- Email: [email protected]
Evaluation of the National Resident Matching Program (NRMP) radiation oncology data (1993–2003)
Int. J. Radiation Oncology Biol. Phys., Vol. 57, No. 4, pp. 1033–1037, 2003 Copyright © 2003 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/03/$–see front matter
doi:10.1016/S0360-3016(03)00734-X
CLINICAL INVESTIGATION
Training
EVALUATION OF THE NATIONAL RESIDENT MATCHING PROGRAM (NRMP) RADIATION ONCOLOGY DATA (1993–2003) LYNN D. WILSON, M.D., M.P.H.,
AND
BRUCE G. HAFFTY, M.D.
Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT Purpose: Radiation oncology continues to evolve as a specialty. In the early 1990s, issues of manpower oversupply, resource allocation, development of academic radiation oncology, and residency training curricula were fervently considered and evaluated. Much of this effort continues. This communication endeavors to examine the National Residency Matching Program (NRMP) results as they pertain to radiation oncology to identify and document applicant trends over the last decade. Methods and Materials: The NRMP database tables for inclusive dates 1993–2003 were evaluated. The database figures were supplied directly from the executive staff at the AAMC/NRMP. Data were reviewed for radiation oncology, and the following variables were evaluated for the study period (1993–2003): Training program participation, positions offered, applicant totals, proportion of US senior applicants, US seniors as a percentage of those who successfully matched, ratio of applicants to positions, and percentage of training program positions filled. Trends over the study period were analyzed. Data were also analyzed for all specialties collectively as a comparison group. Results: The number of training programs has remained relatively stable between 1993 and 2003. In 2003, each radiation oncology program in the NRMP on average accepted two new candidates. The number of positions offered has fluctuated over time. There appeared to be a downward trend until 2003, during which 107 positions were offered. The number of applicants continues to rise with totals of 209 and 214 in 2003 and 2001, respectively. Percentage of US senior applicants compared with the total pool has remained relatively stable, but raw numbers are rising. The number of US seniors as a percentage of those who successfully matched escalated during 2001 compared with previous years. This value has been consistent over the past 3 years, at a level of approximately 94%. The ratio of applicants to positions, which is a broad indicator of level of competition for entrance, began to rise significantly in 2000 to a level of 1.9. It peaked at 2.6 in 2001, and the ratio for 2003 was approximately 2.0. For the first time, all positions offered were filled (100%) through the NRMP match process in 2003. Such positive trends have not been realized to the same degree for all specialties analyzed as a cohort. Conclusion: Acceptance into radiation oncology training programs through the NRMP has become very competitive. The explanation for this trend is likely complex with many variables. These data may be helpful in training program development and will certainly be of service to advisors of medical students seeking entrance into the field in the near future. © 2003 Elsevier Inc.
INTRODUCTION
tion that entry into the field has become more competitive over the past decade. In an effort to evaluate trends and confirm such perceptions, the radiation oncology database from the National Residency Matching Program (NRMP) was studied. The NRMP database serves as an objective source from which to examine numbers of applicants, percentage of US seniors seeking positions, availability of positions, ratios of applicants to positions offered, in addition to other variables. The NRMP data include match information for US seniors and independent applicants. Data from all specialties were also analyzed to serve as a comparison group. What follows is a descriptive analysis of the data and trends for the NRMP as they pertain to the subspecialty of radiation oncology over the last decade.
The specialty of radiation oncology and its training programs have emerged over the past 40 years. It is a wellrecognized subspecialty, with independent departments within schools of medicine and university-based training programs. The academic and clinical content of the field is often not well-understood by the general medical community, but nevertheless, it is considered a highly technical specialty. Formal radiation oncology training evolved from a sidebar in diagnostic radiology to structured, independent programs of 4 years’ duration after internship. Additional training in the postgraduate year (PGY)-6 year may be spent in “fellowship” gaining further experience in a variety of radiation oncology subspecialties. There has been a percepReprint requests to: Lynn D. Wilson, M.D., M.P.H., Associate Professor, Department of Therapeutic Radiology, Yale University School of Medicine, HRT 136, 333 Cedar Street, New Haven, CT 06520; Tel: (203) 737-1202; Fax: (203) 765-4622; E-mail:
[email protected] Received Apr 23, 2003, and in revised form Jun 2, 2003. Accepted for publication Jun 5, 2003. 1033
1034
I. J. Radiation Oncology
● Biology ● Physics
Volume 57, Number 4, 2003
Table 1. NRMP-radiation oncology match data (1993–2003) 1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Number of radiation oncology 60 58 65 61 61 52 51 50 48 47 51 training programs Positions offered 129 117 127 99 99 90 93 85 81 83 107 Total number of applicants 150 142 168 117 100 96 124 161 214 188 209 (US/IA) (107/43) (101/41) (126/42) (71/46) (45/55) (54/42) (84/40) (106/55) (165/49) (140/48) (157/52) US seniors as a percentage of 71% 71% 75% 60% 45% 56% 68% 66% 77% 74% 75% the applicant pool US seniors as a percentage of 83% 81% 87% 80% 68% 74% 88% 89% 96% 94% 91% those who matched Percentage of positions filled 80% 86% 91% 72% 58% 70% 80% 88% 98% 98% 100% Ratio of applicants to positions 1.16 1.21 1.32 1.18 1.0 1.06 1.33 1.89 2.64 2.26 1.95 Abbreviations: US ⫽ United States graduating seniors; IA ⫽ independent applicants; NRMP ⫽ national resident matching program.
