FWIW Residency Expansion and Job Market Panel at ARRO Seminar

[Chartreuse Wombat]

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[PointA]

There was a ASTRO panel in 2015 on the labor market with some of the same panel discussants. The room was overflowing with people sitting on floors and standing in the back. Passions were running high but ultimately nothing happened because of the "anti-trust" argument.

ASTRO panel session on US rad onc labor market

Just wanted to give a heads up to anyone at ASTRO this week. Tomorrow (Monday) at 10:45-12:15pm Dr. Zietman will be moderating a panel session on the rad onc labor market. More details here: Future of the US Radiation Oncology Labor Market.

forums.studentdoctor.net

 

[deleted956486]

There was a ASTRO panel in 2015 on the labor market with some of the same panel discussants. The room was overflowing with people sitting on floors and standing in the back. Passions were running high but ultimately nothing happened because of the "anti-trust" argument.

ASTRO panel session on US rad onc labor market

Just wanted to give a heads up to anyone at ASTRO this week. Tomorrow (Monday) at 10:45-12:15pm Dr. Zietman will be moderating a panel session on the rad onc labor market. More details here: Future of the US Radiation Oncology Labor Market.

forums.studentdoctor.net

Yes, at best it was acknowlegdement of the problem, but realistically pretending there is nothing that can be done is the real problem. More importantly, placing the blame for a worsening match on social media is ridiculous. We dont see online "misanthropes" in radiology, orthopedics, urology (smaller field than rad onc) or other fields. There is a reason for the sdn response. Stop pretending the response is the problem.

 

[medgator]

Somehow derm and Urology have been able to regulate spots just fine without any legal repercussion.

The anti trust argument is basically specious to give the academic leaders the cover they need to expand their programs as they see fit

 

[xrthopeful]

Somehow derm and Urology have been able to regulate spots just fine without any legal repercussion.

The anti trust argument is basically specious to give the academic leaders the cover they need to expand their programs as they see fit

How have they figured out how to regulate? Do you have articles, info etc?

Please share this is vital to the discussion

 

[medgator]

How have they figured out how to regulate? Do you have articles, info etc?

Please share this is vital to the discussion

They just don't expand. And they certainly don't double slots in a decade

 

[deleted956486]

They just don't expand. And they certainly don't double slots in a decade

Exactly. Its not figuring out how to regulate. Its figuring out how not to abuse a system, which seems to be a problem deeply rooted in rad onc ( residency expansion, pushing protons, false marketing, abr fiasco).

 

[Burt Radnolds]

What I have heard is that some specialties have very stringent criteria in regards to expanding ones residency complement that effectively make it almost impossible.

We saw a half hearted attempted to raise the relatively low bar set by our own specialty, but even that was watered down already to something that would result in no meaningful change. I see this as the only reasonable way to limit expansion and its already been botched.

 

[Chartreuse Wombat]

Yes, at best it was acknowlegdement of the problem, but realistically pretending there is nothing that can be done is the real problem. More importantly, placing the blame for a worsening match on social media is ridiculous. We dont see online "misanthropes" in radiology, orthopedics, urology (smaller field than rad onc) or other fields. There is a reason for the sdn response. Stop pretending the response is the problem.

Urology is not smaller than RadOnc. AUA handles the Urology Match not NRMP. Usually about 325 positions annually. About 12K urologists compared to 4-5K RadOnc in US

 

[xrthopeful]

hahahaha i actually missed that. Urology smaller than Rad Onc dear god.

 

[deleted956486]

Urology is not smaller than RadOnc. AUA handles the Urology Match not NRMP. Usually about 325 positions annually. About 12K urologists compared to 4-5K RadOnc in US

I stand corrected. But my point is still relavent. Aside from pathology, and nuclear med (which has essentially disintegrated as a specialty), we dont see social media venting in other specialties. At least not at this level.

 

[DoctwoB]

Well urology has been expanding too, just at a much slower rate. This has less to do with central planning and a goal of keeping spots low (in fact our national organizations all talk about pending shortages, need to train more, etc), and more to do with a greater level of quality control.

