Changes in ACGME program requirements for pediatric radiology fellowships
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- Strife, J.L. & Stephen Amis, E. Pediatr Radiol (2010) 40: 1312. doi:10.1007/s00247-010-1679-6
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The new program requirements for subspecialty training in pediatric radiology have been approved by the Accreditation Council for Graduate Medical Education (ACGME) and will become effective July 1, 2010. The process for revisions of the requirements, the composition of the Radiology Review Committee (RRC), and the relationships with other organizations have been described for diagnostic radiology by the RRC chair [1, 2]. Since the last revision of the program requirements for pediatric radiology, marked changes have occurred in radiology residency and fellowship training including incorporation of the core competencies, their definitions, methods of assessment, and outcomes. The purpose of this communication is to update program directors, faculty, and fellows on the significant changes.
The process of changing the pediatric fellowship requirements involved obtaining guidance, input and direction from SCORCH (the Society of Chairs of Radiology at Children’s Hospitals), the pediatric program fellowship directors through APDR and the leadership of the Society for Pediatric Radiology. Additional input came from the ACGME through its educational programs and multiple APDR-sponsored conferences that addressed implementing the competencies, and potential ways of measuring compliance. The revised program information for pediatric radiology fellowship was then submitted to the ACMGE Requirement Development Committee. After some editing by this committee, the revised requirements were posted along with an impact statement on the ACGME website, and program directors and designated institution officers (DIOs) were notified about the posting through the ACGME communications network. All potential stakeholders were invited to submit comments during the 45-day on-line posting. The RRC reviewed comments, consider additional changes as needed and prepare a final draft of the requirements for submission to the ACGME Committee on Requirements.
The common subspecialty program requirements have been combined with the specific program requirements for pediatric radiology so the document is larger but perhaps easier to use. The integration of the common fellowship program requirements with the specific program requirements makes it a single resource. Although there are many changes in the program requirements, only a few of the major ones will be discussed.
One of the major changes reflects the opportunity of a pediatric radiology fellow to take 3 months elective, at the discretion of the program director. The elective was added specifically to encourage specialization in areas such as cardiac, neuroradiology, fetal, molecular imaging or in other areas such as informatics, quality and safety, education, or research. Furthermore, the restructuring of radiology core residency programs in response to the American Board of Radiology (ABR) changes in certifying exams  will permit a resident to spend up to 16 months in one subspecialty instead of the current maximum of 12 months during radiology residency. As a result, individuals applying for pediatric radiology fellowships might have more advanced pediatric radiology training than in previous years. Just as the scope, complexity and continued evolution of imaging has resulted in the need for subspecialization of many radiologists, the same is true for pediatric radiology [4, 5]. While general radiologists are important, most individuals do not practice in all domains [5, 6]. Subspecialization allows better connection with clinical colleagues and has the potential to advance the science of practice through research and collaborative efforts .
The new program requirements call for programs to document specific methods for measuring mastery of the competencies and to begin determining outcomes of care. Although many of the requirements are not necessarily new and are already incorporated into the program, several of them are specific for pediatric radiology fellowships. Suggested ways to measure the competencies are provided on the ACGME website .
There are different educational experiences defined to offer more training for improving quality, safety, and error reduction within pediatric imaging with emphasis on many of the national safety initiatives. Active participation in morbidity/mortality is essential to increase awareness of the complexity of care. Peer review conferences that involve cases related to systems errors, inappropriate imaging studies and failures of communication of significant test results should be presented and discussed. In addition, there is significant increase in emphasis on reducing radiation in children, such as taught by utilizing the ALARA principle and techniques learned from the Image Gently campaign . Fellowship programs will need to define how they will meet these new requirements and measurement of the competencies at their own institutions. Many programs no longer provide specific lectures on sedating children, as they have shifted to anesthesia/sedation services, and these requirements have been reduced.
Regardless of the modality or subspecialty (e.g., pediatric neuroradiology, fetal chest imaging, etc.), there is new emphasis on recognizing normal images and normal variants. Age-related normal anatomy is important to recognize in order to decrease unnecessary imaging. To further emphasize the importance of recognizing “normals,” the ABR exams will soon include cases with clinical symptoms with an image that is normal or a normal variant.
The Diagnostic Radiology RRC has developed definitions for the six general competencies, and most institutions have developed practice performance measurements suitable for each competency area . Program directors should define the skills and competencies the fellow should be able to demonstrate at the conclusion of the program. In addition, the expectations for learning should include measurable outcomes in pediatric radiology fellowships programs. There are a variety of methods to look at outcomes. For high-risk procedures these include participation in simulations, development of procedural competencies checklists, and direct observation.
New language in the program requirements emphasizes the role of fellows as teachers. The new requirement states that fellows must be involved in teaching conferences for medical students, residents and others. Feedback and evaluations of their skills in preparing and presenting educational or interdisciplinary conferences should be developed. There is renewed emphasis on the role of the pediatric radiologist as a consultant. Interpersonal skills need to be assessed and competence in oral communication judged through direct observation. Programs must provide a method to access competence in written communication judged on the quality and timeliness of reports and adherence to policies and procedures of the department. Resident learning portfolios might be the chronologic continuation of those started in residency but also could be developed according to individual fellowship programs.
One of the most common citations by the RRC has been the failure to hold a quarterly meeting with each fellow and provide written documentation of these meetings at least semiannually. As the program requirements for fellowship are only 1 year, early identification of suboptimal performance allows the program to help the fellow focus on specific issues and provide a realistic pathway for improvement.
There will be parallel changes in the program information forms and the site visitor’s questions. The pediatric radiology index of procedures that had old CPT codes has been updated. The new ones are a representative group of the studies that are performed by fellows. It is not meant to be all-inclusive but a snapshot of activities within the department. The actual number of CPT codes required to be reported in the program information form (PIF) has been reduced in an attempt to decrease the burden of collecting data and statistics.
Individuals confuse the case log system with the resident procedure log. A procedure log was mandated in the previous pediatric radiology fellowship program requirements, documenting the performance of 50 vascular/intervention procedures, 50 nuclear medicine studies, and neuroradiology cases. The requirement for a procedure log has been eliminated. Fellowship programs will now be expected to comply with submission of aggregate data for each fellow using the Case Log System similar to diagnostic radiology programs. In addition, the program director is supposed to review the cases dictated by each fellow. This allows the program director to have an overview of cases dictated and allows comparison of the experiences of all fellows in the program. In the diagnostic radiology programs, the ACGME views the Case Log System as an important initiative, as the RRC plans to use aggregate data on resident experiences during training to set benchmarks that can guide accreditation decisions. Case Log data for each fellow indicating his or her direct involvement with specific imaging examinations and procedures as defined by the CPT procedure codes must be entered into the ACGME Case Log System .
Finally, there has been a change in the eligibility requirements for fellows entering ACGME-accredited subspecialty fellowship programs. Candidates should have completed either and ACGME-accredited or Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited core diagnostic radiology program. The operative word here is “should.” If program vacancies exist, consideration can be given to appropriately trained and credentialed radiologists trained abroad. It is likely this requirement will be tightened by the ACGME in the near future.
In summary, changes in program requirements for training pediatric radiologists are effective July 2010 and were conceived to improve the quality of the training and competency of program graduates. These changes were made after consultation with the appropriate pediatric radiology organizations and with input from program directors.