Abstract
Purpose:
To report trends in the number and types of applicants and matched trainees to radiation oncology in comparison to other specialties participating in the National Resident Matching Program (NRMP) between 2010 and 2020.
Methods and Materials:
Data from the NRMP and Electronic Residency Application System (ERAS) were obtained for 18 medical specialties between 2010 and 2020. We assessed the numbers and types of applicants and matched trainees relative to available positions in the NRMP and Supplemental Offer and Acceptance Program (SOAP).
Results:
In the 2020 NRMP, 122 US MD senior graduates preferentially ranked radiation oncology, a significant decrease from a median of 187 between 2010 to 2019 (interquartile range [IQR], 170-192; P < .001). Across all 18 specialties, radiation oncology experienced the greatest declines in the 2020 NRMP cycle relative to 2010 to 2019, in both the number of ERAS applicants from the United States and Canada (−31%) and the percentage of positions filled by US MD or DO senior graduates (−28%). Of 189 available positions, 81% (n = 154) filled in the NRMP prior to the SOAP, of which 65% (n = 122) were “matched” by US MD senior graduates who preferentially ranked radiation oncology as their top choice of specialty, representing a significant decrease from a median of 92% between 2010 to 2019 (IQR, 88%-94%; P = .002). The percentages of radiation oncology programs and positions unfilled in the NRMP prior to the SOAP were significantly increased in 2020 compared with 2010 to 2019 (programs: 29% vs 8% [IQR, 5%-8%; P < .001]; positions: 19% vs 4% [IQR, 2%-4%; P <.001]). Despite >99% (n = 127 of 128) of US MD or DO senior applicants preferring radiation oncology successfully matching to a radiation oncology position in the 2020 NRMP, 16 of 35 remaining unfilled positions were filled via the SOAP. Radiation oncology was the top user of the SOAP across all specialties participating in the 2020 NRMP, filling 15% of total positions versus a median of 0.9% (IQR, 0.3%-2.3%; P <.001).
Conclusions:
The supply of radiation oncology residency positions now far exceeds demand by graduating US medical students. Efforts to nullify a market correction revealed by medical student behavior via continued reliance on the SOAP to fill historical levels of training positions may not be in the best of interest of trainees, individual programs, or the specialty as a whole.
Introduction
For more than a decade, radiation oncology was among the most competitive residency specialties for applicants participating in the National Residency Matching Program (NRMP).1,2 A series of analyses of NRMP data published by Wilson, Haffty, and colleagues1-9 between 2004 and 2015 found that radiation oncology was among only a handful of specialties with a greater number of senior applicants from US allopathic medical schools than available training positions, alongside only dermatology, neurosurgery, orthopedic surgery, otolaryngology, and plastic surgery. Concern regarding the possibility of waning interest among graduating medical students was first described in their 2015 analysis of the NRMP data, based on an appreciable decline in the ratio of applicants to available training positions.1 This trend persisted in the 2016 to 2018 NRMP cycles despite relative stability in the size of the applicant pool, owing primarily to continued increase in the number of accredited training positions.10 This premonition ultimately was realized in the 2019 and 2020 NRMP cycles, when the number of applicants sharply dropped and, for the first time, there was a surplus of radiation oncology residency positions relative to interested applicants.11-13 The result of this imbalance was a large number of training positions left “unmatched” after the initial phase of the NRMP, although a large number were filled in the Supplemental Offer and Acceptance Program (SOAP) immediately following the Match.10,14
The purpose of the present analysis was to assess trends relevant to the numbers and types of applicants and matched trainees for radiation oncology in the context of 18 medical specialties participating in the NRMP between 2010 and 2020.
