Competitiveness of the Match for Interventional Radiology and Neuroradiology Fellowships Jim Y. Chen, MD, Vikas Agarwal, MD, Philip D. Orons, DO

Purpose: Overall resident interest in certain subspecialties changes with time. We sought to investigate the latest 6-year trend in interventional radiology (IR) and neuroradiology fellowship applications and how it has affected competitiveness in obtaining a position. Methods: We analyzed statistics published by the National Resident Matching Program in Results and Data: Specialties Matching Service from 2008 to 2013. From these data, we calculated the positions per IR applicant (PPIRA) and positions per neuroradiology applicant (PPNRA) for each year. Results: The number of positions per applicant is one way to assess specialty competitiveness on a supply-anddemand basis. A lower PPIRA or PPNRA indicates a more competitive year. PPIRA has decreased every year, from 1.71 to the present 0.84, and contributed to 52 applicants being unmatched in 2013, up from 9 in 2008. Accordingly, the number of unfilled positions has decreased from 86 in 2008 to 8 in 2013. PPNRA waxed and waned from 2008 to 2010 but stabilized at around 1.15 thereafter. The number of unfilled positions has never dropped below 46. The number of unmatched applicants was consistently in the teens, except in 2011, when it increased to 23. Conclusions: Interest in IR fellowship has increased significantly over the past 6 years, whereas interest in neuroradiology fellowships has plateaued. IR fellowships have become increasingly competitive, leading to many unmatched residents. Key Words: Interventional radiology, neuroradiology, fellowship, application, match, competitive J Am Coll Radiol 2014;11:1069-1073. Copyright © 2014 American College of Radiology

INTRODUCTION

Overall resident interest in subspecialty fellowships changes with time. In 1997, interventional radiology (IR) was the most popular subspecialty in radiology, accounting for 22% of residents pursuing fellowship training [1]. The next most popular subspecialties were neuroradiology (NR) at 16% of fellowships, general body imaging at 15%, abdominal imaging at 9%, and musculoskeletal radiology at 6%. By 2000, interest in IR had grown even further, making up 28% of all fellowships [2]. NR fellowships remained the same at 16%, while musculoskeletal fellowships decreased to 3%. Five years after that, the landscape continued to change. By 2005, NR had grown to 22% and became the most popular type of fellowship [3]. Musculoskeletal radiology was third at 17%, and IR fell to 13%. Today, the vast majority of residents pursue fellowship training, and the popularity of various subspecialties among diagnostic radiology graduates continues to University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Corresponding author and reprints: Jim Y. Chen, MD, UPMC Presbyterian Shadyside, 5230 Centre Avenue, Pittsburgh, PA 15232; e-mail: [email protected]. ª 2014 American College of Radiology 1546-1440/14/$36.00  http://dx.doi.org/10.1016/j.jacr.2014.06.006

change. Resident preference among various fellowships is reflected in the yearly number of applicants and positions available. Currently, only IR and NR fellowship programs participate in the National Resident Matching Program (NRMP). The NRMP has fellowship match statistics dating back to 2008. We sought to investigate the latest 6-year trend in IR and NR fellowship applications, and how competitiveness for fellowship positions has changed over that time period. MATERIALS AND METHODS

Both interventional radiology and neuroradiology fellowship programs participate in the NRMP. We analyzed statistics covering 2008-2013 published by the NRMP in Results and Data: Specialties Matching Service [4]. These data are available dating only from 2008. The matching within the NRMP occurs 1 year prior to the appointment year. For example, our 2013 match data represent the fellows who will start in 2014. We evaluated the number of positions and applicants for all years in both subspecialties. There are a few residents who applied to both fields, leading to a small overestimation of the applicant pool. To correct for 1069

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Fig 1. Bar graph (left vertical axis) represents number of IR fellowship positions and applicants from 2008 to 2013. Line graph (right vertical axis) shows PPIRA during the same period.

double counting, we included residents as applicants to a subspecialty only if they ranked only that one subspecialty or if they ranked that subspecialty first of 2 (ie, as first choice), which the NRMP refers to as the “preferred” subspecialty. This method counts only applicants who intended on matching into that subspecialty. From these data, we calculated the positions per IR applicant (PPIRA) and positions per NR applicant (PPNRA) for each year, by simple division. These values represent an assessment of subspecialty competitiveness on a supply-and-demand basis [5]. We also recorded the number of unfilled positions, number of unmatched applicants, and percentage of applicants matching their first choice for each year and both subspecialties. RESULTS

