Resident Physicians' Perceptions of Diagnostic Radiology and the Declining Interest in the Specialty

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Resident Physicians’ Perceptions of Diagnostic Radiology and the Declining Interest in the Specialty Darya Kurowecki, MA, MD, Stefanie Y. Lee, MD, Sandra Monteiro, PhD, Karen Finlay, MD

Rationale and Objectives: The relative competitiveness of radiology and the number of first-choice applicants to diagnostic radiology have steadily declined over the past decade. The purpose of this study was to identify factors contributing to the declining interest in diagnostic radiology as a career and to explore factors affecting specialty choice. Materials and Methods: A retrospective survey was distributed to resident physicians at a single academic center between July and August 2017. Participants identified factors affecting career choice and evaluated level of agreement with statements regarding radiology using 5-point Likert scales. Higher scores indicated stronger agreement. Results: One hundred and fifty-two resident physicians from Canada participated (21.5% response rate): 20 radiology and 132 nonradiology. Of the total, 27% were registered in postgraduate year (PGY) 1, 23% in PGY 2, 15% in PGY 3, 19% in PGY 4, and 16% in PGY 5, or above. Sixty-one percent of the respondents self-reported as female, 34% as male, and 5% as other/unknown. Of those in radiology, 40% selfreported as female, 55% as male, and 5% as other/unknown, compared to 64% female, 31% male, and 5% other/unknown in other specialties. Regardless of specialty, positive clinical/mentoring experiences strongly affected career choice. Radiology residents were attracted to diverse pathology (M = 4.5) and positive staff/resident interactions (M = 4.4). Nonradiology residents were deterred by lack of patient contact (M = 3.9) and dark work environment (M = 3.6). Resident physicians who had applied to radiology were more likely to report positive mentorship during medical school, disagree that technology will replace radiologists, and desire a higher income specialty (Wald = 56.6, p < 0.001). More recent graduates showed a higher level of concern regarding the potential negative impact of technology and outsourcing on the profession (F (3, 189) = 2.6, p = 0.05). Several trainees (21%) considered radiology, but lacked mentorship (52%) and identified job market concerns (29%). Conclusion: More recent graduates are relatively more concerned about technology replacing radiologists, and radiology applicants have less concern about artificial intelligence replacing radiologists. As positive interactions with radiologists and mentorship are key influencers, our results advocate for early training exposure and reinforcement regarding the positive outlook of the profession. Key Words: Medical education; Diagnostic radiology; Resident physicians. © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. Abbreviations: AI artificial intelligence (the theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, and decision-making), ANOVA analysis of variance (a statistical method in which the variation in a set of observations is divided into distinct components), PGY postgraduate year (the number of years of clinical medicine training in a medical residency program)

INTRODUCTION

T

he last decade has seen a decline in the relative competitiveness of radiology as a specialty among final year medical students applying for residency positions

Acad Radiol 2020; &:1–10 From the Department of Diagnostic Imaging, McMaster Hospital, Hamilton Health Sciences, 1200 Main Street West, 2S Radiology, Hamilton, ON L8N 3Z5, Canada (D.K.); Department of Radiology, McMaster University, Department of Diagnostic Imaging, Juravinski Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada (S.Y.L., K.F.); Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (S.M.). Received September 10, 2019; revised January 9, 2020; accepted January 10, 2020. Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Address correspondence to: D.K. e-mail: [email protected] © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2020.01.016

in North America (1,2). While the number of residency positions in radiology has increased, the number of applicants choosing radiology as their first-choice specialty has steadily decreased. In 2019, only 3.8% of American applicants rated diagnostic radiology as their first or only choice specialty compared to 6.5% in 2010 (3). A parallel trend has occurred in Canada with 2.6% of Canadian medical graduates choosing diagnostic radiology as their first-choice specialty in 2019 compared to 4.5% in 2010 (4). The declining interest in radiology as a specialty has fueled widespread speculation as to possible reasons behind this trend. Although greater emphasis on and incentives to enter primary care and overall increases in medical school class size disproportionate to increases in radiology residency positions may account for some of this decrease, the decline in radiology appears greater than that seen in other specialties that might be

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affected by these same factors (4). Research from surgical specialties suffering a similar decline in applicant interest suggests that medical students are increasingly unwilling to tolerate the busy lifestyle associated with surgical specialties due to shifting values and priorities (5,6). Previously considered a “lifestyle” specialty (7), the shift toward 24-hour radiology coverage, decreasing reimbursement for imaging, fluctuations in job market, outsourcing, and perceived competitiveness of training programs balanced against the desire to train/practice in specific locations have all been proposed to contribute to the declining interest in radiology (2). More recent studies suggest a possible role for artificial intelligence (AI) (8), although the data are limited and somewhat contradictory (9). Several studies utilizing medical students have also attempted to identify more controllable factors that could be influencing choice of career and thereby account for the current trends. Timing of rotations, the hidden curriculum, gender, lack of mentorship, and limited exposure in the formal curriculum have been identified as potential barriers to a career in radiology (10 13). Overall, the causes of declining interest are likely multifactorial, with the relative paucity of literature reinforcing the need for further research. Moreover, with the most recent cited study data being from 2014, the available information may be outdated and therefore not accurately reflect the current situation, thereby reinforcing the need for further research on this unresolved issue. To date, factors that contribute to the declining interest in radiology remain poorly understood, with studies limited to the medical student population. To the best of our knowledge, resident physicians’ attitudes toward radiology have yet to be investigated and could offer additional information. The main purpose of this study was to identify factors that may be contributing to the declining interest in radiology in recent years using a survey of resident physicians. It was hypothesized that the causes are multifactorial, with variables such as greater applicant age and postgraduate training level, male gender, more interactive exposure in medical school, positive radiology mentorship, and greater earning potential having a more positive impact on application to radiology. Moreover, it was hypothesized that more negative perceptions of the future of radiology regarding advances in technology, lifestyle, and outsourcing would negatively affect the likelihood of having applied to radiology. Junior trainees were also expected to have more negative perceptions regarding the future of radiology as it pertains to technology, lifestyle, job availability, and outsourcing compared to senior trainees, therefore contributing to the decline in interest in radiology. A secondary purpose of the study was to explore potential factors influencing resident physicians’ decision to pursue radiology and/or their choice of specialty. MATERIALS AND METHODS Following institutional ethics approval, resident physicians registered at a single academic centre were invited to participate in an anonymous online survey between July and August 2017. 2

