Eur Radiol (2006) 16: 437–444

DOI 10.1007/s00330-004-2635-3 RADIOLO GICAL ED UCATIO N

J. M. G. Willatt
A. C. Mason
Comparison of radiology residency programs
in ten countries

Received: 3 March 2004

Revised: 22 November 2004
Accepted: 7 December 2004
Published online: 9 February 2005
# Springer-Verlag 2005
J. M. G. Willatt (*)
Department of Radiology,
John Radcliffe Hospital,
Oxford, UK
e-mail: jonwillatt@doctors.org.uk
Tel.: +44-1865-349944
A. C. Mason
Department of Medical Imaging,
Ridge Meadow Hospital,
11666 Liaty Street,
Box 5000
Maple Ridge, BC, Canada, V2X 7G5
Abstract The purpose of our study
was to compare various aspects of
radiology training schemes in ten
countries. A questionnaire was sent to
senior residents in the UK, USA,
Canada, Australia, New Zealand,
Italy, Egypt, India, Malaysia and
Greece. The questions concerned
length of training, required pre-train-
ing experience, the organization of the
training scheme, teaching, resources,
stages at which residents can inde-
pendently perform and report exam-
inations, fellowships, and progression
to jobs. A wide variety of training,
ranging from highly scheduled pro-
grams with detailed aims and objec-
tives, to self-learning occurs across
the world. Examinations and assess-
ments are also variable. There are
lessons to be learned from varying
practices; more exchanges of ideas
should be encouraged. In view of the
“internationalization” of radiology
services and the variation in training
styles an international qualification
for quality assurance purposes may be
desirable.
. International .
Keywords Training
Residency programs . Quality
assurance

Introduction fication purposes. The questionnaire asked for information

on the following topics:
There are no previous studies in the literature comparing
Qualifications and requirements for entry onto training
training schemes in different countries. It is useful for
schemes
program directors from all nations to have some compara-
Length of training scheme
tive evidence on how schemes are organized internation-
Stages at which trainees can report and perform
ally. It is difficult to assess how well a scheme succeeds in
procedures independently
producing good radiologists, but it is possible to make
On call responsibilities and support when on call
comparisons on the structure of courses and determine how
Requirements to attend clinicoradiological meetings
well trainees are supported during their residency years.
Logbooks
Teaching
Examinations, appraisal, and professional evaluation
Methods
Financial support and requirement to invest in own
training
A questionnaire was sent to each participating country by
Resources: library, computers, CD-ROMs, teaching
email. Participants were selected through local contacts.
files
Respondents were further questioned by email for clari-
438

