Credentialing for radiology
1 Radiology Department, The Alfred Hospital, Melbourne, Victoria, Australia
2 Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
Patients expect to receive safe, predictable and
high-quality care delivered by competent professionals.� Thus, it has become
important to provide specific training in existing and new modalities and prove
on-going clinical expertise.� Hospital credentialing is the process by which
the competence of a doctor is determined by the hospital management. In Australia, radiologists participate in a mandatory program of continuing professional
development and are also required to maintain a logbook of procedures.� The Conjoint
Committee for the Recognition of Training in Peripheral Endovascular Therapy
has been established to advise the respective subspecialty groups on the
requirements for accreditation.� This article examines some of the issues the
committee has considered in preparing the criteria to assist institutions for
the purposes of credentialing and gives an Australian perspective on future
trends. � 2008 Biomedical Imaging and Intervention Journal. All rights
Keywords: Credentialing; certification; radiology;
Credentialing for Radiology
Recent events in Australia, where a surgeon was found to
be inadequately qualified to treat patients safely [1, 2], have increased the
awareness of the general public and hospital administrators to the need for
adequate credentialing of medical doctors, particularly those performing
There is an expectation that patients will receive safe,
predictable and high-quality care delivered by competent professionals . Due
to the rapid development and expansion of diagnostic and interventional
radiology over the past 20 years, it has become important to provide specific
training in existing and new modalities. However it is equally crucial to prove
initial and on-going capacity to deliver a safe service for the patient.� This
capability requires clinical expertise and a commitment to the process of
continuous education .
Hospital credentialing is the process by which the
competence of a doctor is determined by the hospital management . With
appropriate credentials, a medical practitioner can then be accredited for
practice in the areas of work for which the credentials cover.� Often these two
processes are confused.� Accreditation is achieved through documentation of a
proven course of training, performance of the procedure within recognised and
accepted norms, and most importantly, continued competency in the performance
of the procedure.� While professional organisations provide opportunities for
continuing education, they do not provide credentialling; places of work must
do this. Clearly the ultimate goal is to achieve ongoing improvement of
practice and to demonstrate competency as a medical practitioner .
In Australia, radiologists who are Fellows of the Royal
Australian and New Zealand College of Radiologists participate in a mandatory
program of continuing professional development� (CPD) organised and audited by
the College.� CPD provides the opportunity for Fellows to engage in activities
relevant to their professional development, educationally and in other ways. It
helps them to maintain their skills and knowledge in their chosen discipline.
It provides an opportunity for them to contribute to the profession through
engagement with others .�
CPD Points Requirements
One CPD point is approximately equivalent to one hour of
passive education (e.g. attending a lecture). In general, active educational
activities are allocated 2 CPD points per hour; case-based activities are
allocated points on a 'per case' basis, while complex activities (such as
audit) are allocated points on a 'per activity' basis.
- The CPD program operates on a calendar year � i.e. from 1 January to 31
December of each year.
- Participants should accumulate a minimum of 180 points in the triennium
- Participants should accumulate a minimum of 30 points per CPD year,
while no more than 90 points will be credited to any one year.
Participants should also aim to acquire their points
across a range of categories, which include medical expert, communicator,
collaborator, health advocate, manager, professional and scholar, to give an
indication of the major emphasis on the capabilities being developed in the CPD
activity group. Participants can also complete their CPD returns on-line.
In addition, interventional radiologists are required to
maintain a logbook of procedures including the complications and outcome faced
by the patient.� The Radiological Percutaneous Interventional Database (RaPID)
is an electronic database available by registration through the Interventional
Radiology Society of Australasia (IRSA) .� From 2008 these processes, which
were originally voluntary, have become mandatory.� They are subject to random
audit by the Royal Australian and New Zealand College of Radiologists.
