This is article will be updated in the January 2007 issue of the American Journal of Roentgenology. Preview article courtesy of the American Roentgen Ray Society (ARRS).
The Accreditation Council for Graduate Medical Education (ACGME) is a private, nonprofit council that evaluates and accredits medical residency programs in the U.S. The ACGME has 27 different residency review committees (RRC), one for each specialty. The diagnostic radiology RRC is comprised of representatives from the American Board of Radiology (four members), the American College of Radiology (three members), the American Medical Association (three members), and one resident member.
Each RRC evaluates all residency programs in its specialty by conducting site reviews to determine that the facility fulfills the program requirements for resident education. Because programs that fail to meet these requirements risk losing accreditation, the individual programs must take the requirement changes very seriously.
The radiology RRC issued its proposed changes on October 26 this year. Comments must be in by December 13, 2006. The effective date of the proposed revisions is July 1, 2007. Not all of the proposed changes can or should be addressed here, but some of the more substantial or controversial changes are highlighted below.
No independent call for 12 months
The RRC is proposing that residents undergo 12 months -- rather than the current six months -- of training prior to taking independent call. Independent call is defined as "making an interpretation available to patient care providers prior to review of the examination by faculty or senior resident."
Proponents of this change argue that beginning radiology residents cannot possibly master the amount of material required to work independently in six months; in fact, they cannot even rotate through all the primary subspecialties in that amount of time. As imaging becomes more advanced, proponents say, residents need to be more sophisticated before working independently.
In the interest of patient safety, providing final reports the following day is inadequate as the immediate clinical decision has already been made based on the resident's preliminary interpretation. As clinicians depend more upon imaging to guide care, a resident "miss" can have more serious consequences. This rule change would bring radiology in line with other specialties that do not allow residents to take unsupervised call in their first year.
Opponents of this change argue that 12 months is just as arbitrary as six months -- the ability to work independently depends more on adequate preparation than simply on time elapsed. Opponents to the change argue that independent call provides such a valuable learning opportunity for younger residents that they should be given that opportunity as soon as they are ready.
Adequately prepared residents do a good job of what they are expected to do -- make the critical findings that immediately impact patient care. Opponents say that first-year radiology residents are in their second postgraduate year of training; it is unfair to directly compare first-year radiology residents with interns.
Others support this policy in principle, but feel that some minor adjustments might make the changes more feasible without compromising patient safety. They say that nine months would allow adequate time for the residents to complete all of the "core" rotations.
Some suggest that determining whether a resident is ready to take independent call should be based on a direct evaluation of competence, such as internally administered oral and written examinations. Others suggest that perhaps the radiology RRC should instead mandate that the studies read by these residents be reviewed within, say, two hours of the preliminary interpretation.
This way, patient safety standards would be maintained without compromising resident independence. Because clinicians often review radiographs independently and rely on resident opinions only for challenging cases, allowing plain films to be preliminarily interpreted would bring about graduated independence with little impact on patient care.
The proposed change would not affect a number of programs that already have 24-hour faculty or senior-level coverage. However, smaller programs would likely be more heavily impacted. These programs might respond in one of two ways:
- By increasing faculty supervision, which might place an increased financial or logistical burden on the institution.
- By concentrating call more heavily in later years of residency, which would utilize resident time that has traditionally been reserved for filling in gaps in resident education while preparing for board examinations.
Some believe this to be a positive development, as senior-level call helps cement resident expertise and confidence, and places them in a more supervisory role. Others believe that senior residents' final few months of intense and focused study are necessary to prepare them for independent practice, not just for oral boards.
Change in requirement for radiology/pathology education
A proposed change that has received little attention, but has the potential for significant impact, is the deletion of a section that currently reads as follows: "Radiologic/pathologic conferences are required for those residents who do not participate in formalized extramural pathology teaching programs." Under the proposed change, a requirement for radiologic/pathologic correlation would be included in a bulleted list of nine general didactic content items that also include such topics as appropriate imaging utilization, socioeconomics of radiologic practice, professionalism, and ethics.
Some program directors and chairs have indicated that the current requirements virtually force them to send their residents to the six-week radiology-pathologic correlation (RadPath) course hosted by the Armed Forces Institute of Pathology (AFIP), placing an undue financial burden upon the institution -- especially as Medicare is no longer reimbursing programs for residents during this period. Some say that residency programs should be able to provide this education in the manner that best fits the institution, rather than be required to send them elsewhere for such a long period.