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An e-mail invitation containing the survey hyperlink was distributed to all registered resident physicians by the Postgraduate Medical Education office. Informed consent was confirmed when the online survey was started. A reminder e-mail was sent approximately 4 weeks after the initial invitation to Program Directors of all registered programs with the Royal College of Physicians and Surgeons and Canadian College of Family Physicians, who then directly redistributed the e-mail to resident physicians registered in their programs. Based on data from the Canadian Resident Matching Service (4), approximately 708 resident physicians had the opportunity to participate in the survey. The online questionnaire was hosted on a web-based survey provider, LimeSurvey (Carsten Schmitz. Released 2018, version 3.1.1) and contained 19 questions (Supplementary Document 1). The survey questions were predominantly quantitative and utilized a 5-point Likert scale (1 = Strongly disagree, 5 = Strongly agree). Several qualitative questions were also included. Survey questions were identified based on the published literature and following discussion among study team members. The survey was pilot tested on radiology and nonradiology resident physicians and revised for clarity and ease of use through multiple iterations. The survey questions were peer reviewed by three radiologists, two radiology residents, and two nonradiology residents. Demographic data, including age, gender, graduating medical school, current residency program, and current level of training (postgraduate year [PGY] 1 through 5, and other) were collected. Current year of postgraduate training was based on the Canadian system, with PGY 1 being equivalent to ''internship year'' in the United States and other international postgraduate training programs. All participants were asked to rate the extent to which they agreed with 10 statements regarding radiology. Resident physicians who never considered radiology and those who considered but chose not to pursue radiology were asked to rate factors that deterred them from radiology. Resident physicians who applied to radiology were asked to rate factors that attracted them to radiology. All resident physicians were also asked to indicate their prior radiology exposure and factors influencing their overall choice of specialty. Statistical analyses were performed using IBM SPSS Statistics (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.). Descriptive statistics were used to describe the study population. A regression analysis was performed to investigate the influence of age, gender, PGY, degree of interaction during exposure to radiology in medical school, mentorship in radiology, perceptions regarding technology, outsourcing, and lifestyle, and importance of income in choice of specialty on the decision to apply to radiology. A repeated measure analysis of variance (ANOVA) was used to analyze differences between junior (PGY 1) and senior (PGY 5 or higher) resident physicians with respect to perceptions of the future of radiology as they pertain to technology, lifestyle, job availability, and outsourcing. Descriptive statistics were also used to explore trends of radiology and nonradiology residents with respect to perceptions of radiology, factors

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attracting or deterring from pursuing a career in radiology, and factors affecting overall choice of specialty. RESULTS Demographics

A total of 152 resident physicians completed the survey, for an approximate response rate of 21.5%. Of the participants, 20 (13%) were registered in the Diagnostic Radiology residency program, 91 (60%) were in a nonsurgical discipline (e. g., internal medicine, primary care), 32 (21%) were in a surgical discipline (e.g., orthopedic surgery, general surgery), and 9 (6%) were unspecified/unknown. The response rate for radiology residents was 64.5% compared to 18.6% for nonradiology residents. Most participants were between 25 and 29 years of age (n = 79, 47%). Sixty-one percent (n = 92) of all participants self-identified as female, 34% (n = 52) as male, 1% (n = 2) as other, and 4% (n = 6) were unknown. Of those in radiology, 40% (n = 8) self-reported as female, 55% (n = 11) as male, and 5% (n = 1) as other/unknown, compared to 64% (n = 84) as female, 31% (n = 41) as male, and 5% (n = 7) as other/unknown in the nonradiology group. For context, the gender distribution of Canadian medical graduates at the time of the survey was 57% female and 43% male (14) and the gender distribution of resident physicians in Canadian postgraduate medical training was 53% female and 47% male (15). Eighty percent (n = 118) of respondents graduated from a Canadian medical school. A total of 23 (15%) participants reported having applied to a Diagnostic Radiology residency program. Of these, 20 ended up Diagnostic Radiology. Of the remaining three, one ended up in Obstetrics & Gynecology, one in Neurology and one in Ophthalmology. Thirty-one participants (20%) reported having considered diagnostic radiology as a potential career but chose to pursue another specialty. Sixty-four percent (n = 97) reported having never considered diagnostic radiology as a career option. Factors Contributing to the Decision to Apply to Radiology

