Is It Time to Jettison Radiology's Clinical Year Requirement?

W e believe that, for a variety of reasons, the requirement that all US radiology residents complete an initial “clinical year” before commencing a 4-year diagnostic radiology residency should be eliminated. Our reasons are complex but include the following: the content of these first post-graduate year (PGY-1) years varies so widely that the requirement itself has little meaning; there is no evidence that radiology residents or fully trained radiologists who have completed such a year perform any better than those who do not; the costs of such a year outweigh its benefits; and the vast majority of radiology residents are now adding at least one additional year to their training by completing fellowships. To begin, what is required? The Accreditation Council for Graduate Medical Education (ACGME) stipulates, “To be eligible for appointment to [a diagnostic radiology residency program], residents must have successfully completed a clinical year consisting of training accredited by the Accreditation Council for Graduate Medical Education, the Royal College of Physicians and Surgeons of Canada (RCPSC), or the College of Family Physicians of Canada in emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, pediatrics, surgery or surgical specialties, or any combination of these. It may also comprise a transitional year accredited by the ACGME or RCPSC.” (1) Although this and other program requirements have been tinkered with many times over the years, the requirement for a “clinical year” was abandoned in 1971 and then reinstated in 1997. The arguments mounted in favor of the “clinical year” can be divided into two broad categories. First, proponents argued that completing a “clinical year” would enable trainees to feel more comfortable in their interactions with “clinicians.” Those who had completed extra rotations in internal medicine would be more at ease interacting with internists, those with extra training in surgery would be more at ease with surgeons, and so on (2). In support of this perspective, one radiology resident we spoke with commented, “I think the clinical year is key to understanding the torrent of decisions our colleagues make day in and day out. Without that perspective, I think being a relevant radiologist would be difficult. There needs to be some time spent ‘in the trenches,’ and with the extreme limitations placed on medical students these days, med school does not cut it.” In other words, good radiologists need to understand the perspective of referring physicians, and because medical students are now so limited in the amount of responsibility they can assume, a clinical year is necessary to gain it. A second class of arguments for the “clinical year” concerned the development of basic clinical skills. For example, the additional year of training would provide extra experience in dealing with serious illness and end-of-life issues, breaking bad news, and responding more effectively to medical emergencies, such as a cardiorespiratory arrest. More broadly speaking, proponents believed that the additional “clinical year” of training would enable radiologists to better understand how referring physicians think. The implicit assumption here is that the 4 years of the medical school curriculum provide insufficient experience. Another radiology resident we spoke with spoke out strongly in support of the opportunity to develop such clinical skills. “[The clinical year] is incredibly important, and I think it should be either a medicine or surgery year. A transitional year might be okay too, if there were higher standards. If we are going to increase our value to our colleagues, we need to demonstrate that we understand what they need and want to know, as well as the best and most realistic care practices for our patients.” Again, the emphasis is on understanding the perspective of referring physicians. It is also clear, however, that this resident feels that such an experience is warranted only if it provides a clinical experience of sufficient patient care responsibility, which is not always the case. A third, largely unstated argument for the “clinical year” seems to be the assumption that the depth and complexity of different medical specialties should be reflected in the length of training they require to become fully qualified to practice them, which might in turn even be reflected to some degree in the level of compensation associated with each. For example, family medicine requires 3 years of residency training, whereas Acad Radiol 2016; 23:389–391