| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Perspectives |
1 From the Department of Radiological Sciences, University of California, Irvine Medical Center, Orange. Received October 29, 1999; accepted November 2. Address reprint requests to the author, 18961 Castlegate Ln, Santa Ana, CA 92705.
Index terms: Education • Perspectives • Radiology and radiologists
When applying for postgraduate training, the categories used to judge a student's accomplishments include his or her grades, national board/Medical College Achievement Test scores, acceptance into honor societies, Dean's letter, and letters of reference and class standing, if available.
The selected student begins his or her residency program, which involves many years of close association with his or her attending physicians. It generally takes about a year to recognize a student who lacks the ability to become a good physician. I believe that when we recognize a resident who lacks competence or whose personality lacks the necessary humanistic qualities required of a physician, such individuals should be removed from the program no later than by the end of the 2nd year. Too often we procrastinate and allow such residents to remain in the program, deciding to leave this "weeding out" to the certification board. The Residency Review Committee states that each program should review its residents for competence and performance twice each year (Capp P, personal communication, October 1999). Such reviews are frequently perfunctory since there are no standards for overviews. Why are program chairmen so lax in their supervision? It may relate to their desire to avoid potential grievance committee hearings, the realization that their documentation is inadequate to prove incompetence, and/or an unwillingness to interfere with the rotational structure of the program. The executive director of the American Board of Radiology (ABR) estimates that less than one candidate in 2,000 (0.05%) is not recommended for the certification examination by the program director (Capp P, personal communication, October 1999). Obviously, the number of incompetent residents far exceeds this figure. The decision regarding competency is then left for the board to decide.
Senior (1) in 1976 defined competence as that which a physician is capable of doing and performance as that which a physician actually does. Competence may mean that a resident has achieved sufficient knowledge, while performance encompasses additional areas such as ethics, interpersonal relationships, clinical skills, empathy for patients, and the ability to perform tasks. Certification examinations evaluate knowledge but are less efficient in evaluating performance since the examiners have not worked with the candidates. This will still hold true when the ABR emphasizes computer problem solving in future examinations.
Miller's pyramid (2,3) depicts the student's development, starting with the accumulation of knowledge and the gradual transition to practice. Knowledge by itself does not lead to performance, which is the ability to show how knowledge is used. When the resident progresses up the pyramid and shows how he or she uses knowledge for the benefit of the patient, he or she then reaches the apex of the pyramid and can practice his or her specialty. The resident then has the ability to combine clinical judgment, problem solving, and technical skills.
We all know that certification does not always mean that the resident has the necessary competence and performance capability to provide good patient care (4). Certification is our attempt to measure these markers and to try to exclude the incompetent. In a survey of American Board of Internal Medicine members (5), it was estimated that about 15% of certified internists give inappropriate care. The physicians felt that the primary deficiencies in this group were in clinical judgment and factual knowledge. The nonphysicians indicated that the deficiencies were in humanistic qualities. Obviously, the deficiencies are in both knowledge and competence, without which you cannot have performance.
In 1992, anesthesiology program directors (6) were asked whether they would permit their graduating residents to administer three increasingly complex anesthetic regimens to themselves. They replied that for the least complex operation, they would permit 63% of their residents, while for the most complex procedure they would permit only 9.7% of their graduating residents. They stated that they would not permit 7.1% of their resident graduates to perform any operation, and 49% in that latter group were certified by their board.
In our current system for certification, a resident must attend an approved residency program. The program director must state that the resident is qualified for the examination, and the resident must then pass the written examination and, finally, the oral examination. I believe that this system should be reasonably effective in screening residents for knowledge but perhaps somewhat less effective for screening residents for performance. The latter is really the responsibility of the program director.