Table 1 National organization websites 5-year programs may include an element of sub-specialty
Organization Web Address training following a 4-year general radiology training, such
as North America. At present the European Association of
The Royal Australian and New http://www.ranzcr.edu.au Radiology curriculum recommends 4 years of general
Zealand College of Radiologists training with an additional year for either further general
The Royal College of Radiologists, UK http://www.rcr.ac.uk training or sub-specialist training. With the introduction of
General Medical Council, UK http://www.gmc-uk.org new modalities and the expansion of techniques available to
Accreditation Council of Graduate http://www.acgme.org the radiologist, there must be some concern that the shorter
Medical Education, USA courses are unable to cover the necessary content leading to
The Royal College of Physicians and http://www.rcpsc.medical.org under-training and poor skills.
Surgeons of Canada With the exception of Greece, there is a requirement for
The Radiological Society of http://www.rsnajnls.org residents to undertake 1 or 2 years of clinical practice
North America before beginning a radiology training program. Although
The European Association of Radiology http://www.ear-online.org there is no direct evidence for this, there is a widely held
The American Board of Radiologists http://www.theabr.org view that some clinical experience lends the trainee an
understanding of the interaction between radiologists and
physicians as well as a greater knowledge of clinical
Opportunities for elective attachments and fellowships pathophysiology. In addition, clinical experience may help
Support, both professional and pastoral residents to talk to patients armed with an understanding
Training given in life support, management and of the implications of radiological findings. The more
counseling clinically experienced radiologist may therefore be a better
Progress of trainees after completing schemes communicator. The key is to reach a compromise between
furnishing trainees with useful clinical knowledge and
We also contacted the governing bodies of each country experience without extending the length of training beyond
and asked for any information regarding training schemes what is reasonable. Clinical skills can be acquired during
and examinations. Most bodies have websites that provide and after completing radiology training, as is largely the
further information (Table 1). case in Canada and the USA. Currently the only country
that encourages a clinical college or board qualification
prior to entry into radiology is the UK.
Results Programs throughout the world vary in their content
considerably, but by the end of most schemes, trainees
The results are presented in tabular format. Table 2 show the have been through a rotation of the various specialties and
findings gained largely from board and college websites and modalities in radiology, and some of these have been re-
documentation. Table 3 shows information provided by peated. Nuclear medicine is a separate entity for training in
respondents to questionnaires. four of ten countries (Italy, Egypt, India and Greece).
It is reassuring to see that all of the respondents regularly
attend multidisciplinary conferences. Residents should par-
Discussion ticipate in clinicoradiological conferences, initially under
supervision and subsequently in an independent capacity
There is significant individual bias in our results due to the [1].
method of obtaining information. Only one center was Most radiology residents in the survey were satisfied
sampled in each country, and only one trainee on each with the resources provided and the level of training they
scheme. There is bound to be variability between each receive. In a recent study in the UK, 80% of trainees felt
center. However, the findings are nonetheless contributory they had achieved the core skills appropriate to their level
to an understanding of the differences between interna- of training [2].
tional training schemes.

Reporting and on-call responsibilities

General
The variable lengths of training schemes suggest that the
content may vary between those schemes which last for
just 3 years (India, Egypt) and those schemes which last
for 5 years (UK, New Zealand, Australia, Greece). In
India, an optional fourth year is undertaken by a high
proportion of trainees who wish to subspecialise. Some
Residents frequently raise concerns over on-call responsi-
bilities and reporting [3]. A particular concern is the timing
of independent reporting. In the USA and Canada for
medicolegal liability reasons residents do not report inde-
pendently until the completion of training. This produces a
large step up to independence when they have finished their
training. In other countries, reporting for each modality
 439

Table 2 Information obtained from National Organisations

Length Clinical Structure of course Exams Nuclear Programme
of experience medicine for non-
course required interpretive
(years) (years) skills

UK 5 2 6-week physics course Part 1. Physics (3 months) Yes No

3.75-year rotation Part 2a. MCQ exams every 6
months for 2 years on core
specialties
1-year options or fellowship Part 2b. Clinical exam at Royal
College (end year 3)
Italy 4 1 1-year introductory placements Annual exams set by individual No No
teaching centres
3-year subspecially attachments Written thesis during fourth year
Final exam (MCQ oral and
language)
Greece 5 0 3-year compulsory attachments MCQ and film viewing in final No No
2-year options year set by individual teaching
centres
Australia 5 2 1-year compulsory core attachments First year MCQ written and radio- Yes No
graphic exam on anatomy and
physics
3 years further attachments including Fourth year film reading, MCQ,
repeats of core ones essays and oral (pathology
1-year options or fellowship included)
Malaysia 4 1 1-year course in anatomy, First year Part 1 on anatomy, Yes No
physics, techniques physics, techniques (MCQ, film
viewing, essay and oral)
2 years of varied daily placements Third year Part 2 in clinical radi-
1 year further placements and Master degree ology (MCQ, reporting and viva)
India 3 1 1 year of 2-month attachments Set at local level. Yearly written No No
2 years of compulsory placements and oral tests. Thesis in third year
Voluntary further elective placements can lead to an MD
Canada 4 1 1-year pre-radiology rotalling internship, Board exams in final year. MCQ, Yes Yes
4-year structured course leading to optional oral and OSCE components
fellowship fifth year. Nuclear medicine sep- (one centre for all orals)
arate and requires 2 years with an abbre-
viated radiology course of 3 years
USA 4 1 3 years of 3- or 6-month rotallions Board exams. MCQ components in Yes Yes
1-year options third and fourth years Oral com-
ponent in fourth year at one centre
New 5 1 1-year compulsory core attachments First year MCQ, written and Yes No
Zealand radiographic exam on anatomy
and physics
3 years further attachments including Fourth year film reading,
repeats of core ones MCQ, essays and orals
1-year options or fellowship (pathology included)
Egypt 3 1 3 years of compulsory attachments Annual national exams No No

