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Correspondence to: Bhavya Rehani, MD, Assistant Professor, Department of Radiology and Biomedical Imaging, University of California, 1001 Potrero Ave, San Francisco, CA 94110, United States. email@example.com
Telephone: +1-415-2068024 Fax: +1-415-4760616
To assess the state of radiology education across Europe by means of a survey study.
A comprehensive 23-item radiology survey was distributed via email to the International Society of Radiology members, national radiological societies, radiologists and medical physicists. Reminders to complete the survey were sent and the results were analyzed over a period of 4 mo (January-April 2016). Survey questions include length of medical school and residency training; availability of fellowship and subspecialty training; number of residency programs in each country; accreditation pathways; research training; and medical physics education. Descriptive statistics were used to analyze and summarize data.
Radiology residency training ranges from 2-6 years with a median of 5 years, and follows 1 year of internship training in 55% (12 out of 22) European countries. Subspecialty fellowship training is offered in 55% (12 out of 22) European countries. Availability for specialization training by national societies is limited to eight countries. For nearly all respondents, less than fifty percent of radiologists travel abroad for specialization. Nine of 22 (41%) European countries have research requirements during residency. The types of certifying exam show variation where 64% (14 out of 22) European countries require both written and oral boards, 23% (5 out of 22) require oral examinations only, and 5% (1 out of 22) require written examinations only. A degree in medical physics is offered in 59% (13 out of 22) European countries and is predominantly taught by medical physicists. Nearly all respondents report that formal examinations in medical physics are required.
Comparative learning experiences across the continent will help guide the development of comprehensive yet pragmatic infrastructures for radiology education and collaborations in radiology education worldwide.
Core tip: The authers report survey results of radiology education across 22 European countries with respect to length of training, subspecialty fellowship availability, research opportunities, and national certification and credentialing. Given the diversity in training requirements and its impact on cross-border training recognition, our results provide important insights to understand radiology education and its potential on portability across different countries in Europe.
Radiology provides cutting-edge imaging information that guides clinical decision-making. As our understanding of disease processes has grown more complex, radiology itself has branched into increasingly subspecialized fields. The number of distinct subspecialties in the broader scope of the discipline has significant implications for radiology teaching. Radiology training programs around the world face a challenging task in both teaching a common knowledge base across all the imaging modalities and in imparting deep subspecialty knowledge within each specialty domain.
A paucity of literature exists regarding the radiology education infrastructure worldwide. This gap in the literature can be challenging for radiologists who would like to collaborate, contribute and learn from differences, similarities and challenges in radiology education systems outside their country. Highlighting the variations in residency training may encourage exchange of best practices and experiences to better prepare trainees for an ever-evolving practice environment. There is a wide range of training infrastructure and assessment methods across the globe with respect to pre-clinical qualifications, radiology residency structure, on-call requirements, access to teaching, and certifying national or board examinations.
The goal of this paper is to understand the radiology education infrastructure across the European continent, share common practices and explore different perspectives to better prepare the next generation of radiologists leaders.
A comprehensive radiology survey (Table (Table1)1) was created to analyze the state of Radiology education worldwide. Each survey consisted of questions assessing medical school, radiology residency, internship, fellowships and subspecialties, medical physics, research, and accreditation, along with supplemental questions specifically targeted to their specific audience.
Apart from the overall infrastructure of radiology residency and subspecialty training, we also inquired about the number of radiology residency programs in the country, availability and type of subspecialty fellowship programs and the percentage of radiologists who have to travel outside the country for further training. We surveyed fellowship availability in the following subspecialities: Neuroradiology, Interventional Radiology, Musculoskeletal Radiology, Chest Radiology, Abdominal Radiology, Interventional Neuroradiology, Nuclear Medicine, Ultrasound, Breast Imaging, Cardiovascular Imaging, and Pediatric Radiology.
The type of national or university based board certifying exam was questioned. Research requirements to finish residency training were assessed.
Availability of masters programs in medical physics, medical physicists for education, and national radiation safety programs was queried.
The 23-item survey was distributed via email to the International Society of Radiology members, national radiological societies, radiologists and medical physicists. Reminders to complete the survey were sent and the results were analyzed over a period of 4 mo (January-April 2016).
