The Residency Training Landscape

By Dr. Paul Harari, MD, FASTRO, ASTRO Board Chair

March 15 was Match Day, and medical students across the country opened envelopes to learn which medical center and specialty they matched with for their residency training. For the first time in many years, there was a gap in the number of matches for radiation oncology with 29 slots going unfilled.

So why was there a gap in RO this year? Some believe this reflects an anticipated oversupply of radiation oncologists for the future. This concern appears to depend largely on geography, where some markets are showing limited job options and some markets much broader options. Some believe that these unmatched slots signal a concerning decline in the field. Others view the 2019 match as a simple market correction. Many have asked, what could, or should ASTRO or others have done to prevent this? It is important to note that there is no single oversight entity that controls the number of residency slots in a field, and anti-trust laws prohibit organizations such as ASTRO from engaging in activities that could negatively impact the U.S. free marketplace.

There were several preview signs that the specialty could experience this type of Match Day with several factors at play. As a first step, it may be valuable to review the overall resident training and oversight ecosystem. Each player has an integral role in the health of a system that trains a medical student to provide specialized care as a licensed physician.

Association of American Medical Colleges (AAMC): The not-for-profit association whose members include medical schools and teaching hospitals. They help students navigate the journey from pre-med through residency. Because their members include all the accredited medical schools, they manage the national residency matching program (NRMP) which occurred last week. They frequently advocate for federal funding for graduate medical education.

Medicare Program and Graduate Medical Education: In addition to setting the reimbursement rates it will pay for services for Medicare beneficiaries, Medicare recognizes that hospitals who train residents incur real and significant costs beyond those customarily associated with providing patient care. The Medicare program makes payments to teaching hospitals for a portion of these added costs through direct graduate medical education (DGME) payments. The DGME payment compensates teaching hospitals for "Medicare's share" of the costs directly related to the training of residents.

Accreditation Council for Graduate Medical Education (ACGME): The ACGME is an independent, not-for-profit, physician-led organization that sets and monitors the professional educational standards for residency programs. The ACMGE is responsible for defining the residency requirements for each specialty and has review committees for each specialty and fellowship area. The ACGME also has a process to evaluate, improve, and publicly recognize institutions and programs in GME that are in substantial compliance with standards of educational quality established by the ACGME. Lastly, the ACGME manages the case report system residents use to demonstrate progress toward requirements outlined in the residency requirements.

Teaching Hospitals: While Medicare controls how much it will pay per resident to a teaching hospital, a hospital may use its own money to fund additional residents. Each individual hospital decides if it would like to dedicate any of its own funds for this purpose and if so, how much and on which areas it would like to expand its training programs. Thus, the total number of residency slots in any specialty in a year is the sum of each individual teaching hospital’s decision about how many slots it will offer.

While GME funding has been flat since 1997, the number of radiation oncology programs and the number of residency slots has grown over the last decade. As you can see in this chart, both the number of programs and the number of slots offered by programs has expanded over the last decade.

Radiation Oncology Residency: 2006-2018 trends
Residency Trends bar graph showing increase in number of radiation oncology programs and residents

Source: ACGME Data Resource Books

Upon completion of residency training, physicians then prepare for board examinations. In radiation oncology, the American Board of Radiology is the board which designs and tests individuals as to their competency in the practice of radiation oncology. They require individuals to pass three examinations to receive board certification: clinical, (radio)biology and medical physics. Boards also have various requirements to maintain certification that physicians must meet defined by the American Board of Medical Specialties.

Once a medical student or resident identifies their preferred specialty, they often join an affiliated specialty society to begin networking and become a member of the community. ASTRO is the membership organization with members defined as board certified radiation oncologists and medical physicists. ASTRO's role is to provide leadership to help guide the specialty into the future. ASTRO is dedicated to improving patient care and our core priorities including continuing professional education and training and the advancement of quality improvement, science and advocacy.

With regard to the workforce of radiation oncologists, ASTRO regularly studies and identifies trends through surveys and research. ASTRO's scientific journals also publish studies done by others about our workforce, including this 2016 study that predicted that current training program numbers could lead to an oversupply. These forecasts use predominantly historic information and often fail to capture how new scientific discovery and innovation might create new possibilities for the field. Still, it is important that these forecasts be available for medical students so that as they consider their future, they can make informed decisions about which field(s) they wish to pursue.

ASTRO can and does advocate for the modernization of training requirements to prepare radiation oncologists for the future. We anticipate that the ACGME will soon release a proposal to update the radiation oncology residency program requirements, and we will use this as an opportunity to comment with an eye toward the future health and growth of the specialty.

A 2019 ASTRO survey identifies that practicing radiation oncologists are most passionate about patient care interactions and being able to participate in the cure of cancer. Radiation oncology remains a critical modality of cancer treatment for patients around the world. The 2019 Match Day results will trigger highly welcome discourse about the specialty and the residency training landscape. ASTRO will do everything we can to help facilitate discussion and the sharing of accurate information.

Posted: March 20, 2019 | with 3 comments

Simul Parikh
The alarm was sounded much earlier than 2016, when in 2013, Dr C. Shah predicted this. His own leadership and many other people in the field told him how wrong he was, and then as time passed, it became quite apparent how right he was.

It’s multi-factorial - too many residents, hypoFX, declining in reimbursements, weaker ownership of patients as compared to medical oncology/surgery, poor stewardship from the top that did not listen or become of aware of what Dr. Shah and other were prescient about. The ABR fiasco is another reason, but just a downstream event at this point, and further evidence that “they just don’t care”. One can see how they handled the postponement of their boards this year compared to how the ophthalmology boards handled theirs.

The whole thing makes me pity current residents and feel anxious about the future. The stagnancy in the field, the apparent lack of empathy, and the burying of the head in the sand ... it’s too much for one specialty to handle. Let’s see what happens...
3/16/2020 11:06:26 PM

Medical students interact the most with Residents during interviews and rotations. They are able to sense dissatisfaction, and due to the High ABR failure rate, residents are HIGHLY dissatisfied. The ABR did not provide an ample explanation, other than that they used statistics to fail more people. What the ABR doesn't realize is that we all connect and speak to each other, and their explanation doesn't add up. Residents today are in over $200,000 debt, sacrifice months of their lives specifically for this test and when over 40% fail without a good explanation regarding competency, then there will be dissatisfaction. This year, the residents made clear their dissatisfaction with their leadership and nothing was done. When a medical student asks us advice, we will tell them the truth, that leadership has decided to Fail a large chunk of residents for their own ego, not because of actual competency. Thus, we encouraged them to find a specialty where they would not go through an unexplained failure, difficulty with jobs and such. We encouraged them to not go into Radonc. Why? Because our leadership is trying to fail rather than lift us up.

This is a direct consequence of a high ABR failure rate with minimal to no change. No medical student wants to go into a field where their leaders are feeding their young to the wolves. No medical students wants to be miserable and sacrifice their years for nothing. Especially when leaders in OTHER fields encourage residents for success. So that is the reason why. We are in an age where media and communication dictates. ABR thought that by failing people they can show their power and show people that this is a competitive field. It backfired.
3/22/2019 11:52:30 AM

Surjeet Pohar
The 2017 ASTRO Workforce Survey also suggested great concern among Radiation Oncologists about the current and future job market. This has now filtered down to medical students. I believe that programs will need to reduce their intake as was done in the late 1990s. If not done, high quality medical students will enter other fields.
3/20/2019 5:06:41 PM

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