How Competitive Is the Match for Radiology Residency? Present View and Historical Perspective Jim Y. Chen, MDa, Matthew T. Heller, MDa,b
Purpose: Interest in radiology as a career among US medical students has changed. The aim of this study was to investigate the recent and historical trends in residency applications and how they have affected competitiveness in obtaining a position. Methods: Statistics published by the National Resident Matching Program in “Results and Data: Main Residency Match” for 1991 to 2013 were analyzed. Results: The number of radiology residency positions has trended upward over the past 23 years; however, the number of applicants from US medical schools has been widely variable. The number of applicants peaked in 2009 but has since decreased every year. The number of positions per US senior applicant (PPUSA) is a judge of specialty competitiveness on a supply-and-demand basis. A lower PPUSA indicates a more competitive specialty. Radiology saw its most competitive year in 2001, with only 0.91 PPUSA. PPUSA has been on the rise every year since 2009. From 2009 to 2013, the number of residency positions increased by 56, but there were 241 fewer US senior medical students preferring radiology. In 2013, there were 1,143 residency positions available for only 845 US senior medical students who preferred the specialty. The PPUSA was 1.35, making 2013 the least competitive year in obtaining a radiology residency position since 1998. Over the past 23 years, 5.5% of all US senior medical students have applied to radiology for residency. Interest reached an all-time high in 2009, at almost 7%. In 2013, only 4.8% of all US seniors preferred radiology, the lowest since 1999. The historical (1991e2013), current (2011e2013), and most recent (2013) PPUSAs for radiology were 1.19, 1.29, and 1.35, respectively. For comparison, the current PPUSAs for the following specialties were: 0.74 for plastic surgery, 0.83 for orthopedic surgery, 0.95 for dermatology, 1.10 for general surgery, 1.24 for obstetrics and gynecology, 1.31 for anesthesiology, 1.42 for pediatrics, and 1.80 for internal medicine (1.80). Conclusions: Although radiology residency positions have continued to increase, interest among US seniors has dropped every year since 2009. The 2013 match was the least competitive since 1998. Over the past 3 years, the competitiveness of matching radiology on a supply-and-demand basis has been close to that of obstetrics and gynecology and anesthesiology. Key Words: Radiology, residency, application, match, competitive J Am Coll Radiol 2014;11:501-506. Copyright © 2014 American College of Radiology
INTRODUCTION
Diagnostic radiology has traditionally been regarded as one of the more competitive specialties in the residency match. The acronym “ROAD” is popular among US medical students and represents: radiology, ophthalmology, anesthesiology, and dermatology. These 4 specialties are deemed competitive because they offer perceived work-life balance. The mean United States a
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
b
Corresponding author and reprints: Jim Y. Chen, MD, University of Pittsburgh Medical Center Presbyterian Shadyside, Department of Medicine, 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.2013.11.011
Medical Licensing Examination (USMLE) Step 1 score for US applicants who matched into radiology in 2011 was 240 [1]. Only dermatology (244), otolaryngology (243), and plastic surgery (249) applicants who matched into their respective programs had higher average scores. Unlike these 3 specialties, the match rate for US seniors who apply to radiology is very high (99% in 2013) [2]. Radiology also has more positions available through the match than all 3 of these specialties combined. Competitiveness is reflected not just in the quality of the applicants but also in the supply and demand of a specialty’s residency positions. We sought to investigate the recent and historical trends in residency applications, how they have affected competitiveness in obtaining a 501
502 Journal of the American College of Radiology/Vol. 11 No. 5 May 2014
radiology residency position, and how they may impact the radiology workforce of the future. METHODS
