Let’s start with all the things that you should look for in a radiology program except the one that I’ve alluded to in the title. Many of these features are broadly generalizable and largely not unique to Radiology, and no one needs to tell you that they’re important.Read More →
From the awesome and scathing “What Went Wrong With the ABR Examinations?” in JACR:
The new examination format also does a poor job of emulating how radiology needs to be practiced. Each candidate is alone in a cubicle, interacting strictly with a computer. There is no one to talk to and no opportunity to formulate a differential diagnosis, suggest additional imaging options, or provide suggestions for further patient management. The examination consists entirely of multiple-choice questions, a highly inauthentic form of assessment.
Only partially true. Questions can ask you for further management. Additionally, it’s possible to formulate questions (via checkbox) that allow you select reasonable inclusions for a differential. This isn’t the same as having a list memorized but is in some ways more accurate in the world of Google, StatDX etc. Of course, this kind of question isn’t meaningfully present, but multiple choice format itself doesn’t necessarily preclude all meaningful lines of testing.
Another rationale for the new examination regimen was integrity. Yet instead of reducing candidate reliance on recalled examination material, the new regimen has increased it, spawning at least six commercial online question bank sites. The fact that one of the most widely used print examination preparation resources is pseudonymously authored is a powerful indicator that the integrity of the examination process has been undermined, effectively institutionalizing mendacity.
Every board exam has qbank products. Part of why Crack the Core is pseudonymously authored isn’t just the recalls; it’s presumably also related to his amusing but completely unprofessional teaching style. I very much doubt the Core Exam is more “recalled” than anything available for the prior exams. What we should be doing is acknowledging that any standardized test will be prepared for this way via facsimile questions, and there is literally no way to avoid it. It’s not as though Step 1 is any different.
Many of the residents we speak with regard the core examination not as a legitimate assessment of their ability to practice radiology but as a test of arcana. When we recently asked a third-year resident hunkered down over a book what he was studying, he replied, “Not studying radiology, that’s for sure. I am studying multiple-choice tests.” The fact that this sentiment has become so widespread should give pause to anyone concerned about the future of the field.
Yes, this is true. But it also strikes me that the old school boards wrapped a useful and worthwhile skill in a bunch of gamesmanship, BS, and pomp. Nonetheless I can’t dispute that casemanship skills have real-world parallels and that the loss of them may have resulted in some young radiologists sounding like idiots when describing a novel case in front of a group of their peers.
In essence, the ABR jettisoned a highly effective oral board examination that did a superb job of preparing candidates for the real-world practice of radiology and replaced it with an examination that merely magnifies the defects of the old physics and written examinations. The emphasis is now on memorization rather than real-time interaction and problem solving. In our judgment, candidates are becoming less well prepared to practice radiology.
It seems increasingly true that anyone more than a couple years out of residency has now fully fetishized the oral boards. It’s definitely true that traditional case taking skills have rapidly atrophied; residency may feel long but institutional memory is short. Old school casemanship isn’t really the same thing as talking to clinicians, but it certainly has more in common with that than selecting the “best” answer from a list of choices.
It is an important skill/ability to succinctly and correctly describe a finding and its associated diagnosis. Some residents now are still able to get the diagnosis but may struggle with describing the findings appropriately when on the spot. But I don’t how much that matters in the long term and if this lack self-corrects over time. I would be interested in seeing if any of the old vs new debate has would have any impact on the quality of written reports, the fundamental currency of our field in the 21st century. I’ve seen plenty of terrible reports and unclear language from older radiologists, so the oral boards barrier couldn’t have been that formative.
The fact is that neither exam is a good (or even reasonable) metric. Frankly, a closed-book exam in and of itself is inherently unrealistic from daily practice. But any exam that trades in antiquated “Aunt Minnies” or relies on demonstrating “common pathology in unusual ways” are really dealing in academic mind games and not really testing baseline radiologic competence.
Below are the current entries in the ABR Core Exam Series:
The Core Exam Experience
Detailed post describing the process of registering for the exam, selecting testing location and lodging, the actual test day experience, and the exam itself including the exam breakdown, scoring, and results
Approaching the Core Exam
Detailed post discussing approaching the exam, study schedules, picking resources, and exam content including physics & non-interpretive skills
Resources for the Core Exam
Breakdown and brief reviews of commonly used Core resources
Core Exam Question Banks Review
Separate reviews of the currently available Core Exam qbanks
Book Review: Crack the Core, Radiologic Physics War Machine, CTC Case Companion
Unnecessarily in-depth reviews of Prometheus Lionhart’s Crack the Core book series
Book Review: Core Radiology
TL;DR – I liked it
[Last meaningfully updated September 2022. As of Jan 2026, there is also a new qbank for NIS, RISC, and physics called RadCore (I haven’t tried it, and I have no reader discount). As of October 2026, there is also a new free community-supported qbank called CorePrep.]
