Journal of the American College of Radiology
Volume 8, Issue 1 , Pages 53-57, January 2011

A Proposed Medical Physics Curriculum: Preparing for the 2013 ABR Examination

Article Outline

The upcoming ABR examination format for radiology residents is undergoing significant changes in 2013. This requires adaptation of the didactic curriculum for radiology residents entering in July 2010 to meet these changes. Physics will now be incorporated into the core (qualifying) examination during the third year of residency, instead of being tested as a separate examination that was often taken earlier in residency training in past years. In this article, the authors discuss the past, present, and future of medical physics instruction and outline a revised medical physics curriculum for radiology residents that has been internally approved for implementation at the authors' institution and has not been advocated by any society or by the ABR. Starting with this article, the authors hope to encourage a discussion of physics curriculum revision with other institutions.

Key Words: Medical physics curriculum, ABR examination, radiology resident education

 

The recent announcement that the ABR is changing its process for board certification [1] has caused considerable discussion and contemplation by radiology resident training programs to change their instructional activities in response. The ABR and the Diagnostic Radiology Residency Review Committee have been working closely together to improve radiology education [2]. The review committee has issued stricter guidelines for didactic education and a core curriculum (including medical physics) that repeats itself at least every 2 years [3, 4, 5]. These announcements were followed by a period of debate [6, 7]. Now that the dust has settled, radiology residency programs are in the process of adjusting to the changes.

Residency programs will undergo significant changes, and there will be many creative, institution-dependent solutions [8]. A recent article discussed a well-devised proposal for the clinical radiology curriculum for residency training, although the general components of the curriculum such as medical physics were not addressed [9]. That article detailed the difficulties associated with scheduling clinical rotations designed to meet the new ABR examination format.

Medical physics educators face similar hurdles. Precisely how should the medical physics instructional program be modified to accommodate the new ABR requirements? The content of instruction is not in question because the American Association of Physicists in Medicine (AAPM) has published the proposed curriculum content [10, 11, 12]. Moreover, the AAPM, as well as the Radiological Society of North America, have developed Web-based instructional programs [13, 14] for physics education.

Currently, the ABR physics examination is a 4-hour test that may be taken in the second, third, or fourth year of residency. In many programs, residents take the examination early in the second year of training, and physics instruction is therefore concentrated in the first year. Beginning in 2013, physics will be incorporated into each of the 18 categories of a core (qualifying) examination conducted at the end of the third year of residency [1]. Then, 15 months after completing residency, a radiologist will be eligible to take the certifying examination, which will include topics of radiation safety [11].

In anticipation of these changes, it is useful to reflect on the history of medical physics education in radiology residency and to appreciate the vast changes that have occurred and the attendant challenges we now face in educating residents in medical physics. In addition to offering a historical perspective on the evolution of medical physics education at our institution, we describe a proposed medical physics educational program for residents entering training at our institution in July 2010 in preparation for the 2013 ABR examination changes.

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The Early Years (1950s and 1960s) 

Our senior author, Stewart C. Bushong, ScD, joined the faculty of the Department of Radiology in 1966 at the invitation of the first chair of our department, who had arrived in 1956. Between 1956 and 1966, the radiology residency program trained a total of 18 radiology residents, just under 2 per year. Now we train 12 residents each year. Dr. Bushong was hired because the ACGME Diagnostic Radiology Residency Review Committee had placed the department on probation for a lack of medical physics instruction. His first full year of instruction began in 1967 for the 6 residents accepted into the program that year. The 4-year program at that time included radiation therapy, which was allotted 1 of the 4 years.

At that time, radiography and fluoroscopy were the only imaging modalities a radiology resident was required to know. Consequently, the medical physics instruction that Dr. Bushong developed had a considerable component of classical physics and atomic and nuclear physics. The physics of radiography and fluoroscopy was a smaller component of the overall instructional program. Yet his face time with the residents was considerable: 2 hours every Tuesday and Thursday for 2 years, plus a monthly 4-hour laboratory session on Friday afternoon. The medical physics instructional program for each radiology resident totaled 473 hours (Table 1, Figure 1). The vast time allotted to physics education during those years was made feasible by the smaller volume of clinical studies and by a smaller number of imaging modalities at that time (preceding the advent of CT and MRI).

Table 1. Classroom hours of instruction in the medical physics curriculum at our institution by year
Physics Module1967198019911999200220082011
Classical physics6030155556
Health physics75502515776
X-ray production/interaction80603010876
X-ray imaging80603020876
Digital imaging————656
CT—10105556
MRI—10105556
Mammography—10105556
Diagnostic ultrasound—10105566
Nuclear medicine1540303017126
Radiobiology7570352012106
Laboratory sessions8877—————
Examination review——32211010—
Total hours473429237141937866

Note: Notable dates include the following: 1973: first ABR written examination; mid-1970s: separation of radiology into diagnostic radiology and radiation therapy; 1999: diagnostic radiology residents permitted to sit for ABR physics examination after first year of radiology training.