Methods and Materials
Data sources
Primary data on the residency programs and training positions available, filled, and unfilled in the NRMP and SOAP were obtained for 18 specialties from archived Main Residency Match and Charting Outcomes in the Match reports (2010-2020) published by the NRMP.15,16 The denoted year of the NRMP match cycle refers to the annual March NRMP match event of that year. Radiation oncology programs with NRMP code(s) ending in “430C0” and/or “430A0” and postgraduate year (PGY)-1 and PGY-2 positions were counted. Preferred specialty choice was defined, per NRMP, as the specialty of the applicant’s first-ranked program. Applicant types included US Doctorate of Medicine (MD) senior graduates (applicants graduating the same year as the NRMP cycle), Doctorate of Osteopathic (DO) medicine senior graduates, MD and DO nonsenior graduates (applicants graduating before the current NRMP cycle), and international medical school graduates (IMGs), including those with US citizenship (US IMGs) and without US citizenship (non-US IMGs).
The numbers of applicants that applied through the Electronic Residency Application Service (ERAS) for the 2011 to 2020 NRMP cycles were derived from the 2019 ERAS preliminary report published on December 15, 2019.17 The numbers of applicants who ranked at least one radiation oncology program in the NRMP were derived from Tables 13A-B of the annual NRMP Main Residency Match reports. The preliminary estimate for the number of applicants to radiation oncology for the upcoming 2021 NRMP cycle relative to the previous 5 years (2016-2020) was obtained from the preliminary ERAS report published online on January 13, 2021.17,18
Statistical analysis
Descriptive statistics were used to describe trends in the numbers and types of total and matched applicants, as well as the numbers of programs and positions filled or unfilled in the NRMP and/or SOAP. The Mann-Kendall trend test was used to measure the strength and significance of trends over time. The Wilcoxon signed rank test with continuity correction was used to compare repeated measurements in a single sample. Significance was set for all analyses at P < .05. Statistical analyses and data visualization were performed with R Studio (1.3.959), GraphPad Prism (Version 7.0d), and Tableau (2019.2.13).
Results
Applicants to radiation oncology
There were 161 applicants to radiation oncology from the United States or Canada registered through ERAS for the 2020 NRMP cycle, a 31% decline compared with 2010 to 2019 (median, 233; interquartile range [IQR], 226%-238; P = .002). Other medical specialties, on average, experienced an 18% median increase (IQR, 12%-24%) in the number of applicants over the same period (Fig. E1A; Table E1).
Preliminary numbers published by ERAS reported that as of January 13, 2021, 115 US MD, 18 US DO, and 74 IMG candidates submitted applications for the 180 to 190 anticipated PGY1/2 radiation oncology training positions available in the 2021 NRMP cycle (Fig. 1A).18 Compared with the 5 previous NRMP cycles (2016-2020), 47% fewer US MD graduates submitted an application for a radiation oncology residency position via ERAS (115 vs 215, respectively; IQR, 183-220; Fig. 1A). In contrast, there was an 88% rise in the number of DO and IMG applicants relative to 2016 to 2020 (92 versus 49, respectively; IQR, 46-58). For the 2021 NRMP cycle, radiation oncology training programs received, on average, a total of 98 applications, a 60% decline compared with 2016 to 2020 (149; IQR, 121-49). On average, each radiation oncology program received 59 applications from US MD applicants, a 60% decrease relative to 2016 to 2020 (149; IQR, 121-149; Fig. 1B). In contrast, 40% of the total applications (n = 39 of 98) received by radiation oncology programs for the 2021 NRMP cycle were submitted by DOs and IMGs, a 136% absolute increase in applicants relative to the previous 5 years (median = 16 [IQR, 15-23] of 163 total applications [IQR, 138-172]).
Fig. 1.
Applicants and matched candidates in radiation oncology. (A) Numbers of individuals who submitted applications to radiation oncology programs via ERAS for the 2021 NRMP cycle. (B) Mean numbers of applications received by radiation oncology programs. (C) Numbers and types of applicants who ultimately ranked a radiation oncology program to match with the NRMP, grouped by type of applicant and specialty preference. (D) Numbers of trainees who successfully matched to a radiation oncology program in the NRMP before the SOAP. Subgroup numbers are listed if n ≥ 10. †ERAS data published January 13, 2021, with annual numbers from the 2016 to 2021 NRMP cycles. #Applicant ranking a program in the specialty first on their NRMP rank list. Abbreviations: DO = doctor of osteopathic medicine; ERAS = Electronic Residency Application System; MD = medical doctorate; NRMP = National Residency Matching Program; PGY = postgraduate year; Rad Onc = radiation oncology; SOAP = Supplemental Offer and Acceptance Program.
