The New ABR Oral Certifying Exam: What to Expect and What Comes Next
The ABR oral certifying exam is coming back. Beginning in 2028, diagnostic radiology residents will no longer take a purely computer-based multiple-choice certifying exam. Instead, the ABR is reinstating an oral exam. For IR/DR candidates, passing both the DR and IR oral exams will now be required.
This shift marks one of the most consequential—and controversial—changes in radiology education in a decade.
From Oral to Computer and Back Again
The ABR scrapped oral boards in 2013, citing efficiency, standardization, and reduced examiner bias. That decision aligned with the broader move across medical specialties toward computer-based testing.
But a switch to only multiple-choice exams had clear limitations. They rewarded memorization and test strategy more than real clinical reasoning. They didn’t test how radiologists think aloud, communicate, or handle uncertainty in real time. In many instances, the exam presented a list of differential diagnoses and required choosing a single best answer—an approach that oversimplifies clinical reality and doesn’t reflect how radiology is practiced.
Now the pendulum swings back—but not everyone’s convinced this is progress. The stated goal is to better assess clinical reasoning. In practice, it’s an attempt to patch flaws in one system by potentially reintroducing the flaws of another.
What the New Oral Exam Looks Like
· Format: Remote video sessions
· Timing: Twice per year
· Eligibility: One year after residency completion
· Scope: Seven core diagnostic categories + procedures
· Skills tested: Image interpretation, communication, and decision-making under time pressure
It’s meant to mirror real-world reasoning, but it’s still a simulated environment—with artificial time constraints, examiner variability, and the potential for technical issues that didn’t exist in Louisville hotel rooms decades ago.
Preparing for a High-Stress Format
Success on the new oral boards depends as much on composure as on knowledge. Residents will need to practice thinking and speaking clearly under scrutiny—skills not easily learned from textbooks or question banks.
Existing tips from the literature (such as JACR Strategies for Success) along with my own thoughts:
Many suggest treating daily readouts like “mini oral boards,” but that’s easier said than done. With the constant pressure to move cases, few attendings have time to pause for full oral-style questioning. Most days, the focus is on getting through the worklist, not rehearsing for the exam. However, during readouts you can hone your systematic approach that will translate well to oral board examinations: modality → pattern recognition → differential → management.Build structured, timed case practice sessions into your study schedule early. I agree with this suggestion. This will likely take place during existing resident conference time. The earlier you start, the better. Prepare to succeed.
Focus on having clear, structured differentials—think malignant, infectious, vascular, and other causes—and be able to provide them without hesitation. For classic cases, differential diagnoses should become second nature rather than something you need to puzzle through in real time. There are useful resources to build this skill. One example is Top 3 Differentials in Radiology: A Case Review (2nd edition, 2018). I read the first edition, and it’s a solid study tool for the oral boards—it presents one or two representative images followed by the top three differential diagnoses, which closely mirrors what you’ll be expected to do on the new exam format.
Learn to express uncertainty with confidence—it’s an essential part of real radiology practice. You will inevitably encounter cases where you don’t know the answer. In those situations, focus on being honest while outlining a logical next step to reach the correct diagnosis—such as ascertaining specific clinical information, obtaining a specific additional imaging test, or recommending a specific type of image-guided biopsy. “When in doubt, work it out” should be your guiding principle—both for the exam and in daily practice.
Program-Level Challenges
Residency programs are now expected to reverse a decade of de-emphasis on oral case teaching—and do it quickly. Many current faculty also never took oral boards themselves, and institutional bandwidth for developing mock sessions is already stretched thin.
Programs will need to:
Reinstate hot-seat case conferences
Build new case libraries from scratch
Train faculty to evaluate oral performance consistently
Prepare residents during both residency and fellowship years, since the exam is taken one year post-residency
The time and effort required for this transition are far from trivial. Academic departments are already operating under significant pressure, and this change introduces yet another layer of uncompensated workload. I’m particularly concerned about the additional strain it will place on already overextended training programs—and on current junior faculty members who never experienced the oral boards themselves but will now be expected to help residents prepare for them.
The Real-World Problem
The argument that oral boards “create better radiologists” deserves skepticism. Many who advocate for their return describe them (from personal conversations I’ve had) as a terrifying but character-building experience.
That’s not necessarily a pedagogical virtue. In many ways, the return to oral boards feels like a generational echo—those who once endured the old format are now reimposing it on the next cohort. It risks coming across less as a step forward in education and more as a revival of past hardships, driven as much by tradition as by evidence of true educational benefit.
