Training the Radiation Oncology Workforce of the Future: Course Correction to Supply the Demand

Radiation Oncology Workforce: Supply and Demand

Since 2017, the specialty of radiation oncology has experienced its fifth consecutive year of decline in residency applicants, resulting in a high number of unmatched positions. The cause of this precipitous decline is multifactorial. Factors cited include concerns about future job opportunities, the decreased pass rate in the ABR radiation biology and physics boards examinations in 2018, and the continued lack of formal exposure to radiation oncology during medical school training. We summarize the issues facing the field of radiation oncology and discuss how we could learn from similar experiences in diagnostic radiology and other specialties to address these concerns. We propose potential solutions to ensure an adequate and diverse number of residency applicants to serve the future workforce needs in radiation oncology.

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.

Clinical Learning, Didactic Education, and Research Experiences of Radiation Oncology Resident Physicians in Canada

Changes in the field of radiation oncology (RO) impacts residency training. Assessing trainee experiences is essential to inform curriculum development. We aim to explore gaps and strengths in current Canadian RO training, as we move towards competency-based medical education (CBME). An online survey was distributed to residents at all Canadian RO training programs. Surveys consisted of 66 open-ended, Likert-scale, matrix-style, and multiple-choice questions, and assessed clinical exposure, didactic teaching, professional relationships, and research experiences. Statistics were calculated from anonymized, aggregate responses. Out of 128 eligible residents, 53 responded (41% response rate). Of these, 57% were male, and 77% were Canadian medical graduates. Senior residents (PGY-4 to PGY-5) perceived insufficient exposure to lymphoma and ocular malignancies, brachytherapy for breast and esophagus malignancies, and stereotactic radiotherapy of the pancreas, prostate, and adrenal gland. Half (51%) had training on image-guided radiotherapy (IGRT) challenges, and 43% had a formal staff mentor. Most residents presented at least one research project at conferences (77%) and authored ≥ 1 publications (66%) during residency. Canadian RO residents are satisfied with their clinical training and educational experience in high-volume tumor sites and high-volume brachytherapy procedures. Areas identified for potential improvement are (1) low-volume tumor sites; (2) low-volume brachytherapy procedures; (3) low-volume stereotactic radiotherapy sites; (4) IGRT challenges; and (5) mentorship opportunities. These findings will inform future CBME curriculum revisions.

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.

Quantitative Analysis of Practice Size Consolidation in Radiation Oncology: A Trend Toward Bigger and Fewer Practices

PURPOSE

There is evidence of practice consolidation in US health care in recent years. To our knowledge, a detailed quantitative study of recent changes in radiation oncology practice size has not been performed. We aim to evaluate radiation oncology practice size changes between 2012 and 2020 in the United States.

MATERIALS AND METHODS

Using the Medicare Physician Compare Database, we identified practices employing radiation oncologists using their taxpayer identification number and individual radiation oncologists using their national provider identifier. We grouped individual radiation oncologists into categories by practice size (which includes the number of physicians of all specialties) and compared the number of radiation oncologists in each category between 2012 and 2020. Further analyses by US geographic census region, single-specialty practice, academic practice, and high- and low-population density areas were performed.

RESULTS

Between 2012 and 2020, the total number of practicing radiation oncologists increased by 9%, and the number of practices employing radiation oncologists decreased by 11.5%. The number of radiation oncologists in practices of size 1 to 2, 3 to 9, 10 to 24, and 25 to 49 decreased by 3.7%, 4.7%, 4.9%, and 2%, respectively, and the number of radiation oncologists in practices of size 50 to 99, 100 to 499, and 500+ increased by 1.4%, 2.1%, and 11.8%, respectively (all 500+ practices are multispecialty groups). The increase in practice size was significant in all regions, for single-specialty and multispecialty practices, academic and nonacademic practices, and for practices in high-, middle-, and low-population density areas (P < .05 for all comparisons). The proportion of single-specialty practices has decreased significantly (P < .001), and the proportion of academic practices increased significantly (P = .004). Additionally, the proportion of practices and physicians in high- and low-population density regions remained stable during this period (P > .05).

CONCLUSIONS

Our analysis suggests that practice size consolidation has occurred within the US radiation oncology workforce from 2012 to 2020. The impact of this consolidation on quality, cost, and patient access deserves further attention.

Radiation Oncology Resident Quality by National Resident Matching Program Metrics From 2007 to 2018

PURPOSE

To quantify how the quality of US medical students accepted to radiation oncology (RO) training programs, as defined by National Resident Matching Program (NRMP) metrics, has changed over time.

METHODS AND MATERIALS

We examined NRMP data of senior US medical students matched into RO training programs from 2007 to 2018. Metrics include United States Medical Licensing Exam (USMLE) Step 1 and 2-Clinical Knowledge scores, research output, percentage with PhD, and percentage in Alpha Omega Alpha (AOA), among others. Linear regression analysis assessed the statistical significance of changes in available metrics of matched RO residents over time. The Student t test and χ² test compared quality metrics between matched students in RO versus all other specialties.

RESULTS

From 2007 to 2018, the mean USMLE Step 1 and 2-Clinical Knowledge for RO residents significantly increased from 235 to 247 (1.0 point/year; 95% confidence interval [CI], 0.70-1.52; P = .002) and from 237 to 253 (1.3 points/year; 95% CI, 1.27-1.62; P <.001), respectively. The mean number of research experiences and abstracts/presentations/publications increased from 3.7 to 6.1 (0.2/year; 95% CI, 0.12-0.29; P = .003) and from 6.3 to 15.6 (0.78/year; 95% CI, 0.60-1.04; P <.001), respectively. The percentage of RO residents inducted into AOA increased from 24.2% to 35.2%, whereas those with a PhD remained stable (∼21%). Matched RO residents had statistically superior metrics versus all other specialties for USMLE Step 1 scores (mean +13.5 points; 95% CI, 7.26-19.67; P <.001), research experience (mean +2.04; 95% CI, 1.11-2.97; P <.001), abstracts/presentations/publications (mean +6.80; 95% CI, 3.38-10.22; P = .001), percentage with a PhD (22.2% vs 4.1%; P <.001), and percentage in AOA (29.5% vs 15.8%; P <.001).