A binary logistic regression analysis was used to assess whether the likelihood of applying to radiology (coded as “applied to radiology” or “did not apply to radiology”) was influenced by gender (female, male, or other), age (<24, 25 30, 31 34, or >35), PGY 1 5 and above, degree of interaction during exposure to radiology in medical school (no exposure, didactic only, or interactive component), radiology mentorship (yes or no), importance of higher income in specialty choice (Likert-scale), and beliefs that technology will replace radiologists (Likert-scale), that the lifestyle of radiologists is getting worse (Likert-scale), and that radiology will soon be outsourced (Likert-scale). The model was significant, Wald = 56.6, p < 0.001, such that respondents who applied to radiology were more likely to have reported receiving

positive mentorship, B = 2.8, Wald = 3.9, df = 1, p = 0.05 (OR = 16.5), to disagree that technology will replace radiologists, B = 2, Wald = 6.9, df = 1, p < 0.01 (OR = 0.14), and to agree that higher income is important in choice of specialty, B = 2.3, Wald = 8.2, df = 1, p < 0.01 (OR = 10.4). Gender, age, PGY, degree of interaction during exposure to radiology in medical school, and perceptions around lifestyle and outsourcing were not associated with the decision to apply to the specialty. Perceptions of Radiology

A repeated measures ANOVA was used to analyze differences between junior (PGY 1, n = 40) and senior (PGY 5 and higher, n = 25) residents irrespective of specialty based on four perceptions of the future of radiology: technology will soon replace radiologists, the lifestyle of radiologists is getting worse, it is more difficult to obtain a job in radiology in the location of your choice, and radiology will soon be outsourced. There was a significant interaction between training level and the four perceptions, F (3, 189) = 2.6, p = 0.05 (Fig 1). More specifically, both junior and senior residents slightly disagreed that the lifestyle of radiologists is getting worse, with 44% (n = 11) of senior residents and 48% (n = 19) of junior residents disagreeing/strongly disagreeing with the statement. Junior residents disagreed less strongly that technology will soon replace radiologists compared to senior residents, with 13% of junior residents agreeing/strongly agreeing with the statement compared 0% of senior residents. Senior residents were in greater agreement that it is difficult to obtain a job as a radiologist in the location of choice than junior residents. Senior residents were slightly less likely to agree that outsourcing is an issue for radiology in the future than junior residents, with 64% (n = 16) of senior residents disagreeing/strongly disagreeing with the statement compared to 35% (n = 14) of junior residents. There were significant overall differences between the four perceptions, F (3, 189) = 33.25, p < 0.001, such that irrespective of training level, respondents agreed that it is difficult to obtain a job in radiology in the location of choice (M = 3.5, SD = 0.83) and disagreed that the lifestyle of radiology is worsening (M = 2.8, SD = 0.94), and that outsourcing (M = 2.6, SD = 0.8) and technology (M = 2.2, SD = 0.89) will replace radiologists. There was no significant overall difference between training levels, F (1, 63) = 0.55, p = 0.46. There were also several notable differences between radiology and nonradiology residents with respect to perceptions of radiology (Table 1). Of note, the majority (70%) of residents in specialties other than radiology agreed or strongly agreed that outside of interventional radiology, radiologists have little patient contact, compared to 35% (n = 7) of radiology residents (Fig 2). Nearly all radiology residents (n = 19, 95%) disagreed/ strongly disagreed with the statement that radiology is monotonous, while only 39% (n = 51) of nonradiology residents felt the same. Only 10% (n = 2) of radiology residents agreed that radiologists are perceived positively by other physicians compared to 62% (n = 82) of nonradiology residents who believed 3

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Figure 1. Level of agreement with four perceptions of the future of radiology across all specialties (radiology and nonradiology combined) according to training level. Higher scores indicate a greater level of agreement (5 = Strongly agree, 1 = Strongly disagree). Junior residents = PGY 1. Senior residents = PGY 5 and higher.

the same. Most radiology residents (70%; n = 14) agreed that the lifestyle of radiologists is changing for the worse, while only 11% (n = 15) of nonradiology residents believed the same. Ninety-five percent (n = 19) of radiology residents also believed that radiologists see most of the interesting cases in the hospital compared to 60% (n = 79) of nonradiology residents. Both groups of residents generally agreed that radiologists have high job satisfaction and disagreed that technology will soon put radiologists out of a job, that radiologists have little opportunity to interact with others at work, that it is easy to get a job as a radiologist in the location of choice, and that radiology will soon be outsourced (Table 1). Thirty-three (25%) of nonradiology residents also reported that their perceptions of diagnostic radiology changed after starting residency. When asked to expand upon which perceptions changed, several residents reported having learned that radiologists interact more with other healthcare professionals and have greater involvement in patient care, more diverse work, and greater job satisfaction than they had

previously thought. A few radiology residents (20%, n = 4) also reported that their perceptions of radiology changed after starting residency, particularly as it pertained to patient contact. After starting residency, radiology residents reported that there was more patient contact than they had expected. Overall, 60% (n = 78) of nonradiology residents reported a better understanding of what radiologists do since starting residency and 76% (n = 99) were more familiar with radiology as a specialty but still preferred their chosen specialty. Nine (7%) would consider applying to radiology if given the opportunity to repeat the residency match. Factors Attracting to Radiology

Table 2 shows nine potential factors that attracted residents to radiology. Only residents who applied to radiology (n = 23), including those who ended up in radiology (n = 20) and those who ended up in other programs (n = 3), were asked to evaluate these factors. The top three attracting factors were

TABLE 1. Radiology and Nonradiology Residents’ Mean Level of Agreement RM with Statements About Radiology Statement Outside of IR, radiologists have little opportunity for patient contact Radiologists have high job satisfaction Technology will soon put radiologists out of a job Radiology is monotonous Radiologists are perceived positively by other physicians The lifestyle of radiologists is changing for the worse Radiologists have little opportunity to interact with others at work Radiologists see most of the interesting cases that come through the hospital It is easy to get a job as a radiologist in the location of your choice Radiology will soon be outsourced Higher numbers indicate stronger agreement (5 = Strongly agree, 1 = Strongly disagree).

