The CAQ exams are likely the least discussed and widely known facet of radiology certification. Until now.

Background

The CAQ—or, Certificate of Added Qualification—is something most radiology residents and other doctors don’t even know about. It’s an extra subspecialty certification you get by giving the American Board of Radiology (ABR) a bunch of money and taking an extra subspecialty exam so that you can say you did it. Some radiologists then put their CAQ-holding status at the bottom of their reports (“This study was interpreted by a CAQ Neuroradiologist” or equivalent) under the pretense that the CAQ confers authority and quality to their work (as opposed to those things coming from actually being thoughtful and good). You see, many radiology fellowships are actually not accredited by the ACGME, and most subspecialized radiologists have no magical exam they can take for true bragging rights. You can do an MSK fellowship, and you can say you are a fellowship-trained subspecialized musculoskeletal radiologist—but you don’t have a CAQ as a proxy for “subspecialty expertise.”

Historically, CAQs have only been available for neuroradiology, pediatrics, IR (which now has its own boards/residency), and nuclear medicine (which also has a separate board, the ABNM). In practice, neuroradiology is the most popular CAQ. In 2019, 198 examinees sat for it. Compare that with 59 for pediatrics. Nuclear medicine? 4.

Many practicing neuroradiologists have never taken the CAQ exam and do not hold the certificate. Some jobs (especially in academics) demand it. It’s also important as an extra credential for expert witness work (if that’s something you’re interested in). Many clinicians may want a subspecialized neuroradiologist, but the majority have no idea the CAQ itself exists.

For years, the CAQ was another exam you had to fly across the country for. This was especially galling in recent years because it’s just a half-day exam, and—with the advent of the choose your own adventure style of the Certifying Exam—largely an expensive and duplicative waste of time.

Registration & Fees

To officially learn more about the CAQ, see the ABR’s handy page titled neuroradiology.

In order to register, you generally must have completed a 1-year ACGME-accredited fellowship and been in practice for one year (or completed a second year of fellowship) with at least one-third of your time dedicated to neuroradiology. So yes, you can still practice as a general radiologist and sit for the CAQ.

When you register, you will need to provide—in addition to a sack of cash—a diploma from your fellowship and a letter from your service chief or department chair acknowledging that you’ve been in practice long enough and have been doing enough neuroradiology.

Registration is open only from February 1 through April 30. This is because confirming your eligibility is an apparently arduous task and cannot be stomached year-round.

I actually meant to register in 2019 but missed the window. When I tried to see if I could still take it anyway, I was told via email: “The time span from the close of the application window is required to process and approve/decline applications based on training – for which the process is thorough and time intensive.”

What is this process? They check your diploma and letter. Ironically, despite the form being very short and this process being both thorough and time-intensive, they didn’t notice my letter (you do get a copy of your application emailed to you, and it was sitting right there), so I had to re-send it. The ABR person acknowledged it momentarily, and I was then magically approved to send in more money.

In 2020, the fees were $1635 to apply and another $1635 to register for a total of $3,270.

As of September 2021, the exam fees have dropped.

You now spend $640 as an application fee and then later a separate $1280 exam fee for a total of $1,920. You’ll spend another $640 if you fail and need to take it again.

Format

The testing format and software are identical to the ABR’s other computer-based offerings like the Core and Certifying exams with an image-rich gauntlet made up of predominately “single best answer” format (and typically “what is the diagnosis?” style) questions.

The exam is composed of 180 questions in equal parts from the categories of Brain, Spine, and Head & Neck. Unlike the current iteration of the Core Exam, you can condition an individual section and be forced to re-take just that section (at least you won’t have to travel for an hour-long experience). If you condition two sections, you simply fail the test.

You have 3 hours 15 minutes allotted for the questions, 20 minutes of break time, and 20 minutes for the tutorial for a total maximum experience of 4 hours 5 minutes.

Between 2013-2019, between 158-232 examinees have taken the exam annually with a passing rate between 79-95% (mean 86%) and a condition rate between 4-12%.