METHODS AND MATERIALS
●
The NRMP database was provided for study by the executive staff from the Association of American Medical Colleges (AAMC)/NRMP. The period under study was that between 1993 and 2003. The NRMP database tables for inclusive dates 1993–2003 were evaluated. Data were reviewed for radiation oncology, and the following variables were evaluated: Training program participation, positions offered, applicant totals, percentage of US senior applicants, US seniors as a percentage of matched applicants, and ratio of applicants to positions. Percentage of positions filled for each year is also reported in tabular format. Trends over the study period were analyzed. Several caveats should be noted before considering the data: ● ●
●
The evaluation period is between 1993 and 2003. These data do not reflect the figures for applicants or training programs that did not formally participate in the NRMP match. The total number of positions in the NRMP match pool for all specialties has remained relatively stable over the period of evaluation (1993–2003), with a low of 22,396 in 1997 and high of 23,365 in 2003.
● ●
● ●
Data are for PGY-2 positions in radiation oncology and do not reflect results for internships that may be associated with specific radiation oncology programs. Data include US seniors and “independent applicants.” The intention of the data analysis is not to formulate a comparison in degree of competition vs. any other specialty, but to demonstrate trends within radiation oncology. Data for all other specialties within the NRMP database are provided as a baseline for comparison. All data are presented in Table 1 for radiation oncology, and in Table 2 for all NRMP specialties as a single cohort.
RESULTS Radiation oncology Number of radiation training programs (NRMP): The number of residency training programs participating in the NRMP match for radiation oncology has remained relatively stable over the period studied. A total of 65 programs were identified as participating in 1995, and as few as 47 in 2002. In 2003, there was a total of 51 programs participating in the NRMP match. On average, in 2003, each training program accepted slightly more than two new candidates.
Table 2. NRMP—all specialty match data (1993–2003) 1993 Number of programs—all specialties Positions offered—all specialties Total number of applicants US IA Percentage of positions filled Ratio of applicants to positions
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
3677
3715
3800
3830
3847
3814
3775
3769
3790
3736
3719
22,756
22,820
22,830
22,588
22,396
22,451
22,584
22,722
22,878
22,916
23,365
26,470 16,704 9,766 81%
28,756 16,741 12,015 83%
29,763 17,014 12,749 84%
32,202 16,345 15,857 84%
35,652 16,485 19,167 88%
35,765 16,573 19,192 88%
36,109 16,611 19,498 89%
33,202 16,626 16,576 89%
31,148 17,003 14,145 89%
30,456 17,392 13,064 90%
30,770 17,159 13,611 91%
1.16
1.26
1.30
1.42
1.59
1.59
1.59
1.46
1.36
1.33
1.32
Abbreviations: US ⫽ United States graduating seniors; IA ⫽ independent applicants; NRMP ⫽ national resident matching program.
NRMP radiation oncology data (1993–2003)
Positions offered: The number of positions available for PGY2 entry into radiation oncology has fluctuated over the study period. A total of 129 positions were offered in 1993, but only 81 positions in 2001. The downward trend appeared to be stable until this year (2003), when 107 positions were offered. The prior year (2002), only 83 were available, which represents an increase of 29% from 2002 to 2003. Number of applicants: In 2003, there were a total of 209 applicants, This is the highest number of candidates of any year since 1993, with the exception of 2001, which had a total of 214. Since 1993, the numbers have been much lower, but remained relatively stable except for a decline after 1995. Applicants’ totals for 1993, 1994, and 1995 were 150, 142, and 168, respectively. In 1996, a decline to a level of only 117 was noted, with the 2 years after significant for only 100 and 96 applicants, respectively. The pool then began to enlarge again in 1999. US senior applicants as a percentage of the total pool: There has been a clear increase in the raw number of US senior applicants, and this may represent increased interest and awareness of the field by senior medical students. In 2003, there were 157 US senior candidates. This figure is eclipsed only by the pool in 2001, which had 165 US applicants. The percentage of applicants from the US senior class in comparison to the overall group (including independent applicants) in any given year has been relatively stable, with the exception again noted in 1996, 1997, and 1998. The average percentage over the previous 3 years (1993–1995) was 72%, but in 1996, 1997, and 1998, the percentage of US seniors of the total applicant pool was 60%, 45%, and 56%, respectively. The percentages then again appeared to rise thereafter, and have stabilized over the past 3 years at approximately 75%. US senior applicants as a percentage of those applicants who match: Over the past 3 years (2001, 2002, 2003), the percentages have been 96%, 94%, and 91%. Before 2001, the percentages had remained relatively stable, but lower. The previous 7 years had an average percentage of 81% of the total who matched being US seniors, with a range of 68 – 89%. Making an assumption that graduating US seniors may represent the most attractive applicant pool for programs, this recent increase may be a surrogate for enhanced degree of difficulty to gain entrance to the field for all applicants. Percentage of positions filled: Clearly, over the past 5 years, there has been improvement in the percentage of positions filled in radiation oncology. This variable may be considered a surrogate for competition to gain access to the specialty. In 2003, all positions offered were filled (100%). Ratio of applicants to positions: This is representative of the general degree of difficulty in securing a position in a training program. Using offered positions as the denominator, and all applicants as a numerator, there is a notable increase in the ratio over the past four application seasons. The ratio ranged from 1.0 to 1.3 between 1993 and 1999. In 2000, however, the ratio increased to 1.9 and peaked at 2.6
● L. D. WILSON AND B. G. HAFFTY
1035
