Chest Radiography

The NIOSH B Reader Program

Special Notice

B Reader examinations are now open at the NIOSH facility in Morgantown. Call (888) 480-4042 or email CWHSP@cdc.gov to schedule your exam. B Reader examination information includes:

Overview of the New B Reader Examination and How It Is Graded

The new B Reader examination is very different from the older version that was in use for decades. The new examination was developed through a partnership between the National Institute for Occupational Safety and Health and the American College of Radiology. Lessons learned and feedback received during more than forty years of administering the B Reader Program informed the design and approach to the new examination, which uses modern, digitally acquired chest images. More than fifteen experts in ILO classification from around the country contributed to developing the new examination.

The new examination has five domains. Unlike the past examination, you must achieve a passing score in all the five domains to pass the examination as a whole. The five domains are:

Multiple choice questions covering material in the self-study syllabus (new)
Assigning a quality score to the radiograph (new)
Determining the presence or absence of small opacities; and if small opacities are present, assigning a profusion score
Identifying when large opacities are present
Identifying pleural abnormalities; specifically, the presence (and side) of pleural plaques and costophrenic angle obliteration

As noted above, there are two new domains in the new B reader examination. First, there are twenty-four multiple choice questions testing for important concepts relevant to ILO classification which are taken from material in the B Reader study syllabus posted on the NIOSH website. Second the new examination emphasizes the correct evaluation of image quality. While on the previous examination there were no unclassifiable, unreadable, U/R, or Quality 4 images, several images that could be classified this way are included in the new examination and your answers will be scored. Accordingly, you should be vigilant for quality issues on each image; for example, portable studies are, by definition, unreadable/unclassifiable.

A correct classification/answer has been assigned for each domain to each of the images, based upon the responses given by majorities of the experts when independently classifying the radiographs. For an individual radiograph there may be a range of accepted “correct” small opacity profusion subcategories based upon the range of expert responses.

NIOSH recommends that when you are studying for the examination to familiarize yourself with the B Viewer software and to use the new study syllabus and accompanying images to familiarize yourself with the material. Please remember that you must achieve a passing score in each of the examination’s domains to receive a passing score for the entire examination.

B Reader Applications

B Readers, through their demonstrated proficiency in classifying radiographs of the pneumoconioses, are appropriate choices for research, surveillance, and worker monitoring programs and activities. NIOSH has employed B Readers in many epidemiologic and other research studies for nearly 30 years, as have many other organizations.

Physicians who classify chest radiographs for certain federal surveillance programs may be required to be B Readers. For example, in the NIOSH Coal Workers’ X-ray Surveillance Program, physicians who classify radiographs for the program are required to be B Readers for the second and any later readings of each radiograph (42 CFR 37). The Asbestos Medical Surveillance Program (AMSP), administered by the Navy and Marine Corps Public Health Center (NMCPHC), requires that the second reader of each radiograph be a B Reader. B Readers also have important roles to play in epidemiologic research, government programs, and contested proceedings.

Use of B Readers alone is not sufficient for adequate data quality. Their use should be augmented by the adoption of good technical practices to provide information of the highest quality.

Need for a Reader Proficiency Program

In 1949, the International Labour Office (ILO) promulgated standards for systematically describing and recording radiographic appearances of certain abnormalities caused by the inhalation of dusts. The principle intent of the standards was to achieve uniformity in assessing pneumoconiosis across readers. However, it was found that readers, despite employing the classification scheme, still disagreed with each other and with themselves to an excessive degree (Felson 1973). As a consequence, NIOSH concluded that a proficiency program was needed to provide a pool of qualified readers. The NIOSH B Reader Program began in 1974, although it was not until 1978 that the B reader examination was given extensively (Attfield 1992).

Objective of the B Reader Program

The B Reader examination was originally developed to identify physicians qualified to serve in national pneumoconiosis programs directed at coal miners and others who suffer from dust-related illness. This originally included epidemiologic research on coal workers’ pneumoconiosis and the compensation of coal miners with pneumoconiosis under programs processed by government agencies (Morgan 1979). The original intent of the B Reader Program still exists, but B Readers are also now involved with epidemiologic evaluation, surveillance, and worker monitoring programs involving many types of pneumoconioses. The B Reader Program aims to ensure competency in radiographic reading by evaluating the ability of readers to classify a test set of radiographs, thereby creating and maintaining a pool of qualified readers having the skills and ability to provide accurate and precise ILO classifications.

Maintaining B Reader status

Readers must retest every five years to maintain their B Reader status; testing can be done any time within the fifth year. The retest is very much like the original approval examination, except readers are required to classify only fifty radiographs. A reader who fails the retest must take and pass the original approval examination before the end of their five-year approval period expires in order retain their B Reader status. There is no waiting period between failing the retest and taking the original approval examination. B Readers who do not retest before expiration of their approval automatically become A Readers.

For more information on when and where B Reader Examinations are offered please call 1-888-480-4042 or email CWHSP@cdc.gov.

