Patterns and perceptions of “away” rotations among radiation oncology residency applicants

Abstract

Purpose/Objectives

Medical students often complete clinical rotations at other institutions (“away rotations”). This study assesses the number of away rotations undertaken by radiation oncology residency applicants, and their value from the applicants’ perspective.

Materials/Methods

A survey was sent to applicants to a single radiation oncology program from 2015–2017. Questions addressed away rotation frequency, funding, motivations, barriers, and match results. A Chi-square test was used to assess the correlation between number of away rotations and matching to an away program. Binary logistic regression was used to assess factors associated with undertaking >2 away rotations.

Results

The response rate was 39% (n=194); 89% of respondents completed ≥1 away rotation (median 2, IQR 2–3), of which 39% (n=67) matched to an away program. The number of away rotations completed did not differ between those who did and did not match (p=0.29). Also, the number of away rotations did not correlate with matching at an away program (p=0.40). Factors associated with completing more away rotations included male gender and high loan burden (p<0.05). Away rotations were perceived as extremely important (71%), with interest in a specific program (44%) and obtaining letters of recommendation (31%) the most common reasons to pursue away rotations. Only 9% (n=15) of applicants did away rotations because they had no home program. Funding sources included personal savings (29%), family support (26%), and loans (22%). If costs were inconsequential, 67 applicants (35%) noted they would do more away rotations.

Conclusions

Away rotations are common and often result in students matching to an away program, though benefit to ≥2 away rotations appears limited and has associated costs. Limiting the number of away rotations in radiation oncology may decrease costs without sacrificing one’s chances of matching.

Introduction

Residency applicants often perform visiting (“away”) rotations at programs outside of their home medical school. Though the nominal purpose of such rotations is educational, they are increasingly undertaken as “auditions” for residency programs. In a survey of all U.S. applicants to residency programs from 2014–2015, radiation oncology applicants completed the highest number of away rotations (mean 2.4)(1). A survey of applicants to a single radiation oncology program during the 2012–2013 academic year found that a median of three rotations in radiation oncology were completed(2). Away rotations entail financial costs(1), as well as educational opportunity costs, as elective time is limited during medical school(3). Previously published data suggest that while a single radiation oncology rotation improves medical student knowledge, additional rotations have diminishing educational returns(4). We sought to understand the value and barriers of away rotations from the applicants’ perspective.

Methods

An anonymous online survey was created and distributed to applicants to a single radiation oncology program from 2015–2017 (Appendix A). The survey was sent on March 27, 2018, following release of the 2017 match results. Detailed methods and results of a separate analysis were previously reported(5). Eight survey questions addressed away rotations, which were defined as any clinical rotation in radiation oncology outside of one’s home institution. All data were collected through Research Electronic Data Capture (RedCap).

Descriptive statistics were collected for all survey variables. Continuous variables were compared using a Mann-Whitney U test. A Kruskal-Wallis Chi-square test was used to determine if the number of away rotations correlated with matching at a program the student visited. Binary univariable and multivariable logistic regression was performed to determine factors associated with completing more away rotations. Age and loan burden were categorized based on the median. Statistical calculations were performed using R 3.6.1 (The R Foundation, Vienna, Austria) using a p value <0.05 for statistical significance. The Institutional Review Board deemed this study exempt.

Results

The survey was sent to 497 applicants, of which 39% (n=194) responded. Complete baseline characteristics are outlined in Table 1

Table 1.

Characteristics of survey respondents

Characteristic	Response n (%)
Sex
Female	60 (32%)
Male	133 (68%)
Prefer not to answer	1 (1%)
Marital status
Married	72 (37%)
Single	122 (63%)
Dependents
Yes	29 (15%)
No	164 (85%)
Other degrees
None	125 (64%)
PhD or equivalent	34 (18%)
MPH/MBA/MS	34 (18%)
JD	1 (1%)
Research year outside of MD/PhD
Yes	53 (27%)
No	141 (73%)
Financial aid loan burden
$0	51 (30%)
$1-$49,999	9 (5%)
$50,000-$99,999	10 (6%)
$ 100,000-$ 149,999	21 (12%)
$ 150,000-$199,999	18 (11%)
$200,000-$249,999	28 (16%)
$250,000+	32 (19%)

Number of away rotations and match results

The majority (89%) of respondents performed ≥1 away rotation. The median number of away rotations per applicant was 2 (IQR 2–3). Applicants without a home program completed an average of one additional away rotation (median 3 vs. 2, Mann-Whitney U p<0.01).