in 2001. The ratio for 2003 was approximately 2.0. The relative number of applicants compared with positions is on the rise; this is the most important singular variable by which to quickly judge competition for securing entry into a radiation oncology training program. All specialties cohort Number of radiation training programs (NRMP): The number of residency training programs participating in the NRMP match for all specialties has remained relatively stable. A total of 3847 programs participated in 1997, and as few as 3677 in 1993. The number of participants has been stable over the past 5 years. Positions offered: The number of positions available was reported for both PGY1 and PGY2 as a group. The number of positions offered has remained relatively stable with maximum of 23,365 in 2003 and a low of 22,396 in 1997. Number of applicants: Total number of applicants did rise in the late 1990s, and this was primarily attributed to the increase in independent candidates, whereas the number of US seniors remained stable. Percentage of positions filled: This variable has increased during the study period. Notably, the percentage increased from 81% in 1993 to 88% in 1997, and has remained relatively stable since that time. In 2003, the percentage was 91%. Ratio of applicants to positions: This ratio has fluctuated over time. The ratio of 1.16 was calculated for 1993 and was the identical ratio as that noted in radiation oncology. Comparison of this ratio for radiation oncology with all specialties revealed that the findings were comparable until 1997, when a divergence appeared, with all other specialties rising and radiation oncology declining. This divergent trend then reversed itself in 2000. In 2003, the ratio of applicants to positions was 1.32. DISCUSSION Medical school curriculum and postgraduate residency training programs have been critically evaluated for nearly a century. The Flexner Report, published in 1910, was the first comprehensive (and controversial) summary of medical education and programs in the United States (1). There was an expanding concern regarding quality of medical education in the United States and, in 1904, the American Medical Association formed the Council on Medical Education. The Carnegie Foundation commissioned Flexner to perform an “independent” evaluation of US medical schools, and the final report was subsequently made available and highly publicized. The report conveyed a message that focused on elimination of what Flexner considered substandard institutions, need for association of medical education with academic universities, and decrease in clinical practitioners’ impact on education. The Flexner Report was the first of many endeavors to evaluate and restructure the rapidly expanding field of medicine. Although controversial with
1036
I. J. Radiation Oncology
● Biology ● Physics
respect to much of its content, it established the arena for future perspectives and evaluation of medical education and postgraduate training in this country and in Canada. As representation and interest in the field expanded in the 1980s and training programs grew in both number and size, concern developed in the 1990s regarding the possibility of oversupply of radiation oncology specialists. A variety of position papers were published on the evaluation and management of this issue. These projects examined where the field was headed in terms of recruitment, quality, and development. There was significant concern over projections of graduates of training programs vs. the estimates of physicians departing from the field for retirement (2, 3). The graduating class of 1995 was surveyed, and results showed that 95% of the graduates perceived an oversupply in the job market. Only 43% of respondents were satisfied with professional opportunities (4). Much effort was focused on evaluating and improving training programs, in addition to carefully examining the manpower needs of the field in the private and academic sectors. Although the models of clinical practice and academic medicine had changed, the impetus for this reevaluation in radiation oncology was not unlike that of the American Medical Association’s Council for Medical Education regarding the entire medical educational system in the beginning of the 20th century. In 1999, the Radiation Oncology Resident Training Working Group and the members of the Society of Chairmen of Academic Radiation Oncology Programs attempted to address many of the issues surrounding postgraduate education in radiation oncology. Resources, funding, curriculum, educational models, and lack of trainees entering academic medicine were some of the concerns considered by that group (5). It was a time during which the leaders of the specialty had concerns about the future vitality and direction of the field. Surplus of manpower was documented in the private sector relative to the academic community, and this elevated concern and tension regarding academic missions in radiation oncology, specifically in the university environments. Respondents provided data that revealed that radiation oncologists in academic settings were seeing similar numbers of patients (206 annually) in 1997 compared with a similar figure as documented by the Patterns of Care Study for radiation oncology as a general practice. The clinical endeavors of academicians obviously were in addition to the expectations of teaching, research, and publication. Resources to support both education and research were becoming less available, and concerns were mounting about recruitment in academic radiation oncology (6). This was a dilemma without a clear solution. In the mid-1990s, programs were downsized and focus was directed on continued development of high-quality training programs that could meet appropriate accreditation standards. In 1998, training programs moved from the required 3 years (after PGY-1) to 4 years. The report on “The Status of Radiation Oncology Training Programs and Their Graduates” was published in 2001 and was a critical appraisal of the “market” and employment situation. The data
Volume 57, Number 4, 2003
were generated by responses of radiation oncology program directors to a survey. This report was hopeful, as it unfurled a message (as specified by the program directors) that residency training programs were decreasing in size, and that the applicant pool appeared to be improving in terms of overall quality (7). Also, evaluation of the employment market was performed through the perspective of 1997 graduates (8). This study revealed no compelling information provoking cause for concern over unemployment, nor did the data differ significantly from those reported from the graduating class of 1996. So, as evidenced at least by a survey of directors and graduates, the manpower supply situation seemed relatively stable as of the late 1990s. Much of the data generated on the subject of supply, demand, and subjective satisfaction has been provided via survey format and American College of Radiology data. In addition to the interest in issues pertaining to postgraduate training in radiation oncology and the professional future of radiation oncologists after completion of training, we have been intrigued by the trends associated with the process of entry into the field. In this communication, we directed the focus toward the step just before matriculation in training; the actual decision of acceptance into the field— “The Match.” In 1992, Lichter published a summary of the Radiation Oncology Matching Program, which was initiated in 1989. Radiation oncology was the last field to participate in an organized matching process, and lack of participation by many programs continued to be an active issue of contention (9). Evaluating interspecialty competition, a comparison study was published in 1997 that reviewed match results for 19 various specialties (10). The intention of the study was to identify specialties that were most competitive with respect to entry based on evaluation of match results. Data from “independent specialty” match pairings were compared with official NRMP results. Radiation