The Radiation Oncology Job Market: The Economics and Policy of Workforce Regulation

A 15-Year Analysis of Supply and Demand for Hematology and Oncology Training in the United States

PURPOSE

There is a paucity of research on the supply of the hematology and oncology workforce despite projected shortages in the United States Over the past 15 years of the hematology and oncology match (HOM), we hypothesized that there would be more growth in the number of training positions relative to applicants, higher match rates for US allopathic graduates relative to non-US allopathic graduates, and fewer applicants matching at their top fellowship choices.

METHODS

This was a national, retrospective cohort study of all applicants in the HOM (2009-2023). Match rates and applicant-to-training position ratios were calculated and compared over time with Pearson tests.

RESULTS

Growth in the number of annual training positions (426-708; 66% increase) exceeded growth in the number of interested applicants (706-945; 34% increase; P < .001). Annual applicant-to-training position ratios decreased from 1.7 to 1.3 (r = -0.813; P < .001). Match rates increased over the study period for both US allopathic graduates (79%-88%; r = 0.761; P = .001) and non-US allopathic graduates (45%-63%; r = 0.801; P < .001). During each year, match rates for US allopathic graduates exceeded those for non-US allopathic graduates (P < .001). From 2018 to 2023, US allopathic graduates (83%) had higher match rates than US osteopathic graduates (60%) and international medical graduates (50%; P < .001). The percentage of applicants that matched at one of their top three fellowship choices increased from 53% to 60% (r = 0.480; P = .070). Fewer available annual training positions went unfilled over the study period (3%-0.3%; r = - 0.870; P < .001).

CONCLUSION

Match rates have increased in the HOM but remain competitive especially for non-US allopathic graduates. Future investigation is needed to understand disparities in match outcomes by additional applicant and fellowship program characteristics. Ongoing surveillance of HOM outcomes remains critical given the projected shortages in the US hematology and oncology workforce.

Assessing Trends in Supply and Demand for Pediatric Surgery Training

OBJECTIVE

This study assessed the supply and demand for Pediatric Surgery training in the U.S. from 2008 to 2022. We hypothesized that in the Pediatric Surgery Match: match rates would increase over time; U.S. MD Graduates would have higher match rates than non-U.S. MD Graduates; and fewer applicants would match at one of their top fellowship choices.

DESIGN

This was a retrospective cohort study of Pediatric Surgery Match applicants (2008-2022). Cochran-Armitage tests elucidated temporal trends and chi square tests compared outcomes by applicant archetype.

SETTING

Accreditation Council for Graduate Medical Education (ACGME)-accredited Pediatric Surgery training programs in the United States and non-ACGME-accredited programs in Canada.

PARTICIPANTS

A total of 1,133 applicants for Pediatric Surgery training.

RESULTS

From 2008 to 2012, growth in the annual number of fellowship positions (34-43, 27% increase) exceeded growth in number of applicants (62-69, 11% increase) (p < 0.001). Over the study period, the applicant-to-training ratio peaked at 2.1 to 2.2 in 2017 to 2018 and decreased to 1.4 to 1.6 in 2021 to 2022. The annual match rate for U.S. MD Graduates increased from 60% to 68% (p < 0.05), but decreased from 40% to 22% (p < 0.05) for non-U.S. MD Graduates. In 2022, there was a 3.1-fold difference in match rates between U.S. MD and non-U.S. MD Graduates (68% vs 22%, p < 0.001). The percentage of applicants that matched at their first choice (25%-20%, p < 0.001), second choice (11%-4%, p < 0.001), and third choice (7%-4%, p < 0.001) fellowships decreased over the study period. The percentage of applicants that matched at their fourth choice to least desirable fellowship increased from 23% to 33% (p < 0.001).

CONCLUSIONS

The demand for Pediatric Surgery training peaked in 2017 to 2018 and has decreased since. However, the Pediatric Surgery Match remains competitive especially for non-U.S. MD Graduates. More research is needed to understand barriers to matching into Pediatric Surgery for non-U.S. MD Graduates.

Medical workforce in the United States

This section focuses on the professional workforce comprised of the primary medical specialties that utilize ionizing radiation in their practices. Those discussed include the specialties of radiology and radiation oncology, as well as the subspecialties of radiology, namely diagnostic radiology, interventional radiology, nuclear radiology, and nuclear medicine. These professionals provide essential health care services, for example, the interpretation of imaging studies, the provision of interventional procedures, radionuclide therapeutic treatments, and radiation therapy. In addition, they may be called on to function as part of a radiologic emergency response team to care for potentially exposed persons following radiation events, for example, detonation of a nuclear weapon, nuclear power plant accidents, and transportation incidents. For these reasons, maintenance of an adequate workforce in each of these professions is essential to meeting the nation's future needs. Currently, there is a shortage for all physicians in the medical radiology workforce.

