I was at the ACR last weekend (giving a talk about the current radiology practice landscape) and had the chance to enjoy one of the American Board of Radiology’s periodic update sessions, this time given by Executive Director Dr. Wagner (who, for the record, is a nice guy). There were several things that I would have loved to ask (or push back on) but wasn’t able to due to time. I thought I’d share some of that here.
On Representation
Dr. Wagner said that the reason they don’t have specific stakeholder representation slots—like a member from the ACR, trainees (RFS), or young professionals (YPS)—is that they believe those people would advocate for their specific stakeholders as opposed for patients, who are the true mission of the ABR.
The mission, for those who don’t know:
Our mission is to certify that our diplomates demonstrate the requisite knowledge, skill, and understanding of their disciplines to the benefit of patients.
Leave aside that such stakeholder advocacy/perspective would be perfectly reasonable and not necessarily at odds with the ABR’s mission, but if you happened to read my article on the ABR’s bylaws from back in 2019, you may recall how the election of the board of governors works. From the updated November 2024 bylaws:
Section 4.3. Election of Governors. Nominees shall be solicited from the Board of Trustees and the Board of Governors, and may be solicited from any appropriate professional organization. Professional organizations shall provide such nominations in writing. An affirmative vote of at least three-fourths (3/4ths) of the entire Board of Governors shall be necessary for the election of any nominee to the Board of Governors.
I would say this process is insular and suspect, and I don’t see any plausible argument for how this method ensures a board that is more “mission-driven” than any other method. Company boards are usually elected by shareholders and not the boards themselves because external accountability is critical for governance.
Dr. Wagner admits the average age of the board is, in his words, “very old.” But since the board leadership itself selects the future board leadership without external stakeholder accountability or vote, the control and trajectory rest entirely internally. Dissident voices have no power and no recourse to engender change.
(The ABR would tell you they take oodles of feedback via various stakeholder panels and work groups. I really, really, don’t think that’s sufficient. Of course the leadership is old when the process of getting on the board has often meant paying your dues through years of volunteering and ultimately being selected by the board itself to fill its own vacancies.)
If you’ve read the bylaws of the ABR, you would also know that the fiduciary duty of the board members is to the board itself—not to the field of radiology, not to patients, and not even to its stated mission. From Section 6.1, Conflicts of Interest:
It is the policy of this Corporation that the legal duty of loyalty owed to this Corporation by an individual while serving in the capacity as a member of the Board of Governors or Board of Trustees requires the individual to act in the best interests of this Corporation. Consistent with the duty of loyalty, a person serving as a member of the Board of Governors or Board of Trustees does not serve or act as the “representative” of any other organization, and said member’s “constituency” as a member of the Board of Governors or Board of Trustees of this Corporation is solely this Corporation and is not any other organization or its members.
Arthur Jones of Proctor & Gamble once remarked that “all organizations are perfectly designed to get the results they get.” The reality is that this composition, process, and mandate create an unnecessarily insular crowd of well-meaning people designed to make exactly the kind of system we have. Until this process is deliberately opened to demand outside perspectives, they will simply not occur with enough frequency to make a difference.
On Fees
The ABR was also asked about fees, particularly the fact that the fees for initial certification hurt when you are a trainee (here and here and here are a few posts about fees).
The answer was a bit of self-love about how the fees have stayed flat despite inflation (without any consideration to whether they could ever, you know, go down).
I would point out, however, that enrollment in MOC has increased over the years as new diplomates graduate while many of those retiring had been grandfathered—such that revenues from MOC have increased over time.
According to the ABR’s 2023 Form 990, there were approximately 35,200 diplomates enrolled in MOC to the tune of $340 a pop. In 2017, that number was 27,000. The increases won’t continue as grandfathered radiologists eventually all retire, but the revenues from MOC have obviously increased. In 2017, MOC revenues were $9.2 million and total revenues were $17.4 million (a previous deep dive is here if you’re curious). In 2023, it was almost $12 million on total revenues of $18.36 million (this after, to their credit, CAQ exam fees were finally slashed from their ludicrous $3k+ price tag).
This means that MOC accounts for an increasingly large amount of money and a larger fraction of revenues over time. I believe ABMS fees should be decreasing, not increasing—especially for a small group like trainees, who make less, usually do not have assets, and should not be required to pay so much money for certification, especially as MOC for doctors with higher income is now an involuntary permanent revenue stream. Initial certification still costs $3,200—no small sum for a bunch of multiple-choice questions written by volunteers and administered over the internet.
Any inflationary increases in expenses are presumably mostly related to the salaries of their employees. The ABR spent $1.66 million on executive salaries, $7.67 million on other salaries and wages (+$1.1 million on retirement contributions and other benefits), and $1 million on travel.
If the ABR takes its fiduciary responsibilities seriously, I think we can make that math work a little better on behalf of our youngest colleagues.
The Return of Oral Boards
There was frank acknowledgement that the Certifying Exam is duplicative and useless (my words of course, not the way they said it). There was also a caveat that it was a well-intentioned mistake that seemed like a good idea at the time, whereas I think it was pretty clear from the outset that the current Certifying Exam had no value after the very similar Core Exam.
So, Orals are back (my initial thoughts here). Whatever the downsides, there is no denying that oral boards will provide more value than the current Certifying Exam.
There was lip service paid to the consideration of alternative ideas, like perhaps AI could provide value in the certification process? But this was dismissed with a handwave that “If we can’t all agree on what a good report would look like, how could we have an AI do so?”—which is bizarre in the sense that the same problem arises when assessing communication and critical thinking in the context of an oral examination.
What was not acknowledged is that a knowledge-based MCQ assessment doesn’t test skill. A small number of contrived oral board cases unquestionably adds a different and useful kind of information, but even this is a skills assessment in only a very limited fashion.
So the critical question remains: are we sufficiently assessing skill with any of our current or proposed exams?
If we are being forward-thinking, we could just acknowledge that multiple-choice knowledge assessments are suboptimal. They have been historically necessary and remain efficient but are increasingly inappropriate in our modern connected world to provide actionable information. Knowledge is simply only part of the game.
Simulation is the only way the ABR can really fulfill its mission, and we are now living in a world where we could employ batch grading of dictated or typed answers, forcing residents to make findings from real cases and then provide diagnoses or differentials instead of just picking one from a list.
We could do this without AI, but yes, we certainly could employ AI to help grade answers (if not necessarily full reports). This would be a much more meaningful assessment.
The goal of the ABR exam certification process is to differentiate between competent and incompetent radiologists, and I don’t think we’re there yet. As always, I am disappointed by the lack of imagination at play. We can do better.