Are We Training Too Many Radiologists?

November 20, 2014

With a tight radiology job market, it might be time to reduce the number of radiology residency spots.

With around 1,000 radiologists entering the job market each year, finding jobs is becoming increasingly difficult. Radiologists are worried about the oversaturated imaging market at the same time that the Association of American Medical College (AAMC) is sounding alarms about a physician shortage – for specialists and primary care doctors.

Are residency programs churning out too many radiologists? Are supply/demand dynamics applicable in this imaging job market? And who decides how many residency spots to allow?

The Job Market
From 2001 through 2003, radiology was their most requested specialty, said Tommy Bohannon, divisional vice president of Merritt Hawkins, a physician search firm. That year, Merritt Hawkins was hired to fill 230 radiology jobs. This year? Only 15. And radiology failed to land in the company’s top 20 most recruited specialties for the past several years. While they still fill radiology jobs, the firm closed their division which once searched for the hottest specialists: radiologists, anesthesiologists, and hospitalists.

“It’s tough for radiology,” Bohannon said. Health care organizations are only willing to pay someone to fill positions when they can’t do it on their own, which shows how the recruiting decline is a market barometer.

Radiology Competitiveness
Many in the field express concern that the sluggish job market and decline of radiology residency spot competitiveness will affect the specialty’s applicant quality.

“As a profession, we’re going to need to look at things we can do to improve the job market and outlook for those entering the field, or we’ll lose good quality applicants to other specialties,” said Steven L. Blumer, MD, clinical assistant professor of radiology and pediatrics at Jefferson Medical College and director of residency and fellowship training at Nemours.[[{"type":"media","view_mode":"media_crop","fid":"29654","attributes":{"alt":"competition","class":"media-image media-image-right","id":"media_crop_9237573552574","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3079","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 250px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

With an unfavorable job market that doesn't seem to be improving, some radiology residents are currently circulating a change.org petition to present to the ACR and the Accreditation Council of Graduate Medical Education (ACGME), to ask that the number of radiology training spots be reduced. The concern with this is that it could result in a future radiologist shortage, which is seen right now in England.

“We need to start to address the issue so in the future we can improve the job market,” Blumer said. Dermatology, which many cite as a specialty that does a good job of keping physician demand high by keeping the number of residency spots stable, filled 93% of its residency slots with U.S.-trained aplicants, according to the National Residency Matching Program data.

A recent study published in the JACR defined residency competitiveness by the number of positions per U.S. trained applicant. The article showed that the number of U.S.-educated residents seeking out radiology positions peaked in 2009 and has declined since.

“Although radiology residency positions have continued to increase, interest among U.S. seniors has dropped every year since 2009,” the article states. The void is mostly filled by foreign-trained medical students who are thought by some to be less qualified than U.S.-trained doctors, even though they’ve passed certification and licensing exams through the Educational Commission for Foreign Medical Graduates (ECFMG).

Data from the National Resident Matching Program, from which the JACR numbers were taken, show that the percentage of diagnostic radiology positions filled by U.S.-trained physicians (aka U.S. seniors) was among the lowest in the past 15 years. During the 2014 match, 1,008 positions were offered for PG Year 2 physicians, with 68.9% filled by U.S.-trained graduates, and 94.2% total positions filled. By comparison, in 2010, the percentage of radiology residents and fellows with a U.S. medical degree was 84%.

Oversaturation?
The number of diagnostic radiology residency positions increased by 55% from 1980 to 2007, according to an article in the American Journal of Roentgenology. Work volume was increasing and reimbursement was higher. But then the economy tanked and many doctors delayed retirement. And then came radiology reimbursement cuts. A perceived shortage became a perceived oversupply.

As for job prospects, like the law of supply and demand, fewer jobs means more applicants and a less competitive market. Indeed, radiology salaries and benefits have decreased. In the heyday, salaries were close to $450,000 for recruits, said Bohannon. Now, it’s more like $300,000-$350,000 and salary guarantees and vacation time are also down.

It used to be that radiologists looked for the jobs with the highest pay and most vacation, said Bohannon. Now, they say they don’t care where it is or how much it pays, they just want jobs. Bohannon said he placed a radiologist and a psychiatrist couple this year. They opted to find the radiologist’s job first, since there were so few available. The psychiatrist then took a job making 30% less than she could have made elsewhere, because it was the only location her husband could find work.

Institutions Control Their Residency Positions
Most residency positions are partly supported by the Medicare program through Graduate Medical Education (GME) payments. They’re designed to cover Medicare’s share of the residents’ work for that population, with the rest of the funding coming from the institution’s clinical revenue.

In 1997, Medicare reduced its spending for budgetary reasons, said Christiane Mitchell, the AAMC’s director of federal affairs. This froze the number of residency slots at qualifying hospitals, and is known as the “Medicare Cap.” For a hospital to increase the number of residency positions funded by Medicare, it’s a “zero sum,” situation, she said. New positions need non-Medicare funding, with the teaching hospital often footing the entire bill.

An institution wanting to start a new accredited residency program would apply to the ACGME, and they must demonstrate that they have the equipment, faculty, and curriculum to meet national guidelines.

While they accredit residency programs, “ACGME does not regulate or consider workforce needs due to antitrust regulations,” said Felicia Davis, ACGME’s executive director, residence review committee for diagnostic radiology, emergency medicine, and nuclear medicine, in an email statement. “Additionally, accreditation is voluntary and there is no centralized area or decision made to create “new” residency programs in any specialty. Decisions on whether to start a new residency program and changes in existing program size/capacity are local decisions made by each sponsoring institution.”

If an institution wants to shift the number and residency positions in a particular specialty, they can do so without it affecting their Medicare funding, said Mitchell. But “if you’re over the cap, either you add more training slots and pay for it yourself, or add more slots and you look elsewhere to trim slots,” she said. The Medicare GME money goes to the sponsor, which is usually the teaching hospital, not to the resident.

If an institution wants to decrease the number of radiology residency spots, it could do so, shifting the positions to another specialty program within its hospital, without losing the Medicare funding.