oncology was not included in this analysis. Criteria for evaluation of the level of “competitiveness” of a given specialty included: (1) the percentage of US seniors who matched in a given specialty and (2) the ratio of unmatched US senior applications to unfilled categorical positions. Although this type of comparison offers some valuable information, spurious conclusions may be drawn in comparisons of formal NRMP match results with the results of programs that do not participate and are considered independent. Considering the potential complexity of analyzing two different data sets and their inherent potential for reporting error, we examined data exclusively from the NRMP database to assess trends in radiation oncology (11). The data from the last 10 years of NRMP results demonstrate that the field of radiation oncology has become increasingly competitive. This is reflected in both percentage of positions filled and ratio of applicants to positions. Although the percentage of positions filled for all other specialties has also increased, the trend for other specialties has been quite stable since 1997. During the same period, there has been a significant improvement in positions filled
NRMP radiation oncology data (1993–2003)
in radiation oncology. Perhaps most telling is the increase in ratio of applicants to positions offered within the field, whereas this ratio for all specialties has clearly declined. It is important to also note that the number of US seniors in the applicant pool for all specialties has remained relatively stable over time, but has increased significantly in the field of radiation oncology both as a raw number and as a percentage of overall applicant pool. Although other measures to assess applicant quality such as National Board of Medical Examiners scores, and class rank were not available, we have identified improvement in these candidate variables for those applying to our own institution over time. Positive trends have now been documented via NRMP data for the field of radiation oncology over the last decade. Additionally, radiation oncology compares favorably with all specialties with respect to relative applicant interest and enhanced degree of competitiveness within the field as evaluated over the time period of study. It should be noted that this analysis was specifically predicated on objective, official NRMP figures. In the academic year 2002–2003, there were a total of 79 Accreditation Council for Graduate Medical Education programs in radiation oncology. Obviously, there are programs that have not and do not participate in the NRMP match process. Given that caveat, radiation oncology programs that do not actively participate in the NRMP match process are not represented in this review. This factor should be recognized as a potential source of bias that may work either in favor of or against the positive trends that have been highlighted. CONCLUSION Given the advent of technical advances, enhanced capabilities in therapeutics at the molecular and genetic level,
● L. D. WILSON AND B. G. HAFFTY
1037
marketing of technically advanced therapeutic and diagnostic techniques, and escalation of radiation oncologists into mainstream leadership positions, the field has gained more attention by both the general public and students of medicine. We present this as a straightforward, descriptive analysis of the NRMP data over the last decade. It is provided for informational purposes; it is difficult to draw specific conclusions. What it does seem to suggest is that radiation oncology is a specialty that has become significantly more attractive over the past decade to US senior medical students and independent applicants based on NRMP data. Hence, securing a residency training position in radiation oncology has become very competitive. The reasons for this are likely to be various and complex. This is positive news for the field, however. It will be important to continue to observe such trends and study the impact on the field over time. Given a higher level of competition for placement, one might presume that the overall quality of the applicant pool may increase because of the inherently more competitive nature of the selection process. This is important information for mentors of students and medical school deans to consider when assisting in the development of a framework for a student’s medical career and training trajectory. Study of student satisfaction, professional employment, trends in academic radiation oncology, manpower issues, and program development all need to continue to be fervently pursued. We need to consider the current trends and use this information to enhance the quality of our training programs in a dynamic way. Additionally, surveys of graduating students who have secured positions in radiation oncology may be of benefit in identifying factors that have enhanced interest in the field. Such data should be used in future program development and subsequent integration of radiation oncology into the medical school curriculum.
REFERENCES 1. Flexner A. Medical education in the United States and Canada. A report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston: Updyke; 1910. 2. Hussey DH, Horton JL, Mendenhall NP, et al. Manpower needs for radiation oncology: A preliminary report of the ASTRO Human Resources Committee. Int J Radiat Oncol Biol Phys 1996;35:809–820. 3. Flynn DF. Will the radiation oncologist in the 21st century be employed full time? Int J Radiat Oncol Biol Phys 1996;36: 526–527. 4. Flynn DF, Kresl JJ, Sheldon JM. The employment status of 1995 graduates from radiation oncology training programs in the United States. Int J Radiat Oncol Biol Phys 1999;43:1075– 1081. 5. Radiation Oncology Resident Training Working Group and the Members of SCAROP. Radiation oncology training in the United States: Report from the radiation oncology resident training working group organized by the society of chairmen of academic radiation oncology programs (SCAROP). Int J Radiat Oncol Biol 1999;45:153–161.
6. Hussey DH, Sagerman RH, Halberg F, et al. Report of the 1997 SCAROP survey on resident training. Society of chairmen of academic radiation oncology programs. Acad Radiol 2000;7:176–183. 7. Bushee GR, Sunshine JH, Schepps B. The status of radiation oncology training programs and their graduates in 1999. Int J Radiat Oncol Biol Phys 2001;49:133–138. 8. Bushee GR, Sunshine JH, Simon C, et al. Initial employment experiences of 1997 graduates of radiation oncology training programs. Int J Radiat Oncol Biol Phys 2001;50:173–177. 9. Lichter AS. The residency match in radiation oncology. Int J Radiat Oncol Biol Phys 1992;22:1147–1154. 10. Andriole D, Ryan K, Haire-Joshu D. A comparison of the overall NRMP match results with the results for 19 specialties for senior US medical students, 1996. Acad Med 1997;72: 801–803. 11. NRMP Results and Data Book, resident matching program, 1992–2003. Washington, DC: Association of American Medical Colleges (AAMC), 2003.
doi:10.1016/S0360-3016(03)00734-X
CLINICAL INVESTIGATION
Training
EVALUATION OF THE NATIONAL RESIDENT MATCHING PROGRAM (NRMP) RADIATION ONCOLOGY DATA (1993–2003) LYNN D. WILSON, M.D., M.P.H.,
AND
BRUCE G. HAFFTY, M.D.
Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT Purpose: Radiation oncology continues to evolve as a specialty. In the early 1990s, issues of manpower oversupply, resource allocation, development of academic radiation oncology, and residency training curricula were fervently considered and evaluated. Much of this effort continues. This communication endeavors to examine the National Residency Matching Program (NRMP) results as they pertain to radiation oncology to identify and document applicant trends over the last decade. Methods and Materials: The NRMP database tables for inclusive dates 1993–2003 were evaluated. The database figures were supplied directly from the executive staff at the AAMC/NRMP. Data were reviewed for radiation oncology, and the following variables were evaluated for the study period (1993–2003): Training program participation, positions offered, applicant totals, proportion of US senior applicants, US seniors as a percentage of those who successfully matched, ratio of applicants to positions, and percentage of training program positions filled. Trends over the study period were analyzed. Data were also analyzed for all specialties collectively as a comparison group. Results: The number of training programs has remained relatively stable between 1993 and 2003. In 2003, each radiation oncology program in the NRMP on average accepted two new candidates. The number of positions offered has fluctuated over time. There appeared to be a downward trend until 2003, during which 107 positions were offered. The number of applicants continues to rise with totals of 209 and 214 in 2003 and 2001, respectively. Percentage of US senior applicants compared with the total pool has remained relatively stable, but raw numbers are rising. The number of US seniors as a percentage of those who successfully matched escalated during 2001 compared with previous years. This value has been consistent over the past 3 years, at a level of approximately 94%. The ratio of applicants to positions, which is a broad indicator of level of competition for entrance, began to rise significantly in 2000 to a level of 1.9. It peaked at 2.6 in 2001, and the ratio for 2003 was approximately 2.0. For the first time, all positions offered were filled (100%) through the NRMP match process in 2003. Such positive trends have not been realized to the same degree for all specialties analyzed as a cohort. Conclusion: Acceptance into radiation oncology training programs through the NRMP has become very competitive. The explanation for this trend is likely complex with many variables. These data may be helpful in training program development and will certainly be of service to advisors of medical students seeking entrance into the field in the near future. © 2003 Elsevier Inc.
INTRODUCTION
tion that entry into the field has become more competitive over the past decade. In an effort to evaluate trends and confirm such perceptions, the radiation oncology database from the National Residency Matching Program (NRMP) was studied. The NRMP database serves as an objective source from which to examine numbers of applicants, percentage of US seniors seeking positions, availability of positions, ratios of applicants to positions offered, in addition to other variables. The NRMP data include match information for US seniors and independent applicants. Data from all specialties were also analyzed to serve as a comparison group. What follows is a descriptive analysis of the data and trends for the NRMP as they pertain to the subspecialty of radiation oncology over the last decade.
The specialty of radiation oncology and its training programs have emerged over the past 40 years. It is a wellrecognized subspecialty, with independent departments within schools of medicine and university-based training programs. The academic and clinical content of the field is often not well-understood by the general medical community, but nevertheless, it is considered a highly technical specialty. Formal radiation oncology training evolved from a sidebar in diagnostic radiology to structured, independent programs of 4 years’ duration after internship. Additional training in the postgraduate year (PGY)-6 year may be spent in “fellowship” gaining further experience in a variety of radiation oncology subspecialties. There has been a percepReprint requests to: Lynn D. Wilson, M.D., M.P.H., Associate Professor, Department of Therapeutic Radiology, Yale University School of Medicine, HRT 136, 333 Cedar Street, New Haven, CT 06520; Tel: (203) 737-1202; Fax: (203) 765-4622; E-mail:
[email protected] Received Apr 23, 2003, and in revised form Jun 2, 2003. Accepted for publication Jun 5, 2003. 1033
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I. J. Radiation Oncology
● Biology ● Physics
Volume 57, Number 4, 2003
Table 1. NRMP-radiation oncology match data (1993–2003) 1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Number of radiation oncology 60 58 65 61 61 52 51 50 48 47 51 training programs Positions offered 129 117 127 99 99 90 93 85 81 83 107 Total number of applicants 150 142 168 117 100 96 124 161 214 188 209 (US/IA) (107/43) (101/41) (126/42) (71/46) (45/55) (54/42) (84/40) (106/55) (165/49) (140/48) (157/52) US seniors as a percentage of 71% 71% 75% 60% 45% 56% 68% 66% 77% 74% 75% the applicant pool US seniors as a percentage of 83% 81% 87% 80% 68% 74% 88% 89% 96% 94% 91% those who matched Percentage of positions filled 80% 86% 91% 72% 58% 70% 80% 88% 98% 98% 100% Ratio of applicants to positions 1.16 1.21 1.32 1.18 1.0 1.06 1.33 1.89 2.64 2.26 1.95 Abbreviations: US ⫽ United States graduating seniors; IA ⫽ independent applicants; NRMP ⫽ national resident matching program.