Radiation Oncology Fellowship: a Value-Based Assessment Among Graduates of a Mature Program

The University of Toronto - Department of Radiation Oncology (UTDRO) has had a well-established Fellowship Program for over 20 years. An assessment of its graduates was conducted to evaluate training experience and perceived impact on professional development. Graduates of the UTDRO Fellowship Program between 1991 and 2015 were the focus of our review. Current employment status was collected using online tools. A study-specific web-based questionnaire was distributed to 263/293 graduates for whom active e-mails were identified; questions focused on training experience, and impact on career progression and academic productivity. As a surrogate measure for the impact of UTDRO Fellowship training, a comparison of current employment and scholarly activities of individuals who obtained their Fellow of the Royal College of Physicians of Canada (FRCPC) designation in Radiation Oncology between 2000 and 2012, with (n = 57) or without (n = 230) UTDRO Fellowship training, was conducted. Almost all UTDRO Fellowship graduates were employed as staff radiation oncologists (291/293), and most of those employed were associated with additional academic (130/293), research (53/293), or leadership (68/293) appointments. Thirty-eight percent (101/263) of alumni responded to the online survey. The top two reasons for completing the Fellowship were to gain specific clinical expertise and exposure to research opportunities. Respondents were very satisfied with their training experience, and the vast majority (99%) would recommend the program to others. Most (96%) felt that completing the Fellowship was beneficial to their career development. University of Toronto, Department of Radiation Oncology Fellowship alumni were more likely to hold university, research, and leadership appointments, and author significantly more publications than those with FRCPC designation without fellowship training from UTDRO. The UTDRO Fellowship Program has been successful since its inception, with the majority of graduates reporting positive training experiences, benefits to scholarly output, and professional development for their post-fellowship careers. Key features that would optimize the fellowship experience and its long-term impact on trainees were also identified.

Reasons for Declining Applicant Numbers in Radiation Oncology From the Applicants' Perspective: Results From the Applicant Concerns and Radiation Oncology Sources Survey (ACROSS)

PURPOSE

Applications to radiation oncology in the United States have decreased the past 3 years, resulting in unfilled residency positions (30 [14.5%] in 2019 and 35 [18.5%] in 2020). The aim of this study is to understand the concerns among radiation oncology applicants and whether these concerns may have led to a decline in applications.

METHODS AND MATERIALS

An Internet-based survey was e-mailed to all radiation oncology applicants participating in the 2020 National Resident Matching Program Match for whom e-mail addresses could be obtained (n = 145, 78.8%). The survey was open from May to September 2020.

RESULTS

Survey responses were received for 98 applicants out of 145 (67.6%) available applicant e-mails. Applicants' top-rated concerns were location of practice restrictions and residency expansion/oversupply of practicing physicians. Applicants were less concerned about a lack of exposure to the field of radiation oncology, competitiveness of the match, and the content of residency training. The sources of information which applicants used most, which applicants trusted most, and which promoted the most optimism among applicants were radiation oncology attending and resident physicians. The sources of information which applicants used least, which applicants trusted least, and which promoted the most pessimism among applicants were online resources. As a result of their concerns, 27 (28%) respondents strongly considered choosing a different field of medicine. Applicants identified 93 fellow graduating medical students who were interested in radiation oncology but chose not to apply; applicants reported that potential applicants chose not to apply most often due to concerns about location of practice restrictions and residency expansion/oversupply of practicing physicians.

CONCLUSIONS

Applicant concerns about residency expansion and location of practice restrictions are prevalent and may have led to declining applications to radiation oncology. To assuage applicant concerns, radiation oncology stakeholders must address these concerns by mitigating underlying problems.

The Geography of Employment Outcomes for Radiation Oncology Graduates in 2019

PURPOSE

The geographic distribution of practicing radiation oncologists is of concern for multiple stakeholders within the field. Employment outcomes of graduating residents can affect that distribution, and they are of major concern to current residents. Data investigating employment outcomes of recent graduates are sparse. We aimed to analyze the employment outcomes of the radiation oncology residency class of 2019.

METHODS AND MATERIALS

Using publicly available information, we identified the employment of 179 of 183 graduating residents in the class of 2019. For each, the place of employment, residency program, and medical school were geocoded using Google Maps. We used the rural-urban continuum code (RUCC) published by the United States Department of Agriculture to determine the rurality of each location and compared employment outcomes by RUCC and program size.

RESULTS

Two thirds of graduates (66%) took a position in a county within a metropolitan area with a population greater than 1,000,000 people; only 3.4% took a position in a county outside of a metropolitan area. Graduates of smaller programs (≤6 residents) and those in smaller metropolitan areas were more likely to take positions in smaller metropolitan areas or nonmetropolitan areas. The geographic distance between location of employment and residency program did not significantly vary by program size or size of metropolitan area where a residency program was located.

