Subspecialisation recognition in European Radiology—follow-up survey by the Accreditation Council in Imaging and European Society of Radiology National Societies Committee

TL;DR

A survey of European radiology societies shows that subspecialisation in radiology is recognized in some countries but not others, with many wanting future recognition.

Contribution

This paper provides updated data on the recognition of radiology subspecialties across European countries through a follow-up survey.

Findings

Radiology subspecialties are recognized in 25 out of 37 responding European countries.

12 countries do not recognize subspecialties, but 9 of them desire future recognition.

The number of recognized subspecialties varies widely, from 0 to 12, with no country recognizing all 13.

Abstract

To assess the status of radiology subspecialisation recognition across Europe, targeting European Society of Radiology (ESR) National Societies.

A questionnaire was distributed to members of the ESR National Societies Committee regarding the recognition of radiology subspecialties in their respective countries.

Responses were received from 37 out of 47 countries (78%). Radiology subspecialties are recognised in 25 countries, whereas in 12 countries, they are not. Among 12 countries without recognised subspecialisations, 9 expressed a desire for future recognition. There are large variations between countries regarding the number of officially recognised subspecialities, ranging from 0 to 12.

Based on responses from ESR National Societies Committee members, radiology subspecialties are recognised in 25 countries, while 12 countries do not have formal recognition. The majority of countries without recognised subspecialisations express interest in having them acknowledged in the future.

This follow-up survey among ESR National Societies presents the recognition status of radiology subspecialisations in Europe. Among the 37 responding countries, there are significant variations in the number of officially recognised subspecialties, ranging from 0 to 12.

Among the 37 ESR National Societies responding countries, between 0 and 12 out of 13 radiology subspecialties are recognised.No country recognises all subspecialties.The majority of countries without recognised subspecialisations would like them to be acknowledged.

Among the 37 ESR National Societies responding countries, between 0 and 12 out of 13 radiology subspecialties are recognised.

No country recognises all subspecialties.

The majority of countries without recognised subspecialisations would like them to be acknowledged.

Full text

Objectives

The Accreditation Council in Imaging (ACI) is the accreditation body of the European Board of Radiology and provides a one-step service for continuing medical education (CME) accreditation, supporting the European Accreditation Council for Continuing Medical Education in delivering and harmonising the highest level of CME in imaging.

To investigate the latest trends and developments in the radiological community in CME in Europe and beyond, the ACI has performed surveys on an annual basis from 2017 until 2024.

One of the surveys performed among the European Society of Radiology (ESR) membership in 2021 was about “Subspecialisation in radiology in Europe” [1]. The aim of that survey was to obtain information on officially recognised subspecialities, defined as subspecialty diplomas in one of thirteen fields of the Level III European Training Curriculum for Subspecialisation in Radiology [2].

In the survey, we observed heterogeneity in the responses within countries regarding the existence of subspecialties. Therefore, a follow-up survey was developed in close collaboration with the ESR National Societies Committee, and distributed among the 47 members of the ESR National Societies Committee. The aim was to obtain a more accurate overview with regard to all recognised subspecialties in radiology by official bodies in each respective country.

Methods

The survey was distributed on the 27th of September 2023 among the members of the ESR National Societies Committee (n = 47). Societies were asked to submit only one completed survey per country. If respondents were not fully aware of the situation of one particular subspecialisation, they were encouraged to consult experts within their country to ensure that the results were as comprehensive and accurate as possible. Eight reminders were sent, with the final reminder issued on the 18th of July 2024.

The survey included the following questions: (1) Are subspecialties within radiology officially recognised in your country? If yes, which ones? (2) If an area of subspecialisation is not officially recognised in your country, would you like it to be recognised?

In accordance with National Health Service Health Research Authority criteria, this study did not require ethical approval [3].

Results

Responses were received from 37 out of 47 countries (78%)

Radiology subspecialties are recognised in 25 countries, while in 12 countries, they are not (Table 1). Among the countries without recognised subspecialisations, the majority (9 out of 12) expressed a desire for subspecialisation recognition in the future (Table 1).Table 1. General recognition of radiology subspecialties in ESR National Societies countriesCountryAre subspecialties within radiology officially recognised in your country?If an area of subspecialisation is not officially recognised in your country, would you like it to be recognised?AlbaniaYesYesArmeniaYesYesBelarusYesYesCyprusYesYesFinlandYesNoFranceYesNoGermanyYesNoGreeceYesYesHungaryYesYesIcelandYesYesIsraelYesYesN. MacedoniaYesYesMoldovaYesYesNetherlandsYesNoPortugalYesYesRomaniaYesYesRussiaYesYesSerbiaYesYesSlovakiaYesYesSloveniaYesYesSpainYesYesSwedenYesYesSwitzerlandYesNot applicableTurkeyYesYesUnited KingdomYesNoAustriaNoYesBelgiumNoYesEstoniaNoYesGeorgiaNoYesIrelandNoNot applicableItalyNoNoLithuaniaNoYesLuxembourgNoYesMaltaNoYesNorwayNoNot applicablePolandNoYesUkraineNoYesAdditionally, the responses regarding the desire for subspecialty recognition in countries where they are not yet recognised are also presented