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Radiology residents (n = 20) Mean (SD)

Nonradiology residents (n = 132) Mean (SD)

3.0 (1.0) 4.0 (0.6) 1.0 (0.8) 1.7 (0.7) 2.5 (0.8) 3.6 (1.2) 2.2 (1.0) 4.6 (0.6) 2.7 (0.9) 2.2 (0.8)

3.7 (0.9) 3.9 (0.7) 2.2 (0.9) 3.1 (1.1) 3.5 (0.8) 2.5 (0.8) 2.4 (0.9) 3.5 (0.9) 2.5 (0.8) 2.7 (0.9)

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Figure 2. Percent of radiology vs nonradiology residents and their level of agreement with a statement regarding patient contact in diagnostic radiology.

similar regardless of the specialty the resident ended up in. The most important factor was diversity of pathology/cases with 96% of residents in agreement/strong agreement, followed by positive/good mentor in radiology (87% agreed/ strongly agreed), and positive interactions with radiology staff/residents (87% agreed/strongly agreed). Of the factors, a desire for less patient contact had the greatest variability in agreement level, with 48% of participants agreeing/strongly agreeing and 40% disagreeing that it was an important influencing factor. Residents who ended up in radiology were in slightly greater agreement that impact on patient care (M = 4.3, SD = 0.8) and desire for less patient contact

TABLE 2. Factors That Attracted to Radiology, Reported as Means, for all Residents who Applied to Radiology Factor

Diversity of pathology/cases Positive/good mentor in radiology Positive interactions with radiology staff/ residents Impact on patient care Positive perceptions of the field by others Exposure to research in radiology Availability of job after residency Desire for less patient contact Related to undergraduate studies

Residents who Applied to radiology (n = 23) Mean (SD) 4.5 (0.7) 4.3 (0.8) 4.3 (0.7) 4.2 (0.8) 3.5 (0.8) 3.2 (1.3) 3.1 (0.9) 3.1 (1.4) 3.0 (1.4)

Higher numbers indicate stronger agreement (5 = Strongly agree, 1 = Strongly disagree), and the three highest are highlighted in bold.

(M = 3.2, SD = 1.4) were important influencing factors in choosing radiology compared to residents who ended up in another program (M = 3.7, SD = 0.6 and M = 2.7, SD = 1.5, respectively). When given the option to expand upon other reasons not included in the list, residents reported the ability to work from home, higher income, interest in technology, intellectual challenge, and flexibility of the work environment as important additional influencing factors.

TABLE 3. Factors That Deterred From Radiology, Reported as Means, for all Residents who did not Apply to Radiology Factor

Lack of direct patient contact Dark work environment Lack of a good mentor in radiology Didn’t know enough about it to seriously consider Access to imaging through other specialties (e.g., point-of-care ultrasound in ER) Concern regarding future job market Negative perceptions of radiology by others Negative interactions with radiology staff/residents Became interested too late during my training

Residents who did not Apply to Radiology (n = 128) Mean (SD) 3.9 (1.2) 3.6 (1.2) 2.7 (1.1) 2.6 (1.1) 2.4 (1.0)

2.3 (1.0) 2.2 (0.9) 2.1 (1.0) 1.7 (0.8)

Higher numbers indicate stronger agreement (5 = Strongly agree, 1 = Strongly disagree), and the two highest are highlighted in bold.

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Figure 3. Percent of nonradiology residents and whether they agreed/Strongly agreed or disagreed/Strongly disagreed with nine potential factors acting as a deterrent to pursuing radiology as a specialty.

Factors Deterring From Radiology

Table 3 shows the average agreement level with nine potential factors that deterred residents from pursuing radiology. Only residents who did not apply to radiology (n = 128) were asked to evaluate these factors. There were no notable differences between trainees in surgical and nonsurgical programs. The most important deterrent was lack of direct patient contact, followed by dark work environment. Figure 3 depicts the percent of nonradiology residents and their level of agreement with the nine factors. Of note, 30% (n = 39) of residents agreed/strongly agreed that they did not know enough about radiology to seriously consider it as a career option. Thirty-one percent (n = 41) agreed/strongly agreed that the lack of a good mentor in radiology was a barrier to considering radiology as a career option. Overall, residents tended to disagree that negative interactions with radiology staff/residents, negative perceptions of radiology by others, or access to imaging through other specialties deterred them from radiology. A small minority (n = 20, 15%) reported that concern regarding future job market was a deterrent to pursuing radiology. A small number of nonradiology residents (n = 31, 21%) reported having considered radiology but changed their mind or chose not to pursue it. For them, the top three deterrents were similar and included lack of direct patient contact (M = 4.1, 77% agree/strongly agree), dark work environment (M = 3.8, 61% agree/strongly agree), and lack of a good mentor (M = 3.2, 52% agree/strongly agree). Moreover, 16% became interested too late during medical training and 29% reported concern about future job market. When residents who did not apply to radiology were given the option to expand upon any additional or unlisted reasons for not pursuing radiology, the uncertainty of the future of 6

radiology due to AI (n = 1) and international outsourcing of work (n = 3), the competitiveness of the residency program (n = 2), responsibility of being on-call as a resident (n = 3), and difficulty/length of training (n = 3) were reported as deterrents. Others talked about having found their choice of specialty early during training (n = 4), the lack of exposure to radiology during medical school (n = 2), and the observational nature of radiology electives (n = 6) as potential barriers.