The following is a review and comparison of the available online question banks for the Core Exam.1
There are currently six contenders: RadPrimer, BoardVitals, Qevlar, Rock The Boards, RadsQuestions, Radiology Cored, and Face The Core. I’ve tossed in Physics 300 at the end, a dedicated physics question app. (Those looking for rapid physics review might also consider the Radiology Core Physics Plus app (there’s a free sample). Reviews are mixed, and it sounds as if the material may not be 100% original intellectual property.)
A newer free resource that I also haven’t meaningfully tried is Aunt Minnie’s question bank. Did I mention it’s free? As of 2022, it contains 716 questions. The cases I’ve looked at are solid; seems like a no-brainer to me.
Because RadPrimer is free for many if not most residents and is big, the other resources have an upward climb to be worth your time and money. I was able to secure reader discounts for BoardVitals and RadsQuestions.
TL;DR: RadPrimer does just fine on its own despite its limitations, and it’s free for most residents. BoardVitals is #2 followed by Qevlar. RadsQuestions is brand new and has a risk-free trial. Face The Core is a reasonable but unnecessary adjunct, which you can buy a la carte per subject (in a world with so many cheaper (and even free) resources, not sure why you’d bother). (Radiology Cored is brand new, let me know what you think.)
This is a brief discussion of commonly used and discussed resources for the ABR Core Exam. As I discussed in this lengthy post, there a lot of good but no perfect resources for the Core exam. As such, pick a few that feel right and never look back. You’ll be fine.Read More →
We’ll start with some general thoughts on the exam and preparation, delve into the image-rich, physics, and non-interpretative skills. We’ll conclude with my personal approach (which you probably shouldn’t do), and some thoughts on adapting that to a reasonable regimen that should serve many people well. This post, like all of my Core Exam posts, is really long. This is partly because there is almost nothing written online about this exam (and partly because I am long-winded). You should also read my post about the actual Core Exam itself.
It should go without saying that how much you need to study and what you should focus on will depend on you, your radiology foundation, the holes in that foundation, your test-taking skills, the board reviews your program may or may not offer, and how much time you have.
Last revised March 2021.
Here we review Prometheus Lionhart’s multipart book series for the Core Exam. If you’re interested in someone’s thoughts on the Titan Radiology video series, you’ll have to look elsewhere.2
TL;DR: Every book in the Crack the Core series is generally humorous, relatively engaging, high yield, and conversational—as well as full of typos and (mostly minor) errors.Read More →
The ABR has requested that I not use their logo or any images anywhere in this post lest there be any confusion about our non-relationship and non-endorsement. I have of course complied. Let me take this chance to also remind readers that the writing on this site (benwhite.com) reflects the wholly personal views of Ben White (that’s me!) and not any organizations or institutions which I have ever been, currently am, or will ever be affiliated with. Of particular relevance, I have no endorsement from the ABR and possess no insider knowledge. I merely took an exam, and here are my thoughts.
This post details my thoughts on the entire process of registering, traveling, taking, and eventually passing the Core Exam. The ABR’s exam information page is also helpful. To see photos of the testing center setup that I refer to in this post, please see the ABR photo gallery.2
Updated March 2021.
As of 2021, the exam is now and forver virtual. No travel to Chicago or Tuscon required. The exam takes place over 3 days instead of 2. Additionally, it is no longer possible to “condition” the physics section. Physics will now be graded as just another section on the examination along with everything else. I’ve keep the older material here for historical interest but added in more recent info to stay relevent.
Jacob Mandell’s Core Radiology is the book that first year residents should be reading to get a foothold in radiology. The classic Brant & Helms is too unwieldy, too long for a first shot, and a mishmash of styles with lots of words, comparatively few pictures, and a relative dearth of diagrams and other helpful practical knowledge. I wouldn’t characterize Core Radiology as a true Core exam review book; I think he’s using that title as a hook, but it does have the “core” of practical radiology with an obligatory sampling of useless/”classic” board/pimping tidbits.
When I was an R1, I don’t think reading B&H really helped me get a strong foundation in radiology, and I don’t think the ratio of words and concepts to pictures and actionable material helped me with my practical knowledge or approach to daily reading. Core Radiology isn’t as detailed as B&H–which is I think the point: no multicolumned walls of text. It’s a single author viewpoint written over time by a resident (with faculty consultation) and represents a “for us by us”-type First Aid approach to learning radiology. You can read the big textbooks later, but sometimes the big guys just aren’t manageable. Reading them too early can be a lost opportunity, as the extra nuance has no foundation to grow from. It’s a lot of extra work for little payoff.
