Committee Puts Emphasis on Image Quality for Exams
By Daniel C. Davis, MD, ABR Trustee; Stephen F. Simoneaux, MD, ABR Governor; Brian J. Davis, MD, PhD, ABR Trustee; Lydia Warg, ABR Associate Director of Exam Services; and Scott Segal, ABR Director of IT
2025;18(4):3
The Image Quality Committee, which has representatives from all four disciplines the ABR certifies, is one of several standing committees that meet semiannually during ABR Board meetings. The committee makes recommendations regarding image quality and works behind the scenes to offer best practices regarding image submissions.
ABR Governor Stephen Simoneaux, MD, noted variation in image quality while serving as the diagnostic radiology Trustee for pediatrics. To improve image quality and standardize acquisition, he formed an Imaging Task Force in 2019 that eventually became the Image Quality Committee.
Quality is a vital element in the image-rich diagnostic radiology and interventional radiology/diagnostic radiology qualifying and certifying exams, as well as in OLA. Radiation oncology and medical physics exams, especially the oral certifying exams, also include images. The ABR strives to use high-quality images that don’t include extraneous information or distractions, such as patient motion, poorly positioned views, or secondary diagnoses. Technical artifacts may be intentionally included if the concept is relevant to that discipline and part of the assessment. Cross-sectional imaging has improved considerably in the last 20 years, so we work to use images that are contemporary.
Volunteer question writers receive guidance for saving images from their PACS and uploading them into the ABR’s question banking software. These images must not contain any protected health information. Question writers have the option of uploading static images, a series of static images (stacks), and short cine clips. Images can be reformatted to fit ABR size standards while still maintaining resolution and quality. Question writers are encouraged to add relevant arrows or text labels to the images using the ABR’s image upload tool. Modality metadata added to each image is helpful when assembling test modules.
The ABR’s editorial staff reviews all new questions to make sure they meet a certain standard, and accompanying images are reviewed by image processing specialists. At least three members of the appropriate clinical committee vet newly created questions and attached images before they are accepted for future deployment in OLA or on a test module. Frequently, during these reviews, the committee will eliminate redundant images, add clarifying text or arrows, or ask the question writer to obtain additional images to improve the question. Some questions are rejected if the images are confusing or of marginal quality. Periodically, each committee reviews banked questions that are greater than 10 years old to make sure the images meet current standards, and that the content of the questions is current and tests a relevant concept.
In the last few years, the Image Quality Committee, after collaborating with the Language and Style Committee, adopted the standard that MRI images for all future questions will have the specific sequence type labeled, unless the sequence type is part of the content being assessed. All breast images also have standardized labels for orientation. The committee has worked with the RO trustees regarding potential issues for examinees with color-blindness. Certain treatment charts may have graphs in red or green. These color-coded charts are reviewed by the image processing staff using a software tool that helps ensure an examinee will not encounter confusion viewing them. Additionally, this committee has provided advice on the maximum number of images in a stack and length of cine clips, to minimize download times and image review time by the examinee.
Going forward, the Image Quality Committee is collaborating with the ABR’s IT department to develop a platform for how examinees will view images attached to questions. Compared with the current version, this new platform will function more like a simplified version of a PACS. This will be rolled out to question writers and used in all exam platforms in 2026. The ABR is very excited about this upgrade, since it will more closely mimic how examinees view images at their home institution. For instance, an examinee will be able to view up to six series at once, with the option to simply click on an image to enlarge it. As before, the examinee will be able to further magnify, pan, or change the contrast settings of each image.