My Experience & Results

On exam day, I got a brief connection lost warning twice, lasting for a few seconds before being reestablished, otherwise no interruptions. For more discussion of the ABR’s online platform, please see this post: The ABR Online Testing Experience.

Despite the fact that many review resources like to show you multiple questions based on a single image (and the official guide discussing it as I describe in the next section), the vast majority of questions are “What is the diagnosis?” questions. This can lead to some frustration, as in real life, many things (e.g. many spinal tumors) are straight differential cases that you would never come down hard on, and a couple of blurry MR images from the 80s aren’t how anyone is used to reviewing cases in real life.

The easy parts of the exam are similar to the OLA MOC questions, and the harder parts, are, well, harder. The best preparation strategy is to make sure you can get all the easy questions right, leaving yourself room to guess like everyone else when they show you some blown-up spine or a pediatric case you haven’t seen or thought about since you prepared for the Core Exam.

It took me two hours forty minutes including breaks. With the online format, you can take a break whenever you want, but all previously seen questions will be locked and cannot be altered. You can take more than 20 minutes break but exam time will continue to count down during any additional breaks.

The ABR states results are released in 4-6 weeks. In 2021, it was exactly four weeks to the day.

Like the Certifying Exam but unlike the Core Exam, there is no granular data. You either pass or you don’t.

Preparation

As always, the ABR releases a study guide. The current version hasn’t changed since 2017 and is mostly useless: it is a list of all topics in neuroradiology. It does include a few practice questions at the end.

It also seems to be out of date. The guide states that there are 60 individual questions with 180 total items, suggesting that the average case has three questions and that are a lot of second-order questions. Indeed, it states: “The case mix will reflect the typical clinical practice of a neuroradiologist. Thus the majority of the cases will be examples of relatively common entities but the follow-up questions will require a greater depth of knowledge than that expected of a general radiologist.”

This is simply not the case. Like all modern era ABR radiology exams, most questions are standalone diagnosis questions and relatively few are multipart deep dives.

As you might expect, your daily experience as a likely almost entirely adult radiologist does not prepare you very well for peds-type questions or even probably most testable spine pathology, so I encourage you to spend at least a few hours refreshing that material.

Qbanks

A relatively popular but generally not well-reviewed resource is Sulcus, the only neuroradiology-specific question bank. I reviewed it here and think you can skip it.

Board Vitals‘ Certifying Exam Qbank has 179 neuro questions, and 30/82 peds questions are peds neuro (10% off with code BW10). BV has a decent mobile app where you can even download questions for offline viewing and now finally saves your preference for the “show exhibits” toggle in the app, so you only have to hit it once to show the images automatically for all questions. While there is no image manipulation, it’s not necessary in this setting, and you have the choice between untimed vs timed and tutor mode vs test mode.

A practicing neurorad could get through the questions in a few hours, and they are overall easy (you should get most correct without issue), but for the purposes of rapidly getting you in the question-taking mindset, it’s not a bad experience. Then again, you may feel that OLA is enough. Overall, the BV experience is much more pleasant than Sulcus, even though the learning opportunities are lower. It’s definitely a floor, not a ceiling.

There are some negatively framed questions, which I want to say is unacceptable, but the fact is the ABR still hasn’t fully purged them from their tests either. There’s some image reuse for multiple questions, which is a bit lame, as well the habit of asking “which statements about this entity are true” style of question, which isn’t how most ABR questions are formulated these days. Some good high-yield anatomy but giveaway easy for a trained neurorad. I got 90% correct in my warp-speed review; of the ones I missed, I would say 1/2 were straight-up bad questions: a couple were due to bad images (which in fairness the ABR loves to do), and the others had psychometrically bad answer choices on the “which of the following are true” type questions.

Because the peds neuro questions are randomly found within the peds section, I’d recommend doing those on tutor mode so you can just skip the majority. These were super classic diagnoses but may help bring some comfort. I didn’t get any of them wrong but are nice to see since most people don’t do much peds.