There are 19 major participating specialties in the National Resident Matching Program (NRMP). The majority of the specialties in the NRMP system had match statistics available for the past 20 years. Exceptions included internal medicine and pediatrics, neurology, and otolaryngology. We analyzed statistics published by the NRMP in “Results and Data: Main Residency Match” for 1991 to 2013 [3]. Ophthalmology and urology do not participate in the NRMP match. Their match data were accessed through the San Francisco Matching Program and the American Urological Association (urology data are available only from 2008 onward) [4,5]. We recorded the number of positions and number of US senior applicants for each specialty in each year of the match. “US seniors” are defined as students in their final year at US allopathic medical schools. Because there are many applicants who apply to, and rank, multiple fields in the match, the number of applicants for a specialty is often overcounted. For example, if applicant X applies to both general surgery and orthopedic surgery and ranks the latter first and matches into it, the number of applicants to general surgery will be inflated. To prevent double counting, we included candidates as applicants to a field only if they ranked only one specialty (only choice) or if they ranked that specialty first out of multiple specialties (first choice). The NRMP refers to this as the “preferred” specialty. This method counts only applicants who intended on matching into that specialty. We divided the number of residency positions by the number of applicants to determine the number of positions per US senior applicant (PPUSA), which is a judge of specialty competitiveness on a supply-and-demand basis. This calculation is specific to US seniors and is not meant to assess the quality of US seniors versus nontraditional applicants. Nontraditional applicants include previous US MD graduates, osteopathic students,
Canadian students, Fifth Pathway applicants, US international medical graduates, and non-US international medical graduates. The PPUSA is calculated for each specialty in each year of the match. The PPUSA for each specialty is then tabulated as historical (combined for all available years), current (combined for 2011 to 2013), and most recent (2013) values. The 2013 PPUSA is a snapshot of the most recent match competitiveness. However, there could be 1-year outliers. The current or 2011 to 2013 PPUSA will better represent how competitive a field has been in recent times. We then focused on radiology-specific data. We recorded the number of US senior radiology applicants and total US senior residency applicants from 1991 to 2013. Simple division calculated the percentage of US seniors applying to radiology each year. In addition, we tabulated the number of radiology residency positions offered, total positions matched, and positions matched to US seniors from 2009 to 2013. The 2009 match represented the most recent peak in competitiveness for radiology, and we chose to trend the data from 2009 to the most recent year, 2013. This was used to calculate the percentage of positions filled by US seniors, nontraditional applicants, and that remained unfilled. RESULTS
The number of radiology residency positions has trended upward over the past 23 years; however, the number of US senior medical students applying to radiology residency has been widely variable (Fig. 1). Radiology residency programs offered the most positions in 1996 and saw the fewest US senior applicants in 1997. The number of US senior applicants peaked in 2009 but has since decreased every year. PPUSA is a judge of specialty competitiveness on a supply-and-demand basis. A lower PPUSA indicates a more competitive specialty. Radiology saw its least competitive year in 1996 because of a large increase in positions and an almost mirroring decrease in applicants. Radiology saw its most competitive year in 2001, with a PPUSA of only 0.91. PPUSA has been on the rise every year since 2009 (Fig. 2). From Fig 1. Number of radiology residency positions and US seniors applying to radiology from 1991 to 2013.
Chen, Heller/Radiology Residency Match Competitiveness 503
Fig 2. Number of positions per US senior applicant (PPUSA) for radiology from 1991 to 2013.