To check the accuracy of information submitted we contacted radiologists, representatives of national radiology and neuroradiology societies by email who validated the responses and answered specific discordant questions. Descriptive statistics were used to analyze and summarize data.
We gathered data for 22 European countries based upon responses from national radiological society representatives or radiologists (Figure (Figure1).1). Seventy-seven percent (17 out of 22) respondents report six-year medical school training. Radiology residency training ranges from 2-6 years with a median of 5 years, and follows 1 year of internship training in 55% (12 out of 22) European countries.
Subspecialty fellowship training is offered in 55% (12 out of 22) European countries. Within those countries, interventional radiology fellowship is the most common subspecialty followed by neuroradiology, pediatrics, and nuclear medicine fellowships. Switzerland offers the greatest variety of fellowship opportunities including neuroradiology, interventional, neuro-interventional, musculoskeletal, nuclear medicine, and pediatrics training. In contrast, Austria, Estonia and Sweden offer only one fellowship subspecialty. Availability for specialization training by national societies is limited to eight countries. For nearly all respondents, less than fifty percent of radiologists travel abroad for specialization.
Nine of 22 (41%) European countries have research requirements during residency, which range from 1-mo to 9-mo research blocks, or at least one publication during residency with an open time frame of research commitment.
The types of certifying exam show variation where 64% (14 out of 22) European countries require both written and oral boards, 23% (5 out of 22) require oral examinations only, and 5% (1 out of 22) require written examinations only.
Europe is the third most populous continent after Asia and Africa with a wide diversity of cultures and languages. Similarly, there is diversity in radiology education systems. Although medical school training is six years long in the majority of European countries included in our study, there are differences in clinical internship requirement and length of residency training, which may vary by up to two years. Given the diversity in training requirements and its impact on cross-border training recognition, our results provide important insights to understand radiology education and its potential on portability across different countries in Europe.
While some countries have greater than eighty radiology residency programs, others like Armenia, Bulgaria, Estonia, Lithuania, Malta and Slovenia have only one to five radiology residency programs in the entire country. It is unclear if the number of residency programs is sufficient, given the size and population of these countries.
Fellowship training is available in 50% of the respondent countries in our study. The countries that offer at least one fellowship include Austria, Croatia, Estonia, Greece, Hungary, Romania, Serbia, Slovakia, Sweden, Switzerland, and United Kingdom. The most common fellowship offered is interventional radiology. Ultrasound fellowship is only available in one respondent country (Croatia), while none of the respondent countries have chest radiology fellowships.
Compared to the 2004 EAR Education Survey, there has been an increase in both the number of countries that offer fellowship training as well as in the variety of available subspecialties. For example, fellowship training in Switzerland now encompasses interventional radiology (IR), musculoskeletal (MSK), Neurointerventional, and Nuclear Medicine. Similarly, Slovakia increased fellowship training to include Interventional Radiology, Breast, Cardiovascular, and Pediatrics. Estonia, Greece, Hungary, and Romania are additional examples of countries that expanded subspecialty training.
Given rapid innovation across many imaging modalities, increasing exposure to fellowship training is fast becoming a priority to ensure that residents learn up-to-date subspecialty knowledge worldwide. Our results show that less than 50% of radiologists travel outside their respective countries for training. It has been discussed that practicing radiologists understandably face the challenge of meeting clinical demands while maintaining teaching responsibilities. Individual didactic teaching sessions may not be feasible in a high-volume work environment.
This creates a potential role for interactive e-learning teaching modules[6-9] and virtual education to supplement education in a particular subspecialty for self-motivated learners. Accessible electronic modules have served as useful extensions to radiology teaching[11,12]. The European Society of Radiology (ESR) offers accredited electronic modules categorized by subspecialty content with optional self assessments. The ESR has also implemented and continuously updated the European Training Curriculum, a subspecialty-specific framework organized by training level that enhances the quality of radiology education throughout Europe.
The European Society of Radiology offers courses to help prepare trainees for the European Diploma in Radiology (EDiR). The EDiR, a certificate of excellence, helps standardize radiology training in the setting of varied certification methods across Europe as demonstrated in our survey results.