Factors Affecting Overall Career Choice

A repeated measures ANOVA was used to analyze the difference between junior (PGY 1) and senior (PGY 5 and higher) residents based on four factors affecting overall choice of specialty: ease of obtaining a residency spot in the location of choice, job availability after residency, shorter residency, and flexible work hours as staff (Fig 4). There was a significant difference between training levels, F (1, 61) = 19.7, p < 0.001, such that junior residents (M = 3.5, SD = 1.1) were more likely to agree that these factors are important when choosing their specialty compared to the senior residents who generally disagreed (M = 2.5, SD = 1.1). There was a significant difference between the four factors in overall choice of specialty, F (3, 18) = 26.2, p < 0.001, such that on average, resident physicians agreed that job availability (M = 3.4, SD = 1.2) and flexible work hours as staff (M = 3.4, SD = 1.2) are important, were neutral regarding the importance of residency location (M = 3, SD = 1.2), and disagreed that shorter residency is important (M = 2.1, SD = 1.1). The interaction between training levels and the four factors was not significant, F (3, 183) = 1.5, p = 0.23. Table 4 shows the mean agreement level with the nine factors influencing resident physicians’ overall decision to pursue the specialty they were currently training toward. The top

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Figure 4. Level of agreement with four factors affecting overall choice of ANY specialty according to training level. Higher scores indicate a greater level of agreement. (5 = Strongly agree, 1 = Strongly disagree). Junior residents = PGY 1. Senior residents = PGY 5 and higher.

TABLE 4. Factors That Influenced Overall Choice of Specialty of all Residents, Reported as Means Factor in Overall Choice of Specialty Positive clinical experiences during medical school Positive mentoring experiences during medical school Specialty-specific factors Desire to work in a particular setting (e.g., clinic, hospital) Flexible work hours as staff Job availability after residency Higher income potential Ease of obtaining a residency spot in the location of my choice Shorter residency

All Residents (n = 148) 4.4 (0.8) 4.3 (0.7) 4.3 (0.8) 4.0 (0.9) 3.6 (1.2) 3.3 (1.2) 2.9 (0.9) 2.9 (1.9) 2.1 (0.9)

Higher numbers indicate stronger agreement (5 = Strongly agree, 1 = Strongly disagree), with the three highest highlighted in bold.

three factors across all specialties and training levels included positive mentoring experiences during medical school, positive clinical experiences during medical school, and specialtyspecific factors. There was a notable difference between radiology and nonradiology residents with respect to two factors: higher income potential and positive clinical experiences during medical school. More specifically, radiology residents agreed that higher income potential is an important factor (M = 3.5 SD = 0.8) with 60% (n = 12) reporting they agree/ strongly agree, while nonradiology residents disagreed (M = 2.2, SD = 0.9) with 69% (n = 91) reporting they disagree/strongly disagree. Additionally, nonradiology residents agreed slightly more that positive clinical experiences during medical school is important (M = 4.5, SD = 0.8) with 89% (n = 116) reporting that they agree/strongly agree compared to radiology residents (M = 3.9, SD = 1.0), of whom 75% (n = 15) agreed/strongly agreed with the same.

When given the opportunity to expand upon specialty-specific or other factors affecting choice of specialty, participants reported that clinical research opportunities (e.g., clinical trials), the flexibility of general medicine (e.g., family medicine and internal medicine), the desire to work with specific patient populations (pediatrics, obstetrics and gynecology, psychiatry), the ability to develop long-term relationships with patients, and heavier focus on procedures and operating were important in influencing their choice of career. DISCUSSION The relative competitiveness of and interest in diagnostic radiology among trainees has declined over the last decade (1,2). The literature on radiology as a specialty choice has focused solely on medical students and the attitudes of resident physicians have never been assessed. The purpose of this study was to explore potential factors contributing to the declining interest in diagnostic radiology by surveying resident physicians of all training levels and specialties. Consistent with previous literature, our study shows that respondents were more likely to apply to radiology if they reported positive mentorship during medical school. Arleo et al. (2016) surveyed final year medical students and found that two key factors that influenced the decision to pursue radiology were the presence of role models and experience on radiology rotations. Similarly, in our study, two of the top three factors that attracted resident physicians to radiology were the presence of a mentor in radiology and positive interactions with radiology staff/residents. Moreover, our study builds on prior findings by demonstrating that two very similar factors, mentorship and positive clinical experiences during medical school, were also the most influential in overall choice of specialty for resident physicians across all specialties and training levels. As less time is dedicated to radiology in the formal undergraduate medical education curriculum, access to 7