CONCLUSIONS

Among the class of 2019, a small proportion took positions in nonmetropolitan areas. Smaller programs and those in smaller metropolitan areas may be more likely to produce graduates that practice in similar settings, but those graduates might not do so locally. We advocate for a centralized, prospective data collection of employment outcomes for graduating residents to refine these analyses and to reduce employment prospect information asymmetry for trainees.

Evolution of the prevalence of pre-residency peer-reviewed publications among incoming junior residents

Pre-residency peer-reviewed publications (PRP) have been associated with subsequent resident choice of academic versus private practice career. The evolution of PRP prevalence among radiation oncology resident classes has yet to be examined. A list of radiation oncology residents from the graduating classes of 2016 and 2022 were obtained, and PRP was compiled as the number of publications a resident had listed in PubMed as of the end of the calendar year of residency application. Statistical analysis was conducted using Fisher's exact test. Analysis of 163 residents from the 2016 class compared with 195 from the 2022 class revealed that the proportion of residents with zero PRP decreased from 46.6% to 23.6% between the 2016 to 2022 classes (p<0.0001), while that of residents with one PRP increased from 17.8% to 19.0% (p>0.05) and with at least two PRP increased from 35.6% to 57.4% (p<0.0001). Residents with a PhD were more likely to have at least two PRP in each class (p<0.0001). As with the class of 2016, there remained no significant difference in PRP by gender for the class of 2022. Over the past six years, PRP has become more prevalent among incoming radiation oncology residents. Residents in the class of 2016 were 180% less likely than the class of 2022 to have at least one PRP, and 60% less likely to have at least two PRP. These findings are indicative of the increasing pressure on medical students to enter residency with a publication background.

A scoping review of medical education research for residents in radiation oncology

BACKGROUND

Both medical education and radiation oncology have progressed significantly in the past decade, but a generalized overview of educational research for radiation oncology residents has not been produced. This study examines recent research trends in medical education for residents in radiation oncology through a scoping review.

METHODS

We conducted a scoping review of medical education research for residents in radiation oncology to survey the research trends. We used publications available on MEDLINE, PubMed, and Scopus to conduct this scoping review.

RESULTS

We screened 221 full-text articles, 146 of which met our inclusion criteria. These publications showed increased activity in medical education research for residents, most involving affiliations in the United States. We identified persistent interest in training-, contouring-, and technology-related issues. An increase in research related to career, treatment quality, and multidisciplinary training was also observed. However, no research about teacher training was identified.

CONCLUSIONS

This scoping review presents the trends in study interests among stakeholders of medical education research in radiation oncology. With an investigation of existing studies, this research identifies areas of high priority and a lack of studies about teacher training. This study provides potential future directions for medical education research for residents in radiation oncology.

Regional Influence of Radiation Oncology Residency Training on Job Securement over Two Time Periods

Purpose Recent reports have noted conflicting predictions regarding the future of the radiation oncology job market. Residents and practicing radiation oncologists (ROs) report perceptions of an increasingly saturated market. An important factor contributing to the job landscape is the potential geographic maldistribution of ROs in the United States. Given the importance of the evolving job market and appropriate supply and demand for future ROs, this study investigated whether residency training region influences employment region and whether "portability" of residency training has changed over time from 2003-2015. Methods Radiation oncology residency graduates were identified from Association of Residents in Radiation Oncology (ARRO) directories from 2003-2012. This information was cross-referenced with the American Society of Radiation Oncology directory to determine current employment location. The region of residency training and employment were categorized into four regions per the US Census Bureau: Northeast (NE), South (S), Midwest (MW), and West (W). The change in "portability" of residency training over time was determined from the results of an anonymous internet-based survey which provided information on year of graduation and location of first job. "Portability" was defined as the rate at which a trainee in one region could find employment in another region. From the survey, two cohorts were identified: early (graduated from 2003-2006) and late (graduated from 2012-2015). Results Current employment location was available for 817/1168 (70%) residents identified in the ARRO directories from 2003-2012. The percentages of residents who trained in the NE, S, MW, and W were 29%, 28%, 27%, and 15%, respectively. The percentages of residents with current employment in the NE, S, MW, and W were 20%, 34%, 22%, and 24%, respectively. Residents were more likely to remain employed in the region in which they trained (p < 0.05), with 58% having current employment in the region of their training. Residency graduation year and location of first job (in the United States) were available for 139/198 (70%) survey respondents. Portability of residency training did not significantly change from 2003-2012 with 49% of the early cohort securing their first job in the region in which they trained compared to 57% of the late cohort (p = 0.39). Conclusions This study suggests that recent residents are not moving to different geographic regions at an increased rate than previous and that residents are more likely to find employment in the region in which they trained.