Not a great value for the 1-2 days you’d actually use it but cheaper than Sulcus. I think you can probably skip both unless you really want to see more questions.

Case Books

I think good old case books (e.g. RadCases, Case Review Series) are by far the most cost-effective way to prepare.

In my very brief survey, the best collection and value of high-yield low-pain processes and reasonable second-order factoids is Neuroradiology: A Core Review. It includes some high-yield peds and is organized by general theme. The ebook version you unlock with the code inside the cover is essentially a multiple-choice quesiton bank, and each chapter has 34-40 questions grouped into a smaller number of cases (diagnosis question often followed by 1-2 additional fact questions concerning pathogenesis, prognosis, management, etc). A practicing neurorad should probably get almost every diagnosis correct and miss a second-order factoid here and there, which means that it’s probably not a bad resource to use. If you blaze through and know it all, then I think you’re in pretty good shape.

Note that anatomy is not meaningfully covered, so it would still behoove you to make sure you have your gyral and functional anatomy, skull base foramina, cranial nerves, midline sagittal anatomy, head/neck spaces/levels/structures down pat.

While there are a couple of duds, overall the questions demonstrate broad depth, good examples, and some honestly refreshingly well-written explanations. It’s an excellent book. I’m not ashamed to admit I learned some facts that I didn’t know previously or had forgotten, including some fun ones to pimp my residents on and shore up my knowledge of vaguely useful esoterica.

The phone app for the online version is a little buggy, and the images load as thumbnails whether you’re on your phone or just using the full website. You can slam through the book in a dedicated evening at the bare minimum.

If you do more than one case book, you’re going to see a lot of overlap.

Survey Results

I did an informal online survey and got 38 responses. The overall pass rate of the respondents was 86.8%, which is right at the ABR average. Everyone had passed the Core/Certifying exams on their first attempt.

55% had to take the CAQ for their job, and 74% had completed a 1-year fellowship.

How long did people study (and by study I mean an hour or more somewhat consistently)?

• 5 weeks or more – 15.9%
• 4 weeks – 39.4%
• 3 weeks – 18.4%
• 2 weeks – 10.5%
• 1 week – 7.9%
• < 1 week – 7.9%

Of the 5 reported failures, 2 studied for 1 week, 1 for 3 weeks, and 2 for 4 weeks. Not much help there.

I personally studied somewhere around a few hours total looking at Sulcus and BoardVitals during the weeks leading up to the exam and then blazed through A Core Review the night before. So overall less than 1 week, but I think I would have felt better with a full week, maybe two.

I suspect that for most people doing 75%+ neuroradiology—especially if that involves some high-end stuff and not just strokes/hemorrhage/fractures from the ED and degenerative spines from the community—that a week or two is probably fine, but it would seem that over 50% of takers are spending a month or longer with some degree of consistent study.

Only one person who failed remembered and shared their qbank performance: Sulcus: 56%, BoardVitals 76%, and RadPrimer 70%. I’m going to guess you probably want to be at 80%+ on non-Sulcus products, and probably at least 65% if not 70%+ on Sulcus.

I would also guess that if you had borderline performance on the Core Exam, you probably want to put some serious hours in. If you destroyed the Core Exam without a sweat, this will likely be a breeze.

Unfortunately, as with all ABR exams, we simply don’t have the data to meaningfully predict performance.

Conclusion

The CAQ is lame.

It’s expensive, and should absolutely 100% be folded into the Certifying Exam, which can also coincidentally include 180 neuroradiology questions.

There are no particularly good dedicated resources. Sulcus is probably too expensive, too hard, and too demoralizing. While casebooks are generally geared toward the Core Exam, the fact is that they provide a good knowledge floor and will remind you of what should be low-hanging fruit on topics you don’t see often in daily practice.

As with all ABR exams, be prepared to be irritated.