Characteristics of applicant and matched trainee rankings of radiation oncology in the NRMP
In the 2020 NRMP cycle, 184 applicants included a radiation oncology training program on their NRMP rank list: 128 (70%) were US MD senior graduates, 5 (3%) US DO senior graduates, 7 (4%) US IMGs, 27 (15%) non-US IMGs, and 17 (9%) US MD/DO nonsenior graduates (Fig. 1C; Table 1; Table E3). Of these 184 applicants, 169 (89%) ranked a radiation oncology training program as their first choice (122 US MD senior graduates, 5 US DO senior graduates, 4 US IMGs, 24 non-US IMGs, and 14 US nonsenior graduates), whereas 15 applicants ranked a program from a different specialty as their first choice (6 US MD senior graduates, 3 US IMGs, 3 non-US IMGs, and 3 US nonsenior graduates; Table E4).
Table 1.
Applicants to radiation oncology programs in the National Residency Matching Program, 2010-2020
| NRMP match cycle | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | Median [IQR] | P * |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Residency programs, n (ratio relative to participating in NRMP) | |||||||||||||
| Participating in NRMP | 76 | 79 | 83 | 85 | 84 | 86 | 82 | 88 | 89 | 88 | 84 | 84 [82-88] | 1.00 |
| Filled via NRMP (pre-SOAP) | 70 (0.92) | 73 (0.92) | 82 (0.99) | 78 (0.92) | 80 (0.95) | 79 (0.92) | 81 (0.99) | 84 (0.95) | 83 (0.93) | 66 (0.75) | 60 (0.71) | 0.93 [0.92-0.95] | .002 |
| Unfilled (pre-SOAP) | 6 (0.08) | 6 (0.08) | 1 (0.01) | 7 (0.08) | 4 (0.05) | 7 (0.08) | 1 (0.01) | 4 (0.05) | 6 (0.07) | 22 (0.25) | 24 (0.29) | 0.08 [0.05-0.08] | .002 |
| Filled via SOAP | 0 (0) | 0 (0) | 0 (0) | 5 (0.06) | 1 (0.01) | 4 (0.05) | 0 (0) | 4 (0.05) | 5 (0.06) | 14 (0.16) | 16 (0.19) | 0.03 [0.0-0.06] | .002 |
| Filled (NRMP or SOAP) | 70 (0.92) | 73 (0.92) | 82 (0.99) | 83 (0.98) | 82 (0.98) | 82 (0.95) | 81 (0.99) | 87 (0.99) | 89 (1.00) | 80 (0.91) | 76 (0.90) | 0.98 [0.93-0.99] | .002 |
| Unfilled post-SOAP | 6 (0.08) | 6 (0.08) | 1 (0.01) | 2 (0.02) | 3 (0.04) | 3 (0.04) | 1 (0.01) | 0 (0) | 1 (0.01) | 8 (0.09) | 8 (0.10) | 0.03 [0.01-0.07] | .002 |
| Training positions, n (ratio relative to available in NRMP) | |||||||||||||
| Available in NRMP (PGY1/2) | 157 | 171 | 171 | 183 | 179 | 193 | 183 | 193 | 193 | 207 | 189 | 183 [173-193] | .75 |
| Filled via NRMP (pre-SOAP) | 150 (0.96) | 165 (0.96) | 170 (0.99) | 176 (0.96) | 175 (0.98) | 185 (0.96) | 182 (0.99) | 189 (0.98) | 187 (0.97) | 177 (0.86) | 154 (0.81) | 0.97 [0.96-0.98] | .002 |
| Unfilled (pre-SOAP) | 7 (0.05) | 6 (0.04) | 1 (<0.01) | 7 (0.04) | 4 (0.02) | 8 (0.04) | 1 (<0.01) | 4 (0.02) | 6 (0.03) | 30 (0.15) | 35 (0.19) | 0.04 [0.02-0.04] | .002 |