In clinical practice, radiologists have access to colleagues, prior exams, EMRs, and reference tools. The oral board model, even updated and virtual, is still a closed-book, high-anxiety environment that doesn’t reflect how radiologists actually make decisions.
And while multiple-choice exams weren’t perfect, they were at least standardized. The oral format reintroduces subjectivity—no matter how many safeguards are instituted. How articulate you are, how you handle artificial stress, and who happens to grade you that day could all matter.
Concerns About Case Quality
The ABR’s sample cases already raise questions. While reviewing example cases in breast imaging and nuclear medicine I noticed instances of awkward phrasing and complete non-discussion of highly relevant imaging findings. In one case, I found myself questioning the management recommendation; the phrasing made the intended guidance unclear and potentially incorrect. I take this as an indication that the ABR is already overextended in its efforts to make the oral board examination a reality, relying heavily on volunteer radiologists who have limited time to dedicate to the process.
If the case-writing process isn’t carefully refined and repeatedly reviewed, I have concerns about the reliability of the results. Reviewing the example cases was, frankly, somewhat alarming, and I hope the ABR takes significant steps to improve the process before the exam goes live.
Unintended Consequences
The timing of the exam—one year post-residency—introduces new inequities. Residents who transition directly into private practice, a growing trend, may have limited time or institutional support for preparation, whereas fellows in academic settings may asymmetrically benefit from structured mock orals. This could inadvertently disadvantage those entering the workforce directly, despite the increasing need for generalist radiologists.
The timing also raises logistical and financial questions. How can new radiologists and fellows balance exam preparation with clinical productivity expectations? Will practices and departments feel pressured to provide dedicated study time for new hires or fellows? Smaller practices, with less scheduling flexibility, may be disproportionately affected, while larger practices could establish internal preparation programs that smaller practices cannot match, further exacerbating disparities. For any hire who does not pass the oral boards, these circumstances create significant operational challenges.
I anticipate that future job and fellowship postings will advertise incentives such as “two weeks of dedicated study time,” “an internal oral board preparation course covering all subspecialty areas,” or financial support for external oral board preparation programs—offers that are almost certain to appear. While these may seem minor, the cumulative cost to the radiology profession could be substantial, particularly given the time away from image interpretation that may be required for an already strained workforce.
If all preparation time is expected outside of fellowship or practice hours, it adds significant stress to radiologists at a vulnerable career stage. Fellows and new hires often work longer hours than their senior peers, while also managing high study volumes alongside external pressures such as relocation, family responsibilities, and adjusting to a new practice environment. While beginning a radiology career has always been challenging, today’s unprecedented workloads make the task even more daunting—a challenge older radiologists did not face.
I worry that requiring a high-stakes exam at this critical juncture, without accounting for these pressures, risks asking too much of early-career radiologists.
Where This Could Go Wrong (and Right)
If done well—with transparent grading, standardized cases, and accessible prep materials—the oral boards could become a meaningful assessment of clinical reasoning, and have potential to improve the knowledge base of new radiologists.
But if poorly implemented, this could add significant stress, widen gaps between programs, and further burden early-career radiologists, who are frankly already struggling to get by with volume expectations their older radiology peers didn’t have to face straight out of training.
Final Thoughts
The return of the oral exam is being promoted as a step forward, but for many, it feels like déjà vu—reviving an anxiety-heavy tradition that was retired for good reason. Yet, here we are.
Effective oral board preparation requires focus and strategy. Building strong differential diagnoses and providing sound conclusions matter more than perfect delivery, though delivery should also be refined and gamesmanship for oral boards mastered. For example, remember to highlight pertinent negatives; for instance, in breast imaging cases showing possible cancer, note axillary lymph node status without prompting to show forward-thinking and clinical insight.
Clinical readouts alone will rarely be sufficient, so prioritize dedicated board-style review sessions and conferences. Emphasize differential diagnosis and management, since guiding the patient to the correct next step is the ultimate goal.
Preparation will be a team effort. Academic programs should distribute case development and review across faculty and extend support through fellowship, including access to subspecialty expertise. The exam’s timing may disadvantage those entering private practice directly from residency, who often lack institutional support or time, underscoring the potential need for robust online review resources.
I’ll be here to support you through past and future episodes of The Radiology Review Podcast, designed to help you study on the go—whether you’re commuting, exercising, or simply living your life when every minute counts.
Enjoyed this article? Explore more of my insights on AI in breast imaging and common media misconceptions about AI in radiology through the links below.
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