ILO classifications of chest radiographs performed by B Readers are used for a variety of purposes such as public health surveillance of workers potentially exposed to respirable dust, administrative purposes in systems of benefits for work-related lung disease, and for epidemiologic studies. These activities may involve providing medical care; for example, if a chest radiograph submitted to a B Reader has not previously been evaluated by a physician and the B Reader is simultaneously performing a classification and a clinical interpretation, then the activity involves providing clinical care. Alternatively, if a clinical interpretation was previously performed by a physician, then the B Reader’s ILO classification can potentially be viewed as being performed for a purpose other than providing clinical care. In such cases, B Readers should confirm that the clinical interpretations and necessary notifications of results have been communicated to both the ordering physician and patient, as required by the B Reader Code of Ethics. In order to ensure that any and all medical licensure requirements have been met irrespective of the B Reader’s role in evaluating chest radiographs, NIOSH recommends that non-federal employee B Readers consult with relevant State Boards of Medicine and with those engaging them to perform classifications to ensure compliance with potentially applicable State and Territorial laws, rules, regulations and policies. This includes confirming whether a medical license from the particular state in which the radiograph requiring classification was obtained is required. Certification through NIOSH’s B Reader program solely indicates proficiency in classifying radiographs with the ILO system; therefore, B Readers and those engaging them to perform ILO classifications are responsible for ensuring that physicians have valid medical licenses and are performing duties in accordance with applicable state medical licensure laws depending on the nature of the work.

This list will be updated continuously. Listing does not imply medical licensure.

Use this search form to select the criteria for your search. Leaving the Last Name and State fields blank will produce a complete list of B Readers.

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Successful International Examinees

Use this search form to obtain a listing of physicians from outside the United States who have demonstrated competence in applying the ILO classification by successfully completing the NIOSH B Reader examination. Leaving the Last Name field blank will produce a complete list of examinees.

You can use the NIOSH B Reader Study Syllabus at your own location or schedule an appointment to study at NIOSH in Morgantown, WV. Call (888) 480-4042 or email us at CWHSP@cdc.gov.

New Digital Syllabus Available

NIOSH has released a New Self-Study Syllabus developed in partnership with the American College of Radiology. The new Syllabus contains only digitally-acquired images and replaces the previous Self-Study Syllabus that was available online and in compact disc format. The content of the new syllabus aligns with the release in of a new B Reader Certification Examination, composed of only digitally-acquired images, which will replace the existing Analog and Digitized B Reader Certification and Recertification Exams. See New Digital Self-Study Syllabus for more information.

Digital Radiography

Conventional film screen chest radiography has been widely applied in assessing lung health in dust-exposed workers for decades, but this technique is being replaced by digital radiography systems. NIOSH is currently assessing the equivalency of traditional radiography and digital radiography with respect to pneumoconiosis classification using conventional and digital images from patients with a spectrum of dust-related lung disorders and chest pathology. See Digital Radiography for more information.

2011 ILO Revisions

The ILO revised its Classification System in 2011. To assure adherence to this new system, NIOSH has modified the B Reader examinations and related training activities and materials, including the Self-Study Syllabus. See New ILO Revisions for more information.

Quality Assurance Review of Classification Submitted for the DOL Black Lung Benefits Program

NIOSH and the DOL Office of Workers’ Compensation Programs (OWCP) are working together to carry out a quality assurance (QA) activity focused on classifications of chest radiographs according to the International Labour Organization (ILO) classification system that are submitted to the Black Lung Benefits Program operated by OWCP. The QA activity focuses on how the presence or absence of large opacities are classified by B Readers submitting the classifications. Information is available at this web link: https://www.cdc.gov/niosh/topics/chestradiography/breader-blacklung-benefits-qa-program.html

Comments or Concerns about the B Reader Program

The B Reader Program welcomes any comments or concerns about the Program, the examination, or this Web site. Our goal is to serve all persons who interact with this Program and continuously improve the information that we provide. Please use any of the following contact methods:

Call the Program office at (888) 480-4042

Email us at CWHSP@cdc.gov

Mail the Program at:

National Institute for Occupational Safety and Health
Coal Workers’ Health Surveillance Program
1095 Willowdale Road – M/S LB205
Morgantown, WV 26505

Comments or Concerns about Specific B Readers

The purpose of the B Reader Program is to train licensed physicians in use of the ILO Classification System and to assess their ability to apply the ILO Classification System in classifying chest radiographs for the presence and severity of changes potentially associated with exposure to dusts such as asbestos, silica, and coal mine dust. Use of a medical license in order to commit fraud is a violation of the conditions that accompany the medical license. Therefore, complaints about a specific B Reader should be referred to the appropriate State medical licensing board, as these boards are the bodies responsible for assuring the competence and integrity of licensed physicians. Contact information for each State’s medical licensing board can be found on the Federation of State Medical Boards (FSMB) Web site.

Felson B, Morgan WKC, Bristol LJ, et al. Observations on the results of multiple readings of chest films in coal miners’ pneumoconiosis. Radiology 1973;109:19-23.

Attfield MD, Morring K. An investigation into the relationship between coal workers’ pneumoconiosis and dust exposure in U.S. coal miners. Am Ind Hyg Assoc J 1992; 53:486-92.

Morgan RH. Proficiency examination of physicians for classifying pneumoconiosis chest films. Am J Roentgenology 1979;132:803-08.

Wagner GR, Attfield MD, Parker JE. Chest Radiography in Dust-Exposed Miners: Promise and Problems, Potential and Imperfections. Occupational Medicine: State of the Art Reviews 8(1); 127-141, 1993.