2009 to 2013, the number of residency positions increased by 56, but there were 241 fewer US seniors applying to radiology. In 2013, there were 1,143 residency positions available for only 845 US applicants who preferred that specialty. The PPUSA was 1.35, making 2013 the least competitive year for obtaining a radiology residency position since 1998. Over the past 23 years, 5.5% of all US seniors preferred radiology for residency (Fig. 3). Interest was lowest in 1997 but reached an all-time high in 2009 of almost 7%. In 2013, only 4.8% of all US seniors preferred radiology residency, the lowest since 1999. The historical (1991e2013), current (2011e2013), and most recent (2013) PPUSAs for radiology were 1.19, 1.29, and 1.35, respectively (Fig. 4). For comparison, the current PPUSAs were 0.74 for plastic surgery, 0.83 for orthopedic surgery, 0.95 for dermatology, 1.10 for general surgery, 1.24 for obstetrics and gynecology, 1.31 for anesthesiology, 1.42 for pediatrics, and 1.80 for internal medicine. The recent decrease in US applicants has changed the composition of radiology residencies (Table 1). The proportion of residencies filled by US seniors has decreased every year since 2009. Nontraditional applicants now make up almost a quarter of the incoming class. The percentage of unfilled positions has also gone up dramatically, from 6 positions (1%) in 2010 to 86 positions (8%) in 2012. DISCUSSION
Anzilotti et al [6] analyzed the relative attractiveness of radiology to medical students participating in the match from 1990 to 2000. The relative attractiveness declined every year starting in 1991 and reached its lowest point in 1996. That year also corresponded with the most positions offered by radiology residency programs. The cause of this increase is not clear. Compound that with a sharp decrease in US senior applicants (reaching a nadir in 1997), the PPUSA was the highest or least competitive in this time period. The strength of the job market for radiologists and average income also declined during that period. Interestingly, the graph of relative attractiveness
resembled graphs of market strength and income, except that it lagged behind those two factors by 2 years. The authors concluded that medical students were very knowledgeable of the economics and incorporated these factors into their decision process when choosing specialties. Toward the end of the decade, there was a high demand for radiologists because of increasing image volume and a decreased number of residents from previous years. The relative attractiveness of radiology subsequently rebounded. However, we would like to warn that it is difficult to predict supply and demand in a small market. More than a decade later, the landscape has again changed. Bluth et al [7] surveyed employers regarding hiring in the 2012 ACR Commission on Human Resources workforce survey. Practices hired 1,241 radiologists in 2011 but planned on hiring only 1,103 in 2012. That number rebounds to 1,227 hires in 2014 but still remains lower than 2011 levels. The study concluded that there should be jobs available to accommodate each graduating resident, but those jobs might not be in the preferred location, type of practice, or subspecialty that the residents seek. Since 2009, we are seeing a similar (compared with the early to mid-1990s) drop in interest in the specialty of radiology among US medical students. The number of applicants has decreased, the PPUSA has increased, and the percentage of US medical students preferring radiology has dropped below 5% (Figs. 1, 2, and 3). According to the recruiting firm Merritt Hawkins, radiologists were the most sought after specialists in 2003 [8]. Not surprisingly, 2000 to 2004 was a competitive period for radiology applicants (Fig. 2). Nine years later, that rank has dropped to 18th. Main factors include decreased imaging volume and reimbursements [9]. According to Medscape’s Physician Compensation Report 2012, the mean income of radiologists decreased by 10% in 1 year [10]. Yearly reports showed a decrease in overall job satisfaction from 72% in 2011 to 47% in 2013 [11,12]. In 2013, 51% of surveyed radiologists would choose the same specialty again, compared with 82% in 2011. Changes in the
504 Journal of the American College of Radiology/Vol. 11 No. 5 May 2014
Fig 3. Percentage of US senior medical students applying to radiology from 1991 to 2013.
marketplace have also affected how radiologists work. To maintain the same incomes, radiologists now work longer hours and take less time off [9]. Retirement ages are also increasing because of the recession and its toll on retirement funds. In the 2012 match, there were 42 unfilled radiology programs contributing to 86 vacant positions [3]. One year later, 39 programs and 65 positions did not fill. The overall match rate of radiology was 96% in 2011 [1]. Ninety-two percent of applicants with USMLE Step 1 scores in the 211 to 220 range matched. We speculate
that further declines in US applicants for 2012 and 2013 could lead to significant reductions in USMLE scores. Unfortunately, the NRMP will not be publishing “Charting Outcomes in the Match” for the 2013 match. When the supply of positions significantly outnumbers the demand of applicants, USMLE scores become less meaningful as a factor in matching. US senior medical students now represent a decreasing proportion of residents in the field (Table 1). Matched applicants to radiology and orthopedic surgery share the same average Step 1 and Step 2 scores [1]. However, US seniors make
Fig 4. Competitiveness of each specialty ranked by number of positions per US senior applicant (PPUSA). A lower PPUSA indicates a more competitive specialty. PPUSA in the graph is tabulated as historical (all years combined), 2011 to 2013, and 2013.