Our minimum case numbers are no joke. They’re lower then I’d want a graduating resident to have, but as a lower bound it’s a real requirement. we also have limitations on the number of sites we can visit to obtain said numbers, and the RRC will make a program prove that it is greatly exceeding the minimums over several years before granting an expansion. As a result there are very few “community” programs in Urology.

 

[medgator]

Well urology has been expanding too, just at a much slower rate. This has less to do with central planning and a goal of keeping spots low (in fact our national organizations all talk about pending shortages, need to train more, etc), and more to do with a greater level of quality control.

Our minimum case numbers are no joke. They’re lower then I’d want a graduating resident to have, but as a lower bound it’s a real requirement. we also have limitations on the number of sites we can visit to obtain said numbers, and the RRC will make a program prove that it is greatly exceeding the minimums over several years before granting an expansion. As a result there are very few “community” programs in Urology.

Meanwhile, we get places like WVU, Mississippi, Arkansas and long Island trying to create new programs

 

[xrthopeful]

Well urology has been expanding too, just at a much slower rate. This has less to do with central planning and a goal of keeping spots low (in fact our national organizations all talk about pending shortages, need to train more, etc), and more to do with a greater level of quality control.

Our minimum case numbers are no joke. They’re lower then I’d want a graduating resident to have, but as a lower bound it’s a real requirement. we also have limitations on the number of sites we can visit to obtain said numbers, and the RRC will make a program prove that it is greatly exceeding the minimums over several years before granting an expansion. As a result there are very few “community” programs in Urology.

Thank you for posting this. A lot of things get thrown around and it’s nice to have some facts about other fields. I had a feeling that there was no central planning going on in urology

 

[xrthopeful]

I’m hoping people in leadership can continue to improve our case requirements. I was glad the proposed changes a few months ago were seen by everyone including ADROP as weak. Funny just looked at twitter and saw this:

 

[Gfunk6]

For those of you who are eagerly awaiting this seminar, here is a summary of what will be discussed:

 

[126230]

Archives

All historical reports can be found in the report archives.

www.nrmp.org

Residency expansion over the years

Rad Onc:
1995: 137 total spots (combined PGY-1/2, excluding "R" positions for consistency)
2000: 96
2005: 137
2010: 157
2015: 193
2018: 193

Dermatology:
1995: 18 total spots (combined PGY 1 and 2 and excluding "R" positions). Most spots were probably in a different match system.
2000: 251
2005: 316
2010: 360
2015: 407
2018: 437

Diagnostic Radiology/Integrated Interventional Radiology Residency:
1995: 1028
2000: 841
2005: 1018
2010: 1090
2015: 1132
2018: 1202 (combo of PGY1 IR and DR spots and PGY 2 IR and DR spots)

Emergency Medicine:
1995: 913
2000: 1064
2005: 1332
2010: 1575
2015: 1821
2018: 2278


A few notes:
1) This is only the NRMP match data. The DO match data was not included. I would imagine that there are few, if any, DO rad onc residencies. There were a trivial number of derm and radiology DO residency spots. Emergency medicine is unknown but I would think there were a decent number. This matters because in recent years DO spots have merged into the NRMP match making the numbers artificially inflated.
2) Despite #1 there has been a HUGE expansion of EM spots in the country. This was discussed in the EM forums a few months ago: AAEM Position Statement on Growing # of EM Residency Programs
Job market also has turned south a bit (still good overall): Houston Jobs
3) The data makes it clear that Derm has clearly expanded residency positions.
4) The concern for Derm and EM in the future is the expansion of private equity firms and CMGs which will continue to recruit more and more midlevels. This increases the individual docs liability without a commensurate increase in pay. ‘We have met the enemy and he is us’

"The article, published in November, is titled “Skin cancers rise, along with questionable treatments.” The New York Times analyzed recent Medicare dermatology billing data that found that independent billing by PAs and NPs accounted for more than 15% of the skin biopsies billed to Medicare in 2015. This was compared with almost none in 2005, as I pointed out in a comment in the article, for which I was interviewed."

