

Conceived as the first MOC exam, but Conceived as the first MOC exam, but alsoalso

Final certifying exam given by ABRFinal certifying exam given by ABR

– Must pass test of public scrutinyMust pass test of public scrutiny

– Must test competenciesMust test competencies

– Need not test entire breadth of radiologyNeed not test entire breadth of radiology

EOF: Certifying ExamEOF: Certifying Exam

Given 15 months after residency graduationGiven 15 months after residency graduation

Will contain 5 modulesWill contain 5 modules

– Noninterpretive skills (common to physicians)Noninterpretive skills (common to physicians)

– Essentials of radiology (common to radiologists)Essentials of radiology (common to radiologists)

– 3 modules chosen by candidate3 modules chosen by candidate

General radiologyGeneral radiology

Subspecialty radiologySubspecialty radiology

EOF Certifying Exam—ContentEOF Certifying Exam—Content

Emulate practice of radiologist at workEmulate practice of radiologist at work– Some normal examsSome normal exams– Many “real-life” decisionsMany “real-life” decisions

Differential (not single) diagnosesDifferential (not single) diagnosesManagement decisionsManagement decisions

More complicated question typesMore complicated question types– Many possible right answersMany possible right answers– Layout mimicking real patient workupsLayout 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.

Clinical Practice AreasClinical Practice AreasBreastBreastGENERALGENERALCardiacCardiacGIGIMSKMSKNeuroNeuroNuclearNuclear

PediatricPediatricReproductive/EndoReproductive/EndoThoracicThoracicUltrasoundUltrasoundUrinaryUrinaryVascular-InterventionalVascular-Interventional

EOF: Certifying Exam—Example EOF: Certifying Exam—Example CaseCase

A 43 year old man experienced intermittent A 43 year old man experienced intermittent episodes of hematochezia. Capsule endoscopy episodes of hematochezia. Capsule endoscopy showed angiodysplastic changes in the ileal mucosa. showed angiodysplastic changes in the ileal mucosa. Which of the following radiologic examinations is Which of the following radiologic examinations is MOST appropriate for further evaluationMOST appropriate for further evaluation

a) CT enterographyb) MR enterographyc)c) Selective angiographySelective angiographyd)d) EnteroclysisEnteroclysis

Warning: Once you have made

a selection, you may not return

to this screen

What is the MOST likely diagnosis?a)Carcinoidb)GI stromal tumorc) Adenocarcinomad)Metastatic melanoma

Exam PhilosophyExam Philosophy

“The important thing is to make the lesson of

each case tell on your education.”

William Osler

Certifying Exam- 2015Certifying Exam- 2015

How will the exam be graded?How will the exam be graded?

5 modules: Noninterpretive skills, 5 modules: Noninterpretive skills, essentials, three candidate-selected essentials, three candidate-selected modulesmodules

Each will be graded with own passing Each will be graded with own passing standardstandard

Candidate must pass all 5 componentsCandidate must pass all 5 components

No “condition” statusNo “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:Certifying Exam:

Of the three clinical modules, how many can be chosen in the Of the three clinical modules, how many can be chosen in the same category?same category?

All 3. Candidates allowed free choice to construct their exam All 3. Candidates allowed free choice to construct their exam among General or Subspecialty Categoryamong General or Subspecialty Category

Rationale: The clinical modules will comprise only 60% of the Rationale: The clinical modules will comprise only 60% of the exam. Allowing free choice permits early subspecialization, while exam. Allowing free choice permits early subspecialization, while still testing all of DR.still testing all of DR.

It is expected that candidates selecting more modules in a given It is expected that candidates selecting more modules in a given subject will be answering questions of higher difficulty.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 EOF: Certifying Exam—What We NeedNeed

Even more help!Even more help!

Sufficient material and question-writing Sufficient material and question-writing expertise to create graded spectrum of expertise to create graded spectrum of sophistication within every categorysophistication within every category

Example: Neuroradiology contentExample: Neuroradiology content

Core General Modules CAQ

Increasing sophistication

EOF: Certifying Exam—Effect on EOF: Certifying Exam—Effect on Training ProgramsTraining Programs

Restructured 4Restructured 4thth year year– Depends on size and orientationDepends on size and orientation– Will not include Boards frenzyWill not include Boards frenzy

Effect on FellowshipsEffect on Fellowships– Research-orientedResearch-oriented– Narrowly definedNarrowly defined

Recent DecisionsRecent Decisions

Orals ResultsOrals Results

Distribution of Orals resultsDistribution of Orals results

Beta tested in Louisville last OctoberBeta tested in Louisville last October

Very successfulVery successful

Results were available on line quicker than Results were available on line quicker than US mailUS mail

Will do this for upcoming exam in May.Will do this for upcoming exam in May.

