Performance of American Board of Radiology Alternate Pathway Candidates Compared with U.S. Diagnostic Radiology Graduates: A Multi-Specialty Program Director Survey

Purpose: International medical graduates (IMGs) represent an increasingly important component of the U.S. radiology workforce, particularly in the context of projected physician shortages. The American Board of Radiology (ABR) Alternate Pathway (AP) provides a structured route for IMGs to become board eligible in diagnostic radiology. This study aimed to evaluate program director perceptions of APC performance.

Methods/Materials: A structured, anonymous survey was distributed to U.S. radiology fellowship program directors across multiple subspecialties, including neuroradiology, body imaging, pediatrics, chest, interventional radiology, musculoskeletal radiology, nuclear medicine, and breast imaging. Program directors compared APCs with U.S. DR graduates across multiple domains: research skills, clinical skills, teaching ability, ABR Core Examination performance.

Results: Across all specialties, research skills were the domain most favorably rated for APCs, with 31% of programs reporting APCs as stronger than U.S. DR graduates, compared with 10% rating them as weaker; 28% reported equivalent performance. Clinical skills and teaching ability were most commonly rated as equivalent (36% and 38%, respectively), though a higher proportion of programs rated APCs as weaker than stronger in these domains (clinical: 24% weaker vs. 8% stronger; teaching: 19% weaker vs. 10% stronger).
ABR Core Examination performance was predominantly perceived as equivalent between APCs and U.S. DR graduates (72%), with relatively few programs rating performance as better (9%) or worse (7%). First-attempt pass rates were reported as similar, with 32% of programs indicating APCs passed APC/CAQ examinations on first attempt and 33% reporting first-attempt U.S. DR board pass success, although a substantial proportion of respondents indicated insufficient knowledge to assess examination outcomes.

Conclusions: Across radiology subspecialties, program directors generally perceive ABR Alternate Pathway Candidates as performing comparably to U.S. diagnostic radiology graduates in most domains. These findings support the role of the ABR Alternate Pathway as a viable mechanism for integrating IMGs into U.S. radiology training and practice.