begins at different stages. This could be due to varying dictate by themselves. A board exam or other test designed
levels of human resources and service provision. A com- to specifically assess competence at the various modalities
promise is that residents report under supervision for the including plain radiographs could be used as a gateway to
first 2 or 3 years and are gradually allowed the freedom to independent reporting.
 440
Table 3 Information obtained from questionnaire to individual trainees
UK Italy Greece Canada US New Zealand Australia Malaysia India Egypt

No. of appli- 10–20 10–20 Waiting list. No 5 60 10–20 5–10 10–20 5 10–20
cants for each selection
place
Teaching and Structured pro- Structured No formal pro- Structured Structured Structured pro- Semistructured Little formal Variable in- One hour of
private study gramme. Formal pro- gramme. De pro- pro- gramme. Formal weekly lec- teaching. Varied formal group
lectures and in- gramme. pend on senior gramme. gramme. lectures and in- tures and programme of teaching de- teaching
formal film Formal staff at individ- Formal Formal formal film tutorials. exam directed pending on per week
viewing. Mini- lectures ual hospitals lectures lectures viewing. Mini- Weekly out- film viewing availability
mum one session and infor- and infor- and infor- mum one session side lecturers. of senior
per week mal film mal film mal film per week Variable in staff
viewing. viewing. viewing. house infor-
Minimum Minimum Minimum mal teaching
one session one ses- one ses-
per week sion per sion per
week week
Reporting inde- Accident service Very little Plain films after Almost all Almost all On passing the Plain films Accident service Plain films Very little
pendently after a few indepen- 3 months. Ul- studies are studies are part 2 exam in years 1–2 CT/ and plain films at and ultra- indepen-
weeks. Plain dent re- trasound is su- checked by checked by the fourth year all US second 3 months. Ultra- sound dur- dent re-
films after a re- porting pervised on the a board a board modalities from year MRI and sound indepen- ing second porting
porting test at prior to first attachment accredited accredited plain films to CT/ interventional dently after 2 year. Angi- prior to
end of second completion and the hard radiologist radiologist MRI can be re- always months of train- ography and completion
year. Ultrasound of training. copy is checked for for ported indepen- checked. On- ing. Angiography intervention of training.
3 months into ul- On call ul- on the second. insurance insurance dently. On-call call rarely and biopsies after when On call
trasound training. trasound CT/MRI always reasons. reasons. ultrasound from formally consultant per- deemed ap- ultrasound
CT/MRI always also tends checked. Inter- Procedures Procedures the second year. checked mission in sec- propriate by also tends
checked. Inter- to be ventional al- are always are always Procedures al- ond or third year. a consultant to be
ventional checked ways supervised supervised. supervised. ways supervised CT/MRI always (usually checked
normally Only on- Only on- checked third year)
supervised call ultra- call ultra- CT/MRI al-
sound is sound is ways
not not checked
checked checked
Table 3 (continued)

