Drs. Gunderman and Tobben have suggested abolishing the American Board of Radiology (ABR) requirement for a “clinical” year before a diagnostic radiology residency . In my opinion, they are correct in three of their arguments: (1) this is a controversial subject; (2) internship quality is quite variable; and (3) the term “clinical year” is a misnomer because radiologists are, indeed, clinicians. For the latter, this terminology is so deeply entrenched in the world of medicine that it is not worth tackling at this time, and I will continue to use the term “clinical” for the internship year and “clinicians” for nonradiologists.
At the risk of sounding like an old person (which I am), I will tell you my own experience. I graduated from an excellent public medical school in 1978 and started my diagnostic radiology residency that same year; a clinical internship was not required by my program at that time. Back then, I felt strongly that an internship was unnecessary—and I did not want to do one! I do not think my career was negatively impacted by my lack of an internship, despite the fact that my subspecialty has been breast imaging for over 30 years. So why am I now strongly in favor of keeping the clinical internship requirement? This is because neither medical school nor diagnostic radiology is the same as it was back in the 1970s, ‘80s, and ‘90s.
Back in those “olden days,” medical school was more rigorous intravenous line (IV)—there were no duty hours, intravenous line (IV) teams, code teams, or electronic medical records. Physicians actually did physical exams. There were no physician assistants or nurse practitioners. Our fourth year of medical school consisted mostly of electives, but they were usually medicine/medical subspecialty and surgery/surgical subspecialty rotations along with a smattering of radiology and pathology. I did 2 months of radiology and 1 month of pathology because I was trying to decide between those two fields. The rest of the year, I was taking care of patients—and yes, medical students really did take care of patients! Yes, we did a lot of “scut work.” Did we love it? Probably not. Was it valuable? Yes!
What does the fourth year of medical school look like today? As the senior faculty advisor for multiple predominantly radiology-bound medical students each year for more than 30 years, I witnessed the change from “meaty” electives to things like “History of Medicine,” “Narrative Medicine,” “Current Issues and Advocacy in Medicine,” “Leadership In Medicine,” and “Medical History.” Although these may be interesting courses, how do they prepare future radiologists? Gunderman and Tobben suggest that radiology program directors should not allow candidates to fill their fourth year of medical school with such rotations, but program directors have little or no control over—or knowledge of—what the students take. As a faculty advisor, I banned such electives in the students’ initial schedules, but these sorts of rotations often crept back in via last-minute schedule changes.
How does radiology differ today from back when no internship was required? Medicine in general is much more complex, and radiology is now more procedure oriented. As a breast imager, I wished that I had had more experience taking histories and doing physical examinations—and that my technical skills were better. I think a clinical internship would have enhanced my abilities. With the American College of Radiology’s Imaging 3.0 and the Radiological Society of North America’s Radiology Cares programs , we have an imperative to get out of our dark reading rooms to interact with patients, their families, and our clinical colleagues. To be effective members of the healthcare team and to have impact on patient care, we need more robust clinical experience.
There is no doubt that the quality of the clinical internship year varies by specialty and program. In my experience, residents who completed surgery or internal medicine internships were generally better prepared for radiology than those who did less rigorous years, not because they knew any radiology, but because they had better knowledge and proficiency in medicine in general. Certainly, there are internships that are little more than a repeat of the usual third-year medical student. Years ago, the worst internships might be classified as similar to a fourth-year medical student, but the fourth year of medical school has become so variable that the comparison is probably no longer valid. We need to work to improve the quality of internships, particularly transitional years. Unless all radiology programs become “categorical” programs, meaning they include an automatic clinical internship at the same institution, program directors have no control over the internships that their candidates select. Program requirements can be changed only by the Accreditation Council for Graduate Medical Education Residency Review Committee, and concerns have already been expressed to that organization. This is a complex issue, and changes will not occur overnight.
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References
1. Gunderman R., Tobben J.P.: Is it time to jettison radiology’s clinical year requirement?. Acad Radiol 2016; 23: pp. 389-391.
2. Indiana University School of Medicine : Indiana University School of Medicine 2015–2016 Student Electives. Available at: http://mse.medicine.iu.edu/student-affairs/student-records/electives.html Accessed December 15, 2015
3. American College of Radiology : Imaging 3.0. ACR website. Available at: www.acr.org Accessed December 17, 2015
4. Radiological Society of North America : RSNA Radiology Cares. Available at: http://www.RadiologyCares.org Accessed December 17, 2015
5. The American Board of Radiology : The American Board of Radiology website. Available at: www.theabr.org Accessed December 17, 2015
6. Baker S.R., Tilak G.S., Geannette C., et. al.: The value of the internship year for radiologists: a retrospective analysis as assess by current residents and fellows. Acad Radiol 2008; 15: pp. 1205-1210.
7. Cuttino J.T., Scatliff J.H.: First year radiology residents: PGI vs. PGII. AJR Am J Roentgenol 1979; 132: pp. 855-856.
8. Ellis J.H., Vydareny K.H., Bookstein F.L., et. al.: Impact of pre-radiology clinical years on resident performance. Invest Radiol 1989; 24: pp. 568-574.
9. Gay S.B., Hillman B.J., McNulty B.C., et. al.: The effect of preradiology clinical training on the performance of radiology residents. Invest Radiol 1993; 28: pp. 1090-1094.
10. Ravin C.E.: The case for a clinical year prior to radiology residency. Invest Radiol 1986; 21: pp. 287-288.