New coalition for early-career radiologists delivers consensus letter to the ABR regarding Core Exam

Multi-society consensus letter captures mounting frustration with COVID-related delays in high-stakes in-person board certification exam

The newly formed MERCC coalition aims to unite early career radiologists in common purpose.

June 8, 2020

Amidst the backdrop of a historical moment for a country struggling with the multifaceted consequences of global pandemic, resident physicians in radiology and early-career radiologists have organized around discontent with the American Board of Radiology (ABR) handling of delays related to COVID-19 and the Initial Certification (Core) Exam. The newly formed MERC Coalition has unified 10+ radiology professional societies in the common purpose of converging on a more practical solution to administration of the Core Exam.

Originally scheduled for May/June 2020, the Core Exam was subsequently shifted to November 2020, and now faces a tentative new date of February 2021, which would put the exam well into the R4 (PGY-3) year for residents who expected to take the exam at the end of their R3 (PGY-4) year. This places tremendous stress on radiology residents by further delaying the exam date relative to the clinical rotations that reinforce exam-related topics. Compounding this problem is the controversial position of the ABR that dedicated study time is not required to pass this high-stakes exam. In strong contradistinction, residents of past generations have taken as much as 12 months of their final year to study the differential diagnoses presented in board exams prior to the Core.

The letter centers on a proposal for decentralized exam administration as a path to preserving the November 2020 exam against COVID-related uncertainties, which would help residents maintain the intensity of focus and knowledge needed to pass this exam which faced an abysmal 84% pass rate in the previous round.

The full text of this consensus letter is provided below.

See also: February 2021 newly announced tentative month for delayed Core Exam

— Orbit Staff

Date: June 8, 2020

To:
Valerie P. Jackson, MD, Executive Director of the American Board of Radiology (ABR)
Brent J. Wagner. MD. Incoming Executive Director of the American Board of Radiology (ABR)
Vincent P. Mathews, MD, President of the American Board of Radiology

The past several months have presented numerous challenges to communities across the world. Individuals and institutions alike have responded with flexibility, approaching old problems with novel solutions. During these difficult times, adapting to a new reality is paramount. In addition to the mental and physical toll that the COVID-19 pandemic has placed on radiologists, the current third-year radiology trainees and early career physicians have the additional stressor of the Core, Certifying and Subspecialty Exams. We write to you to address our concerns and offer solutions for administering these exams in Fall 2020.

We agree that the in-person exam in its traditional format is not feasible during a time when physical distancing is critical to ensure the safety of our communities. However, the solution should not be to delay the exam with the ultimate goal of administering an in-person examination in either the Tucson or Chicago American Board of Radiology (ABR) testing center. The limitations related to the COVID-19 pandemic will likely be ongoing, and we believe adaptation to this new environment by offering novel solutions is critical to the success of our trainees and practices.

Below, we list our concerns as to why the decision to delay the Core, Certifying and Subspecialty Exams to 2021 adversely affects the radiology community. Additionally, we have included several possible solutions and urge the ABR to consider them.

Concerns:

  • Board certification/eligibility and potential impacts on the radiology workforce: The delay of the Core, Certifying and Subspecialty Exams until 2021 may result in fewer physicians eligible for board certification, with downstream impacts on the radiology workforce. In context of a 15.9% fail rate for the 2019 Core Exam, a significant number of trainees will likely be required to repeat the exam during fellowship or first year in practice, ultimately resulting in delayed completion of the certifying process. This delay may impact their ability to be employed by some radiology practices. Additionally, some practices have salary differentials for board-eligible radiologists as opposed to board-certified or CAQ-certified radiologists; the perpetual delay in the timing of the Certifying and Subspecialty Exams amounts to significant salary losses for these future diplomates. Furthermore, delay in obtaining Authorized User status places newly minted radiologists and nuclear medicine providers at disadvantage in the job market.
  • Trainee clinical availability and the impact on patient care: The decision made by the ABR to postpone the Core Exam has placed trainees and training programs in a uniquely challenging situation less than a month prior to the beginning of the academic year. With both third- and fourth-year residents scheduled to take the exam in the same calendar year, the most senior residents within radiology programs will be unavailable to cover essential radiology services, particularly overnight services. This will have a disproportionate and devastating impact on our small and rural residency programs. The absence of senior residents will be felt by our patients, emergency department providers, and critical inpatient teams.
  • Wellness: Delaying the exams in their traditional format without a novel alternative is incompatible with the ABR’s primary goal of maintaining the health and well-being of exam candidates. The uncertainty regarding exam administration will result in dramatic shift in personal and professional planning leading to undo anxiety, distress, and burn out among our trainees. For example, multiple trainees and early career physicians have expressed concern over the impact of repeated exam delays on their family planning decisions, including but not limited to potential travel restrictions on current and future pregnancies and added health risks. This issue disproportionately affects females and further exacerbates our professions ability to strive toward a diverse and inclusive workforce. Also, as the most junior members of their practices, new hires often have the last pick of their time off from work, and may not be able to accommodate the constantly changing date assignments of these exams. Additionally, these individuals may be unable to recover the time off they have already reserved for the previously scheduled dates, sometimes determined a year in advance.
  • Validation: ABR exams are criterion exams based on performance expected by a uniform cohort. For example, delay of the Core Exam to 2021 introduces complex variability in examinees give the significant differences in PGY-5 experience. This is most evident for Early Specialization in IR (ESIR) or Integrated IR residents as they spend the majority of their PGY-5 year on IR or IR-related rotations. A delay in the Core Exam to 2021 will increase the amount of time elapsed between their last diagnostic radiology rotation and when they sit for the exam. This puts these residents at a disadvantage relative to non-ESIR or non-IR residents, and thus may also distort the psychometrics of this exam. Further, training programs have significant variability in implementation of mini-fellowships for diagnostic radiology residents. This complexity is further amplified for Certifying and Subspecialty exams given the significant heterogeneity in practice case mix.