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mentors in radiology becomes increasingly limited. Given the importance of these factors in attracting trainees to radiology, greater emphasis on medical student mentorship and teaching should be made a priority in radiology departments. The findings from our study also contribute to the very limited number of studies on medical trainees’ perceptions of AI in radiology. Pinto Dos Santos et al. (2019) conducted a survey of medical students’ attitudes toward AI and found that 83% disagreed that human radiologists will be replaced by AI. Consistent with this, we found that resident physicians across all specialties and training levels disagreed that technology will soon replace radiologists. However, Gong et al. (2019) recently showed that even though most medical students disagree that AI will replace radiologists, almost half of those considering radiology as a first-choice specialty are anxious about pursuing radiology because of AI. Expanding upon this literature, our results showed that a stronger belief that radiologists will be replaced by technology was associated with a decreased likelihood of applying to radiology. Moreover, our results suggest that even though concern regarding future job market was considered a deterrent to radiology only by a minority of trainees, it was of greater importance to trainees who were initially interested in radiology but were then dissuaded from pursuing it. Additionally, the results of our study show that senior residents were more likely to disagree that technology will soon replace radiologists compared to first year residents. There are two possible explanations: (1) junior trainees have greater concern about the effect of AI on long-term job prospects in radiology, or (2) senior residents have had more exposure to the reality of technology in medicine and are therefore less likely to fall prey to the sensationalized foretelling of AI replacing radiologists. Regardless, there is greater agreement among junior trainees that technology has the potential to replace radiologists, suggesting that junior trainees are more worried and this is likely contributing to the decline in application rates. Given the key role of mentorship in radiology and the importance of radiologists as a source of information for medical students about AI (8), it is essential that radiology staff and residents become proactive in providing medical trainees with accurate and positive information regarding the role of AI in radiology and reinforce the exciting opportunities and growth in the field in the coming years. With the advent of telemedicine over the last decade, increased outsourcing is another potential factor that has been proposed to contribute to declining interest. The literature on this topic is very limited but suggests that medical students are at least somewhat concerned about the effect of outsourcing (10). Contrary to our hypothesis, we did not find a significant impact of outsourcing on the likelihood of application to radiology. Moreover, our results suggest that resident physicians, regardless of specialty or training level, generally disagree that outsourcing is a significant concern for radiology. These findings suggest that trainees may not be too worried about outsourcing, have limited knowledge regarding this issue, or have seen limited impact of outsourcing on 8

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clinical rotations. Alternatively, outsourcing may be perceived positively by some applicants, with teleradiology becoming a draw for those who desire a flexible lifestyle with the option of working from home. Therefore, reinforcing the value of in-person collaboration, emphasizing active participation of radiologists in patient care (e.g., through multidisciplinary rounds), and promoting the potential positive impact of teleradiology are important in mitigating anxiety around the effect of outsourcing on the future of radiology. The decline in applications to diagnostic radiology has also been attributed to declining remuneration for imaging (2,16). Our study contributes to the body of evidence that stresses the relative importance of higher income to trainees interested in radiology compared to those interested in other specialties (13). Consistent with our hypothesis, the desire for higher income was associated with greater likelihood of pursuing radiology, and higher income was a more important factor in overall choice of specialty for resident physicians in radiology compared to those in other specialties. These findings support the idea that the decline in interest in radiology is at least in part tied to its economic vitality, and particularly the recent decreases in compensation. There has also been much speculation about the changing priorities of junior/younger medical trainees in terms of the desire for greater work-life balance when choosing a specialty, one that allows them to train and practice in the city of their choice and provides plentiful job opportunities and flexible work hours (2,17). In our study, junior trainees were more likely to agree that job availability, flexible work hours as staff, and location of residency are important factors in their overall choice of specialty compared to more senior trainees. These findings reflect the changing values of younger trainees entering medicine and emphasize the importance of appealing to junior trainees’ values by reinforcing the flexible nature of radiology, such as the ability to work from home or to work part-time. Given the importance of this concept of a “controllable lifestyle” in the choice of specialty (7), the demand for 24-hour coverage and overall worsening lifestyle have been proposed to contribute to declining application rates to radiology. Contrary to such speculation, the results of our survey suggest that the perception of a worsening lifestyle does not contribute significantly to likelihood of applying to radiology. One possible explanation for this may be that many trainees are not aware of the changing lifestyle. This is supported by our findings of a discrepancy between radiology and nonradiology residents’ beliefs around the worsening lifestyle of radiologists, with most radiology residents reporting overwhelming agreement and most nonradiology residents disagreeing with the statement. Although it could be argued that the perceptions of radiology residents may be biased by the arduous experience of radiology residency training, they are still more likely to be aware of the changing lifestyle of the profession and higher rates of burnout among staff radiologists (18) than nonradiology residents. Contrary to our hypothesis, exposure to radiology during medical school in terms of no exposure, didactic only, or a