So I like the book (kinda wish I had written it), but it’s definitely not perfect. A book by a single non-expert author training at one institution is going to have some flaws merely by its narrow world-view. Room for improvement:
- Needs more images. Call me old-fashioned, but I don’t think a book should describe the “head cheese sign” and not include a picture of it (especially if it gets several paragraphs of text). It always breaks my heart a little that radiology books love to describe ten diagnoses with three pictures. B&H may be a bigger offender in this regard, but both suffer from a relative dearth.
- Incomplete/misleading descriptions. True mistakes are very rare, but there some specifics that are occasionally off the mark. Sometimes an approach, rule of thumb, or a controversial/debated subjected is characterized as a widely accepted fact. Random examples include leaving breast cancer off the hypervascular metastasis list or that Kasabach-Merritt syndrome is for “splenic” hemangiomas (other locations count too). The OB sono section definitely contains some numbers and statements my attendings would have balked at (e.g. any embryo visible at ultrasound should have a heartbeat in order to be viable).
- Oddly missing facts. Random examples include discussing polysplenia heterotaxy syndrome without even mentioning asplenia and not discussing testable facts like the association of antimitochondrial antibody (AMA) with primary biliary cirrhosis.
- Physics section is basically a joke. This section is almost an afterthought. It reads like some physics notes coupled with a few decent diagrams. Much of it is too terse and unsubstantiated to be helpful for anyone without a solid background, though a few factoids might stick. Super weak. You’ll just need to look elsewhere.
As I mentioned already, this isn’t exactly a Core review book in that it’s not really written toward the test, but it definitely contains enough classic findings, useful differentials, and Aunt Minnies to help for taking cases during lectures and enough of everything else to provide a strong foundation for rotations and the rest of residency. It’s probably the best book available for R1 longitudinal non-case-based reading, and it’s solid for the Core Exam as well.
For those wanting to start some “light” board review in the fall (especially those who haven’t been prodigious readers), Core Radiology makes an excellent springboard for Core Exam prep. I myself read it during the beginning of my dedicated board review and was glad I did, but I wished I had started it earlier. The print is big, the style of concise, and the bullet points keep things moving…but it’s still not exactly short. It’s (a relatively brisk) 895 pages.
Overall: Highly Recommended.
In their newest best practice guidelines in the Annals of Internal Medicine, the American College of Physicians practically begs clinicians to stop chasing phantom pulmonary emboli. Nothing super new here, but they do explicitly call out the big offenders:
Best Practice Advice 1: Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.
Best Practice Advice 2: Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria.
Best Practice Advice 3: […] Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE.
When I cover the ER, I am routinely impressed in the low diagnostic yield of a PE CT (for actual PE). When I review the chart in protocoling/interpreting these studies, it’s obvious that a significant portion of these patients are being imaged inappropriately, either because there is already a better diagnostic explanation from the initial history/workup, PE is clinically extremely unlikely, or because a positive d-dimer is being chased out of context. Until recently, this profligate waste was a winner to all involved parties.
- The ordering clinician could feel their anxiety and liability washed away.
- The patients could feel that they were getting a complete and thorough workup and were relieved when their tests were negative.2
- The radiologist and hospital got paid.
Nagging concerns of radiation and systemic waste aside, everybody wins. And over time, the d-dimer turned into a bludgeon against reason, and the ready availability of CT made it psychologically and medicolegally more sensible to image aggressively.
The d-dimer was never intended as a screening test for every single patient with chest pain in the emergency room. A positive dimer in an inappropriately risk-stratified patient should not mandate a follow-up CTA. This is especially the case when the test is originally ordered by a nurse as part of a standing order protocol and not by physician who is actually responsible for the patient’s ultimate care. In my brief two-month stint doing clinical medicine in the ER as an intern, I often absorbed patients from the waiting room who already had an EKG, chest radiograph, and labs including troponins and a dimer. Then we were “forced” to get a PE protocol CT to “work-up” the dimer, even in patients who had obvious other explanations for the test results (e.g. an obvious pneumonia on the radiograph). Not everyone practices this way, but it’s easier to practice thoroughly (defensively) in most of the same ways it’s easier to give antibiotics for viral illnesses.
There is one important and misleading exception to premise of the ACP report. And that’s the notion that CTs ordered in the context of “suspected” PE are exclusively obtained to evaluate for PE (i.e. PE CTAs don’t have diagnostic value outside of evaluating for PE). Some of these patients have clinical symptoms without radiographic findings, and the ordering providers are obtaining imaging to further evaluate the lung parenchyma for signs of occult infection (as well a rib fractures, anything else). CT is a troubleshooting modality in cases where the clinical picture is cloudy. So the angiographic component of the CTA may be partially a “why-not” inclusion to exclude a potentially life threatening PE in a patient that was destined for imaging anyway.
That said, I still feel like I almost diagnose more PE incidentally on abdominal imaging than I do on dedicated PE studies.