Among all respondents, the overall match rate was 93%. On univariable logistic regression, completing ≥1 away rotation did not correlate with matching (p=0.61). There was no difference in the number of away rotations completed between applicants that did and did not match (median 2 vs 2, Mann-Whitney U p=0.29).

Among respondents who completed ≥1 away rotation, 39% reported matching at a program where they rotated. The proportion of applicants that matched at a program where they completed an away rotation did not correlate with their total number of away rotations; 40%, 36%, 47%, and 25% for 1, 2, 3, and 4 away rotations, respectively (Kruskal-Wallis Chi-square=2.93, p=0.40) (Figure 1). A PhD (Kruskal-Wallis Chi-square=1.16, p=0.28), research year (Kruskal-Wallis Chi-square=0.02, p=0.88), and number of publications (Mann-Whitney U p=0.428) did not correlated with likelihood to match at a program where the applicant completed an away rotation.

Figure 1. Distribution of the number of away rotations completed by survey respondents, and the number of respondents matching at a program based on the number of rotations completed.

Among all respondents, on univariable analysis, factors associated with completion of >2 away rotations included male gender (OR=2.11, p=0.04) and a loan burden of over $100,000 (OR=2.59, p<0.01) (Table 2). Inclusion of all factors in a multivariable analysis confirmed these findings (Table 2).

Table 2.

Factors associated with completion of more than 2 away rotations

Characteristic	More than 2 rotations		Univariable analysis	P value	Multivariable analysis	P value
	Yes	No	OR (95% CI)		OR (95% CI)
Age
> 28 years	59	34	1 [Reference]		1 [Reference]
≤ 28 years	68	33	1.19 (0.66–2.15)	0.57	1.57 (0.77–3.18)	0.21
Gender
Female	48	15	1 [Reference]		1 [Reference]
Male	81	51	2.11 (1.06–4.22)	0.04	2.37 (1.14–4.95)	0.02
Marital status
Single	82	40	1 [Reference]		1 [Reference]
Married	44	28	1.35 (0.74–2.49)	0.33	1.48 (0.68–3.18)	0.32
Dependents
No	107	58	1 [Reference]		1 [Reference]
Yes	19	10	1.00 (0.44–2.29)	1.0	0.74 (0.25–2.18)	0.58
Loan burden
< $100,000	86	30	1 [Reference]		1 [Reference]
> $100,000	40	38 ^	2.59 (1.41–4.75)	<0.01	2.27 (1.16–4.44)	0.02
Research Year
Yes	37	16	1 [Reference]		1 [Reference]
No	89	52	1.31 (0.66–2.59)	0.44	1.71 (0.81–2.60)	0.16
PhD
Yes	27	7	1 [Reference]		1 [Reference]
No	99	61	2.31 (0.95–5.64)	0.07	2.77 (0.94–8.17)	0.06

Motivations to pursue away rotations

Motivations for doing away rotations were queried in part based on reasons described by Halperin et al (3). Table 3 depicts survey questions and results. The majority (72%) of respondents deemed away rotations “extremely important” for matching in radiation oncology; only 8% (n=15) felt they were “unimportant.” Most (56%) felt the optimal number of away rotations was 2, while an additional 28% reported a perceived benefit to performing 3 away rotations. The most common motivators for undertaking away rotations were an interest in a specific residency program (44%) and to acquire letters of recommendation (31%). Only 15 applicants (9%) reported that their primary motivation for doing an away rotation was lack of a home program. Among the 22 applicants who did not do an away rotation, 11 (50%) believed that they would not improve their likelihood of matching.

Table 3.

Away Rotation Survey Response Frequencies

Question	Response # (%)
How important is it for a radiation oncology applicant to do away rotations?	(n=194)
Extremely important	137 (71%)
Important	42 (22%)
Not very important	13 (7%)
Not at all important	2 (1%)
What was your primary motivation for doing away rotations?	(n=172)
Interested in specific residency programs	76 (44%)
Acquire letters of recommendation	53 (31%)
Confirm my commitment to radiation oncology	15 (9%)
Family/personal connection to away program/city	12 (7%)
Did not have a home program	15 (9%)
Other - To compare to home program.	1 (1%)
What choice best describes why you chose not to do away rotations?	(n=22)
No specific program(s) of interest	4 (18%)
Would not increase chances of matching	11 (50%)
Cost of room and board	1 (5%)
Personal/family responsibilities at home	3 (14%)
Not available/ not accepted	3 (14%)
No specific program(s) of interest	4 (18%)
What do you consider to be the optimal number of away rotations for a radiation oncology applicant?	(n=192)
0 (None)	7 (4%)
1 rotation	18 (9%)
2 rotations	109 (56%)
3 rotations	54 (28%)
4+ rotations	6 (3%)
How did you primarily cover the housing expenses of away rotations?	(n=172)
No extra costs incurred	41 (24%)
Personal savings	50 (29%)
Family support	44 (26%)
Additional loans	37 (22%)
If costs were not a concern, would you have done more away rotations?	(n=194)
Yes	67 (35%)
No	127 (65%)