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RESIDENT PHYSICIANS' PERCEPTIONS OF DIAGNOSTIC RADIOLOGY

combination of didactic and interactive (e.g., clinical rotations) did not contribute significantly to the likelihood of application to radiology. The literature on the effect of amount and type of exposure to radiology is mixed. Although some studies suggest that dedicated imaging rotations lead to increased choice of radiology (10), and that taking radiology electives increases interest among students already interested in radiology (19), the same is not necessarily true for those already interested in another specialty (20). The lack of a significant effect in our study may in part be accounted for by the relatively high rates of overall exposure to radiology reported by trainees, with fewer than 3% reporting no exposure. Moreover, even clinical rotations, which are considered more ''interactive'', were reported by trainees in our study to be “observational” and therefore not interactive at all. Targeting more controllable factors such as restructuring of radiology electives to help engage medical trainees can help increase interest in radiology and combat less controllable factors such as decreases in remuneration. Gender also did not contribute significantly to the likelihood of application to radiology. The gender disparity in radiology is well documented, with women making up less than a third of practicing radiologists in Canada and the United States (21 24). Increased attention in recent years has led to some minor improvements, with women reportedly now making up 32% and 25% of practicing radiologists in Canada and the United States, respectively, in 2018 (21,23) compared to 28% and 22% in Canada and the United States, respectively, in 2014 (9,24). The numbers increase to 41% when isolated to practicing radiologists younger than 44 years of age (23). The lack of an effect of gender on likelihood of application to radiology in our survey potentially reflects this recent progress in narrowing of the gender gap. Other factors were also found to influence resident physicians’ choice of specialty and the decision to pursue or not to pursue radiology. The top factor attracting trainees to radiology was diversity of pathology/cases. These findings build upon those of other studies that show that students interested in radiology value intellectual stimulation and the desire to acquire a broad range of knowledge (10,13). Similarly, we found that most radiology residents disagreed that radiology is monotonous, and an overwhelming majority felt that radiologists see most of the interesting cases in the hospital. In contrast, most nonradiology residents felt that radiology is monotonous and a much smaller proportion believed that radiologists see most of the interesting cases in the hospital. Many nonradiology residents also reported not knowing much about radiology. These findings suggest that despite the exposure obtained in medical school, many trainees remain unaware of the diverse and fast-paced nature of radiology. As one of the fastest advancing specialties, radiology offers ongoing intellectual challenge and demands ever increasing knowledge of nearly every medical specialty. The further expected future diversification of the field of radiology should be emphasized to trainees and attempts should be made to correct these misconceptions.

The dark work environment and lack of direct patient contact were the top two factors that deterred trainees from radiology. Nearly a third of participants also agreed that a lack of a mentor was a significant barrier to radiology. Interestingly, the same factors held true for the subset of residents who reported that they considered radiology and changed their mind, but with the lack of a good mentor becoming more important. These findings are in line with prior research demonstrating that a lack of patient contact and dark work environment deter medical students from radiology (10,13). Moreover, many medical students believe that radiologists have no patient contact (10,13). While we also found that most nonradiology residents believe that radiologists have little patient contact outside of interventional radiology, only a small percentage of radiology residents believed the same. Although radiology residents and nonradiology residents may define “limited patient contact” differently, it is important to note that in our survey even radiology residents reported being surprised by the amount of direct patient contact in diagnostic radiology. Regardless, our findings suggest that there is an opportunity to address the idea of patient contact during radiology electives by demonstrating to trainees the various short but meaningful interactions that radiologists have with patients. The results of our study also suggest that nearly a third of the participants who did not apply to radiology agreed that they did not know enough about radiology to seriously consider it as a career option. More than half of residents further reported that their perceptions of radiology changed since starting residency, and that they gained a better appreciation for the diverse work of radiologists, the greater interaction with other healthcare professionals, and the greater involvement in patient care. A small percentage of residents also reported they would now consider applying to radiology if they were going through the residency match again. These findings highlight the importance of exposing medical students to the multifaceted work of radiologists and structuring engaging electives to ensure a broad understanding of the field. There were several limitations of our study. Inherent to all research utilizing a survey, self-selection bias and response bias are possible limitations. The survey respondents were not blinded to the fact that the study was being conducted by the Department of Radiology, and respondents may have therefore been more positive about their responses regarding the future of radiology than they truly believed. The overall response rate was low and may not fully reflect the full spectrum of participant opinions. Despite these possibilities, there was good representation across Canadian residency programs and training levels, increasing generalizability. Another potential limitation was the retrospective nature of the study. Senior trainees are more removed from their medical school training and are therefore more likely to be biased by their training experiences. Changes in attitude comparing junior to senior residents regarding aspects of radiology may therefore not actually reflect a change over time, but may be attributable to changes due to more experience in the field of 9

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medicine, more interactions over time with radiologists, and a better understanding of the role of radiology in patient care (for those not in radiology residency). Despite this, we found significant differences between training levels, which would result in underestimation of the true effect. Although the presence of mentorship and degree of interaction during exposure was explored in the study, information regarding the timing of mentorship and exposure to radiology during medical school training was not gathered despite there being some research to suggest that earlier exposure may lead to longer-lasting positive effects (25). Lastly, the study was limited to a single institution, which was at least partially overcome by the relative diversity of respondents who represented medical schools from across all of Canada. CONCLUSION Interest in diagnostic radiology as a specialty choice among trainees has been declining over the last few years. The results of this survey of resident physicians from across specialties and training levels suggests that the reasons behind this are multifactorial and that both controllable and less controllable factors have a role. The potential negative effects of advancements in technology and changes to reimbursement can be mitigated by placing greater emphasis on mentorship of trainees to help correct misconceptions and highlight the diversity and flexibility of radiology as well as the exciting new opportunities that the future holds. ACKNOWLEDGMENTS The authors thank resident physicians Dr. Elise Azzi, Dr. Natasha Larocque, and Dr. Apoorva Bollu for their feedback on the drafts of the survey. The authors also thank the Program Manager of Postgraduate Medical Education at McMaster University Roberta Preston, Assistant Dean of Postgraduate Medical Education Dr. Parveen Wasi, and the Program Directors of McMaster University Residency Programs for their assistance with distributing the survey. REFERENCES 1. Chen JY, Heller MT. How competitive is the match for radiology residency? Present view and historical perspective. J Am Coll Radiol 2014; 11:501–506. doi:10.1016/j.jacr.2013.11.011. 2. Kenny SA, Esmail K, Hibbert RM, et al. How competitive is the Canadian diagnostic radiology residency match? Application and matching trends from 1991-2014. Can Assoc Radiol J 2016; 67:105–111. doi:10.1016/j. carj.2015.09.004. 3. The Match: National Resident Matching Program. Report archives. Available at:http://www.nrmp.org/report-archives/. Accessed December 2, 2019. 4. Canadian Resident Matching Service. R-1 match reports. Available at: https://www.cma.ca/sites/default/files/2019-01/diagnostic-radiology-e. pdf. Accessed December 2, 2019. 5. Minor S, Poenaru D, Park J. A study of career choice patterns among Canadian medical students. Am J Surg 2003; 186:182–188. 6. Scott IM, Matejcek AN, Gowans MC, et al. Choosing a career in surgery: factors that influence Canadian medical students' interest in pursuing a surgical career. Can J Surg 2008; 5:371–377.

