Program Director's column

The integrated IR residency was created to produce a physician who is more than a proceduralist and more than a diagnostic radiologist. Our graduates must be imagers, consultants, clinicians, operators and leaders of multidisciplinary care. That is an ambitious training mandate, and as the certification pathway evolves, our curricula need to evolve with it. 

A new board timeline, a new curriculum challenge

The upcoming changes to the American Board of Radiology (ABR) examination sequence should prompt every IR program director to take a fresh look at the 5-year integrated curriculum. In the steady state, IR/DR residents will have their first opportunity to take the Qualifying (Core) Examination in the fall of PGY-5/R4, followed by the DR Oral Certifying Examination in June of PGY-5/R4. The IR Oral Certifying Examination timing remains unchanged, occurring after residency completion. Both the DR and IR oral examinations are required for full board certification of an IR/DR graduate. 

This is more than a testing update. It is a curricular design challenge. 

Many integrated IR programs were initially built by layering IR rotations onto a traditional DR framework. While that approach was understandable during the early years of the pathway, it created predictable pressure points. Residents could spend their early years heavily weighted toward DR and call, only to transition into more intensive IR training later. For some trainees, this sequence can make it harder to maintain the clinical skills they developed during internship and harder to sustain their identity as IRs while they are immersed in the early work of becoming competent imaging consultants. 

Balancing DR readiness with early IR identity  

Later years of training can experience different problems. In many programs, residents face a collision of DR knowledge retention, IR knowledge expansion, DR and IR call responsibilities, board preparation, increasing clinical responsibility and progressive procedural expectations. The new board timeline makes that model harder to defend. 

With the Core Exam now occurring in the fall of PGY-5 and the DR Oral Exam following in the spring of the same academic year, residents need meaningful DR exposure close enough to those exams to maintain interpretive fluency. Oral examinations do not simply test stored knowledge. They test pattern recognition, synthesis, organization and communication under pressure. Those skills are maintained through repetition. A resident who spends long stretches away from diagnostic rotations immediately before the DR Oral Exam may be at a disadvantage. 

At the same time, we cannot respond by delaying IR. Integrated IR residents need earlier exposure to clinical IR, longitudinal patient care, procedural fundamentals, consultative decision-making and complication management. They need time to evolve from enthusiastic observers into capable senior residents with graded autonomy. If too much of that growth is compressed into the final year, we risk producing residents who have completed the required rotations but have not had enough time to mature within the specialty. 

The solution is not “more DR” or “more IR.” It is better sequencing. 

Moving beyond layered-on IR training  

As program requirements continue to evolve, one practical model is to move more IR and IR-adjacent clinical rotations into the earlier years of residency while preserving selected diagnostic rotations in PGY-5, closer to the Core and DR Oral Exams. For example, a program might deliberately include more VIR, ICU, vascular surgery and IR-focused outpatient experiences during PGY-2 through PGY-4, rather than waiting until the end of training to create a sustained IR identity. In that same model, PGY-5 can remain a hybrid year, with meaningful IR experience but also enough DR, including high-yield rotations such as abdominal imaging, chest, neuroradiology, nuclear medicine, ultrasound, or mammography, to maintain exam readiness and satisfy program requirements. PGY-6 can then function as the true finishing year for IR, emphasizing senior procedural responsibility, supervision of junior residents, clinical ownership, outpatient care, and transition to practice. 

See how Loma Linda University is restructuring their residency block.

Rethinking call and exam preparation  

This type of restructuring also creates an opportunity to revisit call. For many integrated residents, call burden is not evenly distributed across training. Programs should ask whether the most disruptive call months are clustered during the exact periods when residents are expected to prepare for the Core or DR Oral Exams. Reducing call intensity during those windows is not a retreat from rigor. It is a recognition that fatigue, fragmented study time and poorly timed service obligations do not make better radiologists or better interventionalists. 

Finding the solution that fits your program 

Every program will need a different solution. Some programs have large DR classes and relatively small IR cohorts. Others rely heavily on independent residents or have limited flexibility because of institutional call structures. Some have robust outpatient IR clinics, while others are still building that infrastructure. But the guiding questions should be the same: Are our residents getting enough IR early enough to build identity and competence? Are we preserving enough DR close enough to the new examinations to support retention? Are we protecting key study periods from avoidable service burden? Are we using PGY-6 as a true capstone year, or are we still trying to fix deficiencies that should have been addressed earlier? 

The new examination sequence gives program directors permission to challenge inherited schedules. We should not assume that a block schedule is educationally sound simply because it has survived for years. Integrated IR training is too demanding, and our residents’ time is too valuable, for passive curricular design. 

As program directors, we should view this moment as an opportunity. We can build schedules that are more deliberate, more humane and more aligned with the actual developmental arc of an IR/DR resident. The goal is not merely to help residents pass examinations. The goal is to graduate physicians who can think like radiologists, act like clinicians, operate like interventionalists and lead like consultants. 

The boards are changing. Our block schedules should change with them.