New board exam format more closely represents the practice of radiology.
Education has come a long way since radiology boards were established in 1934 with solely oral components.
"At the time it was introduced, oral exams were state of the art and closely mirrored the actual practice of radiology," explains Anthony M. Gerdeman, PhD, director of psychometrics and evaluation at the ABR. "But as the practice environment changed, the oral exam lost some of its fidelity."
Radiology's reliance on technology advances is one of the primary reasons change in the exam was necessary. "Imaging and technology are so central to radiology that it wasn't possible to keep the oral exam up-to-date as a close representation of radiology practice," explains Gary J. Becker, MD, FACR, ABR executive director.
The Exam of the Future improves upon the old system in myriad ways — from becoming more standardized and requiring less fact recall to including both abnormal and normal images when the prior format did not include the latter.
Gerdeman says the new computer-based exams not only improve the face validity (i.e., whether it really measures what it's meant to) of the board exams but they also provide such new testing tools as the ability to label images. Nevertheless, the 2010 announcement of the revised exam caused anxiety among some radiology program directors.
"Change is hard and costly," says Martha B. Mainiero, MD, FACR, past-president of the Association of Program Directors in Radiology (APDR) and residency program director at the Warren Alpert Medical School at Brown University in Providence, R.I. "But the written physics and diagnostic tests were very much in need of updating. The tests were no longer pertinent. The [new] core exam is absolutely an improvement; we can test what we are teaching."
Less Fact Recall, More Evaluation
Dennis M. Balfe, MD, FACR, ABR trustee and former radiology residency program director at the Mallinckrodt Institute of Radiology in St. Louis, says it just took a while for the change to take hold.
"There are so many very good features about the new exams that I believe most directors welcome [the change]," he says. "The physics section [on the previous board exam] was a little artificial in that it drifted toward the theoretical instead of the practical."
Another significant advantage of the new exam format is that it features less fact recall and more high-level evaluation as would be required in everyday radiology practice, Balfe adds. This not only makes the tests more similar to the practice of radiology, but also diminishes answer-sharing opportunities.
"A big difference in the exam format is the greater amount of case management questions, which now make up 60 percent of the test," says Balfe. Although he has mixed feelings about the oral exam's retirement, he notes that the computerized test will be more fair and free of examiner bias — a subjectivity component that no amount of training or restructuring could eliminate from the oral exam format. "With the orals, no two examinees got the same test," says Balfe. "The public wants more transparency."
Allowing for Specialization
The new exam structure, which includes the core exam administered after the third year of residency, required some radiology residency programs to make curriculum changes. While other institutions — Mallinckrodt, Brown University, and the University of Cincinnati — happen to already require that their residents all have multiple clinical rotations in the core areas within the first three years of residency.
"We haven't had to make as many changes to residency program's as you would expect," says Balfe, who appreciates the new format because it tests residents on general radiology after three years and allows for specialization during the fourth year. "This new system allows people to train earlier — and the earlier the better," he says, as it provides room for residents to subspecialize. "Before, the fourth year of residency was just another year of general radiology."
Residency program directors like Balfe and others play a valuable role in the new board certification process by contributing questions for the core and certifying exams. Mainiero is among the 259 radiologist volunteers serving on 28 committees dedicated to the new tests.
The collective efforts of the ABR and program directors have helped ease the transition to the Exam of the Future. "At first, program directors thought the new format was too different and envisioned all the adaptations they'd have to make," says Becker. "But at the last APDR meeting, it was like old news ... they've moved on mentally and emotionally."
Preparing for the First
In addition to finalizing the exams, the ABR is working hard to help prepare the first group of residents, who began training in July 2010, to be evaluated for board certification using the new exam format. The first core exam will be administered in October 2013 followed by the first certifying exam in 2015.
To ease the transition, the ABR had provided first-time test takers with study guides, an online practice exam that will be available by the end of the year, and the opportunity to take abbreviated pilot exams. Prior to the first core exam, residents will be invited to take a full-length pilot core exam in June 2013. In addition to preparing the first group of test takers, the core pilot exams are providing the ABR with important feedback on test questions and evaluation.
"I encouraged my residents to take the pilot exam last May, and nearly my entire class took it," says Balfe. "They thought the image resolution was good, the questions were at the right level, and they had a reasonable amount of time for the test."
Program directors say the new test format is a nonissue for residents, who are used to taking computerized tests and will continue to be tested with similarly formatted exams through the Maintenance of Certification program. Anthony H. Livorine, MD, a second-year radiology resident at the University of Cincinnati, says his only regret about the new test format is missing out on the camaraderie that develops among radiologists enduring the orals."
"There are so many good stories ... like the guy who lost his luggage and had to go through orals wearing shorts," says Livorine. "But overall, I think it's a good change. From what I hear, the oral exam was unrealistic and unnatural, and the new tests are more like what we will actually do in practice."
By Mary Roberts Henderson