METHODS AND MATERIALS
●
The NRMP database was provided for study by the executive staff from the Association of American Medical Colleges (AAMC)/NRMP. The period under study was that between 1993 and 2003. The NRMP database tables for inclusive dates 1993–2003 were evaluated. Data were reviewed for radiation oncology, and the following variables were evaluated: Training program participation, positions offered, applicant totals, percentage of US senior applicants, US seniors as a percentage of matched applicants, and ratio of applicants to positions. Percentage of positions filled for each year is also reported in tabular format. Trends over the study period were analyzed. Several caveats should be noted before considering the data: ● ●
●
The evaluation period is between 1993 and 2003. These data do not reflect the figures for applicants or training programs that did not formally participate in the NRMP match. The total number of positions in the NRMP match pool for all specialties has remained relatively stable over the period of evaluation (1993–2003), with a low of 22,396 in 1997 and high of 23,365 in 2003.
● ●
● ●
Data are for PGY-2 positions in radiation oncology and do not reflect results for internships that may be associated with specific radiation oncology programs. Data include US seniors and “independent applicants.” The intention of the data analysis is not to formulate a comparison in degree of competition vs. any other specialty, but to demonstrate trends within radiation oncology. Data for all other specialties within the NRMP database are provided as a baseline for comparison. All data are presented in Table 1 for radiation oncology, and in Table 2 for all NRMP specialties as a single cohort.
RESULTS Radiation oncology Number of radiation training programs (NRMP): The number of residency training programs participating in the NRMP match for radiation oncology has remained relatively stable over the period studied. A total of 65 programs were identified as participating in 1995, and as few as 47 in 2002. In 2003, there was a total of 51 programs participating in the NRMP match. On average, in 2003, each training program accepted slightly more than two new candidates.
Table 2. NRMP—all specialty match data (1993–2003) 1993 Number of programs—all specialties Positions offered—all specialties Total number of applicants US IA Percentage of positions filled Ratio of applicants to positions
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
3677
3715
3800
3830
3847
3814
3775
3769
3790
3736
3719
22,756
22,820
22,830
22,588
22,396
22,451
22,584
22,722
22,878
22,916
23,365
26,470 16,704 9,766 81%
28,756 16,741 12,015 83%
29,763 17,014 12,749 84%
32,202 16,345 15,857 84%
35,652 16,485 19,167 88%
35,765 16,573 19,192 88%
36,109 16,611 19,498 89%
33,202 16,626 16,576 89%
31,148 17,003 14,145 89%
30,456 17,392 13,064 90%
30,770 17,159 13,611 91%
1.16
1.26
1.30
1.42
1.59
1.59
1.59
1.46
1.36
1.33
1.32
Abbreviations: US ⫽ United States graduating seniors; IA ⫽ independent applicants; NRMP ⫽ national resident matching program.
NRMP radiation oncology data (1993–2003)
Positions offered: The number of positions available for PGY2 entry into radiation oncology has fluctuated over the study period. A total of 129 positions were offered in 1993, but only 81 positions in 2001. The downward trend appeared to be stable until this year (2003), when 107 positions were offered. The prior year (2002), only 83 were available, which represents an increase of 29% from 2002 to 2003. Number of applicants: In 2003, there were a total of 209 applicants, This is the highest number of candidates of any year since 1993, with the exception of 2001, which had a total of 214. Since 1993, the numbers have been much lower, but remained relatively stable except for a decline after 1995. Applicants’ totals for 1993, 1994, and 1995 were 150, 142, and 168, respectively. In 1996, a decline to a level of only 117 was noted, with the 2 years after significant for only 100 and 96 applicants, respectively. The pool then began to enlarge again in 1999. US senior applicants as a percentage of the total pool: There has been a clear increase in the raw number of US senior applicants, and this may represent increased interest and awareness of the field by senior medical students. In 2003, there were 157 US senior candidates. This figure is eclipsed only by the pool in 2001, which had 165 US applicants. The percentage of applicants from the US senior class in comparison to the overall group (including independent applicants) in any given year has been relatively stable, with the exception again noted in 1996, 1997, and 1998. The average percentage over the previous 3 years (1993–1995) was 72%, but in 1996, 1997, and 1998, the percentage of US seniors of the total applicant pool was 60%, 45%, and 56%, respectively. The percentages then again appeared to rise thereafter, and have stabilized over the past 3 years at approximately 75%. US senior applicants as a percentage of those applicants who match: Over the past 3 years (2001, 2002, 2003), the percentages have been 96%, 94%, and 91%. Before 2001, the percentages had remained relatively stable, but lower. The previous 7 years had an average percentage of 81% of the total who matched being US seniors, with a range of 68 – 89%. Making an assumption that graduating US seniors may represent the most attractive applicant pool for programs, this recent increase may be a surrogate for enhanced degree of difficulty to gain entrance to the field for all applicants. Percentage of positions filled: Clearly, over the past 5 years, there has been improvement in the percentage of positions filled in radiation oncology. This variable may be considered a surrogate for competition to gain access to the specialty. In 2003, all positions offered were filled (100%). Ratio of applicants to positions: This is representative of the general degree of difficulty in securing a position in a training program. Using offered positions as the denominator, and all applicants as a numerator, there is a notable increase in the ratio over the past four application seasons. The ratio ranged from 1.0 to 1.3 between 1993 and 1999. In 2000, however, the ratio increased to 1.9 and peaked at 2.6
