The ACR believes that its SOP advocacy campaign and involvement in maintaining the B-reader course are critical public health initiatives.
Volunteer members and staff of ACR’s Commission on Government Relations’ Federal Regulatory Committee (FRC), along with partners at the state level, are constantly on the alert for regulatory initiatives that might negatively affect members. In late 2024, the CDC’s National Institute for Occupational Safety and Health (NIOSH) published a Request for Information (RFI) in the Federal Register that proposed opening the NIOSH B-reader program to non-physician practitioners (NPPs). This change is contrary to previously espoused HHS and Department of Labor policy and a long-standing ACR policy regarding interpretation of radiographs.
In 1950, the International Labour Organization (ILO) published guidelines for using ILO International Classification of Radiographs of Pneumoconioses. The classification was intended to standardize and improve recognition and recording of the radiographic findings of pneumoconiosis and enhance international comparability. The U.S. government subsequently adopted this system for inclusion in its Federal Coal Mine Health and Safety Act of 1969 (known as the Coal Act) for screening for coal workers’ pneumoconiosis (also known as black lung), and in 1977, NIOSH expanded its use for broader occupational screening applications.
The current B-reader program has evolved from the initial design of the screening regimen, which regulatorily defined two formal levels of reader: A and B. A-readers were physicians who were qualified by submitting sample radiographs with proper classifications to a NIOSH panel or attending a NIOSH-approved course to familiarize them with the ILO guidelines. B-readers were certified by taking and passing a specially designed proficiency exam. Approval of new A-readers was regulatorily discontinued in 2012, and NIOSH approval was thereafter limited to B-readers.
Variability among radiographic reports was the initial catalyst for developing the ILO classification, and early reports of the NIOSH program continued to demonstrate significant variability. In the early 1970s, NIOSH awarded a contract to Johns Hopkins University to develop a proficiency exam by which all B-readers would become certified to participate in the program. This exam was validated by an ACR task force and was fully implemented and opened to any licensed U.S. physician in 1978. ACR developed the first analog home study syllabus under a contract with NIOSH.
Recognizing the need to transition to an online syllabus, a digital exam and a validated testing protocol based on modern psychometric principles, the ACR Pneumoconiosis Certification Program Task Force was convened in 2013 under NIOSH contract. The task force, which was led by a professional qualification exam developer, consisted of radiologists, pulmonologists, occupational lung physicians, an occupational lung pathologist and a psychometrician. Over a 3.5-year period, this group amassed a database of digital chest radiographs and CT scans, created and vetted a new certifying exam and produced a major rewrite of the study syllabus, which was delivered to NIOSH in 2016.
Over a 3.5-year period, this group amassed a database of digital chest radiographs and CT scans, created and vetted a new certifying exam and produced a major rewrite of the study syllabus.
Since then, the study syllabus has undergone at least two revisions by NIOSH-associated non-radiology physicians, resulting in multiple errors in the imaging content. A case-based NIOSH-sponsored ACR Education Center B-Reader Certification Course complementary to the syllabus has been offered since 2020 but will be discontinued after spring 2026 concurrent with closure of the ACR Education Center’s physical location. NIOSH extended four-year B-reader recertification up to five years in response to declining numbers of B-readers and the interruption of certification during the COVID-19 pandemic.
FRC review of the NIOSH RFI raised concerns that NIOSH staff was considering opening the program to Non-Physician Providers (NPPs). This significant increase in NPP scope-of-practice, if promulgated, has potential implications for other radiology-related scope-of-practice issues at the federal and state levels.
The RFI implied that the current B-reader cohort was insufficient to meet current and future needs of the program. Some of the questions raised suggested a lack of internal agency information regarding total numbers of B-reading cases per year, number of active certified readers with additional bandwidth (the current NIOSH directory lists 181 certified B-readers), distribution of cases among readers, case load of current readers and capacity of current participants to carry out the required tasks.
To ensure an informed response to this apparent lack of information, in January 2025, the FRC alerted the radiology community of the concerns, and requested input from B-readers, ACR members and colleague organizations via solicitations in the ACR Advocacy in Action newsletter, on social media accounts and on the ACR website. The FRC sought feedback on specific related questions, including insight regarding the average number of cases per B-reader, impressions of their workload capacity, use of teleradiology, additional non-pneumoconiosis pathologies seen on screening studies and other issues pertinent to the RFI.
College members responded to the FRC request with gratifying speed and clarity. Collating these responses along with additional internal research enabled the FRC to provide a constructive, data-driven response to the NIOSH RFI. In its FRC-developed, formal comments to NIOSH, the ACR made general recommendations for program improvement and specific responses to questions raised in the RFI. General programmatic suggestions included:
FRC responses to specific NIOSH questions included that there was no actionable data to suggest that the current B-reader complement was insufficient to meet program need, and indeed, many participants indicated that they had extra capacity to read more studies. This issue seems primarily related to the current case-distribution methodology. The FRC raised a key concern, with supporting documentation, that the addition of NPPs as B-readers would significantly reduce the accuracy of reporting and lack of recognition of non-pneumoconiosis-related diagnoses. Finally, advances in digital radiography and teleradiology have obviated the need for geographic proximity of B-readers to the primary sources of radiographs; clarification of licensure requirements for this federal program should correct this issue.
Subsequent to the RFI public comment period, no new regulations have been promulgated, but a letter to the editor in the December 2025 edition of Chest submitted by NIOSH staff members indicated that the agency ultimately received 1,270 comments, with 79% (1,005) disapproving of expanding the program to NPPs, and that the agency would consider incorporating many of the FRC’s suggested proposals into the program.
Since ACR is closing the ACR Education Center’s physical location in Virginia and transitioning to virtual and hybrid educational formats, the College will no longer offer the on-site B-reader certification course. Following the COVID-19 pandemic, NIOSH discontinued support of the ACR course, and because of the reduced funding and priority shifts under the CDC and NIOSH, continuation of the B-reader program in its current format is uncertain. ACR continues to explore ways to support this critical public health initiative.
As with all scope-of-practice issues, physicians — and, in this instance, diagnostic radiologists, who currently comprise approximately 70% of certified B-readers — must continue to provide this service. ACR education and advocacy can only track to member interest and involvement.
Authors Disclosures: Drs. Paul Wallner and Matthew Brady are chair and vice chair, respectively, of the ACR Commission on Government Relations’ FRC. Drs. Jeffrey Kanne and Cristopher Meyer are co-directors of the ACR Education Center NIOSH B-Reader Certification Course.
Acknowledgments: The authors wish to thank ACR Senior Director, Government Affairs Michael Peters, Government Affairs Director Katie Grady and ACR Regulatory Policy Specialist Lindsay Robbins, without whom this article and its associated efforts would not have been possible.
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