Potential solutions:

  • Virtual Remote Testing: Numerous certifying agencies within the American Board of Medical Specialties (ABMS) have been able to adopt new testing capabilities to offer secure, fair, reproducible, and valid board exams in response to the pandemic that ensure continued public trust. For example, the American Board of General Surgery will be offering a multi-day home exam with exam security monitored by live video proctoring, highlighting an innovative response with little disruption to the lives of trainees and the workflow of their respective programs. Such solutions have been hailed as a resounding success, with test-takers able to continue on their path to certification without additional undue distress already caused by the pandemic.

    The ability of the ABR to adapt to an altered format is not without precedent, with the organization demonstrating the capability to administer exam questions in a distributed format of the past few years. First, in 2017, after the failure to provide some Core Exam test takers with breast imaging questions, the ABR successfully provided a remote module to address this component of the test. Additionally, the ABR has successfully implemented a remote maintenance of certification (MOC) process with questions very similar to the Core, Certifying and Subspecialty Exam format. The MOC platform can potentially be leveraged and adapted for this purpose.
  • In-Person Local and Regional Testing: Several options exist for the administration of local and regional testing. For example, local testing can be offered at institutions in coordination with program directors, with proctoring at institutions as needed. This approach has been adopted by the American Board of Anesthesiology who has offered residency programs the option of on site testing in lieu of utilization of testing centers.

At this point, it is impossible to predict the course of this pandemic and continued delays are not a sustainable plan. We strongly encourage the ABR to reconsider their decision and work on a temporary distributed exam.

We request that the ABR adopt one of the proposed solutions, offering the exams in a virtual remote or in-person local/regional testing format in Fall 2020 as previously announced. To that end, we ask that the ABR continue to work with relevant stakeholders including program directors, maintaining collaboration with other ABMS boards to evaluate alternative exam processes, and engage trainees and early career physicians in open dialogue to come to a collaborative solution.

Thank you for considering our proposed solutions and the opportunity to represent the concerns of radiology trainees and early career physicians.

Respectfully,

American Alliance of Academic Chief Residents in Radiology (A3CR2), Executive Committee
American Association of Women in Radiology (AAWR), Executive Committee
American Association of Women in Radiology (AAWR), Member-in-Training Committee
American College of Radiology Resident and Fellow Section (ACR RFS), Executive Committee
American College of Radiology Young and Early Career Professional Section (ACR YPS), Executive Committee
American College of Nuclear Medicine (ACNM), Nuclear Medicine Resident Organization Board of Directors
American Roentgen Ray Society (ARRS), Executive Committee
American Society of Functional Neuroradiology (ASFNR) Member-In-Training Committee
American Society of Neuroradiology (ASNR) Young Professionals Committee
Association of University Radiologists (AUR), Executive Committee
Radiological Society of North America Resident and Fellow Committee (RSNA RFC)
Society of Abdominal Radiology Resident and Fellow Section (SAR RFS)
Society of Breast Imaging Resident and Fellow Section (SBI RFS)
Society of Breast Imaging Young and Early Career Professional Section (SBI YPS)
Society of Imaging Informatics in Medicine (SIIM), Executive Committee
Society of Imaging Informatics in Medicine (SIIM), Member-in-Training Committee (SIIM MIT)
Society of Interventional Radiology, Resident, Fellow & Student Section (SIR RFS), Governing Council

Cc: American Board of Radiology Board of Governors 2019–2020

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