Basic and translational research exposure form a significant component of radiology education and should be made widely available. Residents can make considerable contributions to the field because they have a unique perspective on the day-to-day practice from an “in-the-trenches” point of view, ranging from image interpretation to workflow management and on-call demands. Residents also have first hand experiences with different technology platforms and thus can bring new ideas that drive innovation in radiology. In our surveyed European countries, fewer than half of European countries have dedicated research blocks during residency. Challenges in promoting research include limited finances, lack of incentives for researchers, issues of career planning, and gender issues. This also seems to be a challenge worldwide and increased emphasis on research during residency has been encouraged[17-19]. Increasing time and mentorship resources for research will help establish radiology innovation early in the career pathway. Radiologists around the world could assist in mentoring trainees in research outside their programs to encourage future world leaders in radiology.
Medical physics and radiation safety is particularly important given the reported radiation injuries due to imaging[20-22]. The ESR recently noted an increase in inappropriate exposure to ionizing radiation along with significant variations in dosimetry for the same examination. To reduce patient exposure to unnecessary radiation, the ESR plans to implement individual patient dose tracking, mobile dose information for physicians, and radiation protection training with certification. Nearly all survey respondents reported that formal examination in medical physics is required in Europe. In addition, 70% had medical physics training from medical physicist rather than a radiologist. Medical physics degree programs are also offered by majority of respondent European countries.
Each European country included in our study offers a unique perspective on radiology education based on what is feasible for resident teaching, subspecialty training, and research. Comparative learning experiences across the continent will help guide the development of comprehensive yet pragmatic infrastructures for radiology education and collaborations in radiology education worldwide.
Limitations of our study include a sample size of twenty out of a total of forty-eight European countries. As such, our data may not be representative of the radiologic education landscape across all of Europe. In addition, our survey response rate indicates that our results represent only a fraction of all countries in Europe, likely due to the approach in questionnaire distribution and collection. Our survey channels through the International Society of Radiology also may have introduced bias in selecting for countries that are its participating members.
Future research may involve potential collaboration with the European Society of Radiology to gain insight into the radiology infrastructure across a greater number of European countries. E-learning modules may help augment the variety of fellowship training and increase resident engagement with real time communication and feedback. Innovative technology platforms that offer indexed and searchable didactic content will contribute to a sustainable solution for international radiology education.
We would like to profoundly thank International Society of Radiology for collaboration and radiologists in Europe who participated in this survey.
The status of radiology education in Europe, particularly in specialty fellowship training and research, merits an in-depth study in order to gain an understanding of challenges and potential collaborations among the regional training programs.
Recent advances in technology platforms for web-based applications and mobile tools have enabled trainees to gain access to specialty training that may supplement availability of radiology education at their home institutions.
This study demonstrates that subspecialty fellowship training is offered in approximately half of European countries and the availability for specialization training by national societies is limited to eight countries. Other differences in board certifications and medical physics curricula differ among the regional training programs. The European Training Curriculum serves as a reference for the establishment and revision of national training programs and sets the basis for the European Diploma in Radiology exam.
Practical applications of this study include the use of country-specific training availability data to augment radiology education and in providing access to online teaching curricula to supplement radiology education.
This is a well-written paper regarding radiology education in Europe.
Institutional review board statement: The University of California San Francisco IRB does not consider this project as human subject research.
Conflict-of-interest statement: Bhavya Rehani is the recipient of a RSNA Education Scholar grant for development of RISEMed.org. All other authors have no conflict of interest to disclose.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at firstname.lastname@example.org. Consent was not obtained but the potential benefits of sharing these data outweigh the potential harms because the data does not contain any personal information. The data only pertains to radiology education infrastructure on a national level.
Manuscript source: Unsolicited manuscript
Specialty type: Radiology, nuclear medicine and medical imaging
Country of origin: United States
Peer-review report classification
Grade A (Excellent): A, A
Grade B (Very good): B, B, B
Grade C (Good): C
Grade D (Fair): 0
Grade E (Poor): 0
Peer-review started: July 31, 2016
First decision: September 2, 2016
Article in press: December 2, 2016
P- Reviewer: Boffano P, Gao BL, Pinto A, Quattrocchi CC, van Beek EJR, Wan YL S- Editor: Kong JX L- Editor: A E- Editor: Wu HL