PD to get results very close in time to PD to get results very close in time to release of results to residents.release of results to residents.

September 30 RuleSeptember 30 Rule

If a candidate plans to take the current If a candidate plans to take the current Orals then training must be completed by Orals then training must be completed by Sept 30Sept 30thth of that year. of that year.

Certificate will be held until completed.Certificate will be held until completed.

Extenuating CircumstancesExtenuating Circumstances

Exception must be attested by PDException must be attested by PD

Review by ABRReview by ABR

Enough is Enough RuleEnough is Enough Rule

Applies to candidates that repeatedly try to pass Applies to candidates that repeatedly try to pass the Examthe ExamCurrently 10 yearsCurrently 10 yearsIn EOF it will be 5 years to pass Core after In EOF it will be 5 years to pass Core after becoming eligible ( 36 months of training).becoming eligible ( 36 months of training).In EOF it will be 5 years to pass Certifying after In EOF it will be 5 years to pass Certifying after first qualifying to take exam. (15 mos)first qualifying to take exam. (15 mos)Additional year of training if not able to meet the Additional year of training if not able to meet the requirement.requirement.No need to take Core again once passed.No need to take Core again once passed.

20132013

Last year of full Orals June 2-5, 2013Last year of full Orals June 2-5, 2013

First year of Core ExamFirst year of Core Exam

Week of September 30-October 4, 2013Week of September 30-October 4, 2013

Following year will move Core earlier to 3Following year will move Core earlier to 3rdrd week of June---probablyweek of June---probably

Transition PlanTransition Plan

What happens to those in process who do not What happens to those in process who do not finish Written or Orals when we convert in 2013?finish Written or Orals when we convert in 2013?

Elaborate timing diagram with every permutation Elaborate timing diagram with every permutation with Condition and Failwith Condition and Fail

Fail Written 3 times Fail Written 3 times Core Core

Fail Orals 3 times Fail Orals 3 times Core Core

Condition Orals 3 times Condition Orals 3 times Certifying Module Certifying Module Plus Essentials and Non-InterpretativePlus Essentials and Non-Interpretative

Louisville and BeyondLouisville and Beyond

After 2015 will go onAfter 2015 will go on

RP and RO plan on continuing their Oral RP and RO plan on continuing their Oral exams for the futureexams for the future

Now assessing the sites available to give Now assessing the sites available to give the future exams: computer storage, ability the future exams: computer storage, ability to show our exam material etcto show our exam material etc

Simulation possibilitiesSimulation possibilities

MQSA- CurentlyMQSA- 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."

Exemption- CurrentlyExemption- Currently

But if you pass your Boards first time: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- EOFMQSA- EOF

Works in progress -Awaiting final FDAWorks in progress -Awaiting final FDAGraduates after 2014Graduates 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."

Current MQSA Requirements, Before 2014

No Exemption

etc.

With Exemption

etc.

Proposed MQSA Requirements, After 2014

No Exemption (no change)

etc.

With Exemption (proposed)

etc.

Date qualifies as Interpreting Physician

R1 R2 R3 R4

F2/PR1 R2 R3

Interpreting Physician

P

960 exams in 24 months continuing experience

If not enough exams,

must requalify

F1/P F2/P or 240 exams


P P

Date qualifies as

240 exams

or 240 exams

or 240 exams

Year of Residency

Oral Certifying Exam (Pass)

240 exams


R4

Year of Fellowship or Practice

If not enough exams,

must requalify

Oral Certifying Exam (Fail)

P960 exams in 24 months continuing

experience

F1/P

Core Exam (Fail)

R1 R2 R3 R4 F1/P F2/P P P240

exams960 exams in 24 months continuing

experience960 exams in 24 months continuing

experience

Date qualifies as If not enough exams,Interpreting Physician must requalify

Certifying Exam

Core Exam (Pass before residency end)

R1 R2 R3 R4 F1/P F2/P P P240

exams or 240 exams

or 240 exams

or 240 exams

Exams under Supervision

Initial and Continuing Experience Requirements for New Interpreting Physicians Under MQSA

Date qualifies as If not enough exams,Interpreting Physician must requalify



IMG PolicyIMG Policy

Most candidates from India.Most candidates from India.

