DOI: 10.1148/rg.281075176
RadioGraphics 2008;28:13-20
© RSNA, 2008
Education Techniques for Lifelong Learning
International Variations in Initial Certification and Maintenance of Certification in Radiology: A Multinational Survey1
Linda Bresolin, PhD, MBA, CAE,
Theresa C. McLoud, MD,
Gary J. Becker, MD, and
Francis Kwakwa, MA
1 From the Radiological Society of North America, 820 Jorie Blvd, Oak Brook, IL 60523 (L.B., F.K.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (T.C.M.); and Department of Radiology, University of Arizona Health Sciences Center, Tucson, Ariz (G.J.B.). Received August 21, 2007; accepted August 22. L.B. is a stockholder with Johnson & Johnson and Edwards Lifesciences and an employee spouse of United-Health Group (United Behavioral Health); G.J.B. is a developer for Edwards Lifesciences, an investigator for CH-Werfen (Bolton Medical), and a consultant with OrbusNeich; the remaining authors have no financial relationships to disclose.
Address correspondence to L.B. (e-mail: bresolin{at}rsna.org).
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Abstract
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A survey was sent to representatives of national and regional radiology societies around the world regarding the status of certification, maintenance of certification (MOC), and continuing medical education (CME) requirements. Data were forthcoming from 24 countries (response rate, 71%), including the United States. The survey results indicated that most responding countries now have a standardized process and requirements for initial certification of diagnostic and therapeutic radiologists. Similarly, most reporting countries now have some form of mandatory CME, although the degree to which compliance is tracked varies. There is considerable heterogeneity in what these countries require for recertification or MOC, and the development of such requirements is cited as a goal for many of the countries. The standardization and institutionalization of certification and recertification requirements is in rapid evolution globally.
© RSNA, 2008
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Introduction
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Representatives of radiology societies from around the world convened at the 2005 Annual Meeting and Scientific Assembly of the Radiological Society of North America (RSNA) to discuss maintenance of certification (MOC) processes and requirements in their countries and international regions. At that meeting, the participants agreed to conduct a survey of the current certification, recertification, and continuing medical education (CME) practices and requirements in countries around the world. In this article, we briefly describe the methods used in conducting the survey and summarize our findings.
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Methods
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In February and March 2006, a 15-item questionnaire was sent by the RSNA via e-mail to representatives of radiology societies in 34 countries. The survey recipients were identified from a list maintained by the RSNA Committee on International Relations and Education (CIRE), as well as from a list of individuals named by participants in the 2005 meeting on global MOC. The U.S. participant in the survey was identified by the American Board of Radiology (ABR). A single recipient for each country was surveyed.
Multiple follow-ups were conducted by e-mail. Respondents were asked to return their completed surveys to the RSNA by e-mail or fax. This report is based on the data from the 24 countries that responded (response rate, 70.6%).
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Results
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Certificates Awarded
Respondents were asked what certificates are awarded in their country to radiologists who have completed the required training. All responding countries except the United Kingdom award certificates in diagnostic (71%) or general (37%) radiology or both. The United Kingdom awards a joint certificate in "clinical radiology and clinical oncology." Forty-two percent of responding countries award certificates in radiation oncology. Other areas in which certificates are awarded include ultrasonography (Brazil), nuclear medicine (Germany, Singapore, Thailand), medical imaging (Romania), and radiologic physics (United States). Japan indicated that beginning in 2006 (the year the survey was conducted), it would begin dividing its board examination into two components: diagnostic and therapeutic radiology.
Subspecialty Certificates
With regard to subspecialty certification, 54% of respondents indicated that their countries did not offer any. Table 1 provides a list of the subspecialty certificates offered by the remaining countries.
Entities Issuing Certificates
In 15 of 24 countries (63%), governmental or quasi-governmental institutions issue the certificates. Table 2 provides a list of the entities issuing certificates by country.
Requirements for Initial Certification
Respondents were asked to describe the certification process and the requirements for certification in their countries. The most common requirements for initial certification were (a) postdegree clinical training (general medical), (b) a formal training program (radiology), (c) a written examination, (d) an oral examination, and (e) a medical license or government certificate. Table 3 summarizes the requirements for initial certification.
Certification Renewal
Only nine of the 23 responding countries (39%) require radiologists to renew their certificates: Brazil, Canada, China, Germany, Hong Kong, Japan, Mexico, Romania, and the United States. Japan requires renewal at 4-year intervals and the United States at 10-year intervals. Hong Kong did not specify an interval, and the remaining six countries require renewal at 5-year intervals. The reported requirements for certification renewal are summarized in Table 4.
Maintenance of Certification
Sixteen of the 24 countries (67%) have MOC programs, most of which are voluntary. Of these 16 countries, eight have MOC reciprocity with other countries. Table 5 lists these reported reciprocity arrangements by country.