A detailed analysis revealed large variations in the number of officially recognised subspecialities across countries, ranging from 0 to 12. No country recognises all thirteen subspecialties as defined by the Level III ECTSR [2] (Table 2). According to the responses, the highest number of recognised subspecialty diplomas are in Slovenia (n = 12), Switzerland (n = 11), and Finland (n = 10). The most commonly recognised subspecialties across all countries are Interventional Radiology (n = 18), Neuroradiology (n = 13), and Gastrointestinal and Abdominal Radiology, along with Paediatric Radiology (n = 10 each). Medical Imaging Informatics is not recognised as a subspecialty in any country. Several countries provided additional information about the status of subspecialisation within their respective countries in the comment section of the survey. In the Netherlands, Gynaecological and Obstetric, as well as Urogenital Radiology, are integrated in the Gastrointestinal and Abdominal Radiology subspecialisation. Neurointerventional Radiology is recognised as a separate subspecialty in Finland, while Advanced Interventional Radiology holds distinct recognition in France. In France, the official national diploma in Radiology offers access to perform and report all subspecialty exams except Advanced Interventional Radiology. Recognition of expertise in 1 or 2 domains during residency training is possible in France (Table 2). In Greece, the only official subspecialisation is Interventional Radiology. All the remaining domains are covered by radiologists who have a special interest in the topic. In Ireland, the Medical Practitioners Act does not allow the Medical Council to recognise subspeciality status. In Poland, radiology subspecialisation is non-existent either. In Italy, the official law considers three separate specialities, i.e. Diagnostic Radiology, Therapeutic Radiology, and Nuclear Medicine. Neuroradiological expertise and Breast cancer screening programme could be requested only in the form of documented clinical experiences.Table 2. Detailed ESR Level III subspecialties recognition among respondents from ESR National Societies, listed in descending order of recognitionSubspecialty/countrySLOCHFINLILMDEMKARMPHSRBDISROSALBYCYGRRUSSKTRUKFTotalInterventional radiologyYYYYYYYYYYYYYYYYYY18NeuroradiologyYYYYYYYYYYYYY13Breast radiologyYYYYYYYYYY10Gastrointestinal and Abdominal RadiologyYYYYYYYYYY10Paediatric radiologyYYYYYYYYYY10Chest radiologyYYYYYYYYY9Musculoskeletal radiologyYYYYYYYY8Cardiac and vascular radiologyYYYYYYY7Head and neck radiologyYYYYYYY7Emergency radiologyYYYY4Urogenital radiologyYYYY4Oncologic imagingYYY3Medical imaging informaticsTotal1211109888744332222111111110Other (please specify)1234Country codes [8]: AL Albania, ARM Armenia, BY Belarus, CY Cyprus, FI Finland, F France, D Germany, GR Greece, H Hungary, IS Iceland, IL Israel, MK North Macedonia, MD Moldova, NL Netherlands, P Portugal, RO Romania, RUS Russia, SRB Serbia, SK Slovakia, SLO Slovenia, E Spain, S Sweden, CH Switzerland, TR Turkey, UK United Kingdom^^1 Neurointerventional radiology^^2 Gynaecological and obstetrics, and urogenital radiology are integrated in the abdominal subspecialisation^^3 Nuclear Medicine is recognised as a separate speciality (not within radiology)^^4 Advanced interventional radiology. Recognition of expertise in 1 or 2 domains during residency training is possible

Discussion

Since the introduction of the first European Specialist Diploma Examination in 1984, more than 30 disciplines now organise European examinations every year under the European Union of Medical Specialists (UEMS)–Council of European Specialist Medical Assessment (CESMA) (UEMS–CESMA) umbrella [4].

Medical subspecialties are also becoming increasingly structured. Therefore, the aim of this study was to provide an additional comprehensive overview of radiology subspecialties in each country, as assessed by ESR National Societies, and make the findings available to the radiology community.