UK Italy Greece Canada US New Zealand Australia Malaysia India Egypt

On-call respon- One in eight. Ju- No on-call At least two re- Tend to be One in Tend to be resi- One in five On-call from first One in six. On-callfrom
sibilities nior and require- sidents on-call resident. seven or dent. Normally or six. From year. Three resi- Junior and beginning
senior rotas. May ment for at any one time. Normally eight. only one person home. Fixed dents of varying senior rotas. ofsecond
sleep at home. trainees One in six. only one Junior and on-call. Consul- morning levels on-call at May sleep year.No
Consultant avail- Normally resi- person on- senior tant available by sessions on any one time. at home. other
able by phone dent. Consultant call. Con- rotas. phone weekend. Consultant avail- Consultant resident
available by sultant Normally Consultant on able by phone available by support.
phone available resident. phone phone Consultant
by phone Consultant oncallfrom
available home
by phone
Log book? National None None Optional Intervention Intervention only Intervention None Intervention None
only only only
Required to at- Yes Yes Yes Yes Yes Yes Encouraged Yes Yes Yes
tend multidisci-
plinary
meetings
Percentage 20 0 10 20 80 90 20–30 10–20 1 0
going on to fel-
lowships
Personal finan- No Yes Yes No No No For some of No No Yes
cial investment the teaching
in the training
Percent working 0 0 60 0 90 0 30 60 90
in private sector
on completion
of training
Is there training Yes Yes Yes Yes Yes Yes No Yes No No
in life support
Adequate provi- Yes No No Yes Yes No No Yes Yes No
sion of pastoral
care for trainees
Aims and feed- Yes Only infor- Yes Yes Yes Yes No formal Yes By each Only
back for each mally feedback hospital in- informally
attachment dividually
Computer facil- Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
ities and inter-
net access?
Drop out rate on 10% None None Very few Very few 5% 5% 5% None None

441
your course
442
On-call generally seems to be well supported and
followed up the next day. The high ranking of “call-related
feeling of incompetence” in a study of resident stress
underlines the importance of adequate academic prepara-
tion before undertaking on-call responsibilities and of
senior support whilst on duty [3]. A further study [4]
demonstrates that subsequent review of on-call cases by a
subspecialist leads to a change in management in a
significant proportion. Of note is the fact that none of our
respondents reported a formal system of testing prior to
beginning on-call, although there were moves at the time
of writing to initiate this in the USA.
Aims, objectives and feedback for individual rotations
A study of the websites of the radiology governing bodies
of the USA, Australia and New Zealand, Canada and the
UK reveal that clear guidelines on setting goals and
objectives, on periodic assessment and on annual review
are laid out. The European Association of Radiologists has
produced a similar document (EAR website), but the
greater independence of institutions in Europe has led to a
more fragmented policy. There are, for example, dis-
crepancies in the length of schemes in member countries.
In Italy, India, Egypt and Greece the progress of each
resident is the responsibility of the training hospital rather
than of a national body.
Any institution may maintain its own review system
alongside one prescribed by a governing body, and each
individual trainer may have a personal approach towards
the struggling trainee or the gifted resident. This balance
between the personal approach and the official one is a
vital ingredient in the management of the individual.
Every resident has different strengths and weaknesses, and
these can be developed to produce a variety of char-
acteristics and qualities alongside the standard competences
achieved through the exam system. Needham [5] describes
a system of appraisal employed by one of the leading UK
supermarket groups (J Sainsbury plc), stressing the im-
portance of developing rather than controlling an individ-
ual’s potential.
Also employed by J Sainsbury, recommended by the
Accreditation Council of Graduate Medical Education
(ACGME) in the USA [6] and adopted by the Royal
College of Radiologists in the UK under the guidance of
the government and the General Medical Council, is the
360° evaluation, which incorporates comments from
fellow professionals of all levels (GMC website).
Log books
In most cases logbooks are used only for interventional
work. These are devised locally or by residents themselves.
Attempts to produce logbooks by governing bodies have
been made without much success. A more accurate and
objective record of how many studies and procedures train-
ees have performed may become common practice as vali-
dation of competence becomes a requirement internationally.
Education
Over the past 10 years, education has changed dramatically
in medical schools, including the evolution of evidence
based medicine and problem-based learning (PBL) pro-
grams. It may be that over the coming years radiology will
undergo the same kind of changes. Greater numbers of
radiologists are required [7]. There is greater emphasis on
subspecialisation [8]. The days of one-on-one teaching are,
by necessity, becoming outdated and creative approaches
are needed to ensure the quality of resident education and to
motivate staff radiologists to teach in different circum-
stances [1].
In many cases, teaching is considered less important than
clinical commitment [9]. In the UK, there is little con-
tractual requirement for consultant radiologists to teach, and
therefore it is only those who are dedicated enough to give
the time for preparation and teaching who provide edu-
cation for trainees. In addition, each hour a staff radiologist
puts into teaching is an hour lost to clinical commitments. In
many countries where health systems are working to their
limits, teaching and research are the parts of a radiologist’s
work which fall down the priority list [10].
One crucial topic is curriculum development, and
whether this is done at a local or national level. Currently
it is the role of the national body in most countries to set
a minimum set of standards to achieve registration or
certification, but not necessarily to provide guidelines on
how to develop competent radiologists. In simple terms, a
curriculum in radiology can be divided into interpretive
and non-interpretive skills.
Interpretive skills are easy to define, but it is not so easy
to work out how best to teach them. At present residents
rely heavily on the teaching they receive from sitting in
with radiologists during reporting sessions. Across our
sampled programs there is a variable provision of didactic
lectures. Residents are then expected to learn much of
radiology on their own through independent study, leading
to a potential culling of those who have neglected factual
learning at exam time. Dropout rates range from 0% in
India to up to 10% in the UK for this reason.
All respondents report access to computers with website
access for research and education purposes. Web based
education opens up all sorts of possibilities for interactive
tutorials, self-assessment, and tracking learning objectives,
which could not have been dreamt of previously. The
Radiological Society of North America provides free
membership to the online versions of its journals for
trainees. RSNA also provides an Internet-based computer
education program with pre- and post-presentation tests to