| Filled via SOAP | 0 (0) | 0 (0) | 0 (0) | 5 (0.03) | 1 (<0.01) | 5 (0.03) | 0 (0) | 4 (0.02) | 5 (0.03) | 19 (0.09) | 27 (0.14) | 0.02 [0.0-0.03] | .002 |
| Filled (NRMP or SOAP) | 150 (0.96) | 165 (0.96) | 170 (0.99) | 181 (0.99) | 176 (0.98) | 190 (0.98) | 182 (0.99) | 193 (1.00) | 192 (0.99) | 196 (0.95) | 181 (0.96) | 0.99 [0.97-0.99] | .34 |
| Unfilled post-SOAP | 7 (0.05) | 6 (0.04) | 1 (<0.01) | 2 (0.01) | 3 (0.02) | 3 (0.02) | 1 (<0.01) | 0 (0) | 1 (<0.01) | 11 (0.05) | 8 (0.04) | 0.02 [0.01-0.04] | .02 |
| Applicants (NRMP), n (ratio relative to positions available) | |||||||||||||
| All applicants | |||||||||||||
| Total | 213 (1.36) | 225 (1.32) | 257 (1.51) | 217 (1.19) | 227 (1.27) | 238 (1.23) | 228 (1.25) | 238 (1.23) | 223 (1.16) | 194 (0.94) | 184 (0.97) | 1.24 [1.20-1.31] | .003 |
| US MD seniors | 174 (1.11) | 186 (1.09) | 222 (1.30) | 171 (0.93) | 195 (1.09) | 197 (1.02) | 191 (1.04) | 205 (1.06) | 194 (1.01) | 163 (0.79) | 128 (0.68) | 1.05 [1.01-1.09] | .002 |
| Non-US MD seniors | 39 (0.25) | 39 (0.23) | 36 (0.21) | 46 (0.26) | 32 (0.18) | 41 (0.21) | 37 (0.20) | 33 (0.17) | 29 (0.15) | 31 (0.15) | 56 (0.30) | 0.20 [0.17-0.23] | <.001 |
| Radiation oncology preferred specialty | |||||||||||||
| Total | 201 (1.28) | 213 (1.25) | 247 (1.44) | 204 (1.11) | 215 (1.20) | 228 (1.18) | 218 (1.19) | 223 (1.16) | 215 (1.11) | 184 (0.89) | 169† (0.89) | 1.19 [1.12-1.23] | <.001 |
| US MD seniors | 163 (1.04) | 181 (1.06) | 217 (1.27) | 166 (0.91) | 188 (1.05) | 192 (0.99) | 186 (1.02) | 196 (1.02) | 190 (0.98) | 160 (0.77) | 122‡ (0.65) | 1.02 [0.99-1.05] | <.001 |
| Non-US MD seniors | 29 (0.18) | 32 (0.19) | 30 (0.18) | 38 (0.21) | 27 (0.15) | 36 (0.19) | 32 (0.17) | 27 (0.14) | 25 (0.13) | 24 (0.12) | 47 (0.25) | 0.18 [0.14-0.19] | <.001 |
| All PGY1/2 matched trainees (pre-SOAP), n (ratio relative to positions available) | |||||||||||||
| Total | 150 (0.96) | 165 (0.96) | 170 (0.99) | 176 (0.96) | 175 (0.98) | 185 (0.96) | 182 (0.99) | 189 (0.98) | 187 (0.97) | 177 (0.86) | 154 (0.81) | 0.97 [0.96-0.98] | <.001 |
| US MD Seniors | 137 (0.87) | 155 (0.91) | 168 (0.98) | 151 (0.83) | 169 (0.94) | 179 (0.93) | 169 (0.92) | 180 (0.98) | 177 (0.92) | 160 (0.77) | 122‡ (0.65) | 0.92 [0.88-0.94] | .002 |
| Non-US MD Seniors | 13 (0.08) | 10 (0.06) | 2 (0.01) | 25 (0.14) | 6 (0.03) | 6 (0.03) | 13 (0.07) | 9 (0.05) | 10 (0.05) | 17 (0.08) | 32 (0.17) | 0.06 [0.04-0.08] | <.001 |
Abbreviations: IQR = interquartile range; MD = medical doctorate; NRMP = National Residency Matching Program; PGY = postgraduate year; SOAP = Supplemental Offer and Acceptance Program.