 

[Krukenberg]

Archives

All historical reports can be found in the report archives.

www.nrmp.org

Residency expansion over the years

Rad Onc:
1995: 137 total spots (combined PGY-1/2, excluding "R" positions for consistency)
2000: 96
2005: 137
2010: 157
2015: 193
2018: 193

Dermatology:
1995: 18 total spots (combined PGY 1 and 2 and excluding "R" positions). Most spots were probably in a different match system.
2000: 251
2005: 316
2010: 360
2015: 407
2018: 437

Diagnostic Radiology/Integrated Interventional Radiology Residency:
1995: 1028
2000: 841
2005: 1018
2010: 1090
2015: 1132
2018: 1202 (combo of PGY1 IR and DR spots and PGY 2 IR and DR spots)

Emergency Medicine:
1995: 913
2000: 1064
2005: 1332
2010: 1575
2015: 1821
2018: 2278


A few notes:
1) This is only the NRMP match data. The DO match data was not included. I would imagine that there are few, if any, DO rad onc residencies. There were a trivial number of derm and radiology DO residency spots. Emergency medicine is unknown but I would think there were a decent number. This matters because in recent years DO spots have merged into the NRMP match making the numbers artificially inflated.
2) Despite #1 there has been a HUGE expansion of EM spots in the country. This was discussed in the EM forums a few months ago: AAEM Position Statement on Growing # of EM Residency Programs
Job market also has turned south a bit (still good overall): Houston Jobs
3) The data makes it clear that Derm has clearly expanded residency positions.
4) The concern for Derm and EM in the future is the expansion of private equity firms and CMGs which will continue to recruit more and more midlevels. This increases the individual docs liability without a commensurate increase in pay. ‘We have met the enemy and he is us’

"The article, published in November, is titled “Skin cancers rise, along with questionable treatments.” The New York Times analyzed recent Medicare dermatology billing data that found that independent billing by PAs and NPs accounted for more than 15% of the skin biopsies billed to Medicare in 2015. This was compared with almost none in 2005, as I pointed out in a comment in the article, for which I was interviewed."

Wow this is great, thank you. Interesting to see the #s for other specialties compared to us. Kind of deflates this myth that derm has controlled their #s. I think there was just so much pent up demand that even with that increase they still have a good job market. But they do have other problems to be concerned about (private equity and midlevel encroachment).

Interestingly, over on the derm forum they also worry that many other specialties are trying to get in on the cosmetics action and making it a much more competitive market.

 

[medgator]

Wow this is great, thank you. Interesting to see the #s for other specialties compared to us. Kind of deflates this myth that derm has controlled their #s. I think there was just so much pent up demand that even with that increase they still have a good job market. But they do have other problems to be concerned about (private equity and midlevel encroachment).

Interestingly, over on the derm forum they also worry that many other specialties are trying to get in on the cosmetics action and making it a much more competitive market.

Amazing to think that our sister specialty, DR, is barely up from their 1995 slot level. I think RO would be in a much better place if that were similar for us today.

The mid 90s was a bad time for the RO job market and the specialty made efforts to address it during that decade.

As for derm, I know that's been a growth industry in my neck of the woods, being in a sunbelt state vs the hypofx happening in our field. Tons of skin ca as the boomer generation continues to age.

The NP/PAs being used here are basically to help staff satellites in larger pp, while the physicians basically travel to do things like mohs/surgeries

 

[evilbooyaa]

How have they figured out how to regulate? Do you have articles, info etc?

Please share this is vital to the discussion

It's likely a behind closed doors agreement. Also, the chairmen/women of Derm/Urology aren't interested in mortgaging the future for temporary monetary gain. I'm not entirely sure on case minimums for residency (especially for Derm) but some of Urology's are pretty high based on frequency of a procedure.

EDIT - Nevermind, appreciate the insight from @DoctwoB

Increasing case minimums significantly across the board is the way to go, IMO. Let's follow the Urology path.

 

[evilbooyaa]

I’m hoping people in leadership can continue to improve our case requirements. I was glad the proposed changes a few months ago were seen by everyone including ADROP as weak. Funny just looked at twitter and saw this:

Whole heartedly agree with Kenneth Olivier.

Segmented requirements for treatment of all sites of disease are desperately needed. Definitive treatment minimums are required.

 

[medgator]

Whole heartedly agree with Kenneth Olivier.