The interrelationships between training and certification are complex. Training programs vary not only in their quality but also in the content of their material. Within programs, there are substantial variations in the balance between practice and teaching. This is becoming even more pronounced as the pressures of health maintenance organization (HMO) medicine demand increased clinical output. This was expressed in a recent article (Chesbrough RM. Poor training of radiology residents compromises patient care. Diagnostic Imaging. 1999; 10:35–36.) in which the author, who was the residency coordinator of a program with 16 residents, stated that none of the staff had the time to attend meetings to discuss resident performance. Readout sessions were rushed without time for teaching. There was no curriculum for residents and no requirement to cover specific material. He commented that the first-time pass rate on board examinations was 20%, but the Accreditation Council for Graduate Medical Education still accepted the program. Obviously, this is an example of a failure in our present system.
I believe that if we consider the average resident group entering residency programs, 20% will be excellent, regardless of the efforts of the faculty, 10% of them will do poorly, and the ability of the remaining 70% will depend on the effort put into teaching and the challenging of the resident to be the best that he or she can be. I am a firm believer that challenging residents at various stages of their residency with meaningful tests is an effective way of increasing knowledge. With that in mind, are we challenging residents sufficiently, or is there a better way to assess and stimulate the acquisition of knowledge?
Can we improve on our evaluation of competence? At the start of the residency program, the unfamiliar surroundings, new attendings, and plethora of new and confusing facts stimulate the resident to concentrate on accumulating knowledge. I would estimate that this lasts about 6 months. We then have a nonstimulatory period when the resident's knowledge is not formally challenged, which lasts until the beginning of the 3rd year, when residents concentrate on preparing for the written examination. During these 18 months, residents are acquiring knowledge in methodology and experience, but for those 70% of residents who respond to challenges (ie, testing) for increasing their knowledge, this time is not well utilized.
How can we better assess and stimulate the acquisition of knowledge? I have always thought that we should present the resident at the start of each year of residency with a syllabus representing the minimal amount of information that he or she will be required to learn in that year. At the end of each year, he or she would be tested, by means of written examination and/or computer problem solving, on the material in the syllabus, and if he or she failed that test, required to pass a makeup test within 3 months. If the resident failed the makeup test, then he or she would be removed from the program. This would weed out those who are less capable after 15 months of residency. This must be coupled with an assessment of performance, as defined above, which must be conducted by the attending faculty who worked with the resident. There would be no syllabus in the 4th year to allow for elective specialty rotations. The final examination would be the ABR certification examination, which would be the final test for competence.
A program such as this would have several advantages: (a) Residents would be continually challenged each year; they would be stimulated to continually apply themselves to the acquisition of information. (b) The program would automatically weed out poor residents, something that frequently is not done under our present system. (c) Formal assessment of residents at the end of each year would require the faculty to assess performance as well as knowledge; this is rarely done today. (d) The residents in every program would receive the same syllabus and have a written record of the minimum amount of information they would be required to know. (e) Every program director would know the minimum they are expected to teach the residents in a given year. (f) The final ABR examination basically would be an overall competency examination.
Some of the disadvantages of such a program would be (a) it would be difficult for every program to provide the same rotation/information within a specified period; (b) programs that lost residents would have problems with unbalanced rotations; (c) the examining process would become more complicated and more expensive; (d) there would be an increased effort required by the faculty.
The cornerstone of academic medicine has always been balanced on the concepts of teaching, research, and practice. We all recognize that these three principles represent academic medicine. Practice is financially supported by billings or salary. Research has its own financial support from foundations and the National Institutes of Health. My concern is the drastic change that is now occurring in the practice of medicine, that is, HMO- style medicine, which will sacrifice teaching time for productive and lucrative practice time. Some departments are beginning to measure clinical effort and use it to determine income, which again will decrease the faculty time devoted to education. The program I am suggesting would require a major increase in the support of teaching, which is receiving less financial support each year. Programs would need added financial support from the Dean's office, which eventually should be included as an additional subsidy in clinical reimbursement or as a subsidy to support teaching from state or federal sources.
