Appendix 3 — Interventional Radiology

The evolution of interventional radiology (IR) into its own specialty began with the ever-growing variety of image-guided interventional procedures, recognizing their importance to patient care [1,2]. In 1994, the ABMS recognized vascular and interventional radiology (VIR) as a subspecialty of radiology and established a VIR Fellowship Match Program. In 1995, the ABR implemented the Certificate for Additional Qualifications (CAQ) in VIR. Over the past 25 years, the ABR examination for IR has also evolved. In 1996, the traditional radiology pathway of a written clinical core and physics examination and an oral board-certifying examination was established. Those completing a one-year IR fellowship would then take an oral examination for their CAQ.

In 2000, a six-year clinical pathway in IR was created and modeled after the Holman Research Pathway, a program that allows 18–21 months of research during a diagnostic radiology (DR) residency. This new program allowed medical students to directly match into this IR clinical pathway out of medical school. This pathway included 16 months of patient care, 29 months of DR, 24 months of IR, and three months of research. Very few institutions embraced this new IR pathway, although it provided insight into how to best organize the current integrated IR residency.

In 2006, the Society of Interventional Radiology (SIR) convened a Primary Certificate Task Force to codify the competencies for proficiency of VIR trainees in diagnostic imaging, image-guided procedures and nonprocedural patient care. After several years of collaborative efforts between stakeholders (including the SIR, ABR, Association of Program Directors in Radiology and Society of Chairs of Academic Radiology Departments), a consensus was reached. The proposal debated at the 2011 ACR Annual Meeting was unanimously approved by the ACR Council.

In 2012, the ABMS approved IR as a primary specialty, and in 2014, the Accreditation Council for Graduate Medical Education (ACGME) approved programming for an IR residency. Two IR residency pathways were created, both leading to a potential dual certification in DR and IR: 1) an integrated six-year IR residency directly out of medical school, and 2) an independent IR residency, consisting of either a two-year independent IR residency after completing a DR residency or a one-year early subspecialization in IR (ESIR) independent residency that includes seven months of IR training and five months of clinical training during their 48 months of DR residency. Consequently, fellowships in IR and the ABR IR CAQ examination were eliminated as of June 30, 2020.

Residents completing an integrated IR or an independent ESIR program take the core ABR DR examination at the same time as their DR peers, during their third year of residency, but they can take the written DR/IR certifying examination either three months or 15 months after completing their integrated IR or ESIR independent residency [3,4]. For the certifying examination, the IR resident must complete four computer-based modules, one of which must be the noninterpretive module. These IR residents can sit for the ABR IR oral certifying examination 15 months after completing their residency. The two-year independent IR residents can sit for their DR certifying examination 15 months or 27 months after completing their DR residency and for their ABR oral IR certifying exam 15 months after completing their independent IR residency.

As various certifying boards began to sunset lifetime board certification and introduce MOC programs, confusion about and dissatisfaction with the process arose within many specialties, including radiology. In response to feedback and in an effort to replace the proctored and recurring (every 10 years) MOC examination, the ABR introduced the Online Longitudinal Assessment (OLA) program to create more flexibility, provide immediate feedback and eliminate the need to travel to meet all the requirements for MOC.

However, some significant unforeseen and unintended consequences have arisen with the OLA program as it relates to providing access to image-guided procedures and IR services to healthcare communities across the nation. The MOC process and OLAs do not always accommodate for many procedures such as biopsies, pain injections, fluid drainages, enteral tube placements and venous access that are being performed by diagnostic radiologists, especially in nonurban, smaller and more rural communities. These radiologists provide critically important image-guided procedures for a significant proportion of the nation’s population. Similarly, a large number of interventional radiologists also provide a substantial volume of diagnostic radiology services, which may not adequately be assessed by new MOC processes and OLAs [5,6].

The conundrum is that none of the OLA options contain image-guided-related multiple-choice questions specific to the types of procedures that diagnostic radiologists frequently perform, while typical IR OLAs seem to be more focused on IR procedures for which most DRs do not routinely engage. This dichotomy could thus lead to some diagnostic radiologists not being able to provide these services at their local institutions. Therefore, one of the potential unintended effects of OLAs is to further divide the roles and professional identities of diagnostic and interventional radiologists, compromising their ability to work together to serve the broader image-guided procedural needs of their communities. Therefore, the collective challenge for the ABR and organized radiology is to better align certification requirements and testing to ensure adequate patient access to quality DR and IR patient care services in an effort to serve society’s broader health care at a time when predictions suggest a shortage of diagnostic and interventional radiologists [7].


  1. Kaufman JA. The interventional radiology/diagnostic radiology certificate and interventional radiology residency. Radiology. 2014;273(2):318–321.
  2. Marx MV. Evolution of Interventional Radiology and ABR Certification: Birth of the ABR Certificate in Interventional Radiology and Diagnostic Radiology. Published September 2017. Accessed July 14, 2020.
  3. The American Board of Radiology. Holman research pathway. Updated January 23, 2020. Accessed July 14, 2020.
  4. Di Marco L, Anderson MB. The new Interventional Radiology/Diagnostic Radiology dual certificate: "higher standards, better education". Insights Imaging. 2016;7(1):163–165.
  5. Ross JR. How will the generalist survive? November 22, 2019. Accessed July 14, 2020.
  6. Stempniak M. Dwindling number of generalists in radiology could have ‘far-reaching implications’. Published January 7, 2020. Accessed July 14, 2020.
  7. Rosenkrantz AB, Hawkins CM, Ryu RK, Duszak, Jr R. Clinical practice characteristics of radiologists based on American Board of Radiology Interventional Radiology Certification status. Am J Roentgenol. 2020;214:149–155.