Preparation by Excavation: Strong Digs Deep for Rads Taking the ABR Certifying Exam

If a mad scientist were to meld the mind of a passionate teaching radiologist with that of an especially acquisitive museum curator, the result would surely be someone very much like Benjamin W. Strong, MD. 

Levity aside, consider the evidence. Strong, Chief Medical Officer of the teleradiology giant vRad, is the primary (if unofficial) caretaker of somewhere between 15,000 and 20,000 digitized imaging-based radiology teaching files. The oldest of these, an instructional compilation of historic x-ray cases willed to Strong by one of his earliest mentors, dates to 1939. The files of more recent vintage come from every imaging modality and from any number of vRad’s 500-plus radiologists, who work in all 50 states and collectively read well more than 6 million studies every year. 

It’s this vast—and still expanding—stockpile of instructional resources from which Strong will draw on Oct. 9, when he conducts a four-hour review session for radiologists preparing to pass the American Board of Radiology’s Oct. 22-23 certifying exam.

The format will be a free online webinar. The images will be cinematic as well as static. And the pace will be fast yet thorough—and targeted. 

In the weeks leading up to the single-evening course, “I try to find studies that tell a diagnostic story,” says Strong, who has conducted the single-evening session (6 to 10 p.m. CDT) annually since 2015. “A case that demonstrates a single radiology finding is, to me, inadequate as a teaching case.”

Connecting Diagnostic Dots

As an example of a case that fills the bill, Strong describes a chest x-ray showing pneumonia, just as the ordering physician expected. However, musculoskeletal imaging of the shoulder is incidentally inspectable on many chest radiographs, and the pneumonia case up for review also happens to show a shoulder dislocation. 

That finding is both unusual and often associated with seizures, Strong says. Seizure patients are unable to protect their airways should they vomit, as they frequently do. Sometimes the result is an aspiration pneumonia. 

“Because aspiration pneumonia is complicated with gastric acid and anaerobes from the mouth and whatnot, it requires a different type of therapy than a straightforward community-acquired pneumonia might,” Strong says. This is an important diagnostic distinction, he points out, and “it’s one that you can derive even without any knowledge of the patient from the two seemingly disparate findings on the film.”

Such multi-finding/single-diagnosis cases are quite few and far between, Strong says. But they’re also “favored fodder” for board examinations. 

“These are exactly the kinds of diagnoses the ABR wants to see radiologists make before awarding them board certification,” Strong underscores. “They want to know that you can not only make the major finds but also make the one or two seemingly less important findings that help flesh out the full diagnostic picture. 

“That’s the great cognitive challenge in radiology,” he adds. “And it’s one that the board exam is meant to challenge you on.”

Not incidentally, vRad’s library of imaging studies that tell a complex diagnostic story includes 20 years’ worth of cases flagged for training purposes during clinical interpretations made by Strong himself. In fact, this latter subset probably could fill a coursebook on its own, as Strong’s medical experience spans not only radiology across several subspecialties but also internal medicine and emergency medicine. 

Add this background to his penchant for collecting interesting studies, and it doesn’t seem a stretch to assume vRad has one of the largest collections of radiology teaching files in the world. 

Emergency Imaging on the Rise

Strong’s Oct. 9 preparation session will begin with two full hours dedicated to emergency chest and abdominal CT, including trauma cases. Emergency and trauma reads are right in vRad’s wheelhouse, and Strong believes this part of the presentation fills a gap that’s common to many other radiology educational programs. 

“Oftentimes there is no dedicated faculty for an emergency radiology department, and the radiology residents get exposure to it only through overnight call,” says Strong, who, along with seeing to medical leadership duties at vRad, still devotes 10 to 20 percent of his time to interpreting images. “The stuff I’ll be showing in those first two hours really reflects the types of studies that vRad radiologists see on a nightly basis.”

Strong notes that all 500 of vRad’s radiologists are welcome to submit cases into the practice’s teaching file. Many of these submissions are vetted by vRad’s quality-assurance committee before getting the green light as teaching resources. 

“We can’t know the exact cases the examiners will present, but we can and will cover the principles behind the cases they’ll test on,” he says.

