Board Certification: An Important Marker

Along with the Radiological Society of North America, American College of Radiology, American Radium Society, and American Medical Association Section on Radiology, the American Roentgen Ray Society (ARRS) co-sponsored the founding of the American Board of Radiology (ABR) in 1934. The mission of the ABR is to certify that our diplomates have demonstrated and maintained the requisite knowledge, skill, and understanding of their disciplines for the benefit of their patients.

Board certification serves as an important marker for the highest standard of care. It reflects the critical core values of compassion, patient-centeredness, and a commitment to life-long learning. Patients, physicians, medical physicists, health care providers, insurers, and quality organizations look for board certification as the best measure of a physician’s or medical physicist’s knowledge, experience, and skills to provide quality care within a given specialty.

Board certification and participation in a maintenance of certification (MOC) program has many benefits. It assures patients, privileging committees, payers, and regulators that the physician has successfully completed a training program and continues to expand his or her medical knowledge, which leads to improvements in their practice and patient safety. In 2007, the ABR instituted a requirement for practice quality improvement projects, which must be relevant to one’s practice, achievable, provide measurable results, and likely to improve quality. This remains a major component of the MOC program. Over the years, the number of qualified projects and participatory activities has been greatly expanded to reflect the integration of radiologists into the health care system.

Since the founding of the ABR in 1934, the field of radiology has grown dramatically, and it became increasingly difficult to master the entire field. Thus, separate residency training programs were developed for diagnostic radiology and radiation oncology. (Most recently, a primary residency for interventional radiology has been approved.) Continued advances and the development of new imaging modalities resulted in many diagnostic radiologists restricting their practice domains to some extent. The ABR responded by providing subspecialty certification to reflect the importance of subspecialization. Subspecialty certification was offered for pediatric radiology and vascular and interventional radiology in 1994, for neuroradiology in 1995, and nuclear radiology in 1999. Given the speed with which these many advances in medical science changed the field of radiology, it became apparent that remote board certification was no longer pertinent. Something was needed to assure the public that physicians were keeping up with these new developments. The four subspecialty certificates offered by the ABR were timelimited from their inception, and the last lifetime primary certificates issued by the ABR were given in 2001. MOC would now be required to maintain ABR certification for all but lifetime certificate holders.

The four components of MOC are:

1. professionalism and professional standing
2. life-long learning and self-assessment
3. assessment of knowledge, judgment, and skills and
4. improvement in medical practice.

Originally, these requirements were met by maintaining an unrestricted state medical license in each state of practice, participating in continuing medical education that includes self-assessment, a cognitive exam, and participation in quality improvement projects. The ABR MOC requirements have been modified over the years, based on feedback from our diplomates.

Initially, a cognitive exam was required to satisfy Part 3 for MOC participants. However, this required radiologists to take time away from their practices and to pay for expenses to travel to a testing center. Furthermore, the cognitive assessment was required only every 10 years, an interval that many considered too long. An improved program was needed that would be meaningful, but not onerous for the diplomates.

The ABR Online Longitudinal Assessment (OLA) was introduced for diagnostic radiology in 2019, and for interventional radiology, radiation oncology, and medical physics in 2020. Each week, participating diplomates receive an email giving them the opportunity to answer one or two questions. Most diplomates are required to answer 52 questions a year. (Some with multiple certificates are required to answer more questions.) These questions were designed to test “walking around knowledge”—information diplomates should know “off the top of their head,” if asked by a colleague, resident, or patient. Furthermore, it is a learning experience, as the rationale for the correct answers and a reference is provided immediately.

Reaction to OLA has largely been positive. Many radiologists enjoy receiving two questions every week in their selected areas of practice. Since the “shelf life” of a question is four weeks, diplomates can elect to answer eight questions every four weeks, if they prefer “batching” the questions rather than answering two questions every week. Most radiologists have enjoyed participating in OLA, as it takes only a few minutes each week and does not require travel. Many continue to answer the weekly questions even after completing their yearly requirement of 52 items. More than 20,000 radiologists are now actively participating in MOC.

Questions for all ABR examinations are written by volunteers and reviewed by a subspecialty committee, before being submitted to be included in the cognitive assessment. The next step is the test assembly meetings, where all questions are again reviewed. Despite this rigorous process, an occasional problematic question may appear on an examination. These are picked up when ABR staff review the results of the exam. The ABR is fortunate to have two psychometricians and multiple experienced exam developers on staff, who review any potentially questionable item. Often, problematic questions are referred to a radiologist member of the Board of Trustees or the appropriate Committee Chair to participate in the decision whether to keep or remove the item from examination scoring.

The ABR is a non-profit organization, which is highly dependent upon its many volunteers. The ABR has more than 900 diagnostic radiologists serving as volunteers on 68 different committees. Most of the paid office staff live in the Tucson, Arizona area and work at the ABR office building. Volunteers do much of their work electronically, but they do have periodic committee meetings in the Chicago testing center, near O’Hare airport, or at ABR headquarters in Tucson.

The volunteers contribute their time and expertise in writing questions, reviewing them for image quality and appropriateness as well as for constructing examinations. Before an examination is administered, another group of volunteers sets the passing standard (cutscore) using the Angoff Method. The Angoff Method is done by having a group of subject matter experts— many of whom are residency program directors—evaluate each item to estimate the proportion of minimally competent candidates who would correctly answer the item. The cutscore is the score that the panel estimates a minimally qualified candidate would receive. This is the legally defensible method used for many high-stakes examinations in the United States.

The goal of the ABR is to conduct examinations in which the candidates are comfortable and can do their best in demonstrating their knowledge. Thus, videos have been created to demonstrate the examination experience in both Chicago and Tucson. The ABR also communicates with their diplomates, candidates for certification, and the public through a variety of other means. The ABR has a booth at several of the larger radiology meetings to provide in-person answers and advice to attendees. The BEAM is the ABR’s newsletter that has recently increased from three to six issues a year. The ABR’s blog received more than 23,000 views last year. Additional communication efforts, which began in November 2018, include the social media outlets of Facebook, Twitter, Instagram, and LinkedIn.

The American Board of Radiology, along with the other 23 American Board of Medical Specialty member boards, strives to advance our field, improve patient care, and protect the public by assuring that our diplomates have acquired and maintained the requisite knowledge and skills to be effective practitioners. Board certification is an important marker of those attributes.

The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.