Translating the ABR’s Response to Exam Postponement Discontent

Two days after they announced the second cancellation of scheduled exams this year, the ABR felt compelled to rapidly address the massive discontent in the radiology committee. Perhaps hearing that a joint letter from every trainee and many rad organizations was in the pipeline gave them the extra incentive to try and preempt (unsuccessfully, see below) formal censure from its stakeholders.

On the whole, ABR President Vincent P. Mathews’ letter is…defensive. And it addresses the core concerns by calling them out but largely without meaningful explanation that would make the ABR’s repeated unforced errors in the handling of the pandemic look like anything other than inept and out of touch. It sounds like he’s inherited this mess, but the ABR needs more than a bigger listening ear: They need a paradigm shift.

I’ve been asked if I could translate from ABR-speak into English, so without further ado.

Colleagues,

Based on feedback received after the ABR’s announcement that we are canceling most of our exams for 2020 due to the COVID-19 pandemic, I want to provide more information regarding the considerations that led to this decision.

Restrictions on large gatherings in many locations, including Chicago, where we have our largest testing center, are very unlikely to be lifted before the fall. In addition, our staff had thoroughly investigated the logistics required to deliver an in-person exam, and our conclusion was that we could not guarantee the safety of our candidates, diplomates, and staff to the level required to proceed.

We know everyone told us that planning for an in-person exam in November was nuts. We know there was never any chance the virus would magically disappear or that chilly Chicago in November would ever be a better place for humans than June let alone a safer place for virus-free travel. I know people told us it never had a chance of happening and that if somehow we did have the ability to force people to come that it would be a disaster. Instead of listening, we wasted valuable time that we could have spent preparing a remote solution trying to figure out a way to use the testing centers we should have never built.

Many continue to ask about giving our exams at local testing centers. We do offer some of our Radiation Oncology and Medical Physics Exams at Pearson VUE centers, and we still have some scheduled in December. Neither Pearson VUE nor Prometric has the technical capability to deliver our Diagnostic Radiology Exams and have not been interested in developing those capabilities when we have inquired repeatedly over several years. Currently, these centers are closed, and it is uncertain when and where they will open.

A long time ago when we developed these exams we didn’t take into account the available capabilities of commercial centers (though we haven’t and have no intention of ever disclosing what those missing capabilities are or why we didn’t just go back and pay some nerds to re-make the software to make this feasible). After all, a bunch of our own exams as well as those offered by the American Board of Nuclear Medicine and the ACR In-service are offered at places like this. In the end, building our own centers so that we could reduce the ambient light by a few lux seemed like an easier and more profitable solution.

Others have asked why we can’t deliver a virtual exam. We are actively exploring alternatives and are collaborating with other ABMS boards to evaluate options. Currently, we have no reliable, secure option for a high-stakes exam such as the initial certifying exams that we deliver. We are aware that the American Board of Surgery and the American Board of Ophthalmology have announced they will give virtual oral exams in 2020. Their exams are different than ours, and they have not validated the ability to use radiologic images in those exams. No board has developed a secure initial certification written exam virtual platform that would be needed to deliver our Diagnostic Radiology and Interventional Radiology Core and Certifying Exams. When the breast content on the core exam was not successfully delivered to all candidates in 2017, we devised a solution for individuals to take that content remotely rather than come back to the testing centers. During this administration, some candidates had technical problems that we were able to fix “on the fly,” which was possible because of the small number of candidates taking the short exam at any given time. That exam contained very limited content and, in fairness to the candidates, we removed some items that were potentially too subtle without the monitor display control we have in our testing centers. Fortunately, it worked for a session of less than an hour for a minority of our candidates; however, we are not confident that it would work for a 10-hour exam for more than 1,000 candidates. Because of the magnitude of the significance of our initial certification exams, we must ensure near complete reliability. As we have experienced on two occasions in the past few years, even a minor failure in the delivery of these exams is extremely disruptive to everyone involved.

I know that no one actually expects us to have a ready-made, rapidly-deployable remote solution, but I feel compelled to conflate the fact that that we currently lack this capacity with our general unwillingness to pursue this goal with full vigor and the financial might of our near limitless cash reserves.

Our exams aren’t like other exams. Each exam is truly unique, like a snowflake.

We know that our continued harping on “image quality” is tone-deaf and completely meaningless given the functionality of literally every computing device used over the past twenty years, the existence of image-rich exams in multiple settings including our very own OLA, and the fact that cross-sectional modalities use images that could have been displayed by a Super Nintendo.

We also know that trying to crap on the “reliability” of our one-time remote experiment may also fall flat given that said effort came because our home center was even less reliable in the first place.

These mental gymnastics may be nonsensical, but they’re our party line, and they’re the best we got.

To reiterate, we just don’t have a reliable platform to give our computerized or oral exams right now. We are exploring our options for each of our specific types of exams in our various specialties and, hopefully, we can find solutions in the coming months. Programs have been asking for a decision soon because they are creating their resident schedules for the next academic year; therefore, we decided to move ahead with our announcement. We know that it will be highly disruptive to have two years of residents taking the Diagnostic Radiology and Interventional Radiology/Diagnostic Radiology (IR/DR) Core Exam in June 2021. Therefore, we hope to offer an administration in Chicago and Tucson in February 2021 in the event we do not have a virtual option. We are finalizing the dates and will make an announcement as soon as possible. We will also engage program directors and others as we progress with any virtual solutions.

We are looking, but we don’t want to promise to do the right thing. We’d rather arbitrarily postpone the date to another fictional timepoint instead of promising to carry out a remote solution on the dates we already provided and for which all programs and individuals have since prepared.

That said, we know—deep down—that we must provide a remote testing solution. And we know, since commercial centers won’t be able to take on this business, that it must either involve programs/institutions or people at home. But we are simply not ready to admit this to ourselves or others except in the most oblique of ways.

This is another unfortunate situation created by an unprecedented pandemic, and I hope you understand that this decision was not made lightly. We are fully aware of the disruption this causes for our candidates and their programs and desperately would have liked to have an acceptable solution sooner. We take responsibility for not engaging more stakeholders in the conversation leading to this decision, and we commit to doing better in this regard. Over the next two years of my service as ABR President, with the full support of the entire organization and Board, I will make this a priority. However, I do not think we would have arrived at a different outcome at this point in time.

We know that announcing a plan isn’t the same thing as having a solution in place, but we hope you understand that we believe all the current drama is entirely secondary to an unavoidable pandemic and not at all a reflection of our systemic deficiencies. We are sorry that we didn’t listen to your concerns formally before ignoring them. We promise to have an increased number of superfluous token conversations in the future.

And so

This may have delayed the formal response from a ton of radiologists by a day or two, but it changed nothing:

It’s a good letter, and you should read it. The joint effort covers the salient points in measured tones and doesn’t once devolve into the ruthless mockery that less restained commentators might have been unable to resist.

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