Since the 2023 analysis [1] three new ESR endorsed subspecialty diplomas/certifications have been introduced: the European Diploma in Gastrointestinal and Abdominal Radiology, organized by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR); the European Society of Thoracic Imaging Lung Cancer Screening Certification (ESTI LCS), organized by ESTI [5]; and the European Certification in Prostate MRI, provided by European Society of Urogenital Radiology (ESUR) [6] (Table 3).Table 3. Overview of existing European subspecialty exams and diplomas in radiology and their endorsementSubspecialty (Level III)European subspecialty societyEuropean subspecialty exam and diplomaEuropean subspecialty certificationESR endorsementUEMS-CESMA appraisalTitleBreast radiologyEUSOBIEDBIYesEBBICardiac and vascular radiologyESCREBCRYesEBCRChest radiologyESTIESTI diplomaYesESTIESTI LCSYesEmergency radiologyESEREDERYesFESERGastrointestinal and abdominal radiologyESGARYesYesHead and neck radiologyESHNREBiHNR diplomaYesInterventional radiologyCIRSEEBIRYesYesEBIRMusculoskeletal radiologyESSRYesYesEDiMSKNeuroradiologyESNREBNR (multiple)YesOncologic imagingESOINo–––Paediatric radiologyESPREDiPRUrogenital radiologyESURYesYesEDiURESUREuropean certification in prostate MRIYesMedical imaging informaticsEUSoMIINo–––List of subspecialties in radiology (according to the European Training Curriculum for Subspecialisation in Radiology), their corresponding European subspecialty society, the name of an existing European Subspecialty Exam and Diploma, endorsement by the ESR and/or the CESMA, and title to be added behind the name of successful candidates indicating full subspecialisation in radiology as allowed by the subspecialty societyCESMA Council of European Specialist Medical Assessment, CIRSE Cardiovascular and Interventional Radiological Society of Europe, EBBI European Board of Breast Imaging, EBCR European Board of Cardiovascular Radiology, EBiHNR European Board in Head and Neck Radiology, EBIR European Board of Interventional Radiology, EBNR European Board of Neuroradiology, EDBI European Diploma in Breast Imaging, EDER European Diploma in Emergency Radiology, EDiMSK European Diploma in Musculoskeletal Radiology, EDiPR European Diploma in Paediatric Radiology, EDiUR European Diploma in Urogenital Radiology, ESCR European Society of Cardiovascular Radiology, ESR European Society of Radiology, ESTI European Society of Thoracic Imaging, ESTI LCS European Society of Thoracic Imaging Lung Cancer Screening Certification, ESER European Society of Emergency Radiology, ESGAR European Society of Gastrointestinal and Abdominal Radiology, ESHNR European Society of Head and Neck Radiology, ESNR European Society of Neuroradiology, ESOI European Society of Oncologic Imaging, ESPR European Society of Paediatric Radiology, ESSR European Society of Musculoskeletal Radiology, ESUR European Society of Urogenital Radiology, EUSOBI European Society of Breast Imaging, EUSoMII European Society of Medical Imaging Informatics, FESER European Fellow of Emergency Radiology, UEMS European Union of Medical Specialists

As shown by the answers received, there is a heterogeneity in the countries of the ESR national societies with regard to the existence of officially recognised subspecialities within radiology, ranging from 0 to 12. Some countries are satisfied with their status quo of none or only very few recognised subspecialties in radiology, but the majority of countries would like an area of subspecialisation that is not officially recognised in their country to be recognised in the future. The overall results of the current survey, therefore, indicate that there is a desire for greater subspecialty recognition in radiology, also at the level of ESR National Societies. This aligns with a similar desire, expressed by ESR membership in 2023 [1].

A substantial proportion of countries (12 out of 37) still do not recognise radiology subspecialties. Additionally, no country recognises all thirteen subspecialty diplomas, as Medical Imaging Informatics is not recognised as a subspecialty in any country. The responses also revealed two new subspecialties: Neurointerventional Radiology in Finland and Advanced Interventional Radiology in France. All the above highlights the need for further harmonisation and implementation of subspecialty training in radiology at a European level.

The comments in the survey also identified several disciplines that are not part of the thirteen ESR-recognised subspecialties (Nuclear Medicine, Gynaecological and Obstetric radiology, Breast cancer screening programme, and Lung cancer screening programmes), representing possible further fields of increasingly structured radiology subspecialties or certifications.

As the UEMS–CESMA appraisal for subspecialty exams in radiology is currently limited, an additional challenge for the radiology subspecialty societies, in collaboration with the ESR National Societies Committee, could be to achieve UEMS–CESMA endorsement for more subspecialties. Currently, only the subspeciality diploma offered by the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), the European Board of Interventional Radiology (EBIR) is endorsed by the ESR and the UEMS-CESMA. The European Board of Neuroradiology (EBNR) provides multiple diplomas in the field of neuroradiology [7]. All EBNR diplomas are only endorsed by the UEMS-CESMA.

One of the limitations of this survey is a response rate of only 78% (37 out of 47 ESR National Societies). Therefore, information about the situation of all recognised subspecialties in radiology in the countries of the ten ESR National Societies is still lacking.

Despite increasingly structured subspecialisations, it is still equally important to remember that, in the future, both general radiological knowledge and subspecialised radiological expertise will remain crucial to maintaining a high standard of radiology during all hours of 24/7 service [1].

Conclusions

According to ESR National Societies, radiology subspecialties are recognised in 25 European countries, while in 12 countries they are not. No country recognises all subspecialties. The majority of countries without recognised subspecialisations would like these areas to be recognised in the future.