At the hospital level it is recognised that due to the
complexity of modern radiology a single radiologist may not have the necessary
experience and expertise in every imaging modality or procedure. As a
consequence, clinical privileges are only granted with evidence of proof of
adequate training, expertise and documented performance. This has led to the
development of guidelines for both training and competency.� While the
requirements for new graduates are relatively straightforward, it is important
that the experience of older graduates be recognised. Thus the �grandfather�
qualification has been introduced to demonstrate that an individual
practitioner has sufficient experience and competence .� In most cases when
a new modality or procedure is developed, it is necessary to determine what
experience and proof is required for �grandfathering� older specialists.�
In the proposed national registration requirements for
specialist radiologists, the Commonwealth Government of Australia has asked for
input from radiologists and other specialists including cardiologists and
vascular surgeons who perform aspects of interventional radiology.� This has
resulted in the formation of the Conjoint Committee for the Recognition of
Training in Peripheral Endovascular Therapy (CCoPET).� This committee is a
joint initiative of the Royal Australasian College of Surgeons, the Royal Australasian College of Physicians and the Royal Australian & New Zealand College
of Radiologists . �This Committee has been established to advise the
specialist colleges of appropriate criteria for training of peripheral
endovascular therapists who wish to practice in Australia or New Zealand.� The criteria established by the Conjoint Committee are then available to
institutions for the purposes of credentialing. Each subspecialty has
representatives on the committee and decisions regarding the extent of training
are made by consensus.� This committee does not provide any certification or
examination; it merely serves to advise the respective subspecialty groups on
the requirements for accreditation.
The greatest challenge facing committees of this type is
determining what kind of training is required and how many procedures are
needed to demonstrate competency for new graduates and ongoing accreditation.�
In radiology there is competition from specialists of different disciplines for
the same procedure [10, 11].� It is extremely important that the lofty ideals
of credentialing are not used as a weapon to exclude suitably qualified medical
practitioners from practicing their craft.� One example would be if the same
requirements were applied to cervical (extra cranial) carotid artery stenting
as to the more rigorous procedures for intracranial interventions and acute
stroke intervention .
However, each subspecialty has its own idea of how long
training needs to be. Radiologists are generally surprised that extensive
training in all CV imaging modalities can be achieved in a single year of
training as suggested by the American College of Cardiology .� By contrast,
does every imaging specialist need 5 years of general radiology and barium
enema experience to be a skilled interventional radiologist? The reality in Australia is that additional fellowship training is required for interventional radiology.
Some of the suggested requirements for accreditation are
becoming difficult to achieve due to changes in clinical guidelines and
practice. For example an accumulated total of 100 diagnostic cervicocerebral
angiograms before postgraduate training in coronary artery stenting procedures
 ignores the rapid displacement of cervicocerebral angiograms by other
imaging modalities especially CTA and MRA.
Another problem which the Conjoint Committee has faced is in
determining the number of procedures required for unusual or rarely performed
procedures.� In this instance the concept of equivalency of more commonly
performed procedures has been used to indicate competency in a more general
way. For example a doctor who has completed many angioplasty procedures may be
considered competent to perform selective thrombolysis. While not ideal, this
is particularly relevant for practitioners in remote areas or in small
hospitals with limited numbers of procedures, who may struggle to achieve the
required numbers to prove competency.� One solution may be to provide access
for such persons in larger centres to undertake training from time to time.
This would need to be supported by providing locum services for their remote practices
during these training periods.� However, remote area practitioners would then
be competing for cases with new trainees.� The alternative of a �remote area
exemption�, such as applies in respect to radiologist attendance in some types
of musculo-skeletal ultrasound, would not be appropriate for credentialing.
Credentialing of diagnostic radiology is simpler than for
interventional radiology procedures.� Patient selection, informed consent and
technical procedural skills are not generally required by diagnostic
One solution, which is widespread in screening
mammography, is double reading to improve sensitivity and accuracy.
Computer-aided detection is also used to reduce the human costs involved in
double reading .� However, these practices are not easily transferable to a
busy general radiology practice.� With more widespread use of PACS it will be
possible to provide random audits of previous reports and possibly also
document outcomes. However, outcome analysis is not generally possible in a
small clinical radiology service, as patients with more complex conditions may
It is becoming increasingly difficult to learn
interventional radiology skills because of fewer �straightforward� procedures
and growing concerns for patient safety .� Computer-based simulation has
the potential to allow an operator to realistically perform a virtual procedure
with feedback about performance, which could at least reduce some of the
patient's role during the learning process .� The requirements for
outcome-based and proficiency-based assessments have increased interest in the
use of simulators for interventional radiological procedures. While they cannot
replicate the experience of performing cases in real patients, there may be a
role for it in procedural training in the future .