Costs and other barriers

Among applicants who completed an away rotation, most used personal savings (29%), family support (26%), or loans (22%) to fund away rotations. Barriers were cited by 32% of the applicants who did complete an away rotation; barriers included cost (5%), family responsibilities (14%), and unavailability of rotations (14%). Nonetheless, 35% of all respondents reported that if cost was negligible, they would have pursued more away rotations. Several respondents noted in free-text comments that rotation-scheduling conflicts were a barrier (Appendix B).

Discussion

This investigation suggests that students are motivated to complete away rotations in radiation oncology in order to match into the specialty, which is consistent with another recent analysis(1). Only 9% of survey respondents cited that lack of a home program was a motivator for completing an away rotation, which is consistent with a prior estimate of 7%(6).

The probability of matching at a program at which the applicant completed an away rotation was fairly high (39%) in this cohort. A survey of all U.S. residency applicants from 2014–2015 reported 46% of radiation oncology applicants matched at a program where they completed either an away or home rotation(1). Another analysis of a publicly-available, self-reported dataset found that 52% of applicants matched at an away or home rotation, with 28% matching at a program where they completed an away rotation (7). Importantly, in our study there was no correlation between the number of away rotations completed and the likelihood of matching at one of those programs. This was independent of applicant strength, based on limited information including number of publications, PhD status, or completion of a research year. This challenges the observed medical student perception that doing more away rotations is superior.

Nonetheless, the high rate of matching at a program where the applicant has rotated suggests a likely continuation of away rotations for purposes of “auditioning.” Performing away rotations entails costs that could deter some applicants, which is particularly concerning in light of ongoing efforts to increase diversity in the specialty(8). The mean cost of a single away rotation was previously estimated at $958(1).We identified several reasons why cost may determine the number of away rotations an applicant completes; many respondents chose to rotate in locations where they would not incur additional costs, required additional funds for rotations, and reported that if cost were negligible, they would do more rotations. Nevertheless, we found that students with a higher loan burden completed more away rotations. We speculate that this may reflect the behavioral economic theory of diminishing sensitivity, in which one’s loss aversion is greater for $110 compared to $100, than $1010 compared to $1000. Alternatively, students with greater loan burden may be motivated to match into a higher-paying specialty.

Solutions to limit the financial burden of away rotations should be considered. Offering shorter (2-week) electives or more flexible scheduling could provide applicants with their desired exposure to residency programs while limiting cost and academic disruption. Given that 31% of applicants pursued an away rotation to get a letter of recommendation, limiting the number of letters from radiation oncologists might reduce time spent on away rotations. Lastly, students should not be penalized by residency programs for rotating at multiple local institutions.

Limitations of these data should be noted, including lack of academic information; students with high STEP 1 scores or Alpha Omega Alpha Honor Society status may complete fewer away rotations, which was previously documented in a survey of orthopedic surgery residency applicants(9). It will be interesting to observe how trends in away rotations evolve after STEP 1 becomes a pass/fail exam in 2022(10). Another change that limits the generalizability of these findings is the recent decline in applicants to radiation oncology residency(11), which could lead to programs favoring rotators to ensure filling slots in the match. We only surveyed applicants to a single radiation oncology program, which might not be fully representative of the total applicant pool. However, the majority of radiation oncology applicants (78% in 2017) applied to our program, so it is likely a representative sample. The response rate (39%) may contribute to response bias. Surveying applicants from 2015–2016 in 2018 may also contribute recall bias. Despite these limitations, our findings are consistent with prior reports (1,7).

Conclusions:

This is the first published investigation regarding away rotation perceptions and barriers among radiation oncology applicants. These data confirm that “audition” rotations are a widespread practice with perceived benefit, but that pursuing multiple away rotations does not necessarily increase the likelihood of matching at all, or at a program the student visits. These results raise questions about whether the expectation to perform away rotations is placing significant financial burdens on applicants, particularly when data is lacking regarding their effectiveness in the match. Broadly, these data could inform a larger discussion in radiation oncology about the purpose of away rotations and how they may detract from the goal of obtaining a well-rounded medical education before residency.