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The Middle Years (1970s and 1980s) 

Before 1973, there was only an oral ABR examination. At that time, residents' knowledge of physics was tested by one physics examiner during the oral boards. The first written ABR examination was in 1973 (Figure 1). In the mid-1970s, the specialty of radiation therapy was separated from diagnostic radiology and became a stand-alone residency program (Figure 1). At about the same time, the ABR began to examine residents in CT, diagnostic ultrasound, and nuclear medicine. MRI was added to the ABR examination in the early 1980s. The instructional program in 1985 continued to be presented over a 2-year period and totaled 429 hours (Table 1, Figure 1). It consisted of 6 courses, which were also registered in the graduate school at our institution, and 4 to 6 graduate students attended along with radiology residents. At that time, residents could take the physics examination during September of their third or fourth year.

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The Recent Years (1990s and 2000s) 

In 1991, because of increasing clinical demands on resident time, the total hours of physics instruction were reduced to 237 hours (Table 1, Figure 1). In 1999, when the ABR allowed residents to take the physics examination in September of their second year, the 2-year physics curriculum had to be accomplished in 1 year (Figure 1). At the same time, the departmental education committee asked if the required material could be completed with less face time. In response, the laboratory sessions were abandoned, and Dr Bushong's face time with the residents was reduced to 141 hours over a 1-year period (Table 1, Figure 1). The physics curriculum was now designed for first-year radiology residents only. In 2002, further reduction in classroom time resulted in a total of 93 hours of physics instruction (Table 1, Figure 1). This 93-hour program was supplemented with an institution-sponsored online program powered by Blackboard Academic Suite (Blackboard Inc, Washington, DC), whereby reading assignments were posted online. In 2008, an additional reduction in classroom time resulted in a total of 78 hours of physics instruction (Table 1, Figure 1).

For residents who elected to take the physics examination during their third year, there was an approximate 14-month gap between the conclusion of the medical physics didactic curriculum (at the end of the first year of radiology training) and the actual examination. To refresh the residents' physics knowledge, a 14-week review began in June before the examination. During June and July, question banks were posted for resident review. One module, consisting of approximately 100 questions, was posted per week. The residents were subsequently given open-ended conceptual review questions and participated in module-specific hour-long question-and-answer sessions 4 days per week in August and early September (the final 6 weeks before the examination). These review sessions were structured to address questions posted in the weekly modules, as well as questions from the Radiological Physics Exam issued annually by the Radiological and Medical Physics Society of New York through the courtesy of AAPM [15].

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The Future (2010 and Beyond) 

The year 2010 brings a new challenge for medical physics instruction of radiology residents. The written physics examination is being replaced by incorporating physics into a 2-day computerized core (qualifying) examination starting in 2013 (Figure 1). In the first year of the new examination format (2013), the core examination will be held in October, taking into account the fact that fourth-year residents will be taking oral boards in June under the previous format. For the subsequent years (2014 and beyond), the core examination will be held in June. Although the physics questions will be integrated into all 18 categories of the core examination, instead of being tested in a separate category, physics will still be graded separately and must be passed [11]. Many physics questions will be image-based, with an emphasis on working backward from images to medical physics principles as recommended by the AAPM in 2006 [16]. Thus, more diagnostic images and clinical scenarios will need to be assimilated into the curriculum as a complement to the basic science concepts constituting the bulk of the current curriculum.

In addition, the shift in the timing of physics assessment to after 36 months of radiology training mandates the creation or adaptation of a physics curriculum that extends beyond the first year of residency. This is necessary to minimize residents' loss of information due to any time lapse between completion of the didactic physics curriculum and the core (qualifying) examination. These changes in the format and timing of medical physics assessment will help decrease the perception of the physics portion of the ABR certification as a onetime hurdle to be overcome. Instead, the new examination will evaluate knowledge that has been accumulated over the course of residency, reflecting the importance of medical physics to a career in radiology [11]. To accommodate these new challenges, Dr. Bushong proposed a new medical physics instructional program to our institution's education committee, and it has been approved. The following curriculum is an institutional solution and has not been approved by the ABR or by any society.

The first component of the new curriculum is a module-specific lecture series. Each of the 11 medical physics modules identified by the ABR will be covered during one 2-hour session per month over the course of 1 year, exclusively attended by the first-year residents (Table 2). These 11 modules in the initial 1-year session are classical physics, health physics, x-ray production and interaction, x-ray imaging, digital imaging, CT, MRI, mammography, diagnostic ultrasound, nuclear medicine, and radiobiology. The initial year of module-based physics education allows the first-year residents to learn a focused physics curriculum in a small-group setting. In addition to the suggested reading assignments per month, residents will be instructed to complete each of the AAPM and Radiological Society of North America Web-based instructional programs (Table 3). The residents will also be encouraged to use other Internet sources of medical physics instructional material, such as the extensive collection of topic-specific PowerPoint slideshows (Microsoft Corporation, Redmond, Washington) provided by the medical physics instructors at the University of Washington [17]. The residents will continue to practice taking questions from Radiological Physics Exam.