Chen, Heller/Radiology Residency Match Competitiveness 505
Table 1. Composition of residency positions in the match for diagnostic radiology from 2009 to 2013 Match % US % Positions % Year Seniors Nontraditional Unfilled Unfilled 2009 2010 2011 2012 2013
86.6 84.3 79.0 74.8 72.2
12.5 15.1 17.3 17.5 22.1
10 6 41 86 65
0.9 0.6 3.6 7.7 5.7
Note: Nontraditional applicants include previous US MD graduates, osteopathic students, Canadian students, Fifth Pathway applicants, US international medical graduates, and non-US international medical graduates.
up 92% of the 2013 match class for orthopedic surgery, compared with 72% for radiology. Orthopedic surgery also had only 1 vacancy out of 700 positions [3]. As the PPUSA has increased since 2009, so has the number of unfilled residency positions. The number of unfilled positions will remain high in the coming years if interest from US seniors continues to decline and the number of nontraditional applicants does not fully fill those needs. Figure 4 shows interesting recent trends in specialty competitiveness. Despite being already very competitive, urology, otolaryngology, and neurologic surgery have become even more competitive in recent years (as indicated by the negative slope in PPUSA). Radiology, pediatrics, and internal medicine are decreasing in match difficulty (as indicated by the positive slope in PPUSA). The PPUSA of ophthalmology has been 1.0 every year for the past 17 years. The data indicate that it may be time to redefine the notion of competitiveness in the match. Board scores and other variables traditionally used to gauge competitiveness can be confounded when there is a mismatch created by an overabundance of available positions. We feel that the PPUSA may provide a better estimation of competitiveness because it is based on supply-and-demand and more closely reflects market value. Table 2 shows our updated Residency Match Competitiveness Scale, derived from the PPUSA for various specialties over the past 3 years. The scale is divided into 6 categories, with plastic surgery being the most competitive specialty. Radiology is labeled as “more competitive,” and its difficulty of matching on a supply-and-demand basis has been similar to those of obstetrics and gynecology and anesthesiology. Like the US economy, medical students’ interest in radiology stands in a recession. The number of applications from US senior medical students has decreased and partly contributed to the perennial occurrence of radiology vacancies on match day over the past 3 years. Faced with a similar situation, residency programs in the late 1990s reacted by drastically decreasing the number of residency positions. This caused a shortage of radiologists and the reopening of many positions. Since that time, radiology residency has expanded its annual size by 253 spots (22% increase) over 17 years. This overexpansion
has led not only to vacancies on match day but has also resulted in annual additions to the national radiology workforce. This discrepancy between positions offered and applicant interest can potentially decrease the quality of future residents, contribute to a glut in the job market, and unintentionally lead to the commoditization of radiology. Economic constraints and the changing health care environment have resulted in a radiology job market that can barely support the recently graduated trainees. Unfortunately, it seems that relief is not in sight in the immediate future; the ACR Commission on Human Resources workforce survey predicts a drop in hires for 2012 and 2014 [7]. We suggest two solutions to the apparent problems. First, we need to put a moratorium on residency expansion and, perhaps, consider contracting (or “rightsizing”) current training programs. Because of the length of training, these actions will not affect the job market for 6 to 7 years. In the future, radiology may consider following the trend set by ophthalmology residency; its expansion by only 13 positions over 17 years (a 3% increase) has led to a PPUSA of 1.0 every year. This constancy has allowed ophthalmology to better control its job market and to avoid volatility with supply and demand. Second, we need to re-generate student interest and stop the exodus of US applicants. This endeavor may best be started with honesty and transparency of the