Modern Perspectives on Radiation Oncology Residency Expansion, Fellowship Evolution, and Employment Satisfaction

PURPOSE

In an effort to better characterize the extent and impact of residency expansion and job placement, the authors conducted a multilevel survey of radiation oncologists exploring the current state of the radiation oncology employment market.

METHODS

A multilevel survey was conducted using the Qualtrics platform in the spring of 2017. Survey participants were categorized into five groups within radiation oncology: (1) chairpersons, (2) program directors, (3) new practitioners (at least 1 year out of residency), (4) new residency graduates (radiation oncology postgraduate year 5 graduates with new jobs), and (5) medical students. The Wilcoxon-Mann-Whitney test was used to compare Likert scale scores.

RESULTS

A total of 752 participants were surveyed, with an overall response rate among all five groups of 31% and 92% of those completing the entire survey. Chairpersons were more likely to consider expanding their residency programs compared with program directors. Fellowship remained low on the job search, with less than 10% of new graduates and new practitioners interested in fellowship positions. Job satisfaction was high with 85% of new graduates, and 78% of new practitioners moderately to very satisfied with their future or current employment. The vast majority of both new practitioners (85%) and new graduates (81%) was moderately to very satisfied with their location of practice.

CONCLUSIONS

Resident job satisfaction remains high, whereas interest in radiation oncology fellowships remains low. Conflicting perception regarding the job market and residency expansion could have downstream impacts, such as deterring potential applicants.

Resident satisfaction with radiation oncology training

Purpose

Residency training environments can differ significantly; therefore, resident satisfaction may vary widely among programs. Here, we sought to examine several variables in program satisfaction through a survey of radiation oncology (RO) trainees in the United States.

Methods and materials

An anonymous, institutional review board-approved, internet-based survey was developed and distributed to U.S. residents in RO in September 2016. This email-based survey assessed program-specific factors with regard to workload, work-life balance, and education as well as resident-specific factors such as marital status and postgraduate year. Binomial multivariable regression assessed the correlations between these factors and the endpoint of resident-reported likelihood of selecting an alternative RO residency program if given the choice again.

Results

A total of 215 residents completed the required survey sections, representing 29.3% of U.S. RO residents. When asked whether residency allowed for an adequate balance between work and personal life, the majority of residents (75.6%) agreed or strongly agreed, but a minority (9.3%) did not feel that residency allowed for sufficient time for personal life. The majority of residents (69.7%) indicated that they would choose the same residency program again, but 12.2% would have made a different choice. Almost three-fourths of residents (73.0%) felt that faculty and staff cared about the educational success of residents, but 9.27% did not. Binomial multivariable regression revealed that senior residents (odds ratio: 6.70; 95% confidence interval, 2.20-22.4) were more likely to desire a different residency program. In contrast, residents who reported constructive feedback use by the residency program (odds ratio:0.22; 95% confidence interval, 0.06-0.91) were more satisfied with their program choice.

Conclusions

Most RO residents reported satisfaction with their choice of residency program, but seniors had higher rates of dissatisfaction. Possible interventions to improve professional satisfaction include incorporating constructive resident feedback to enhance the program. The potential impact of job market pressures on seniors should be further explored.

Radiation oncology residency selection: A postgraduate evaluation of factor importance and survey of variables associated with job securement

BACKGROUND

Medical students often choose to pursue a career in radiation oncology with limited meaningful exposure to the field. We previously identified factors that were most influential to an applicant's rank list order. Here, we sought to assess if residency graduates had differing views regarding those factors. We also polled recent graduates' attitudes of the current job market.

METHODS AND MATERIALS

An anonymous, internet-based survey was developed and distributed to graduates of radiation oncology residencies from 2003 through 2006 and 2012 through 2015 to assess the importance of factors with regard to residency selection, training, and job securement and attitudes toward the job market within the United States.

RESULTS

Responses were received from 198 of 848 (23%) of those invited to participate. The respondents were divided into 2 cohorts for analysis, an "early" cohort (2001-2009) and a "contemporary" cohort (2010-2016). Respondents recalled "quality of clinical training," "perceived happiness of residents," and "sense of community among faculty and residents" as the 3 most important factors influencing the rank list. Postresidency, the most valued factors of the residency experience were "quality of clinical training," "geographic location," and "faculty mentorship." Factors that were assigned the greatest differential value in hindsight to influence the rank list included "faculty mentorship," "willingness of faculty to call employer," and "quality of alumni base." Sixty-four percent of respondents reported the job market to be difficult or very difficult. This perception was more common among contemporary graduates (P < .05). Sixty percent of respondents reported "far too many" or "somewhat too many" residency positions for the actual job needs in the United States.

CONCLUSION

After training, residency graduates place higher value on factors in residency that can directly improve job procurement. This finding is more common among more recent graduates, potentially a result of the perception of a tightening job market with too many radiation oncologists in training.