When I finally got around to taking the Neuroradiology CAQ Exam this fall, I finally had the pleasure of partaking in the ABR’s remote testing platform. I put a lot of work into my posts about the Core and Certifying Exams back in the day, but they do hail from the pre-pandemic era.

Here are some thoughts on taking an ABR exam from the comfort of not Chicago or Tucson:

Big Brother

ABR relies on a third-party company called Proctorio for monitoring. Update: As of 2022, the ABR is now handling remote monitoring in-house instead of relying on a third-party vendor.

Everything—including the real-time video monitoring, capturing a photo of your picture ID during the start-up process, and the “room scan”—rely on the webcam. This feature was clearly intended to be used on a laptop, which you could easily pick up and spin around the room. The ABR now requires a separate dedicated side-view webcam, which makes the acrobatics a bit more complicated.

Instead of buying a separate webcam, I used a super old DSLR with a $15 HDMI to USB video capture card (the knockoff of the better Cam Link). This works fine (and it’s what I use for Zoom calls to have that beautiful bokeh so that people like me more), but it’s worth noting that if you don’t have good autofocus (and mine is so old that it does not), that it may take a few tries to get the screengrab of your photo ID good enough to satisfy Proctorio’s artificially intelligent needs. Depending on your desk set up, a relatively short cable connecting the camera to the computer or a tripod to have the camera high enough to actually see anything if you don’t have a dresser or something suitable nearby can make the room scan awkward and a bit tenuous. A longer USB cord helps. After around 5 minutes of finagling, eventually, I was allowed to take the test.

You could also use your phone as a webcam by using one of many inexpensive apps like Camo or EpocCam, which is probably the best option, especially if you already have some sort of suitable stand or one of the infinite variety of cheapo phone tripods.

Anyway, what I’m trying to say is I don’t think most people need to buy a dedicated external webcam just for the purpose of taking one of these ABR tests. Especially since most webcams are terrible.

I will say that Proctorio didn’t make me install any apps on my phone, and the Chrome Extension is easy to uninstall. I don’t think anyone is going to have their identity stolen or be harassed by call center employees. While I am admittedly not very experienced with the myriad options for education spyware, it seems like the ABR picked one of the better players.

Computer Set-up

I really wanted to use my home workstation. It has direct fiber internet and a system I use every day for radiology-type stuff. However, Proctorio and the ABR have a 1 monitor rule, and I—in my radiologist glory—have 4 monitors. To satisfy Proctorio, any extra monitors in the space have to be missing from your system entirely, so simply turning them off isn’t good enough. They need to be totally unplugged from your computer so that they don’t show up. I use a dual PC system set-up to read simultaneously for the hospital and our outpatient PACS by swapping monitors and peripherals between two different PCs using a KVM switch. It’s awesome. But the nest of monitor cords is no joke, and the settings are just how I like them, and there was no way I was going spend the time unplugging stuff and jeopardize any of that in order to take a 3-hour exam with a bunch of low-quality JPGs.

Instead, I took it on my 2017 iMac over WiFi, which is across the house from the router, and it was fine. The biggest problem was getting Proctorio happy with the backlighting from the adjacent window overexposing the camera and making me look too dim.

Yes, I did roll over my attending chair, the Herman Miller Embody, from across the house for the experience, and it was worth it.

The Practice Test

The practice test is a 98 question process, but really it’s just designed to get you to make sure you can pass Proctorio’s welcome barriers and familiarize yourself with the software. The content is a random hodgepodge of questions, but there is no performance feedback or answer key, limiting usefulness as an actual practice exam experience.

The content parallels the Core Exam, which is to say I found it more difficult now as a super high-performing experienced attending radiologist than I would have as a resident. Go figure.

The Online Platform

I would show you some screenshots, but, you know, I can’t.

The software is totally fine. It works. You have a bunch of tools to manipulate the images, but since most images are just static screen grabs of middling quality, you usually don’t need to do anything. In fact, the image sizes are small enough and the questions themselves short enough that you really don’t need or even want a large monitor or anything fancy to take the exam. Your average laptop screen has plenty of real estate.