Others, however, agree that the current requirements encourage programs to send their residents to the AFIP or else provide a suitable substitute -- which is exactly why it is necessary.
This group opposes deleting the current language. They argue that the program requirements should focus on defining what constitutes appropriate resident education, then figure out how to finance it, rather than letting the financing determine what is appropriate. The broad support of the AFIP by residents and practitioners alike attests to its educational value. There has been no change in imaging or in pathology that has made radiologic/pathologic correlation any less important -- if anything, as imaging becomes increasingly complex, the AFIP has become even more vital.
Whether the change in wording would actually threaten the viability of the AFIP would depend on how the requirement would be implemented. As radiologic/pathologic correlation is still included in the document, it may be that the standards would not change and that programs would still need to provide a legitimate substitute to the AFIP course if a program chose to forgo it.
On the other hand, removing the paragraph dedicated to radiologic/pathologic correlation might imply a dramatic relaxation of what would be considered an allowable substitute. This would likely pose a significant threat to AFIP, since institutions' incentives to participate in the course would be greatly diminished.
Tracking resident learning
The radiology RRC has proposed several changes meant to more carefully track residents' educational progress, bolster resident scholarly activity, and increase residents' accountability. For example, one change would require that every resident "must engage in a scholarly project ... the results of such projects must be published or presented at institutional, local, regional, or national meetings."
In a similar vein, each resident would be required to undergo a "learning activity that addresses one's ability to identify, develop, and implement a system solution to a system problem." Finally, programs/residents would be required to keep track of diagnostic and interventional cases by using the ACGME case log system.
The radiology RRC proposes that the responsibility of documenting the attainment of learning objectives should rest primarily with the resident in the form of a resident learning portfolio. The portfolio would document compliance in eight categories, including a case/procedure log, conferences and meetings attended, compliance with institutional and departmental policies (such as HIPAA, JCAHO, patient safety, infection control, dress code, and so on), and several others.
Other changes
A few other examples of proposed rule changes include the following:
- The current one-to-one faculty-resident ratio requirement would be removed. Instead, at least one full-time subspecialty-trained faculty member for each of the nine major subspecialties would be required.
- A more structured set of rules would guide the didactic curriculum, which would need to be repeated every two years.
- Special attention would be given to education in nuclear medicine, particularly to radionuclide safety, as mandated by the Nuclear Regulatory Commission.
- Twenty-four hour access to major journals (electronic or print) would need to be provided to residents, though only "access" (rather than "ready access") to a major medical library would be required.
- All resident-reviewed cases would need to be reviewed by faculty within a 24-hour period.
- The minimum board examination pass rate would be relaxed to include those with a single condition, but who rectify the condition at the first attempt. Also, the minimum pass rate would no longer include written board examination results.
- A teaching file would no longer need to be kept by the institution as long as the ACR learning file, or its equivalent, was available.
The radiology RRC has characterized the proposed changes as "major revisions" to the current program requirements. The committee members have put significant effort into creating changes that would strengthen resident education. Many of the proposed changes may also have indirect effects on other considerations, such as the ability of smaller programs to incorporate these changes, recruitment of residents into academic radiology, and the sustainability of AFIP as we know it.
The document containing the proposed revisions can be viewed at the ACGME Web site. The comment period closes on December 13 this year and, as mentioned on the site, "if a response is not received by the above date, the ACGME will assume that the addressee has no objection to the proposed revisions."
Whether you agree or disagree with the proposed changes, this is the time to engage in the discussion of how to shore up resident education as academic radiology continues to deal with significant challenges.
By Dr. David Larson
AuntMinnie.com contributing writer
December 5, 2006
Larson is a radiology resident at the Unversity of Colorado Health Sciences Center, University Hospital in Denver. This article was originally published in the American Journal of Roentgenology (January 2007, Vol. 188:1). Reprinted by permission of the ARRS.
The opinions expressed in this policy brief are those of Dr. David Larson; they do not necessarily reflect the viewpoint or position of the American Roentgen Ray Society, the University of Colorado Health Sciences Center, or AuntMinnie.com.
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