Eighty-one IR fellowship programs participated in the NRMP matching [4]. The number of accredited positions has increased every year (Fig. 1). The number of applicants increased dramatically from 108 in 2008 to 271 in 2013. In 2008, there were 77 more positions than applicants; in 2013, however, applicants outnumbered positions by 44. A lower PPIRA or PPNRA indicates a more competitive year. PPIRA has decreased every year from 1.71 to the most recent factor of 0.84. This led to 52 unmatched applicants in 2013, up from just 9 in 2008 (Fig. 2). Accordingly, the number of unfilled positions has decreased from 86 in 2008 to only 8 in 2013. The percentage of applicants who matched to their first choice has decreased from 65% to 37%. Seventeen programs (21%) filled every position from 2008 to 2013. Seventy-two NR fellowship programs participated in the NRMP matching [4]. The number of positions increased every year except for a small decline in 2012 (Fig. 3). The number of applicants trended up from 139 to plateau in the 180s during the most recent 3 years; however, available positions have always outnumbered applicants by at least 26. PPNRA was somewhat variable

but stabilized at approximately 1.15. The number of unfilled positions has never dropped below 46 (Fig. 4). The number of unmatched applicants was in the teens, except in 2011, when it increased to 23. Approximately 50%-65% of applicants received their first choice over the years. Thirteen programs (18%) filled every position from 2008 to 2013. DISCUSSION IR

IR fellowship has become fiercely competitive from 2008 to 2013, owing to a 151% increase in applicants, whereas positions have increased by only 23% (Fig. 1). PPIRA has decreased by half, and there were more than 50 unmatched residents in the latest year. Most fellowship programs filled in 2013, compared with 46% unfilled just 5 years earlier (Fig. 2). Now, only about one-third of all residents are matched to their first-choice fellowship program. Presently, programs generally are not in danger of having unfilled positions and benefit from a large pool of high-quality candidates. The demand for future careers in IR outstrips the supply of fellowship positions. This is a golden opportunity for programs to recruit the best residents into their field. Why has IR fellowship become so popular over the past few years? We theorize that it is a response to the job market. Overall, the radiology job market is stagnant, for multiple reasons. Use of CT, MRI, and cardiac nuclear imaging has decreased since 2010, along with payments for those services [6]. Senior radiologists are deferring retirement, resulting in limited vacancies to add new trainees [7]. Anticipated further decreases in reimbursement cause unease in future projections. We might also be training too many residents, which could oversaturate the workforce [5]. Finally, some forces affect not just radiology but all facets of the US economy. In any recession, businesses

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Fig 2. Bar graph (left vertical axis) represents number of unfilled IR fellowship positions and unmatched applicants from 2008 to 2013. Line graph (right vertical axis) shows percentage of applicants matching first choice during the same period.

face uncertainty and are less likely to hire. Jobs are usually late to rebound after a recession ends. However, employment in some subspecialties is more active than in others. According to the 2013 ACR Commission on Human Resources Workforce survey, general interventional radiologists are the most common subspecialists currently employed in radiology [8]. They represent 11.4% of the workforce. In 2012, employers hired 213 of these physicians, representing 15.1% of all hires, and more than any other position. For 2013, employers plan on hiring another 213 (14.0% of all hires) general interventional radiologists, making them second most in demand. That number is greater than the 201 residents who matched IR fellowships for graduation year 2013 (appointment year 2012). This might translate into an adequate job market for new IR trainees. Since the Commission projected little change between 2012 and 2013 hires for IR, it might be prudent to resist the temptation to expand IR fellowship positions in the short term despite the increasing demand from Fig 3. Bar graph (left vertical axis) represents number of NR fellowship positions and applicants from 2008 to 2013. Line graph (right vertical axis) shows PPNRA during the same period.

residents. Such an approach will prevent oversaturation of the IR job market for new trainees. NR

Applicants to NR fellowships have also increased but plateaued recently (Fig. 3). The number of applicants has never been greater than the number of positions. PPNRA stabilized at around 1.15 in recent years. However, the number of positions continues to increase (except in 2012), and recently, positions have outnumbered applicants by 25-30. A little more than one-fifth of all positions have been unfilled for the past 3 years (Fig. 4). The number of unmatched residents has not increased. NR was more competitive than IR fellowship in 2008, but the inverse is presently true. Overall competitiveness for NR fellowship has increased since 2008, but has remained stable from 2011 to 2013. It is still a buyer’s market for residents, and more than half have received their first choice for fellowship.

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Fig 4. Bar graph (left vertical axis) represents number of unfilled NR fellowship positions and unmatched applicants from 2008 to 2013. Line graph (right vertical axis) shows percentage of applicants matching first choice during the same period.