Table 2. Residency match competitiveness scale Specialty PPUSA 6. Most competitive Plastic surgery 5. Extremely competitive Urology Orthopedic surgery Otolaryngology Neurological surgery Radiation oncology Dermatology 4. Very competitive Ophthalmology Surgery Emergency medicine Internal medicine/pediatrics 3. More competitive Obstetrics and gynecology Radiology-diagnostic Anesthesiology Pediatrics 2. Competitive Neurology Psychiatry Physical medicine and rehabilitation Internal medicine Pathology 1. Less competitive Family medicine
Purpose: Interest in radiology as a career among US medical students has changed. The aim of this study was to investigate the recent and historical trends in residency applications and how they have affected competitiveness in obtaining a position. Methods: Statistics published by the National Resident Matching Program in “Results and Data: Main Residency Match” for 1991 to 2013 were analyzed. Results: The number of radiology residency positions has trended upward over the past 23 years; however, the number of applicants from US medical schools has been widely variable. The number of applicants peaked in 2009 but has since decreased every year. The number of positions per US senior applicant (PPUSA) is a judge of specialty competitiveness on a supply-and-demand basis. A lower PPUSA indicates a more competitive specialty. Radiology saw its most competitive year in 2001, with only 0.91 PPUSA. PPUSA has been on the rise every year since 2009. From 2009 to 2013, the number of residency positions increased by 56, but there were 241 fewer US senior medical students preferring radiology. In 2013, there were 1,143 residency positions available for only 845 US senior medical students who preferred the specialty. The PPUSA was 1.35, making 2013 the least competitive year in obtaining a radiology residency position since 1998. Over the past 23 years, 5.5% of all US senior medical students have applied to radiology for residency. Interest reached an all-time high in 2009, at almost 7%. In 2013, only 4.8% of all US seniors preferred radiology, the lowest since 1999. The historical (1991e2013), current (2011e2013), and most recent (2013) PPUSAs for radiology were 1.19, 1.29, and 1.35, respectively. For comparison, the current PPUSAs for the following specialties were: 0.74 for plastic surgery, 0.83 for orthopedic surgery, 0.95 for dermatology, 1.10 for general surgery, 1.24 for obstetrics and gynecology, 1.31 for anesthesiology, 1.42 for pediatrics, and 1.80 for internal medicine (1.80). Conclusions: Although radiology residency positions have continued to increase, interest among US seniors has dropped every year since 2009. The 2013 match was the least competitive since 1998. Over the past 3 years, the competitiveness of matching radiology on a supply-and-demand basis has been close to that of obstetrics and gynecology and anesthesiology. Key Words: Radiology, residency, application, match, competitive J Am Coll Radiol 2014;11:501-506. Copyright © 2014 American College of Radiology
INTRODUCTION
Diagnostic radiology has traditionally been regarded as one of the more competitive specialties in the residency match. The acronym “ROAD” is popular among US medical students and represents: radiology, ophthalmology, anesthesiology, and dermatology. These 4 specialties are deemed competitive because they offer perceived work-life balance. The mean United States a
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
b
Corresponding author and reprints: Jim Y. Chen, MD, University of Pittsburgh Medical Center Presbyterian Shadyside, Department of Medicine, 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.2013.11.011
Medical Licensing Examination (USMLE) Step 1 score for US applicants who matched into radiology in 2011 was 240 [1]. Only dermatology (244), otolaryngology (243), and plastic surgery (249) applicants who matched into their respective programs had higher average scores. Unlike these 3 specialties, the match rate for US seniors who apply to radiology is very high (99% in 2013) [2]. Radiology also has more positions available through the match than all 3 of these specialties combined. Competitiveness is reflected not just in the quality of the applicants but also in the supply and demand of a specialty’s residency positions. We sought to investigate the recent and historical trends in residency applications, how they have affected competitiveness in obtaining a 501
502 Journal of the American College of Radiology/Vol. 11 No. 5 May 2014