assess learning. Continuing medical education credits can
be attained on-line and stored by computer for adminis-
tration and personal portfolio development. Websites such
as Aunt Minnie offer daily cases with imaging, questions
and a review of the pathology and imaging features of
varying disease processes. The European Association of
Radiologists also has a comprehensive e-learning website
which includes cases in English, Spanish and French (http:\\
www.eurorad.org). The Royal College of Radiologists in
England are developing an integrated training initiative
which will involve radiology academies set up alongside
existing training departments equipped with computers and
other training equipment where trainees will spend sub-
stantial amounts of time in an educational environment and
out of the clinical environment. A comprehensive electronic
teaching resource will be included [11].
In practice most trainees in the world find themselves
experiencing a combination of teaching methods to varying
degrees according to our survey. Individuals may find some
learning approaches more to their own liking than others. It
is the responsibility of the residency program director,
assisted by individuals within the department who are
interested both in teaching and in the progress of individual
residents, to ensure that, through a combination of formal
teaching, use of resources, allocation of time and private
study, the end product is a rounded radiologist.
Residents can learn a great deal from the discipline of
research work beyond the subject matter of the project [12].
At present only a minority achieve a higher diploma such as
a PhD although in the Netherlands (not part of our survey)
this is mandatory (Van-Delden, personal communication).
Over recent years, there has been a greater recognition
of the need to train residents in non-interpretive skills as
well as in image interpretation [13, 14], and some national
bodies have been very influential and proactive in sup-
porting this aim. Radiology skills have previously been
limited to lesion detection and differential diagnosis, but a
greater emphasis should be placed on the cultivation of
other core capabilities, such as critical thinking, interper-
sonal communication, and research methods. The ACGME
has defined specific program requirements for each spe-
cialty and The American College of Radiology/Association
of Program Directors has established curricula for each
level of training in subspecialty areas in radiology. These
include reviews of ethical, socioeconomic, medicolegal and
cost-containment issues that affect medical practice. The
ACGME has also developed a series of videos which are
shown to American residents on topics including job search
and contracting issues, business aspects of radiology,
standards, accreditation, critical thinking, ethics, service
orientation, interpersonal skills and medical organizational
politics. Despite the intimidating proliferation of jargon, the
videos have been well received by residents [15]. Our study
reveals that in several countries, including Italy, India,
443
Australia and Egypt, little credence is paid either to the need
to define objectives to the residents themselves or to the
necessity to develop the budding radiologist as a rounded
and multi-skilled individual.
Another way of ensuring that newly qualified radiolo-
gists are well rounded in both interpretative and non-
interpretive skills is to start with appropriate selection
procedures. There must be emphasis on assessing inter-
personal and communication skills as well as academic
suitability [1].
If the science of imaging is badly taught, the quality of
health care will suffer [9]. Governing bodies should design
exams with the best interests of trainees and educators at
heart, and not simply offer a restrictive or exclusive chal-
lenge to prevent entry of those unable to excel at written
papers. Those who enjoy teaching should be encouraged to
do so by making their job plans conducive to this part of
their work, as well as giving credit for it in their contrac-
tual arrangements. Education must exist alongside clinical
commitments or service provision as a key priority, and to
do this teaching skills should be a significant factor in the
appointment to a radiology staff position.
Examinations and appraisals
In Canada, the US, the UK, and Australia and New
Zealand there are national examinations, which are, to
varying degrees, made uniform by the governing bodies.
In the other countries this does not apply. Australia and
New Zealand, Canada and the USA have also moved
towards standardization of exams by using one national
center for the oral stages with identical images for each
examinee. In Canada an objective structured clinical exam-
ination (OSCE) forms part of a comprehensive evaluation,
including MCQs and four body-system subdivided oral
elements. In the USA a mixture of body-system and mo-
dality based sections are used in an intensive oral based
examination.
In Europe there are enormous differences in the ways in
which residents are examined [16]. Some countries have
no exam at all, but assessment by regional boards, which
determine when to award a diploma. In some countries
exams are optional, and in others there are compulsory
exams set at a local level.
Residents tend to learn only that which they expect to be
evaluated on, which means the choice of educational as-
sessment strategies powerfully affects where their focus
lies. When they discover that exams pay little heed to abil-
ities such as critical lateral thinking they redirect their
attention to the parameters that the exam tests best; namely,
the memorization of facts [17]. In addition, knowledge by
itself does not lead to performance. Nor indeed does cer-
tification necessarily lead to competence [16].
444

