Decreasing the Diagnostic Cerebral Angiogram Requirements for Neuroradiology Fellows Would Be a Mistake

There is currently a discussion taking place among academic neuroradiology programs concerning the minimum number of required diagnostic cerebral angiograms for neuroradiology fellows. Currently, fellows in Accreditation Council for Graduate Medical Education–approved programs are required to perform 50 cerebral angiograms to satisfy the requirements. In recent years, some fellowship programs have been lobbying for a reduction in the cerebral angiography requirements for fellows. I think it is important for patient safety and the credibility of our subspecialty to at least maintain the requirements at the current level or, better yet, increase the number to 75.

The pressure to reduce cerebral angiography requirements has developed primarily as a result of increasing noninvasive MR imaging and CT procedure volumes. At institutions that are “fellow driven,” fellows are needed to run the MR imaging and CT services. To keep up with growing cross-sectional volumes, opportunities for fellows to perform conventional angiography are compromised. A simple solution is to reduce the number of required angiograms and thus time spent away from cross-sectional services. This solution, however, has 2 serious consequences. First and foremost, patient safety is compromised if fellows finish their training with less than 50 angiograms and begin performing these potentially dangerous procedures unsupervised. The performance of cerebral angiography has not become easier in the last several years and neuroradiology fellows are presumably not smarter than their predecessors. If we considered 50 cerebral angiograms to be a minimum requirement in the past, why are we considering a reduction in the numbers now? The second consequence to decreased training in cerebral angiography is the inevitable erosion of our credibility among other specialties when it comes to the performance of this procedure. Without a doubt, neuroradiologists are currently the experts when it comes to performing and interpreting cerebral angiograms. No other specialty can claim equivalent training in imaging-guided procedures and radiation physics; however, we put our expertise in significant jeopardy if we dilute our training requirements. The competence of trainees who have performed less than 50 cerebral angiograms is suspect at best and places patients and our credibility at risk.

As a subspecialty community, we should carefully weigh the consequences of reducing the fellowship training requirements for cerebral angiography. Diluting the numbers with noninvasive angiography techniques such as MR angiography and CT angiography cannot replace the hands-on training required to competently perform conventional angiography. Although simulator devices can be an important adjunct to training, these too are insufficient to serve as a surrogate for performing angiograms on patients and adequately dealing with the many complications that can occur.

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