Segmented requirements for treatment of all sites of disease are desperately needed. Definitive treatment minimums are required.

I always thought it was crazy how a program could meet their caseload with a ton of palliative cases without any upper threshold on them

 

[Krukenberg]

Whole heartedly agree with Kenneth Olivier.

Segmented requirements for treatment of all sites of disease are desperately needed. Definitive treatment minimums are required.

+1. Have talked to faculty who have done visiting professorships and are really surprised at how poor some programs’ training in more complex disease sites is.

 

[xrthopeful]

At the bare minimum:

1) freeze on allowing new programs to open

2) increasing the requirements of a program, but grandfathering the ones that are currently open that wouldn’t meet some of the tougher requirements so that people don’t see this as a backwards way of closing down small programs which although I am fine with because that’s one way to reduce the number of slots, that would be political nightmare, and when this idea came up before on this forum people screamed bloody murder. This would make it difficult for programs to expand.

 

[medgator]

At the bare minimum:

1) freeze on allowing new programs to open

2) increasing the requirements of a program, but grandfathering the ones that are currently open that wouldn’t meet some of the tougher requirements so that people don’t see this as a backwards way of closing down small programs which although I am fine with because that’s one way to reduce the number of slots, that would be political nightmare, and when this idea came up before on this forum people screamed bloody murder. This would make it difficult for programs to expand.

Most of us would be fine closing smaller/community programs I would think. There are a lot of spots to address, I think going in the other direction a little too much would be ok given that we have been oversupplied for a few years now

 

[bluebubbles]

Close programs that can’t meet higher case minimums, big or small. Downsize big programs. 600 definitive external cases, at least 5x increase in interstitial brachytherapy and SBRT minimums to 25 and 50, respectively, double the intracavitary and SRS minimums with cap on cylinders. Help current residents at those programs to meet case minimums by arranging rotations at more robust programs. Halt acceptance of new residents at those programs, however, and once current residents have graduated, shut them down. Halt program expansion across the board while we grapple with the existential crisis of having 50% of program spots go unfilled in 2019-2020 NRMP, pre-SOAP.

I have full confidence that RRC can update requirements of training programs to reflect current practice patterns and accepted standards of care, while increasing the quality of training programs & their graduates.

 

[xrthopeful]

Wasn’t 50 percent. But agree

Edit: you’re guessing for 2020 match, never mind. My mistake

 

[medgator]

Halt program expansion across the board while we grapple with the existential crisis of having 50% of program spots go unfilled in 2019-2020 NRMP, pre-SOAP.

Your best guess for next year's match? At 190-200 spots, I would imagine it could get close to that

 

[GapCalc]

I have heard the proposed changes made by RRC are being, uh, strongly opposed, by many academicians. I would be very surprised if the changes don’t end up very watered down. I do not think there will end up being any real downward change in residency slots as a result of the proposed changes. Just my opinion, though.

 

[xrthopeful]

Yeah the proposed changes were trash

 

[Neuronix]

I have heard the proposed changes made by RRC are being, uh, strongly opposed, by many academicians. I would be very surprised if the changes don’t end up very watered down. I do not think there will end up being any real downward change in residency slots as a result of the proposed changes. Just my opinion, though.

100% agreed and posted the same in the past. Anytime there is a meaningful proposal it gets shot down or watered down. There is no will to fix this outside of the "malcontents" of SDN.

Your best guess for next year's match? At 190-200 spots, I would imagine it could get close to that

I'm not sure that a horrible match will fix anything though. Look at pathology last year...

601 positions offered, 216 US Applicants, 33% of positions filled by US seniors, 95% filled (62% non-US seniors).

So if there's no will to fix this (and so far there isn't), that's probably our future. Unless we get to how radiology was in the 00s and even the non-US seniors won't do it, which is unlikely considering how many unemployed US Caribbean and DO grads there are these days and a shortage of residency positions overall.


PS: No idea what xrthopeful means in the post below. I did post on this in the past (as I noted in this post), and I'm just re-iterating.

 

[xrthopeful]

For someone in academics Neuronix seems way behind the times.

The proposed RRC changes were incredibly weak and pointless and did nothing to improve the field or curb expansion. They opened themselves up for Public comments and were clearly soundly shut down. Pretty sure this was even discussed here at that time.