Conclusions There are lessons to be learnt from all the programs we

Given the variability of training programs throughout the
world, we should ask whether a high level of diversity as
demonstrated by our study can be maintained or whether
some conformity in an age of expanding communication
can be established. With these variations standards are
likely to differ, not only internationally but also between
different schemes in the same country. Economic factors
and local organizational forces are bound to play their part.
Rapidly changing technology will dictate the need for a
highly skilled and probably internationally mobile or
wired workforce. This may in turn require an international
radiology qualification to unify standards across the globe.
Radiology is a unique specialty in its approach to
training requiring specific skills for which there is no
current selection process. It is also unique in being rather
more of a global currency than say surgery or psychiatry,
which are of necessity locally based due to close patient
interaction. Witness the recent proliferation of commercial
teleradiology performed by nighthawks in countries far
removed from the origin of the images.
have sampled. Exchange of ideas and views would be of
use, as would be expansion of international fellowship
schemes. This would be particularly useful for those
countries where it is not currently common practice for
residents to have the opportunity to go abroad.
Acknowledgements We are indebted to the following for kindly
answering long and tortuous questionnaires, and also for responding
to subsequent questions promptly: Dr. Vaishali Parulekar, LTMG
University Hospital of Bombay, India; Dr. Liong Weh Chuen,
National University of Malaysia; Dr. David Liu, University Hospital
of British Columbia, Canada; Dr. Wayne Bailey, Christchurch
Hospital, New Zealand; Dr. Charles White, University of Maryland
Medical Center, USA; Dr. Deborah Cunningham, St. Mary’s Uni-
versity Hospital, London, England; Professor Antonio Chiesi, Uni-
versity of Brescia, Italy; Dr. Ahmed Hisham Attar, King Abdul Aziz
University Hospital, Egypt; Dr. Johanes Johannides, Aristotle Uni-
versity Hospital of Saloniki, Greece; Dr. Joanne Wood, North Tees
Hospital, UK; Dr. Anthony Swingler St Vincents Hospital, Melbourne,
Australia

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