Neuroradiologists make up 11.2% of the radiology workforce and constitute the second most common type of subspecialist [8]. In 2012, employers hired 152 neuroradiologists (10.8% of all hires). For 2013, employers plan on hiring 174 of these physicians. Overall, this makes them the fourth most in demand after general radiologists, general interventional radiologists, and breast imagers. Musculoskeletal and body imagers come in fifth and sixth, respectively. With 174 projected hires, NR fellowship matched 165 residents for graduation year 2013 (appointment year 2012). These numbers might appear to represent a shortage, but 48 positions went unfilled (of 213 total positions), leaving them open to be filled by other means than the NRMP match. Unlike IR, which filled 93% of its positions during the past 3 years, NR only filled 78% of an average of 214 positions per year. NR fellowship programs may consider reducing the number of fellowship spots, because 22% of these positions remain vacant in the NRMP matching program, and the current job market cannot support more than 200 new positions. New IR Residency and Other Fellowships

We acknowledge that the advent of the new IR/Diagnostic Radiology (DR) certificate will considerably change the IR fellowship process. The program will broaden the training of IR/DR residents to include periprocedural care, critical care medicine, active inpatient clinical services, and outpatient clinics [9]. In 2013, the ABR stated that it would certify interventional radiologists who would train under the new IR program [10]. The ACGME also approved the creation of new residency programs in IR. The first IR residency programs are expected to apply for accreditation beginning in early 2015, with possible approval by the end of that year. The IR residency will be 5 years long, after 1 year of required clinical internship. The first 3

years of the residency, postgraduate years 2-4, will be virtually identical to the DR residency. The final 2 years will focus on IR and its clinical aspects described earlier. DR residents will be able to transfer into IR residency programs at the postgraduate year 3-6 levels. The first medical students are anticipated to match into IR residency programs in 2016. The traditional 1-year IR fellowship will be discontinued after a 7year transitional period beginning from the accreditation of IR residency. The Diagnostic and Interventional Radiology Enhanced Clinical Training (known as DIRECT) Pathway will also be phased out. The IR residency match at NRMP will completely replace the traditional IR fellowship match, but this will not occur for at least 8 years from the time of this writing. Currently, we do not believe it is possible to confidently predict the popularity or competitiveness of this future residency program. However, it will definitely change the landscape of IR training, and we predict that a significant number of DR residency positions will be reallocated into IR residencies. Unfortunately, only NR and IR are part of the NRMP match, and centralized fellowship data are only available for these 2 subspecialties. It would be interesting to see how resident interest in other fellowships has changed over recent years. TAKE-HOME POINTS

 IR fellowships have become very competitive recently, leading to 52 unmatched residents in 2013.  Since 2008, NR fellowships have consistently provided more positions than applicants, which resulted in many unfilled positions.  The job market for IR appears adequate for the current number of new graduates.

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 A reduction in the number of NR fellowship positions should be considered.

5. Chen JY, Heller MT. How competitive is the Match for Radiology residency? Present view and historical perspective. J Am Coll Radiol 2014;11:501-6.

REFERENCES

6. Levin DC, Rao VM. The declining radiology job market: how should radiologists respond? J Am Coll Radiol 2013;10:231-3.

1. Sunshine JH, Simon C, Bushee GR, et al. 1997 graduates speak: initial employment experiences of residency and fellowship graduates. AJR Am J Roentgenol 2000;175:1225-32. 2. Goodman CJ, Lindsey JI, Whigham CJ, et al. Diagnostic radiology residents in the classes of 1999 and 2000: fellowship and employment. AJR Am J Roentgenol 2000;174:1211-3. 3. Shetty SK, Venkatesan AM, Foster KM, Galdino GM, Lawrimore TM, Davila JA. The radiology class of 2005: postresidency plans. J Am Coll Radiol 2005;2:852-8. 4. National Resident Matching Program historical reports 2008e2013. Results and data: specialties matching service. Available at: http:// www.nrmp.org/match-data/nrmp-historical-reports. Accessed April 11, 2014.

7. Cronan JJ, Coleman BG, Harolds JA, Bluth EI. Retirement issues for radiologists and the radiology practice, part 1: a report of the ACR Commission on Human Resources, subcommittee on retirement. J Am Coll Radiol 2013;10:101-7. 8. Bluth EI, Truong H, Nsiah E, Hughes D, Short BW. The 2013 ACR Commission on Human Resources workforce survey. J Am Coll Radiol 2013;10:750-6. 9. ABR. Interventional radiology/diagnostic radiology (IR/DR)—latest information. Available at: http://www.theabr.org/sites/all/themes/abrmedia/pdf/ABR-IR-DR-FAQ.pdf. Accessed April 23, 2014. 10. Kaufman JA, Laberge J. The IR/DR certificate and new IR residency. Available at: http://members.sirweb.org/members/misc/IRQ/F4_from_ IRQWinter2014.pdf. Accessed April 23, 2014.

Competitiveness of the match for interventional radiology and neuroradiology fellowships.

Overall resident interest in certain subspecialties changes with time. We sought to investigate the latest 6-year trend in interventional radiology (I...
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