 

[Krukenberg]

Most of us would be fine closing smaller/community programs I would think. There are a lot of spots to address, I think going in the other direction a little too much would be ok given that we have been oversupplied for a few years now

I think when the RRC changes were proposed the same SDN posters who are most vocal about expansion were upset at smaller programs being targeted

 

[xrthopeful]

The RRC proposed changes honestly weren't even strong enough to attempt to close smaller programs down. Changing interstital brachy requirements from 5 to 7 for example does nothing.

I think the smaller program thing came up more often regarding the physics/rad bio stats that ABR presented that suggested that smaller programs did worse, though most agree that's spurious at best.

In general though, there would be a big outcry of 'elitism' by many if smaller programs were somehow targeted, which is partly why that will never happen. Best to hope for is a freeze. Let the population growth catch up.

 

[Krukenberg]

The RRC proposed changes honestly weren't even strong enough to attempt to close smaller programs down. Changing interstital brachy requirements from 5 to 7 for example does nothing.

I think the smaller program thing came up more often regarding the physics/rad bio stats that ABR presented that suggested that smaller programs did worse, though most agree that's spurious at best.

In general though, there would be a big outcry of 'elitism' by many if smaller programs were somehow targeted, which is partly why that will never happen. Best to hope for is a freeze. Let the population growth catch up.

Wasn’t there a proposal that minimum program size would be 6?

 

[xrthopeful]

Oh you are right I forgot about that. Yes you’re right some people didn’t like that here.

But that was partly because people worried it would be impetus to expand.
Others had an issue with the idea that program size matters.

To me it’s clear that program size matters. Smaller programs are at disadvantages. Of course people at small programs can do well, but for multiple reasons the deck is stacked against them from the start. They’re needed in clinic more, fewer attendings go uncovered, tougher time on the job hunt, less chance of having protected time for research or boards studying, needing to stay in clinic when visiting professors come, etc.


Personally I think a limit on program size was one of the few good things the RRC suggested. It would at least raise the barrier to entry for a new program

 

[medgator]

Best to hope for is a freeze. Let the population growth catch up.

We are well beyond that point. If we kept existing slots at 2007 levels, hypofx/surveillance/sbrt would have canceled out pop growth right there

 

[xrthopeful]

We are well beyond that point. If we kept existing slots at 2007 levels, hypofx/surveillance/sbrt would have canceled out pop growth right there

Well yeah but it’s sort of like gun control. Probably the best you can do is a freeze. Places arent going to give up approved residency slots unless you take them from their dead fingers. And the overall numbers we are talking about are too small too. Like maybe in another field you can say ‘every program has to give up one spot per year’ to try and be fair about it but then in rad onc that would be too many probably.

 

[xrthopeful]

I do think one good thing is it’s been three years or so since a new program has popped up (I think?). And since that time Drexel, CPMC, and Texas A&M have shut down

Probably easier to close programs down then make existing ones contract

 

[deleted774703]

When did Texas AM shut down? They are still listed is open on ACGME and their website.

 

[GapCalc]

Regarding the OP (ASTRO panel). Let us take a look at the invited speakers:

Dr. Royce: co-author on the (infamous) paper with an 8% response rate that discussed the impact of SDN/the Google doc. Expectation: repetition of the party line (i.e. “nothing we can do because anti-trust).

Dr. Falit: co-author of very reasonable work force papers published in 2016 (here and here). Fled to Hawaii, hasn’t been heard from since (probably enjoying that aloha lifestyle). Expectation: will speak freely, because he’s in HI and probably DGAF.

Dr. Lee: famous (or at least SDN famous) for suggesting, along with Dr. Amdur, that the ABR exams might not actually be minimal competency exams. Expectation: will gracefully avoid stepping on toes while supporting residency contraction.

Dr. Vapiwala: RCC member and incoming ASTRO big wig (treasurer?). Expectation: pleasant, but won’t suggest that anyone can actually do anything due to “anti trust.”

Dr. Steinberg: UCLA chair, 21CO affiliations, hopelessly conflicted. Expectation: “there isn’t a problem, network more”

All in all, I look forward to an interesting panel. I plan on sitting close to the mics so I can offer my sardonic commentary.