India advisory committee to ABR.India advisory committee to ABR.

Must have completed training and certification .Must have completed training and certification .

Chair is PD. Hired as junior faculty.Chair is PD. Hired as junior faculty.

All 4 years MUST be in same institution.All 4 years MUST be in same institution.

If they switch the 4 years start over again.If they switch the 4 years start over again.

Can take Certifying Exam after 4 years of Can take Certifying Exam after 4 years of training. Do not have to wait the 15 monthstraining. Do not have to wait the 15 months

Practice AnalysisPractice Analysis

Survey instruments finalizedSurvey instruments finalized

Could add question about focused practiceCould add question about focused practice

Will be distributed electronicallyWill be distributed electronically

Results to be discussed by October, 2010Results to be discussed by October, 2010

Recognized not most scientific way to Recognized not most scientific way to gather datagather data

Should look at feasibility of obtaining Should look at feasibility of obtaining CTP/ICD-9 codes from sample practicesCTP/ICD-9 codes from sample practices

ABRF ProposalABRF Proposal

ABRF –President Bill HendeeABRF –President Bill Hendee

New venture to help Residents and PDsNew venture to help Residents and PDs

RFP to go out soonRFP to go out soon

14 Ethics and Professionalism modules14 Ethics and Professionalism modules

Modeled after the Physics modulesModeled after the Physics modules

ETA: April 2011ETA: April 2011

VolunteerismVolunteerism

EOF Committees all formedEOF Committees all formed

BUT…..BUT…..

Terms of service on these committee Terms of service on these committee range from 2-4 yearsrange from 2-4 years

Still need 1000s of items for the exams, Still need 1000s of items for the exams, both Core and Certifyingboth Core and Certifying

Orals still around for a few more years….Orals still around for a few more years….

MIRCMIRC

Medical Imaging Resource CenterMedical Imaging Resource CenterA simple way to identify, index and retrieve images, A simple way to identify, index and retrieve images, teaching files and other radiology information teaching files and other radiology information The ability to search multiple imaging libraries as if they The ability to search multiple imaging libraries as if they were a single library organized by medically important were a single library organized by medically important categories categories An authoring tool that makes it easy to create radiology An authoring tool that makes it easy to create radiology teaching files and other electronic documents in flexible teaching files and other electronic documents in flexible formats with a common underlying structure formats with a common underlying structure Tools to enable sites to manage and exchange images Tools to enable sites to manage and exchange images and research data sets for imaging clinical trials and research data sets for imaging clinical trials

17 Ways ABR Communicates17 Ways ABR Communicates

Leadership meetingsLeadership meetings Discussions at ABR boothDiscussions at ABR booth Trustee presentations at Trustee presentations at

society meetingssociety meetings The BeamThe Beam Email from ABREmail from ABR Web content, FAQsWeb content, FAQs 1-on-1 phone 1-on-1 phone

conversations in officeconversations in office ““Open microphone”Open microphone”

Pamphlet distributionPamphlet distribution Paper & electronic Paper & electronic

newsletters of societiesnewsletters of societies Major journal articlesMajor journal articles Snail mail from ABRSnail mail from ABR Responses to email Responses to email

questions (individual)questions (individual) SurveysSurveys Annual reportAnnual report VideoVideo Phone or Webex with Phone or Webex with

practicespractices

EOF: Final ThoughtsEOF: Final ThoughtsABR mission, to protect the public, is vitalABR mission, to protect the public, is vital

No part of its mission is possible without the work of No part of its mission is possible without the work of hundreds of volunteershundreds of volunteers

Thanks to everyone who has or will contribute their Thanks to everyone who has or will contribute their cases and writing expertise to continue our missioncases and writing expertise to continue our mission

If we are to survive, we must establish the culture If we are to survive, we must establish the culture of lifelong learning in each of our diplomatesof lifelong learning in each of our diplomates

Concluding ThoughtConcluding Thought

“One never notices what has been done, one can only see what remains to be done.”

Mdm Marie Curie

Contact :[email protected]

APDR/APCR ABR UPDATE March 2010

Health & Medicine

Transcript of APDR/APCR ABR UPDATE March 2010