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7. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003; 290:1173–1178. doi:10.1001/jama.290.9.1173. 8. Gong B, Nugent JP, Guest W, et al. Influence of artificial Intelligence on Canadian medical students' preference for radiology specialty: a national survey study. Acad Radiol 2019; 26:566–577. doi:10.1016/j. acra.2018.10.007. 9. Pinto Dos Santos D, Giese D, Brodehl S, et al. Medical students' attitude towards artificial intelligence: a multicentre survey. Eur Radiol 2019; 29:1640–1646. doi:10.1007/s00330-018-5601-1. Epub 2018 Jul 6. 10. Arleo EK, Bluth E, Francavilla M, et al. Surveying fourth-year medical students regarding the choice of diagnostic radiology as a specialty. Am J Roentgenol 2016; 13:188–195. doi:10.1016/j.jacr.2015.08.005. 11. Pianosi K, Bethun C, Hurley KF. Medical student career choice: a qualitative study of fourth-year medical students at Memorial University, Newfoundland. CMAJ Open 2016; 19:E147–E152. doi:10.9778/ cmajo.20150103. eCollection 2016 Apr-Jun. 12. Visscher KL, Faden L, Nassrallah G, et al. Radiology exposure in the undergraduate curriculum: a medical student perspective on quality and opportunities for positive change. Can Assoc Radiol J 2017; 68:249– 256. doi:10.1016/j.carj.2016.10.004. 13. Zener R, Lee SY, Visscher KL, et al. Women in radiology: exploring the gender disparity. J Am Coll Radiol 2016; 13:344–350. e1. doi:10.1016/j. jacr.2015.10.019. 14. Canadian Post MD. Education registry (CAPER). Gender Analysis of Postgraduate Medical Trainees in Canada; Available at: https://caper. ca/sites/default/files/pdf/presentations/2018-GenderAnalysis_en.pdf . Accessed December 28 . 15. Pinto C, Damberger K, Clements K. Examining the gender shift in Canada's medical student population. Ont Med Rev 2019; 86(6):46–49. Available at: http://omr.dgtlpub.com/2019/2019-12-31/home.php . Accessed December 28, 2019 . 16. Anzilotti K, Kamin DS, Sunshine JH, et al. Relative attractiveness of diagnostic radiology: assessment with data from the National Residency Matching Program and comparison with strength of job market. Radiology 2001; 221:87–91. 17. Harris J, Gonzalez Lopez-Valcarcel B, Ortun V, et al. Specialty choice in times of economic crisis: a cross-sectional survey of Spanish medical students. BMJ Open 2013; 3:3002–3051. 18. Zha N, Patlas MN, Neuheimer N, Duszak R. Prevalence of burnout among Canadian radiologists and radiology trainees. Can Assoc Radiol J.201;69:367 372. https://doi.org/10.1016/j.carj.2018.05.005 19. Dobre MC, Maley K. Medical student radiology externs: increasing exposure to radiology, improving education, and influencing career choices. J Am Coll Radiol 2012; 9:506–509. 20. Freundlich IM, Murphy Jr. WA. Medical students who choose a radiology elective: career decisions, motivations and intentions. Acad Radiol 1995; 2:527–532. 21. Bender CE, Bansal S, Wolfman D, et al. 2018 ACR commission on human resources workforce survey. J Am Coll Radiol 2019; 16:508–512. doi:10.1016/j.jacr.2018.12.034. 22. Bluth EL, Bansal S, Macura KJ, Fielding J, Truong H. Gender and the radiology workforce: results of the 2014 ACR workforce survey. J Am Coll Radiol 2015; 12:155–157. doi:10.1016/j.jacr.2014.07.040. 23. Canadian Medical Association. Diagnostic radiology profile2018. Available at: https://www.cma.ca/sites/default/files/2019-01/diagnostic-radiology-e.pdf. Accessed January 4, 2019. 24. Canadian Medical Association. College of family physicians of Canada 2014. National Physician Survey. Available at: http://nationalphysiciansurvey.ca/result/2014-results-medical-specialists-specialty/ . Accessed January 4, 2019 . 25. Branstetter BF, Humphrey AL, Schumann JB. The long-term impact of preclinical education on medical students’ opinion about radiology. Acad Rad 2008; 15:1331–1339.

SUPPLEMENTARY MATERIALS Supplementary material associated with this article can be found in the online version at doi:10.1016/j.acra.2020.01.016.