The author argues for eliminating the 1-year internship and mandating specialty training to ensure that radiologists can be competitive

Radiology residency training guidelines are increasingly the topic of scrutiny and discussion. On October 26, 2006, the radiology Residency Review Committee (RRC) issued proposed changes to the program requirements for diagnostic radiology resident education. These are significant, but they dealt mostly with revisions to documentation, oversight, support systems, and minor curriculum changes. In July 2005, the Intersociety Conference (ISC), sponsored by the American College of Radiology (ACR), meets to consider a selected issue in our specialty: how to best design training programs to meet future needs.¹

The primary recommendations of the conferees were to reduce the time for training in general radiology to 3 years; shift the "clinical" training to a required 3-year subspecialty/research fellowship; and consider delaying the oral boards examination until at least 1 year after completion of training. These, in turn, have engendered much discussion and alternative proposals, some of which further reduce the general diagnostic radiology exposure; increase the subspecialty training and/or research; and even substitute nonradiology training for general radiology, thereby opening subspecialty radiology certification to nonradiologists. Indeed, the ISC raised the specter of abandonment of the notion of a general radiologist. "The underlying theme is that our field has become so complex that no one individual can maintain the level of expertise needed to practice the entire field of radiology. Because no one practices the entire field, why do we insist that radiologists become at least ‘minimally competent' in the entire field?"

The latest round of public discussion of potential changes to radiology training programs was publicly heralded in the Chairman's column in the ACR Bulletin in May 2003 by E. Stephen Amis, MD. Amis wrote, "Some feel that cutting residency training from 4 years back to 3 might be the answer; others maintain this would ‘dumb down' the specialty. Many other options were considered, but each one had significant flaws."

Six months prior to the publication of Amis' column, I had hosted the second of two informal symposia on the topic of "The Future of Interventional Radiology." Fifteen department chairmen and interventional radiologists from seven hospitals in Connecticut (five of which have residency programs) addressed the issue of radiology training in the era of turf battles, subspecialization, and radiologist shortages, among other subtopics. We, too, lamented a "dumbing down" of our specialty, but felt that it was already at risk as a result of the flight from subspecialty fellowship training engendered by the hot job market for radiologists. This has prompted many overburdened radiology groups to forego longstanding policies to hire only fellowship-trained radiologists and to dangle offers before graduating residents that these debt-burdened trainees cannot resist. Unfortunately, with the incursions of nonradiologists performing imaging procedures, these general-only radiologists may be less well-trained in the specific subspecialty than the nonradiologists. Now that is dumbing down. Radiology practices and departments need the subspecialists who are familiar with advanced imaging and the specific clinical issues, both of which can be garnered only through advanced experience and/or training. The economic imperatives will dictate the loss of fellowship training and will change radiology irreversibly and for the worse.

In addition to the need for providing state-of-the-art clinical and scientific education in our discipline, the appropriate structure for radiology training programs must address the aforementioned issues. I propose several possible measures to the American Board of Radiology (ABR):

1. Keep the required total training period at 5 years. Lengthening the time would have two drawbacks: diminishing the flow of new practitioners into radiology at a time when a small workforce is detrimental to the future of our specialty; and reducing the relative attractiveness of our specialty for medical graduates.
2. Keep the residency at 4 years. There is much to learn in the not-yet-mature fields of ultrasound, CT, MRI, and PET, and much more is coming in molecular imaging. There remains a need for general radiology training, and shorter or fewer rotations in the broader specialty will weaken just as many departments and practices as will be strengthened by additional subspecialty training.
3. Eliminate the requirement of a clinical internship. The absolute requirement of a clinical internship has not always been the case. When it was not required by the ABR, many excellent programs either made it optional or reserved PGY-1 radiology slots for top candidates. The residency program in my department was one of those, and we were able to attract excellent candidates, many of whom turned out to be among our best residents and are now successful private and academic radiologists. As pointed out in the ISC report, the required PGY-1 clinical year "has little value in today's practice."
4. Require a subspecialty fellowship in either clinical radiology or research. Aside from enhancing the expertise of the entrants into the workforce and the quality of the practices they join, this has numerous indirect benefits. By raising the overall expertise of radiologists, it presents a more formidable defense in turf issues with other specialists whose training may include specific exposure to imaging in their specialties. Academic departments will benefit by the assured supply of fellows, the enhanced likelihood that exposure to research will lead to choices of academic careers, and the increased supply of subspecialists. The supply of new radiologists would not be interrupted because the PGY-1 clinical year would no longer be required.
5. Alternatively, if eliminating the internship year is not acceptable, we should still require subspecialty training. One way of including the subspecialty training while minimizing the loss of general training would be to move the oral boards examinations to a year or more after completion of residency. This would restore the training portion of the second half of the fourth year of the radiology residency and allow it to be used for mandatory subspecialty training.

Radiology has thrived on change. We have adopted new technology, adapted to socioeconomic trends, and had a profound effect on health care. The current discussion of training requirements is a healthy exercise.

Alan Kaye, MD, is president of Advanced Radiology Consultants, Bridgeport, Conn. For information, contact .

Reference

1. Dunnick NR, Applegate K, Arenson R, Levin D. Training for the future of radiology: a report of the 2005 Intersociety Conference. J Am Coll Radiol. 2006;5:319-324.