European Diploma in Radiology: How it works

By Prof. Laura Oleaga Zufiría, AuntMinnieEurope.com contributing writer

June 21, 2019 -- Since it was established in 2011, the European Diploma in Radiology (EDiR) and its self-developed examination platform have become a benchmark for medical specialty examinations in Europe. But what do you actually need to know about the EDiR, how is it organized, and how can it boost an individual's career?

The EDiR is an additional qualification of excellence, which serves as a tool for the standardization and accreditation of radiologists across European borders. It is officially and fully endorsed by the European Union of Medical Specialists (UEMS) and the European Society of Radiology (ESR).

Test takers sitting at table working on laptops
Since it was established in 2011, the European Diploma in Radiology has grown in popularity. All photos copyright of the European Board of Radiology.

The EDiR's success has been largely thanks to its now fully computer-based examination system -- developed by the European Board of Radiology (EBR), the body in charge of organizing the EDiR -- which has made it possible to incorporate all the steps of the examination onto one platform. This new platform has revolutionized the entire examination process, making it possible to test hundreds of candidates in one day without compromising standards.

The new software developed by the EBR office supports the fully computer-based examination and integrates all the steps of a certification process, including the upload and review of the material by submitters and reviewers, scoring of the cases by the examiners, and the actual exam taken by the candidates. Submitters, reviewers, and examiners can do their work remotely from home or their hospital.

The software is not only used by the EBR but also by some ESR subspecialty societies, such as the European Society of Cardiovascular Radiology (ESCR) and the European Society of Breast Imaging (EUSOBI), as well as by international societies such as the Consejo Mexicano de Radiología e Imagen (CMRI).

How the concept grew

When it was conceived, the EDiR examination was designed to test knowledge, skills, and competence in anatomy, pathophysiology, imaging procedures, physics, and management in general radiology. It consisted of multiple response questions (MRQs), short cases (SCs), and an oral examination.

By 2016, the growth in the number of candidates and the need to offer an online-based and even better standardized examination system led to replacing the oral part with the Clinically Oriented Reasoning Evaluation (CORE) examination. The CORE cases are clinical cases that consist of several questions, and the software developed by the EBR features a DICOM viewer for case analysis, simulating the daily work of radiologists.

Two men looking at a radiology case on a screen
CORE cases use software developed by the European Board of Radiology. The software features a DICOM viewer for case analysis, simulating the daily work of radiologists.

The DICOM viewer has several tools such as manual and automatic window levels, zoom, and pan. Each case is graded between zero and 10 points and the points are distributed among the questions. Different weights may be assigned to the questions depending on their importance and/or difficulty. Several free-text questions are included without providing a list of options to choose from. Additionally, examiners can grade CORE cases with the score "unsafe." Unsafe is assigned when a catastrophic error is made (in observation, interpretation, or management) that would have a major impact on the patient.

The first two sections of the examination (MRQs and SCs) are automatically calculated by the system, but the CORE section is scored manually by the examiners. For consistency, the correction criteria for all cases of an examination are reviewed and have to be unanimously approved by all examiners in a preparatory meeting held prior to the examination.

Checking quality

A statistical analysis to determine the reliability and consistency of the examination with this new structure was performed by a group of experts from the Universitat Autònoma of Barcelona. Six oral cases and six CORE cases were presented in the EDiR exam at ECR 2016, and the correlation between these two parts was analyzed. Similar results were obtained. Individuals who do not have the required competences differ significantly from those who have them (both in the oral and in the CORE parts, but there were no statistically significant differences between them). The CORE has proved to be more objective as the same examiner scores the same case for all participants, ensuring that the same criterion applies to all.

There are very stringent protocols in place for the preparation of each EDiR examination. Each one is prepared from scratch. Questions are provided by the members of the Written Evaluation Committee (in charge of the MRQs and SCs) and CORE Committee (in charge of the CORE cases and scoring), both of which include subspecialists from different areas. The material undergoes a professional proofreading and the EBR carries out a format-wise quality control to guarantee it meets the standards set by the Standards Committee. Then, the content of the cases is thoroughly revised by the coordinator of the corresponding committee.

EDiR candidates taking the test at rows of computers
The overall pass rate for EDiR candidates is 70%.

A preliminary selection of the questions is made following the EDiR blueprint, which is based on the ESR's European Training Curriculum and sets out the recommended proportions for each category and for each examination. This selection is then reviewed and approved by the panel of experts. Lastly, it undergoes a final quality assurance by the EDiR scientific director or by the respective committee chair for consistency and suitability purposes.

The pass mark is set by a statistical procedure called equating. This way, the difficulty of the corresponding section can be determined when setting the grade curve for passing the examination. The overall pass rate, which has proved to be stable over the years, is 70%.

Moving forward, one of the next projects in the pipeline is to use structured reports in the CORE cases. The objective is twofold: On the one hand, it will be easier for the examiners to score, and on the other hand, candidates will learn how to structure the information when facing a clinical case in their daily work.

Full details about upcoming examinations are available on the EBR website.

Editor's note: To provide an example of what a CORE case looks like, the organizers of the EDiR have prepared a case report that we will publish soon in our Case of the Week feature.

Prof. Laura Oleaga Zufiría currently serves as EDiR scientific director. Since 2009, she has been head of the radiology department at the Hospital Clínic of Barcelona in Spain. Also, Oleaga Zufiría is a reviewer for the journals Radiología, European Radiology, and Neuroradiology.


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