The cases Strong is likely to present in this extended first section reflect his observation that emergency radiology as a subspecialty of radiology is on the rise. In fact, he believes it will soon be recognized as specialty unto itself. 

Two factors fuel his forecast. The first is the growth of committees within the American College of Radiology and the American Society of Emergency Radiology specifically set up to concentrate on emergency radiology. The second is the rapidly increasing use of imaging in the ER for initial diagnosis. 

“ER patients are now regularly scanned prior to their even being seen by a physician,” Strong says. “So the first diagnosis of any acutely ill patient in the ER now lies with the radiologist. Ten years ago, no one foresaw this development.”

The ABR Has a Heart for Heart Care 

Next up will be one hour focused on coronary CT angiography (CCTA). From 2006 to 2008, Strong was vRad’s designated CCTA expert. He taught the modality, handled nearly all interpretations for vRad and, not surprisingly, amassed a sizeable CCTA teaching file. Strong and many others thought CCTA was about to become the definitive test for acute chest pain across the country, 24 hours a day.  

This all changed in 2008, when CMS got balky about reimbursing for CCTA and physicians started complaining the tests were difficult to staff, schedule and perform. Today CCTA is only sporadically ordered. 

So why dedicate an hour to it in the Oct. 9 board-exam prep course? “Paradoxically, the falloff makes my collection particularly valuable,” he says. “I’ve collected examples of all kinds of myocardial, vessel and valvular abnormalities over the years, largely because they appeal to the internist in me.”

Meanwhile, a large study published Aug. 25 in the New England Journal of Medicine showed CCTA was associated with a 41 percent lower subsequent risk of nonfatal myocardial infarction or death from coronary artery disease than standard care alone. (See David Newby et al., “Coronary CT Angiography and 5-Year Risk of Myocardial Infarction.”) 

And here’s the kicker. The ABR has recently added—perhaps with uncanny prescience—a new section on sophisticated cardiac imaging for their certifying exam. 

On the strength of the latter reason alone, Strong says, “it certainly makes sense that I dig into my files”—including intricate gated movies of valvular, septal, myocardial and congenital cardiac abnormalities—“to show the CCTA cases I’ve collected.”

Fun, Prizes—and Unparalleled Preparation 

Strong’s fourth and final review hour on Oct. 9 will zero in on emergency chest and abdominal radiographs. Along with cases like the aforementioned example of aspiration pneumonia, Strong will present more than 30 x-ray cases that tell enlightening diagnostic stories. 

“With all the emphasis on cost containment, there’s a bit of a resurgence in x-ray utilization,” Strong says. Besides, the cases he’ll go over “are just spectacular examples” of anticipated and additional findings that allow for a specific diagnosis.

Attendees will encounter numerous pulmonary patterns and an illustrative compilation of life-threatening conditions, all diagnosable on the humble radiograph, Strong says. 

Much of the webinar’s final hour will allow Strong to put on his gameshow-host hat—and allow participants to vie for prizes. He’ll present 20 cases covering chest, abdominal, musculoskeletal and pediatric radiology—four prominent sections on the board exam—and then, after each, challenge attendees to be the first to key in the correct answer.

“It’s a fun, fast-paced game that we’ve played each year when doing this review,” Strong says. And the action is not just for bragging rights: Valuable prizes will be up for grabs. In years past, these have included dinners for winners’ residency programs as well as computer peripherals and input devices, such as a left-handed mouse proprietary to vRad that allows a radiologist to interact more efficiently with a PACS. 

Add those 20 quiz cases to the 35 or so review cases leading into the board-review game, and attendees will see a total of 55 edifying x-ray cases in just one hour. “All of these cases will come in pretty rapid succession,” Strong says, “meaning it’s a very good use of attendees’ time.”

The same could surely be said of the entire four-hour course. After all, Strong’s tireless interest in continually building vRad’s teaching library—even though its medical images may already outnumber the individual dinosaur fossils in the Smithsonian Institution’s National Museum of Natural History—would make the session worthwhile even for radiologists who aren’t preparing for the ABR’s certifying exam.

To register for the online board review course, click here