P value determined by Wilcoxon signed rank test with continuity correction, 2020 versus 2010 to 2019.
Data are as reported from “Charting outcomes in the match (2020): Senior students of US MD Medical Schools (2nd Edition).”16
There were 122 US MD senior graduates and 5 US DO senior graduates participating in the NRMP who preferred radiation oncology as their choice of specialty. Of these, 121 US MD senior graduates and 5 US DO senior graduates successfully matched to a radiation oncology program prior to the SOAP. Of 6 US MD senior graduates who applied to radiation oncology as their non-preferred specialty, 1 matched to a radiation oncology program prior to the SOAP.
Although medical specialties on average experienced a 10% increase in the number of US MD senior graduates who ranked their respective specialty as the preferred choice for the 2020 NRMP compared with the previous decade, radiation oncology experienced the greatest relative decrease across all specialties in the number of applicants ranking it as their top choice of specialty (Fig. 2A). Compared with 2010 to 2019, 35% fewer US MD senior graduates ranked radiation oncology as their preferred specialty for the 2020 NRMP (122 vs median of 187; IQR, 170-192; P < .001; Table 1; Table E5). Relative to the number of available PGY1/2 positions, the number of US MD senior graduate applicants ranking a radiation oncology program as their first choice peaked in 2012, when 217 individuals graduating from allopathic US medical schools applied for 171 PGY1/2 positions (ratio = 1.27; Table 1). In 2020, 122 US MD senior graduates applied for 189 radiation oncology training positions, representing a 36% relative decrease in the median ratio of US MD senior graduate applicants to available positions from 2010 to 2019 (0.65 vs 1.02, respectively; IQR, 0.99-1.05; P < .001). Among all evaluated specialties, in comparison to the previous decade, radiation oncology experienced the greatest relative decrease in 2020 in the number of US MD senior graduate applicants preferring the specialty relative to the number of available positions (Fig. 2B; Table E6). In contrast, 56 applicants other than US MD senior graduates ranked a radiation oncology program in the 2020 NRMP, a significant increase relative to the number of available PGY1/2 positions between 2010 and 2019 (30% vs 21%, respectively; IQR, 17%-23%; P < .001).
Fig. 2.
Numbers of United States senior medical graduate applicants across specialties. (A) Relative change in the number of United States senior medical graduates ranking a specialty “first” in the 2020 NRMP versus the median between 2010 and 2019. (B) Relative change in the ratio of US senior medical graduates ranking a specialty “first” relative to the number of available PGY1/2 positions in each specialty in the 2020 NRMP versus the median between 2010 to 2019. Abbreviations: MD = medical doctorate; Med = medicine; NRMP = National Residency Matching Program; OB/GYN = obstetrics and gynecology; PGY = postgraduate year; PM&R = physical medicine and rehabilitation.
Of the 189 PGY1/2 positions available in the 2020 NRMP, 122 (65%) were filled by US MD senior graduates who preferred radiation oncology as their top of choice of specialty, a significant decrease from the previous decade (92%; IQR, 88%-94%; P = .002; Fig. 1D). In contrast, 32 positions (17%) were filled by applicants other than US MD senior graduates, a significant increase from the median from 2010 to 2019 (6%; IQR, 4%-8%; Table 1; Fig. 1D; Table E5). Of the 122 US MD senior graduates who ranked radiation oncology as their preferred choice of specialty in 2020, 121 (99%) successfully matched with a radiation oncology program in the NRMP before the SOAP (Fig. 1B; Table E4).16 Of the 45 applicants other than US MD senior graduates who ranked radiation oncology as their preferred choice of specialty, 31 to 34 successfully matched (5 of 5 [100%] US senior DOs, 1 of 4 [25%] US IMGs, 16 of 24 [75%] non-US IMGs, and 9-12 of 17 US nonsenior graduates; Table E4). Of the 28 applicants who did not successfully match into a radiation oncology program before the SOAP, between 14 and 17 had listed radiation oncology as their preferred specialty (1 US MD senior, 3 US IMGs, 8 non-US IMGs, and 2-5 US nonsenior graduates), whereas between 11 and 14 preferred a different specialty (5 US MD senior graduates, 3 US IMGs, 3 non-US IMGs, and 0-3 US nonsenior graduates; Table E4).