Radiologists need to maintain certification and
documentation of professional competency. This ensures on-going knowledge of
new advances in the field and up-to-date methods. In the future the task of
auditing might be tendered to a large academic institution and the results of
the audit benchmarked across several institutions.� Because of the
sensitivities involved, however, such an audit process is still some way off.
Given the cost and potential risk of interventional
radiology, it is inevitable that institutions and governments will develop
their own set of regulations for the practice of radiology, unless
subspecialties provide suitable alternatives.� In the meantime, each radiologist
should personally consider how well-qualified they are to perform the tasks
they currently undertake and how they would be able to prove their safety and
competency. While some may find this an onerous task, ultimately it is the
patients who will benefit.
Mancuso R. Queensland's 'Dr Death' linked to 80 deaths. The Age. 25 May 2005.
Lessons from Dr Death. Sydney Morning Herald. 26 April 2005.
Strife JL, Kun LE, Becker GJ et al. American Board of Radiology Perspective on Maintenance of Certification: Part IV--Practice Quality Improvement for Diagnostic Radiology. Radiographics 2007; 27(3):769-74.
Madewell JE, Hattery RR, Thomas SR et al. Maintenance of certification. AJR Am J Roentgenol 2005; 184(1):3-10.
Connors JJ 3rd, Sacks D, Furlan AJ et al. Training, competency, and credentialing standards for diagnostic cervicocerebral angiography, carotid stenting, and cerebrovascular intervention: a joint statement from the American Academy of Neurology, the American Association of Neurological Surgeons, the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, the Congress of Neurological Surgeons, the AANS/CNS Cerebrovascular Section, and the Society of Interventional Radiology. J Vasc Interv Radiol 2004; 15(12):1347-56.
RANZCR Program Outline. RANZCR CPD 2007 - 2009 [Web Page]. Available at http://www.ranzcr.edu.au/cpd/handbook07/introduction.cfm#1. (Accessed 7 February 2008).
IRSA RaPID Registration Form [Web Page]. Available at http://www.irsa.com.au/rapidform.pdf. (Accessed 7 February 2008).
Conjoint Committee for the Recognition of Training in peripheral Endovascular Therapy. Grandfathering [Web Page]. Available at http://conjoint.surgeons.org.AM/Template.cfm?section=Grandfathering. (Accessed 1 February 2008).
Conjoint Committee for the Recognition of Training in peripheral Endovascular Therapy [Web Page]. Available at http://conjoint.surgeons.org. (Accessed 1 February 2008).
Levin DC, Rao VM, Bonn J. Turf wars in radiology: the battle for peripheral vascular interventions. J Am Coll Radiol 2005; 2(1):68-71.
Venkatesan AM, Shetty SK, Galdino GM et al. The impact of professional turf battles on radiology resident education: perspectives from the radiology class of 2005. J Am Coll Radiol 2006; 3(7):537-43.
Beller GA. A proposal for an advanced cardiovascular imaging training track. J Am Coll Cardiol 2006; 48(7):1299-303.
Helvie M. Improving mammographic interpretation: double reading and computer-aided diagnosis. Radiol Clin North Am 2007; 45(5):801-11, vi.
Gould DA. Interventional radiology simulation: prepare for a virtual revolution in training. J Vasc Interv Radiol 2007; 18(4):483-90.
Desser TS. Simulation-based training: the next revolution in radiology education? J Am Coll Radiol 2007; 4(11):816-24.
|Received 11 February 2008; accepted 25 February 2008
Correspondence: Radiology Department, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia. E-mail: email@example.com (Maryann Street).
Please cite as: Street M, Thomson KR,
Credentialing for radiology, Biomed Imaging Interv J 2008; 4(1):e14