radiology residency position, and how they may impact the radiology workforce of the future. METHODS
There are 19 major participating specialties in the National Resident Matching Program (NRMP). The majority of the specialties in the NRMP system had match statistics available for the past 20 years. Exceptions included internal medicine and pediatrics, neurology, and otolaryngology. We analyzed statistics published by the NRMP in “Results and Data: Main Residency Match” for 1991 to 2013 [3]. Ophthalmology and urology do not participate in the NRMP match. Their match data were accessed through the San Francisco Matching Program and the American Urological Association (urology data are available only from 2008 onward) [4,5]. We recorded the number of positions and number of US senior applicants for each specialty in each year of the match. “US seniors” are defined as students in their final year at US allopathic medical schools. Because there are many applicants who apply to, and rank, multiple fields in the match, the number of applicants for a specialty is often overcounted. For example, if applicant X applies to both general surgery and orthopedic surgery and ranks the latter first and matches into it, the number of applicants to general surgery will be inflated. To prevent double counting, we included candidates as applicants to a field only if they ranked only one specialty (only choice) or if they ranked that specialty first out of multiple specialties (first choice). The NRMP refers to this as the “preferred” specialty. This method counts only applicants who intended on matching into that specialty. We divided the number of residency positions by the number of applicants to determine the number of positions per US senior applicant (PPUSA), which is a judge of specialty competitiveness on a supply-and-demand basis. This calculation is specific to US seniors and is not meant to assess the quality of US seniors versus nontraditional applicants. Nontraditional applicants include previous US MD graduates, osteopathic students,
Canadian students, Fifth Pathway applicants, US international medical graduates, and non-US international medical graduates. The PPUSA is calculated for each specialty in each year of the match. The PPUSA for each specialty is then tabulated as historical (combined for all available years), current (combined for 2011 to 2013), and most recent (2013) values. The 2013 PPUSA is a snapshot of the most recent match competitiveness. However, there could be 1-year outliers. The current or 2011 to 2013 PPUSA will better represent how competitive a field has been in recent times. We then focused on radiology-specific data. We recorded the number of US senior radiology applicants and total US senior residency applicants from 1991 to 2013. Simple division calculated the percentage of US seniors applying to radiology each year. In addition, we tabulated the number of radiology residency positions offered, total positions matched, and positions matched to US seniors from 2009 to 2013. The 2009 match represented the most recent peak in competitiveness for radiology, and we chose to trend the data from 2009 to the most recent year, 2013. This was used to calculate the percentage of positions filled by US seniors, nontraditional applicants, and that remained unfilled. RESULTS
The number of radiology residency positions has trended upward over the past 23 years; however, the number of US senior medical students applying to radiology residency has been widely variable (Fig. 1). Radiology residency programs offered the most positions in 1996 and saw the fewest US senior applicants in 1997. The number of US senior applicants peaked in 2009 but has since decreased every year. PPUSA is a judge of specialty competitiveness on a supply-and-demand basis. A lower PPUSA indicates a more competitive specialty. Radiology saw its least competitive year in 1996 because of a large increase in positions and an almost mirroring decrease in applicants. Radiology saw its most competitive year in 2001, with a PPUSA of only 0.91. PPUSA has been on the rise every year since 2009 (Fig. 2). From Fig 1. Number of radiology residency positions and US seniors applying to radiology from 1991 to 2013.
Chen, Heller/Radiology Residency Match Competitiveness 503
Fig 2. Number of positions per US senior applicant (PPUSA) for radiology from 1991 to 2013.