ASTRO meet up?

 

[PointA]

Dr Falit is a lawyer and an advocate of the “anti-trust” argument. I feel like we are going in circles and we can’t even modernize our residency case requirements. I wish I could be more optimistic.

 

[seper]

It'll take a while for the RadOnc match to get to Path status (geez!) and to start people in charge thinking.

 

[xrthopeful]

Look, I mean both can be true - that they can't write anything strict into law about capping spots because of anti-trust law (same reason no one else in any other field can or has done that) but also find backward loophole ways into limiting expansion and spots. I think that is possible in tightening requirements.

I think/hope there are people who are creative to think about this, like some of the ideas that have come up here on SDN. A lot of good discussion came out on social media in response to the WEAK RRC propositions as well.

It's silly to just write off 'anti-trust' because if we are going to talk about real things that can be done in the real world, this matters.

This is the difference between us posting on a board and someone actually trying to improve things.

 

[bluebubbles]

This seminar is run by ARRO. ARRO is run by residents. Why did residents invite these very nice, very forward-thinking, very well-meaning people?

 

[thecarbonionangle]

This seminar is run by ARRO. ARRO is run by residents. Why did residents invite these very nice, very forward-thinking, very well-meaning people?

The best people, very good people.

 

[radoncgrad2019]

I'll wait and reserve judgement on how the discussion goes. For one thing, one of GapCalc's summaries/expectations is dead wrong, which I know for a fact, ha. I'm glad ARRO decided on this as one of their panels, and glad these people agreed to participate. It's a open forum for anyone to ask questions. Hopefully current residents will report back on how it went down.

Beware judging opinions or biases of someone just based on a blurb. One could google some of the prolific posters here and come to some potentially unfair judgements as well, right?

 

[medgator]

Beware judging opinions or biases of someone just based on a blurb. One could google some of the prolific posters here and come to some potentially unfair judgements as well, right?

Definitely.... All of us who graduated a nearly a decade+ ago just can't wait to get our new grads even cheaper thanks to residency expansion.... Oh wait.

 

[fiji128]

Close programs that can’t meet higher case minimums, big or small. Downsize big programs. 600 definitive external cases, at least 5x increase in interstitial brachytherapy and SBRT minimums to 25 and 50, respectively, double the intracavitary and SRS minimums with cap on cylinders. Help current residents at those programs to meet case minimums by arranging rotations at more robust programs. Halt acceptance of new residents at those programs, however, and once current residents have graduated, shut them down. Halt program expansion across the board while we grapple with the existential crisis of having 50% of program spots go unfilled in 2019-2020 NRMP, pre-SOAP.

I have full confidence that RRC can update requirements of training programs to reflect current practice patterns and accepted standards of care, while increasing the quality of training programs & their graduates.

This seems more then obvious.

"Have talked to faculty who have done visiting professorships and are really surprised at how poor some programs’ training in more complex disease sites is."

I know this to be 100% true from personal experience.

 

[evilbooyaa]

Oh you are right I forgot about that. Yes you’re right some people didn’t like that here.

But that was partly because people worried it would be impetus to expand.
Others had an issue with the idea that program size matters.

To me it’s clear that program size matters. Smaller programs are at disadvantages. Of course people at small programs can do well, but for multiple reasons the deck is stacked against them from the start. They’re needed in clinic more, fewer attendings go uncovered, tougher time on the job hunt, less chance of having protected time for research or boards studying, needing to stay in clinic when visiting professors come, etc.


Personally I think a limit on program size was one of the few good things the RRC suggested. It would at least raise the barrier to entry for a new program

There is ZERO evidence in support of any of this. Why not just increase requirements across the board (completely agree with @bluebubbles) and let the chips fall where they may?

A good, small (6 or less, for the sake of example) program, that has residents for educational and research purposes and NOT for scut, with attendings capable of running their own services, will have residents more than capable of standing toe to toe with 'larger' programs.

Does this mean all small programs are great and big programs are evil? No, of course not.

Judge a program not by the number of residents within it, but by the quality of the education that those residents receive, IMO.