Major Goals
Respondents were asked the following question: "What are your country’s major goals at this time with regard to radiology certification, maintenance of certification, and continuing medical education?" Responses indicated that offering quality CME programs is by far the most important goal for the majority of the countries. Table 6 summarizes the responses to this question.
Resources and Assistance
Respondents were asked the following question: "With which of these programs would information from the RSNA and/or ABR be especially helpful to you?" Representatives from only nine countries responded to this question, and the most common responses were (a) starting an MOC program and (b) offering or stimulating production of quality CME programs. The responses are summarized in Table 7.
Mandatory CME
CME is mandatory in 13 of the 24 responding countries (54%) and mandatory under certain circumstances in another four countries (17%). Responses are summarized in Table 8.
In most cases, failure to meet the mandatory CME requirements leads to loss of licensure or certification. Table 9 shows the consequences for failure to meet mandatory CME requirements by country.
CME Tracking
Finally, respondents were asked to indicate whether their society or accrediting body has a formal system for tracking the CME credits earned by their members. Almost all of the respondents (92%) indicated that there was a system of accounting for CME credit through issuing certificates or storing credits in a centralized database. Responses are summarized in Table 10.
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Discussion
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Survey results suggest that initial certification of radiologists and radiation oncologists is a well-established concept internationally. Many countries supplement their general diagnostic certificates with subspecialty certifications. Although in some cases the specialty society is involved in this certification process, in most cases the certificates are awarded by a governmental or quasi-governmental entity. With regard to the initial certification process and the certifying entities, respondents reported much commonality, which may explain why many countries recognize the certification of other countries and global regions. The content and rigor of training required for certification were not explored in this survey.
Most countries have mandatory CME requirements. Although in some cases this requirement is linked to the license to practice medicine, in others it is linked only to certification as a radiologist or radiation oncologist. Most respondents indicated that their countries have some system for accounting for CME credit; in many cases, however, this "accounting" is limited to issuing CME certificates that may or not be collected and audited. About one-half of countries store the data in an official database and share that information with accrediting bodies. It is not clear whether this CME requirement is linked to a recertification or MOC process.
The picture on MOC is less clear. Although 67% of respondents indicated that their countries have an MOC process, only 39% reported that physicians are required to renew their certificates periodically. Possible explanations for this discrepancy are that (a) participation in MOC programs in some countries is voluntary rather than required, (b) MOC is viewed as a more extensive process than simple recertification, or (c) differing degrees of enforcement exist in different countries. In future surveys, an attempt should be made to clarify the perceived differences between mandatory recertification and MOC.
With regard to the processes of initial certification and MOC in the United States, a few points stand out. First, the cycle of certification renewal is much longer—twice as long or more—than that for other countries. Second, the United States does not have reciprocity arrangements with other countries. Thus, certification to practice in the United States must be earned and maintained there. On the other hand, the expectations for time-limited certificate holders to maintain their certificates seem to be more extensive than those of many other countries, with the possible exception of Canada. Finally, the United States does not yet maintain a centralized system for tracking and monitoring the CME activities of certified radiologists, radiation oncologists, or physicists, although a partial system has been initiated through the multisocietal CME Gateway.
Despite these differences, many countries look to the United States as a potential source of information and assistance with respect to these issues, especially MOC and the planning and offering of high-quality CME opportunities for physicians.
This survey includes a limited selection of countries, all of which have already demonstrated interest in postgraduate education and professional self-improvement by representatives’ attendance at the RSNA Scientific Assembly and Annual Meeting or through participation in RSNA CIRE activities. Consequently, the results may be biased to suggest a higher level of formalized requirements and standardization than would be the case if it were possible to evaluate all countries with radiology societies.
In the United States, the portfolio of requirements to maintain certification is more diverse than that of many other responding countries. MOC requirements for professional licensure, lifelong learning and self-assessment, and an episodic cognitive examination have been fully implemented. There is an active effort to roll out MOC Component 4, practice quality improvement, which will also be required of individuals holding time-limited certificates.
There has been a significant evolution around the world in efforts to accredit physicians and hold them to educational and training standards at the start of their clinical practice and beyond. Although early efforts are often directed at standardizing the initial certification process and formalizing and raising the quality of CME, it is likely that this movement will rapidly transition to formalizing a process for MOC and lifelong learning. A repetition of this survey process in the next few years should shed light on the rapidity with which this transition is occurring and the degree to which expectations for radiologists and radiation oncologists will become comparable internationally.
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Footnotes
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Abbreviations: ABR = American Board of Radiology, CIRE = Committee on International Relations and Education, CME = continuing medical education, MOC = maintenance of certification, RSNA = Radiological Society of North America
See the commentary by Hattery et al following this article.
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Abstract
Introduction