CONCLUSIONS

RO resident quality, defined by routinely reported NRMP metrics, increased from 2007 to 2018. Furthermore, RO resident quality is significantly higher than in all other specialties combined for most metrics. Whether the recent decline in medical student interest in RO will correlate with reduced NRMP quality metrics is unknown.

A 15-Year Profile of U.S. Radiation Oncology Residency Growth by Geographic Region, Metropolitan Size, and Program Size

PURPOSE

The size and growth of U.S. radiation oncology (RO) residency positions have important implications for the RO workforce. There are no data on residency growth by geographic region, major urban centers, and program size. We aim to fill this gap.

METHODS AND MATERIALS

A database of all RO programs and positions from 2003 to 2018 was created using National Resident Matching Program data. Programs were categorized by U.S. Census Bureau geographic region, major metropolitan location (top 10 combined statistical area vs all other), and program size (small [≤6 trainees], medium [7-12], and large [>12 trainees]). Linear regression with interaction terms was used to determine the effect of region, major metropolitan location, and program size on RO program and position growth over time.

RESULTS

There has been a 69% (54-91) and 82% (106-193) increase in the number of RO programs and annual positions from 2003 to 2018. Differences in program and position growth, respectively, were seen in each category. Growth in the Northeast (92% and 83%), South (81% and 113%), and West (125% and 130%) has outpaced the Midwest (17% and 33%). Growth in top 10 metropolitan areas (77% and 92%) is higher than in all other areas (63% and 73%). Growth in medium (68% and 80%) and large (175% and 153%) programs is greater than in smaller (36% and 33%) programs.

CONCLUSIONS

There has been a major increase in the number of RO residency programs and positions over the past 15 years. Growth is occurring in every major category but there are differences in magnitude within each category. This information can inform future decisions about RO training programs in the United States.

Learning radiotherapy: the state of the art

BACKGROUND

The last two decades have seen revolutionary developments in both radiotherapy technology and postgraduate medical training. Trainees are expected to attain competencies using a mix of experiential learning, formal postgraduate teaching, self-directed learning and peer education. Radiation (Clinical) Oncology is a recognised 'craft specialty' where the apprenticeship model of training is applicable. This scoping review examines the evidence in relation to how medical trainees learn radiotherapy.

METHODS

A systematic search of MEDINE and EMBASE was undertaken to identify studies of trainee and/or trainer experience of radiotherapy learning published 1999-2018. Results pertaining to Medical Oncology, workforce trends, undergraduate radiotherapy exposure, academic training, global health, non-medical staff, health service infrastructure and recruitment to training programmes were not included.

RESULTS

A total of 146 publications were included in the synthesis. Five themes were apparent through careful iterative analysis representing broadly inter-related issues. Most articles studied radiotherapy training from the perspective of the trainee doctor. Most literature reports results of observational, local or national surveys with a tightly defined scope. Considerable variation exists within hospitals, within countries, over time and between different curricular areas.

CONCLUSIONS

Medical education has not kept pace with changes in the field of radiotherapy and large differences are demonstrated in experience between trainees in different hospitals, countries and training stages. Interpersonal relationships, departmental organisation, and national curricula impact on training quality. Qualitative and quantitative research examining modern radiotherapy learning has been uncommon and uncoordinated, until recently. To date no single study has been designed to comprehensively assess a department's training scheme.

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.

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.

Domestic Job Shortage or Job Maldistribution? A Geographic Analysis of the Current Radiation Oncology Job Market

PURPOSE

To examine whether permanent radiation oncologist (RO) employment opportunities vary based on geography.

METHODS AND MATERIALS

A database of full-time RO jobs was created by use of American Society for Radiation Oncology (ASTRO) Career Center website posts between March 28, 2016, and March 31, 2017. Jobs were first classified by region based on US Census Bureau data. Jobs were further categorized as academic or nonacademic depending on the employer. The prevalence of job openings per 10 million population was calculated to account for regional population differences. The χ² test was implemented to compare position type across regions. The number and locations of graduating RO during our study period was calculated using National Resident Matching Program data. The χ² goodness-of-fit test was then used to compare a set of observed proportions of jobs with a corresponding set of hypothesized proportions of jobs based on the proportions of graduates per region.

RESULTS

A total of 211 unique jobs were recorded. The highest and lowest percentages of jobs were seen in the South (31.8%) and Northeast (18.5%), respectively. Of the total jobs, 82 (38.9%) were academic; the South had the highest percentage of overall academic jobs (35.4%), while the West had the lowest (14.6%). Regionally, the Northeast had the highest percentage of academic jobs (56.4%), while the West had the lowest (26.7%). A statistically significant difference was noted between regional academic and nonacademic job availability (P=.021). After we accounted for unit population, the Midwest had the highest number of total jobs per 10 million (9.0) while the South had the lowest (5.9). A significant difference was also observed in the proportion of RO graduates versus actual jobs per region (P=.003), with a surplus of trainees seen in the Northeast.

CONCLUSIONS

This study presents a quantitative analysis of the RO job market. We found a disproportionately small number of opportunities compared with graduates trained in the Northeast, as well as a significant regional imbalance of academic versus nonacademic jobs. Long-term monitoring is required to confirm these results.