Participation in the SOAP
The percentages of programs and positions that did not successfully match with an applicant in the 2020 NRMP before the SOAP significantly increased relative to 2010 to 2019 (programs: 29% vs 8%, respectively [IQR, 5%-8%; P < .001]; positions: 19% vs 4%, respectively [IQR, 2%-4%; P < .001]; Table 1; Tables E7 and E8). Of the 24 programs and 35 positions that did not match in the first phase of the 2020 NRMP before the SOAP, 16 (67%) and 27 (77%) were filled in the SOAP, respectively. Overall, 20% of programs and 15% of positions were filled in the SOAP by applicants who did not match in the NRMP, representing significant increases from the previous decade (programs: 19% vs 3%, respectively [IQR, 0%-6%; P = .005]; positions: 14% vs 2%, respectively [IQR, 0%-3%; P = .002]; Table 1). Only 8 (9.5%) programs and 8 (4.2%) positions remained unfilled after the SOAP (Table 1; Table E7). Compared with the median numbers from 2010 to 2019, there were 6.3-fold and 9.3-fold increases in the numbers of radiation oncology programs and positions, respectively, that relied on the SOAP to fill in the 2020 NRMP cycle. Across all 18 medical specialties, radiation oncology was the specialty with the greatest proportion of programs and positions that filled via the SOAP in both 2019 and 2020, at rates significantly greater than the median across all specialties (P < .001 for all; Table 2).
Table 2.
Residency programs and positions filled via the Supplemental Offer and Acceptance Program, with rates across specialties
| Specialty | Filled via the SOAP | |||
|---|---|---|---|---|
| Programs, n (%)* |
Positions, n (%)* |
|||
| 2019 NRMP | 2020 NRMP | 2019 NRMP | 2020 NRMP | |
| Radiation oncology | 14 (17%)‡ | 16 (20%)‡ | 19 (10%)‡ | 27 (15%)‡ |
| Family medicine† | 87 (14%)§ | 119 (18%)‡ | 238 (6%)‡ | 294 (6%)§ |
| Internal medicine† | 40 (7%) | 47 (8%) | 176 (2%) | 316 (4%) |
| Neurology | 17 (11%)‡ | 12 (7%) | 32 (4%)§ | 21 (2%) |
| Diagnostic radiology | 6 (3%) | 17 (8%) | 10 (<1%) | 25 (2%) |
| Pathology | 11 (7%) | 9 (6%) | 21 (4%)§ | 13 (2%) |
| Pediatrics† | 22 (10%)∥ | 21 (10%)‡ | 60 (2%) | 49 (2%) |
| Dermatology | 2 (1%) | 3 (2%) | 4 (<1%) | 6 (1%) |
| Psychiatry | 3 (3%) | 1 (1%) | 3 (<1%) | 4 (<1%) |
| Physical medicine & rehabilitation | 9 (3%) | 8 (3%) | 15 (<1%) | 16 (<1%) |
| Otolaryngology | 0 (0%) | 2 (2%) | 0 (0%) | 2 (<1%) |
| Orthopedic surgery | 2 (1%) | 4 (2%) | 3 (<1%) | 4 (<1%) |
| Emergency medicine | 12 (5%) | 4 (2%) | 27 (1%) | 10 (<1%) |
| Surgery | 0 (0%) | 4 (1%) | 0 (0%) | 5 (<1%) |
| Obstetrics/gynecology† | 2 (1%) | 2 (<1%) | 3 (<1%) | 3 (<1%) |
| Plastic surgery | 6 (3%) | 0 (0%) | 9 (<1%) | 0 (0%) |
| Neurosurgery | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) |
| Anesthesiology | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) |
| Median percentage [IQR] | 2.9% [0.8-7.4] | 2.0% [1.1-7.9] | 0.9 [0.3-2.2] | 0.9 [0.3-2.3] |
Data show the percentage of residency programs and training positions filled via the SOAP for the 2019 and 2020 NRMP cycles.