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in 2001. The ratio for 2003 was approximately 2.0. The relative number of applicants compared with positions is on the rise; this is the most important singular variable by which to quickly judge competition for securing entry into a radiation oncology training program. All specialties cohort Number of radiation training programs (NRMP): The number of residency training programs participating in the NRMP match for all specialties has remained relatively stable. A total of 3847 programs participated in 1997, and as few as 3677 in 1993. The number of participants has been stable over the past 5 years. Positions offered: The number of positions available was reported for both PGY1 and PGY2 as a group. The number of positions offered has remained relatively stable with maximum of 23,365 in 2003 and a low of 22,396 in 1997. Number of applicants: Total number of applicants did rise in the late 1990s, and this was primarily attributed to the increase in independent candidates, whereas the number of US seniors remained stable. Percentage of positions filled: This variable has increased during the study period. Notably, the percentage increased from 81% in 1993 to 88% in 1997, and has remained relatively stable since that time. In 2003, the percentage was 91%. Ratio of applicants to positions: This ratio has fluctuated over time. The ratio of 1.16 was calculated for 1993 and was the identical ratio as that noted in radiation oncology. Comparison of this ratio for radiation oncology with all specialties revealed that the findings were comparable until 1997, when a divergence appeared, with all other specialties rising and radiation oncology declining. This divergent trend then reversed itself in 2000. In 2003, the ratio of applicants to positions was 1.32. DISCUSSION Medical school curriculum and postgraduate residency training programs have been critically evaluated for nearly a century. The Flexner Report, published in 1910, was the first comprehensive (and controversial) summary of medical education and programs in the United States (1). There was an expanding concern regarding quality of medical education in the United States and, in 1904, the American Medical Association formed the Council on Medical Education. The Carnegie Foundation commissioned Flexner to perform an “independent” evaluation of US medical schools, and the final report was subsequently made available and highly publicized. The report conveyed a message that focused on elimination of what Flexner considered substandard institutions, need for association of medical education with academic universities, and decrease in clinical practitioners’ impact on education. The Flexner Report was the first of many endeavors to evaluate and restructure the rapidly expanding field of medicine. Although controversial with
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I. J. Radiation Oncology
● Biology ● Physics
respect to much of its content, it established the arena for future perspectives and evaluation of medical education and postgraduate training in this country and in Canada. As representation and interest in the field expanded in the 1980s and training programs grew in both number and size, concern developed in the 1990s regarding the possibility of oversupply of radiation oncology specialists. A variety of position papers were published on the evaluation and management of this issue. These projects examined where the field was headed in terms of recruitment, quality, and development. There was significant concern over projections of graduates of training programs vs. the estimates of physicians departing from the field for retirement (2, 3). The graduating class of 1995 was surveyed, and results showed that 95% of the graduates perceived an oversupply in the job market. Only 43% of respondents were satisfied with professional opportunities (4). Much effort was focused on evaluating and improving training programs, in addition to carefully examining the manpower needs of the field in the private and academic sectors. Although the models of clinical practice and academic medicine had changed, the impetus for this reevaluation in radiation oncology was not unlike that of the American Medical Association’s Council for Medical Education regarding the entire medical educational system in the beginning of the 20th century. In 1999, the Radiation Oncology Resident Training Working Group and the members of the Society of Chairmen of Academic Radiation Oncology Programs attempted to address many of the issues surrounding postgraduate education in radiation oncology. Resources, funding, curriculum, educational models, and lack of trainees entering academic medicine were some of the concerns considered by that group (5). It was a time during which the leaders of the specialty had concerns about the future vitality and direction of the field. Surplus of manpower was documented in the private sector relative to the academic community, and this elevated concern and tension regarding academic missions in radiation oncology, specifically in the university environments. Respondents provided data that revealed that radiation oncologists in academic settings were seeing similar numbers of patients (206 annually) in 1997 compared with a similar figure as documented by the Patterns of Care Study for radiation oncology as a general practice. The clinical endeavors of academicians obviously were in addition to the expectations of teaching, research, and publication. Resources to support both education and research were becoming less available, and concerns were mounting about recruitment in academic radiation oncology (6). This was a dilemma without a clear solution. In the mid-1990s, programs were downsized and focus was directed on continued development of high-quality training programs that could meet appropriate accreditation standards. In 1998, training programs moved from the required 3 years (after PGY-1) to 4 years. The report on “The Status of Radiation Oncology Training Programs and Their Graduates” was published in 2001 and was a critical appraisal of the “market” and employment situation. The data
Volume 57, Number 4, 2003
were generated by responses of radiation oncology program directors to a survey. This report was hopeful, as it unfurled a message (as specified by the program directors) that residency training programs were decreasing in size, and that the applicant pool appeared to be improving in terms of overall quality (7). Also, evaluation of the employment market was performed through the perspective of 1997 graduates (8). This study revealed no compelling information provoking cause for concern over unemployment, nor did the data differ significantly from those reported from the graduating class of 1996. So, as evidenced at least by a survey of directors and graduates, the manpower supply situation seemed relatively stable as of the late 1990s. Much of the data generated on the subject of supply, demand, and subjective satisfaction has been provided via survey format and American College of Radiology data. In addition to the interest in issues pertaining to postgraduate training in radiation oncology and the professional future of radiation oncologists after completion of training, we have been intrigued by the trends associated with the process of entry into the field. In this communication, we directed the focus toward the step just before matriculation in training; the actual decision of acceptance into the field— “The Match.” In 1992, Lichter published a summary of the Radiation Oncology Matching Program, which was initiated in 1989. Radiation oncology was the last field to participate in an organized matching process, and lack of participation by many programs continued to be an active issue of contention (9). Evaluating interspecialty competition, a comparison study was published in 1997 that reviewed match results for 19 various specialties (10). The intention of the study was to identify specialties that were most competitive with