MEDICAL STUDENT PERSPECTIVES
In April of 2023, the American Board of Radiology (ABR) announced the reinstatement of the diagnostic radiology (DR) oral exam starting in 2028. The original oral exam was administered to residents up until 2012, when the ABR shifted to exclusively computerized assessments. Currently, radiology residents must pass two multiple-choice exams to obtain board certification: the DR Qualifying Exam, which is typically taken in the third year of residency, and the DR Certifying Exam, which is taken as early as one year after residency. The ABR has confirmed that beginning in 2028, the DR Certifying Exam will be replaced with a DR Oral Exam for all residents hoping to be certified after 2027.
The shift in DR examination presents a new landscape for radiology programs to navigate. “The ABR’s decision to transition to an oral certifying exam, which seeks to incorporate the best elements of previous iterations, comes with a variety of challenges and opportunities. The class of 2027 will be the first to sit for the new certifying exam,” says Arif Musa, MD, MS, a diagnostic radiology resident at Detroit Medical Center.
The ABR justifies the transition to an oral exam with the intention of evaluating skills that cannot be easily assessed on a computer-based exam. These skills include differential diagnosis ranking, case discussion, clinical judgement and awareness, professionalism and communication. Additionally, the ABR has acknowledged weaknesses of the past oral board exams that it hopes to improve on in coming years. For instance, the oral exam required that examinees travel to Louisville, Ky., for the assessment. In 2028, the ABR will administer the oral exam in a virtual format to provide more flexibility and conducive test-taking environments to examinees. ABR also intends to reduce examiner bias and subjectivity by introducing a standardized testing and scoring protocol.
Beyond general preference, test-taking comfort and performance anxiety represent significant considerations in the transition back to an oral examination format.
Preparing for Concerns
While the ABR is optimistic about the change, there are some concerns among radiology educators and examinees. Since the first class of residents who will take the oral exam have already initiated their radiology training, residency programs have not yet had the opportunity to redirect funds toward oral board preparation. This may put current residents at a disadvantage. Programs may need to allocate additional resources toward oral board preparation, including structured mock oral examinations, faculty-led case discussion sessions and formal communication skills training. These changes may pose logistical challenges, particularly for smaller or resource-limited programs, but also present an opportunity to more closely align resident education with real-world radiology practice.
Additionally, the oral examination format is not entirely preferable among test-takers. Radiology residents were polled regarding their test-taking preferences, and the results demonstrated that the majority experienced less anxiety during computerized exams. Beyond general preference, test-taking comfort and performance anxiety represent significant considerations in the transition back to an oral examination format. Studies across medical education have demonstrated that oral examinations are associated with higher levels of anticipatory stress compared to written or computerized assessments, even when controlling for baseline knowledge. This heightened anxiety may disproportionately affect otherwise well-prepared examinees, potentially confounding true clinical competence with performance under pressure. However, the ability to reason clearly, communicate effectively and make sound clinical decisions under stressful conditions may be an intentional component of the ABR’s assessment of readiness for independent practice.
Finally, bias and subjectivity may hinder the validity and perceived fairness of the oral examination. Historically, oral board examinations have faced criticism for variability in examiner scoring and susceptibility to implicit bias. Even when examiners are well-intentioned, unconscious biases related to race, ethnicity, gender, accent or communication style may influence perceptions of confidence or clinical competence.
Ensuring a Smooth Transition
The ABR has acknowledged these concerns and has emphasized efforts to improve standardization and objectivity in the redesigned oral exam, including structured case prompts, standardized scoring rubrics and examiner training. The transition to a virtual format may further reduce some sources of variability by limiting environmental and interpersonal influences present in prior in-person examinations. Nonetheless, continued evaluation of exam outcomes will be critical to ensuring that performance differences reflect true clinical competency rather than examiner-related variability. Ongoing transparency, examiner diversity and incorporation of trainee feedback may help reinforce confidence in the validity and equity of the new certifying examination.
"The transition to an oral certifying exam by the ABR could enhance the assessment of practical communication skills, decision-making and the ability to explain complex concepts clearly,” says Evien Albazi, PGY-1 diagnostic radiology resident at Trinity Health, Grand Rapids. “However, it also raises concerns about added pressure, subjectivity and the logistical challenges of evaluating candidates in this format.”
While challenges remain in the establishment of a new certifying examination, the ABR has demonstrated a commitment to comprehensive and evolving evaluation of radiology candidates. The Board has acknowledged critiques of prior exam models and is dedicating substantial effort toward refining the structure, delivery and fairness of the forthcoming assessment. With adequate time and institutional support, both radiology residents and program directors can successfully adapt to these new standards. Ultimately, the goal remains unchanged: To ensure the certification of highly qualified, clinically competent diagnostic radiologists who are prepared to meet the demands of modern practice.