The concept of a national syllabus for each year of the first 3 years of training would provide a working base for the residents. The concept of a yearly examination based on such a syllabus would provide the challenge that the majority of residents need to acquire knowledge. The need to pass the examination would weed out the poor residents. I believe this would provide the base of Miller's pyramid—knowledge and competence. For certification, performance must be judged by the department faculty and knowledge, by the final board examination.
I thought it would be of interest to the readers to know how radiology certification is conducted in European countries (7,8). The only country with a national certification program similar to ours is England.
In France, after 4 years of training, a regional board examines the files of each candidate and decides whether to award him or her a diploma. The minimum training time is four periods of 6 months each in a radiology department, with the other 6-month periods in either a radiology or clinical department.
In Belgium, 5 years of training are required. An examination that tests theoretic knowledge is conducted at a local level. The national board requires that each candidate prove that he or she has attended regularly a formal theoretic course during the 5 years and that a minimum of 3 years of training has been performed at one of the university training centers.
In Austria, there is no legal obligation for a board examination at this time, but it is planned for 2002. Six years of training are required to become a radiologist. The training time includes 6 months of internal medicine, 3 months of surgery, and 3 months of another clinical specialty. Currently, there is a nationwide board examination organized by the Austrian Radiological Society that is taken on a voluntary basis.
In Sweden, a resident needs a minimum of 5 years of service in radiology to be accepted as a specialist. Eighteen months of training in clinical areas are required; this can include 3 months of radiology. There is no formal examination, but there is a voluntary one, which about 30% of candidates take.
In Italy, there is no nationwide board examination, but there are examinations locally managed by the universities. Four years in diagnostic radiology training are required before the resident can take such an examination. Clinical rotation is required before entering radiology.
In Germany, there is 1 year of clinical training and 4 years of training in radiology. Board examinations are managed locally and are the responsibility of the 16 states of the Federal Republic of Germany. Usually, the board examination is an oral interview conducted by two experts.
With the formation of the European Union there may be a more unified approach to examinations in the future.
Wilbur Smith (9) stated that assessing the performance of a resident in diagnostic radiology is like trying to solve a puzzle for which there is no simple solution because the resident's job is so complex. The job includes acquiring a cognitive knowledge base, focusing perceptual attitudes, forming integrational abilities, and developing appropriate interpersonal skills. He stressed the difficulty of trying to estimate the performance of residents on the basis of objective tests.
The program chairman and his or her faculty have the responsibility of assessing the competence and performance of the resident. They are in a far better position to do this than the ABR, and we know that examination results by themselves do not predict the success of a resident. Our aim should be to provide the resident with a suitable medium in which to grow. This includes stimulating the acquisition of knowledge by periodically challenging the resident. Informal conferences, although of considerable value, do not challenge residents sufficiently. I am suggesting that an annual test based on a yearly syllabus for the first 3 years of residency would provide a suitable challenge. The knowledge that such testing would occur would stimulate the resident to maintain a high level of knowledge acquisition throughout the program and allow an early weeding out of inadequate residents.
We must be aware that knowledge does not guarantee satisfactory performance, and the latter must be judged by the teaching faculty. Record keeping is essential. Poor competence or poor performance must be documented. The yearly examination, in effect, would judge the adequacy of the training program as well as that of the resident. Deans and hospital administrators must realize the importance of protecting teaching resources with recognition and funding. In my mind, teaching is the most endangered portion of the academic triangle of research, teaching, and clinical practice.
References
This article has been cited by other articles:
|
|
 |
|
  R. B. Gunderman, Y.-P. Kang, R. E. Fraley, and K. B. Williamson Instructional Technology and Radiologic Education Radiology, October 1, 2001; 221(1): 1 - 4. [Full Text] [PDF]
|
|
|
|
|
|
J. B. Masterson and R. M. Friedenberg Radiology Training and Certification in Ireland Dr Friedenberg responds: Radiology, January 1, 2001; 218(1): 304- - 304. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