2009 to 2013, the number of residency positions increased by 56, but there were 241 fewer US seniors applying to radiology. In 2013, there were 1,143 residency positions available for only 845 US applicants who preferred that specialty. The PPUSA was 1.35, making 2013 the least competitive year for obtaining a radiology residency position since 1998. Over the past 23 years, 5.5% of all US seniors preferred radiology for residency (Fig. 3). Interest was lowest in 1997 but reached an all-time high in 2009 of almost 7%. In 2013, only 4.8% of all US seniors preferred radiology residency, the lowest since 1999. The historical (1991e2013), current (2011e2013), and most recent (2013) PPUSAs for radiology were 1.19, 1.29, and 1.35, respectively (Fig. 4). For comparison, the current PPUSAs were 0.74 for plastic surgery, 0.83 for orthopedic surgery, 0.95 for dermatology, 1.10 for general surgery, 1.24 for obstetrics and gynecology, 1.31 for anesthesiology, 1.42 for pediatrics, and 1.80 for internal medicine. The recent decrease in US applicants has changed the composition of radiology residencies (Table 1). The proportion of residencies filled by US seniors has decreased every year since 2009. Nontraditional applicants now make up almost a quarter of the incoming class. The percentage of unfilled positions has also gone up dramatically, from 6 positions (1%) in 2010 to 86 positions (8%) in 2012. DISCUSSION
Anzilotti et al [6] analyzed the relative attractiveness of radiology to medical students participating in the match from 1990 to 2000. The relative attractiveness declined every year starting in 1991 and reached its lowest point in 1996. That year also corresponded with the most positions offered by radiology residency programs. The cause of this increase is not clear. Compound that with a sharp decrease in US senior applicants (reaching a nadir in 1997), the PPUSA was the highest or least competitive in this time period. The strength of the job market for radiologists and average income also declined during that period. Interestingly, the graph of relative attractiveness
resembled graphs of market strength and income, except that it lagged behind those two factors by 2 years. The authors concluded that medical students were very knowledgeable of the economics and incorporated these factors into their decision process when choosing specialties. Toward the end of the decade, there was a high demand for radiologists because of increasing image volume and a decreased number of residents from previous years. The relative attractiveness of radiology subsequently rebounded. However, we would like to warn that it is difficult to predict supply and demand in a small market. More than a decade later, the landscape has again changed. Bluth et al [7] surveyed employers regarding hiring in the 2012 ACR Commission on Human Resources workforce survey. Practices hired 1,241 radiologists in 2011 but planned on hiring only 1,103 in 2012. That number rebounds to 1,227 hires in 2014 but still remains lower than 2011 levels. The study concluded that there should be jobs available to accommodate each graduating resident, but those jobs might not be in the preferred location, type of practice, or subspecialty that the residents seek. Since 2009, we are seeing a similar (compared with the early to mid-1990s) drop in interest in the specialty of radiology among US medical students. The number of applicants has decreased, the PPUSA has increased, and the percentage of US medical students preferring radiology has dropped below 5% (Figs. 1, 2, and 3). According to the recruiting firm Merritt Hawkins, radiologists were the most sought after specialists in 2003 [8]. Not surprisingly, 2000 to 2004 was a competitive period for radiology applicants (Fig. 2). Nine years later, that rank has dropped to 18th. Main factors include decreased imaging volume and reimbursements [9]. According to Medscape’s Physician Compensation Report 2012, the mean income of radiologists decreased by 10% in 1 year [10]. Yearly reports showed a decrease in overall job satisfaction from 72% in 2011 to 47% in 2013 [11,12]. In 2013, 51% of surveyed radiologists would choose the same specialty again, compared with 82% in 2011. Changes in the
504 Journal of the American College of Radiology/Vol. 11 No. 5 May 2014
Fig 3. Percentage of US senior medical students applying to radiology from 1991 to 2013.
marketplace have also affected how radiologists work. To maintain the same incomes, radiologists now work longer hours and take less time off [9]. Retirement ages are also increasing because of the recession and its toll on retirement funds. In the 2012 match, there were 42 unfilled radiology programs contributing to 86 vacant positions [3]. One year later, 39 programs and 65 positions did not fill. The overall match rate of radiology was 96% in 2011 [1]. Ninety-two percent of applicants with USMLE Step 1 scores in the 211 to 220 range matched. We speculate
that further declines in US applicants for 2012 and 2013 could lead to significant reductions in USMLE scores. Unfortunately, the NRMP will not be publishing “Charting Outcomes in the Match” for the 2013 match. When the supply of positions significantly outnumbers the demand of applicants, USMLE scores become less meaningful as a factor in matching. US senior medical students now represent a decreasing proportion of residents in the field (Table 1). Matched applicants to radiology and orthopedic surgery share the same average Step 1 and Step 2 scores [1]. However, US seniors make
Fig 4. Competitiveness of each specialty ranked by number of positions per US senior applicant (PPUSA). A lower PPUSA indicates a more competitive specialty. PPUSA in the graph is tabulated as historical (all years combined), 2011 to 2013, and 2013.