Table 2. Proposed classroom hours of medical physics instruction for residents entering in July 2010
Hours per MonthNumber of MonthsHours
Medical physics modules211(R1)22
Clinical medical physics conference144(R1-R4)44
Total hours 66

Note: R1 = first-year residents; R4 = fourth-year residents.

Table 3. AAPM and RSNA Web-based instructional program
Radiation risks
Radiation dose and safety in interventional radiology
Radionuclide dosimetry and nuclear regulations
Basic concepts of radiography
Image quality and dose in radiography
Fluoroscopy systems
Basics of x-ray and mammographic systems
Image quality and dose in mammography
Radiographic image receptors
CT systems
CT image quality and protocols
Radiation dose in CT
Basic principles of nuclear magnetic resonance
MRI image formation
MRI pulse sequences
MRI image characteristics
MRI special acquisition methods
MRI instrumentation
MRI image quality/bioeffects/safety
MRI tissue properties, contrast agents, and reactions
MRI siting and environmental protection
Basic ultrasound imaging and display
Image quality/artifacts/Doppler
Ultrasound concepts and transducers
Gamma cameras/image quality
Nuclear medicine principles and radiopharmaceuticals
SPECT/SPECT-CT/image quality
PET/PET-CT/image quality
Basic radiation biology
Radiation effects

Note: AAPM = American Association of Physicists in Medicine; RSNA = Radiological Society of North America; SPECT = single photon-emission CT.

The second component of the new curriculum consists of a series of 1-hour clinical conference lectures to be held for 11 months out of every year, attended by the first-year, second-year, third-year, and fourth-year residents (Table 2). These conferences will be an update on the physics of the modality or system that is being taught that entire month as part of the clinical didactic curriculum. The clinical conference series will extend the physics curriculum across all 4 years of radiology residency, allowing medical physics to always remain fresh in the residents' minds. Also, the clinically relevant physics lectures will help prepare the residents for image-based physics questions in the future ABR examination. The new curriculum results in a total physics instruction time of 66 hours. The US Nuclear Regulatory Commission and Diagnostic Radiology Residency Review Committee now require radiology residents to receive 80 hours of didactic training on nuclear medicine-related topics, including radiologic physics, safety, chemistry, biology, pharmacology, and quality control as it pertains to nuclear medicine [18]. We will comply with this requirement through both the physics and clinical didactic curricula. In addition, Dr. Bushong has petitioned the Nuclear Regulatory Commission to accept the AAPM and Radiological Society of North America Web-based instructional programs to be accredited for 1 hour each toward this requirement.

In conclusion, a tremendous amount of material must be covered in a physics curriculum for radiology residents. The new ABR examination format provides new challenges and opportunities for accomplishing this education. This is our institution-specific plan for future education of the radiology resident in medical physics. We are open to suggestions and hope to foster discussion among other institutions regarding medical physics curriculum revision as the new ABR examination format approaches.

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References 

  1. American Board of Radiology. Overview of ABR changes: the exam of the future. http://www.theabr.org/present/overview_changes_2.pdfAccessed April 30, 2010
  2. Amis ES, Dunnick NR. Improvement in radiology education: joint efforts of the American Board of Radiology and the Diagnostic Radiology Residency Review Committee. J Am Coll Radiol. 2009;6:103–105
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  9. Nicholson BT, Cohen MA, Harvey JA, Gay SB. Creating a new curriculum to prepare for the 2013 ABR testing changes: an academic residency perspective. J Am Coll Radiol. 2010;7:229–232
  10. American Association of Physicists in Medicine. Diagnostic radiology residents physics curriculum: AAPM Subcommittee of the Medical Physics Education of Physicians Committee, May 2009. http://www.aapm.org/education/documents/Curriculum.pdfAccessed April 30, 2010
  11. Hendee WR. Teaching physics to radiology residents. AJR Am J Roentgenol. 2009;192:855–858
  12. Mahesh M, Detorie N, Hendee WR, Heintz PH. The update on the new curriculum for educating radiologists about physics. J Am Coll Radiol. 2007;4:254–255
  13. Radiological Society of North America. RSNA/APPM physics modules. http://www.rsna.org/education/physics.cfmAccessed April 30, 2010
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  15. Radiological and Medical Physics Society of New York. RAMPS history. http://chapter.aapm.org/RAMPSAccessed June 30, 2010
  16. Hendee WR. Improving physics education in radiology. J Am Coll Radiol. 2007;4:555–559
  17. University of Washington School of Medicine, Department of Radiology. Diagnostic radiology imaging physics course. http://courses.washington.edu/radxphys/PhysicsCourse.htmlAccessed June 30, 2010
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PII: S1546-1440(10)00464-3

doi:10.1016/j.jacr.2010.08.016

Journal of the American College of Radiology
Volume 8, Issue 1 , Pages 53-57, January 2011

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