respect to entry based on evaluation of match results. Data from “independent specialty” match pairings were compared with official NRMP results. Radiation oncology was not included in this analysis. Criteria for evaluation of the level of “competitiveness” of a given specialty included: (1) the percentage of US seniors who matched in a given specialty and (2) the ratio of unmatched US senior applications to unfilled categorical positions. Although this type of comparison offers some valuable information, spurious conclusions may be drawn in comparisons of formal NRMP match results with the results of programs that do not participate and are considered independent. Considering the potential complexity of analyzing two different data sets and their inherent potential for reporting error, we examined data exclusively from the NRMP database to assess trends in radiation oncology (11). The data from the last 10 years of NRMP results demonstrate that the field of radiation oncology has become increasingly competitive. This is reflected in both percentage of positions filled and ratio of applicants to positions. Although the percentage of positions filled for all other specialties has also increased, the trend for other specialties has been quite stable since 1997. During the same period, there has been a significant improvement in positions filled
NRMP radiation oncology data (1993–2003)
in radiation oncology. Perhaps most telling is the increase in ratio of applicants to positions offered within the field, whereas this ratio for all specialties has clearly declined. It is important to also note that the number of US seniors in the applicant pool for all specialties has remained relatively stable over time, but has increased significantly in the field of radiation oncology both as a raw number and as a percentage of overall applicant pool. Although other measures to assess applicant quality such as National Board of Medical Examiners scores, and class rank were not available, we have identified improvement in these candidate variables for those applying to our own institution over time. Positive trends have now been documented via NRMP data for the field of radiation oncology over the last decade. Additionally, radiation oncology compares favorably with all specialties with respect to relative applicant interest and enhanced degree of competitiveness within the field as evaluated over the time period of study. It should be noted that this analysis was specifically predicated on objective, official NRMP figures. In the academic year 2002–2003, there were a total of 79 Accreditation Council for Graduate Medical Education programs in radiation oncology. Obviously, there are programs that have not and do not participate in the NRMP match process. Given that caveat, radiation oncology programs that do not actively participate in the NRMP match process are not represented in this review. This factor should be recognized as a potential source of bias that may work either in favor of or against the positive trends that have been highlighted. CONCLUSION Given the advent of technical advances, enhanced capabilities in therapeutics at the molecular and genetic level,
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marketing of technically advanced therapeutic and diagnostic techniques, and escalation of radiation oncologists into mainstream leadership positions, the field has gained more attention by both the general public and students of medicine. We present this as a straightforward, descriptive analysis of the NRMP data over the last decade. It is provided for informational purposes; it is difficult to draw specific conclusions. What it does seem to suggest is that radiation oncology is a specialty that has become significantly more attractive over the past decade to US senior medical students and independent applicants based on NRMP data. Hence, securing a residency training position in radiation oncology has become very competitive. The reasons for this are likely to be various and complex. This is positive news for the field, however. It will be important to continue to observe such trends and study the impact on the field over time. Given a higher level of competition for placement, one might presume that the overall quality of the applicant pool may increase because of the inherently more competitive nature of the selection process. This is important information for mentors of students and medical school deans to consider when assisting in the development of a framework for a student’s medical career and training trajectory. Study of student satisfaction, professional employment, trends in academic radiation oncology, manpower issues, and program development all need to continue to be fervently pursued. We need to consider the current trends and use this information to enhance the quality of our training programs in a dynamic way. Additionally, surveys of graduating students who have secured positions in radiation oncology may be of benefit in identifying factors that have enhanced interest in the field. Such data should be used in future program development and subsequent integration of radiation oncology into the medical school curriculum.
REFERENCES 1. Flexner A. Medical education in the United States and Canada. A report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston: Updyke; 1910. 2. Hussey DH, Horton JL, Mendenhall NP, et al. Manpower needs for radiation oncology: A preliminary report of the ASTRO Human Resources Committee. Int J Radiat Oncol Biol Phys 1996;35:809–820. 3. Flynn DF. Will the radiation oncologist in the 21st century be employed full time? Int J Radiat Oncol Biol Phys 1996;36: 526–527. 4. Flynn DF, Kresl JJ, Sheldon JM. The employment status of 1995 graduates from radiation oncology training programs in the United States. Int J Radiat Oncol Biol Phys 1999;43:1075– 1081. 5. Radiation Oncology Resident Training Working Group and the Members of SCAROP. Radiation oncology training in the United States: Report from the radiation oncology resident training working group organized by the society of chairmen of academic radiation oncology programs (SCAROP). Int J Radiat Oncol Biol 1999;45:153–161.
6. Hussey DH, Sagerman RH, Halberg F, et al. Report of the 1997 SCAROP survey on resident training. Society of chairmen of academic radiation oncology programs. Acad Radiol 2000;7:176–183. 7. Bushee GR, Sunshine JH, Schepps B. The status of radiation oncology training programs and their graduates in 1999. Int J Radiat Oncol Biol Phys 2001;49:133–138. 8. Bushee GR, Sunshine JH, Simon C, et al. Initial employment experiences of 1997 graduates of radiation oncology training programs. Int J Radiat Oncol Biol Phys 2001;50:173–177. 9. Lichter AS. The residency match in radiation oncology. Int J Radiat Oncol Biol Phys 1992;22:1147–1154. 10. Andriole D, Ryan K, Haire-Joshu D. A comparison of the overall NRMP match results with the results for 19 specialties for senior US medical students, 1996. Acad Med 1997;72: 801–803. 11. NRMP Results and Data Book, resident matching program, 1992–2003. Washington, DC: Association of American Medical Colleges (AAMC), 2003.