Abbreviations: IQR = interquartile range; NRMP = National Residency Matching Program; SOAP = Supplemental Offer and Acceptance Program.
Calculated as the number of programs or positions filled via the SOAP out of those that ultimately were filled via either the NRMP or the SOAP. P values were determined by a Wilcoxon signed rank test with continuity correction.
Categorical, not including combined programs or preliminary/transitional year programs.
P <.001.
P <.01.
P <.05.
Radiation oncology experienced the greatest relative decrease in the percentage of positions that were successfully matched in the 2020 NRMP compared with the previous decade across all 18 specialties (Fig. 3A; Table E9). Specifically, radiation oncology had the greatest relative decrease in the percentage of positions filled by US MD and DO senior graduates in 2020 relative to the previous decade, compared with the other specialties (−28% vs −0.8%, respectively; IQR, −2.8% to 3.9%; P < .001; Fig. 3B; Table E10), and the greatest relative increase in the percentage of positions filled by IMGs (419% vs 9%, respectively; IQR, −20% to 24%; P < .001; Fig. 3C; Table E11). Only 65% of available PGY1/2 training positions in 2020 were successfully filled in the NRMP by US MD senior graduates who had applied to radiation oncology as their preferred specialty.
Fig. 3.
Numbers and types of candidates successfully matching across specialties. Relative change in the percentage of positions filled and the type of matched candidate in the 2020 NRMP prior to the SOAP versus the median between 2010 and 2019. (A) Total filled positions; (B) US MD and DO senior graduates; and (C) international medical graduates. Abbreviations: DO = doctor of osteopathic medicine; MD = medical doctorate; Med = medicine; NRMP = National Residency Matching Program; OB/GYN = obstetrics and gynecology; PM&R = physical medicine and rehabilitation; SOAP = Supplemental Offer and Acceptance Program.
Discussion
In this article, we provide a comprehensive analysis of trends relevant to the recruitment of medical students to radiation oncology in comparison to other medical specialties. Similar analyses of NRMP data have been presented in a series of publications, including recent reports describing changes in applicant numbers and matched trainees in the 2019 and 2020 cycles.2-13 The first such analysis of NRMP data for radiation oncology, published in 2003, was introduced as “a straightforward, descriptive analysis of the NRMP data over the last decade … for informational purposes.”3 With this same intent, we provide an updated report of the 2010 to 2020 NRMP and ERAS data for radiation oncology, with a specific emphasis on how these trends compare with those appreciated by other medical specialties participating in the NRMP.
Among the 18 medical specialties included in these analyses, radiation oncology experienced the greatest relative decrease across a number of measures previously used as an indicator of a specialty’s “competitiveness,” including the percentages of positions filled in the NRMP both overall and by senior US graduates, as well as the calculated ratio of applicants to available positions.1,3 These trends have been driven by a dramatic reduction in the number of applicants from US allopathic medical schools. A similar decrease was not observed regarding the numbers of applicants comprising DO senior graduates, IMGs, and MD/DO nonsenior graduates. Although medical specialties, on average, experienced an approximately 10% increase in the number of US MD senior graduate applicants for the 2020 NRMP cycle relative to the past decade, radiation oncology experienced a 35% decrease.