Chen, Heller/Radiology Residency Match Competitiveness 505
Table 1. Composition of residency positions in the match for diagnostic radiology from 2009 to 2013 Match % US % Positions % Year Seniors Nontraditional Unfilled Unfilled 2009 2010 2011 2012 2013
86.6 84.3 79.0 74.8 72.2
12.5 15.1 17.3 17.5 22.1
10 6 41 86 65
0.9 0.6 3.6 7.7 5.7
Note: Nontraditional applicants include previous US MD graduates, osteopathic students, Canadian students, Fifth Pathway applicants, US international medical graduates, and non-US international medical graduates.
up 92% of the 2013 match class for orthopedic surgery, compared with 72% for radiology. Orthopedic surgery also had only 1 vacancy out of 700 positions [3]. As the PPUSA has increased since 2009, so has the number of unfilled residency positions. The number of unfilled positions will remain high in the coming years if interest from US seniors continues to decline and the number of nontraditional applicants does not fully fill those needs. Figure 4 shows interesting recent trends in specialty competitiveness. Despite being already very competitive, urology, otolaryngology, and neurologic surgery have become even more competitive in recent years (as indicated by the negative slope in PPUSA). Radiology, pediatrics, and internal medicine are decreasing in match difficulty (as indicated by the positive slope in PPUSA). The PPUSA of ophthalmology has been 1.0 every year for the past 17 years. The data indicate that it may be time to redefine the notion of competitiveness in the match. Board scores and other variables traditionally used to gauge competitiveness can be confounded when there is a mismatch created by an overabundance of available positions. We feel that the PPUSA may provide a better estimation of competitiveness because it is based on supply-and-demand and more closely reflects market value. Table 2 shows our updated Residency Match Competitiveness Scale, derived from the PPUSA for various specialties over the past 3 years. The scale is divided into 6 categories, with plastic surgery being the most competitive specialty. Radiology is labeled as “more competitive,” and its difficulty of matching on a supply-and-demand basis has been similar to those of obstetrics and gynecology and anesthesiology. Like the US economy, medical students’ interest in radiology stands in a recession. The number of applications from US senior medical students has decreased and partly contributed to the perennial occurrence of radiology vacancies on match day over the past 3 years. Faced with a similar situation, residency programs in the late 1990s reacted by drastically decreasing the number of residency positions. This caused a shortage of radiologists and the reopening of many positions. Since that time, radiology residency has expanded its annual size by 253 spots (22% increase) over 17 years. This overexpansion
has led not only to vacancies on match day but has also resulted in annual additions to the national radiology workforce. This discrepancy between positions offered and applicant interest can potentially decrease the quality of future residents, contribute to a glut in the job market, and unintentionally lead to the commoditization of radiology. Economic constraints and the changing health care environment have resulted in a radiology job market that can barely support the recently graduated trainees. Unfortunately, it seems that relief is not in sight in the immediate future; the ACR Commission on Human Resources workforce survey predicts a drop in hires for 2012 and 2014 [7]. We suggest two solutions to the apparent problems. First, we need to put a moratorium on residency expansion and, perhaps, consider contracting (or “rightsizing”) current training programs. Because of the length of training, these actions will not affect the job market for 6 to 7 years. In the future, radiology may consider following the trend set by ophthalmology residency; its expansion by only 13 positions over 17 years (a 3% increase) has led to a PPUSA of 1.0 every year. This constancy has allowed ophthalmology to better control its job market and to avoid volatility with supply and demand. Second, we need to re-generate student interest and stop the exodus of US applicants. This endeavor may best be started with honesty and transparency of the
Table 2. Residency match competitiveness scale Specialty PPUSA 6. Most competitive Plastic surgery 5. Extremely competitive Urology Orthopedic surgery Otolaryngology Neurological surgery Radiation oncology Dermatology 4. Very competitive Ophthalmology Surgery Emergency medicine Internal medicine/pediatrics 3. More competitive Obstetrics and gynecology Radiology-diagnostic Anesthesiology Pediatrics 2. Competitive Neurology Psychiatry Physical medicine and rehabilitation Internal medicine Pathology 1. Less competitive Family medicine