The ABR locks your past performance every 30 questions to prevent you from altering your responses to prior questions after you’ve left the surveillance zone for breaks (aka cheating). Locking so frequently is a touch annoying, and I’m sure the policy frustrates the people who want to blaze through the whole test and then agonize for hours on all the questions they flagged at the end. Psychologically, this is probably healthier, though it does make flagging a question basically useless.

I wish they just locked questions at breaks and not after so short a period, but given intermittent connectivity issues, the shorter batch size probably helps substantially reduce their tech support demands. It’s a worthwhile price to pay for the convenience.

Another irritating feature is that the ABR really wants you to move forward through the exam and not backward to revisit old questions, so much so that if you try to visit the previous question, the software prompts you with a pop-up saying (paraphrasing) “forward is so much better, are you sure you want to go back?”…which is annoying. I think the idea here is that they especially don’t want you to see a question, not answer, go backward, lose access in some way, and then have to unlock the question for you and/or question your integrity. 

On exam day, I got a brief “connection lost” warning twice, lasting for a few seconds before being reestablished automatically, otherwise no interruptions. I know people personally and online who had less good luck, sometimes being completely kicked out and needing to call to have questions unlocked. To their credit, I’ve only heard good things about ABR customer service when it comes to helping with exam connectivity issues.

Overall

Overall these inconveniences are a small price for being able to wear pajamas and take a break literally whenever you want, which is wonderful. The ability to use a bathroom mere feet away or get drinks and snacks on a whim creates a completely different ambiance than a typical testing experience.

Not having to pay for flights and hotels, waste days on both ends for travel, and leave your family is also almost priceless.

In some ways, it’s a little harder to get in the normal high-stakes exam headspace without the suffering, but it’s a breath of fresh air that I enjoyed nonetheless. I bought a twelve-pack of Diet Mountain Dew just for the occasion, and I made myself a nice fresh ice coffee as well (see above, hat tip double-walled insulated glasses) to sip while answering ludicrous questions about differentiating spinal cord tumors. 

If that’s not the dream, I don’t know what is.

In recent years, the American Board of Radiology (ABR) has utilized a membership fee model, where—for example—those working towards an initial certification in diagnostic radiology would pay a $640 annual fee until passing the Certifying Exam. Since one takes the Certifying Exam 15 months after finishing residency, that has meant recent diplomates have paid a specialty tax of around 1% of their gross income for a total of five years before enjoying the privilege of paying a mere $340 per year for MOC forever.

The fee schedule looked like this:

To illustrate, here’s my payment history (the annual fee actually increased a bit during my training because money).

As of September 2021, ABR has moved to “an exam fee model.” How does that look? Well, a one-time $640 application fee followed by a $1280 Core Exam fee and a $1280 Certifying Exam fee.

It doesn’t require a doctorate to note that the total cost for initial certification is the same: $3200.

That fee continues to put radiology in the highest echelon of medical specialties in terms of board costs, as enumerated in this 2017 paper (which incidentally undercounted the radiology costs).

What has changed is that this fee structure is now standard across other exams and is resulting in a decrease in the (otherwise ludicrous) subspecialty exam fees.

You see, until now, the much shorter half-day CAQ exams actually cost the most! As above, you can see I paid $3,280 this spring for the privilege of spending a morning taking a poorly formulated exam to pseudo-prove that I can totally do the thing I already do every day. That’s more than the cost of the combined total of the much, much bigger Core and Certifying Exams.

But, as of this September 17, 2021 update, it’s merely the same $640 application fee + $1280 exam fee for a total of $1,920 (a savings of $1,360!).

Of course, before you get any warm fuzzies about their generosity, keep in mind that the CAQ exams comprise a relatively small proportion of ABR revenues since only ~200 people take them every year, and, meanwhile, MOC revenues continue to grow year after year. The ABR, per its internal narrative and official documents, has recently been operating at a loss.

Thankfully, they have some retained earnings on hand to mitigate the red.