For both the 2019 and 2020 NRMP cycles there were fewer applicants to radiation oncology programs than available training positions. Based on preliminary ERAS data published in January 2021, there are projected to be even fewer applicants for the 2021 NRMP cycle. The numbers of programs and positions unfilled via the NRMP have demonstrated concomitant increases since 2017; this is a striking change because radiation oncology was considered one of the most competitive residency specialties in 2015.1 Despite being the second smallest specialty of the 18 analyzed, radiation oncology was proportionally the top user of the SOAP over the past 2 years, ultimately filling 20% (n = 16) and 15% (n = 27) of programs and positions in 2020, respectively. Of the 128 US MD or DO graduating seniors who preferentially applied for a radiation oncology training position in the 2020 NRMP, 127 (>99%) were successfully matched to a program in the main match; nevertheless, 16 of these 24 unfilled positions were filled in the SOAP.
These data also demonstrate a demographic shift in the radiation oncology applicant profile over the past decade. Of the 189 available PGY1/2 radiation oncology residency positions in the 2020 NRMP, only 67% (n = 127) were filled by US MD or DO graduating seniors who preferentially applied to radiation oncology. This suggests the emergence of a level of comparative indifference to the field among US medical students currently in training that has not been historically experienced, with critical implications reflective of a specialty transitioning from being highly competitive to less competitive.19 Radiation oncology has been fortunate over the past decade to be the preferred choice of specialty among the most competitive medical students, as defined by routinely reported NRMP metrics.20 Importantly, although the quantity of US MD senior graduates ranking radiation oncology as their specialty of choice has precipitously declined since 2016, their overall quality, as measured by test scores, research experience, graduate degrees, and membership in Alpha Omega Alpha, remained extremely high in the 2018 and 2020 NRMP cycles.13,16,20 Whether radiation oncology will continue to attract the most competitive applicants in upcoming NRMP cycles remains to be seen. Calls for a more holistic review of applicants, with greater emphasis placed on emotional intelligence and potential as an empathetic and competent clinician, are laudable and merit unreserved support, but should be adopted regardless of the relative competitiveness of the applicant pool.21
The presented analyses and discussion are most critically limited by the lack of publicly available data regarding applicant types, preferred specialty choices, and levels of exposure to radiation oncology among the trainees who were offered and accepted a residency position in radiation oncology as a result of the SOAP. Although these numbers can be at least partially deduced (see Table E4), comprehensive data on trends within the SOAP would be helpful for applicants and programs, as well as stakeholders within the specialty. Based on preliminary data published by ERAS in the fall of 2020, we will once again have a surplus of available training positions in the 2021 NRMP cycle relative to applicants who have selected radiation oncology as their preferred choice of specialty. If these same patterns are repeated, many programs will again fill unmatched positions via the SOAP.
Conclusion
There is now a well-documented, sustained surplus of accredited radiation oncology residency positions that increasingly exceeds demand among US senior graduating medical students. This newfound reliance upon the SOAP by radiation oncology residency programs to fill a significant and growing proportion of training positions left unfilled in the Match is not experienced by any other medical specialty participating in the NRMP. Given the lack of meaningful exposure to radiation oncology for the majority of US medical students, offering these positions to graduating seniors who unexpectedly find themselves to have not matched to their preferred specialty, particularly under the artificial time constraints and stress of the SOAP, is ethically questionable. Continued utilization of the SOAP ignores an apparent market correction revealed by waning medical student interest and could confer long-term workforce implications. Our specialty may benefit from a workforce analysis performed by an independent consultant to provide clarity regarding the appreciable supply–demand disparity and its implications for current and future trainees.22 We ask those in leadership positions, particularly those at the individual training program level, to exercise thoughtfulness and restraint if faced with the prospect of unmatched residency positions.
Supplementary Material
Acknowledgments
This manuscript is submitted on behalf of the Association of Residents in Radiation Oncology (ARRO) Executive Committee.
Footnotes
Disclosures: C.D.F. reports grants from the National Institutes of Health during the conduct of the study.
Research data are provided herein and are available in raw format at http://www.nrmp.org/report-archives/ and https://www.aamc.org/eras-statistics-2019.
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijrobp.2021.03.006.
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