The Impact of Graduates' Job Preferences on the Current Radiation Oncology Job Market

Academic and Geographic Employment Outcomes for Graduating Residents in Radiation Oncology: 2015-2022

PURPOSE

Little is known about how the academic and geographic employment outcomes of new radiation oncology (RO) graduates have changed over time. In this study, we sought to trace the evolution of these outcomes for all RO residents who graduated between 2015 and 2022.

METHODS AND MATERIALS

Using publicly available data sources, we identified the first permanent, clinical employment positions accepted by graduating members of the RO residency classes of 2015 to 2022. We additionally determined the medical school and residency program attended by each graduate. We then classified each clinical employment position by its rural-urban continuum code and core-based statistical area, and whether it was academic or nonacademic.

RESULTS

Of 1478 RO graduates identified, 1396 first accepted clinical positions in the United States after residency. A majority accepted positions in the largest metropolitan areas (N = 878, 62.9%) and in nonacademic settings (N = 719, 51.5%). The proportion of graduates who accepted academic positions climbed steadily from 2015 to 2020 before dropping by 31% in 2021 and partially rebounding in 2022. Women and graduates of large-sized academic programs were more likely to have accepted academic positions. In contrast, graduates of small-sized residency programs were more likely than those of large-sized residency programs to have accepted positions in nonmetropolitan areas. At least 288 of the examined individuals (20.6%) had switched jobs at least once at the time of this analysis.

CONCLUSIONS

Most new RO graduates in this study accepted clinical positions in large metropolitan areas. A slight majority accepted nonacademic positions. While the RO job market was able to absorb the vast majority of these new graduates between 2015 and 2022, there is no guarantee that this equilibrium will hold in the future. Additional studies aiming to refine projections of future RO demand are needed.

Prospective 5-Year Analysis of the United States Radiation Oncology Job Market Using the ASTRO Career Center Website

PURPOSE

We provide 5-year results of prospectively collected radiation oncology (RO) job opportunities and a longitudinal assessment of RO graduate numbers within the United States.

METHODS AND MATERIALS

Full-time domestic RO job opportunities were collected and categorized using the American Society for Radiation Oncology (ASTRO) Career Center from July 1, 2016 to June 30, 2021. A chi-square test was used to compare regional job availability by city size and position type. The corresponding number of graduating United States (US) RO residents (2017-2021) was collected. US census and Medicare database resources were used as comparators for population and workforce estimates. Pearson's correlation coefficients were used to examine changes in data over time and a 2-tailed t test was used to assess for statistical significance.

RESULTS

Over the 5-year study period, 819 unique job offers were posted, compared with 935 RO graduates (0.88 total jobs-to-graduates ratio). Most jobs were nonacademic (57.6%), located in populated areas >1 million (57.1%; median: 1.57M), with the largest proportion of jobs seen in the South region (32.4%). One-third of academic jobs were located at satellites. Regional differences were seen between academic versus nonacademic job availability (P < .01), with the highest proportion of academic jobs seen in the Northeast (60.3%) and the lowest in the Midwest (34.5%). Differences between regions were also observed for jobs in areas >1 million versus ≤1 million (P < .01), with the most jobs in areas >1 million seen in the West (64.6%) and the least in the South (51.3%). Regional job availability over time did not differ by position type (academic vs nonacademic) or population area size (P = .11 and P = .27, respectively). Annual graduate numbers increased with time (P = .02), with the highest percentage of graduates trained in the South (30.8%). Regional distribution of jobs versus graduates significantly differed (P < .01) with the lowest jobs-to-graduates ratio observed in the Northeast (0.67) and highest ratio in the West (1.07). Regional RO workforce estimates based on the 4336 radiation oncologists who were Medicare providers in 2020 were compared with total jobs and graduates by region with no difference observed between the distributions of the workforce and jobs (P = .39), but comparisons between the workforce and graduates were proportionally different (P < .01). The number of total jobs (vs graduates) per 10 million population in the Northeast, South, Midwest, and West were 30.2 (45.1), 21.0 (22.7), 30.6 (33.4), and 22.6 (21.2), respectively.

CONCLUSIONS

This multiyear quantitative assessment of the RO job market and graduates identified fewer job opportunities than graduates overall in most regions, most notably in the Northeast. Regional differences were seen between available job type (academic vs nonacademic) and population size (>1 million vs ≤1 million). The findings are worrisome for trainee oversupply and geographic maldistribution. The number and distribution of RO trainees and residency programs across the US should be evaluated to minimize job market imbalance for future graduates, promote workforce stability, and continue to meet the future societal needs of patients with cancer.

Geographic Employment Outcomes for Graduating Residents in Radiation Oncology: 2021

PURPOSE

In light of the persistent disparity in the prevalence of radiation oncologists between rural and urban areas in the United States, we sought to characterize the geographic employment outcomes of the radiation oncology (RO) residency class of 2021.

METHODS AND MATERIALS

We identified the employment positions accepted by 2021 RO residency graduates using publicly available information. Then, we classified each position as academic or nonacademic and determined the rural-urban continuum code and core-based statistical area (CBSA) of each position, residency program, and medical school associated with the 2021 graduates. Last, we compared the geographic employment outcomes of the 2021 class with those of the 2019 class.

RESULTS

Most 2021 graduates accepted employment positions outside of the counties, CBSAs, and states in which they attended medical school or residency. A total of 116 graduates accepted nonacademic positions, and 65 graduates accepted academic positions. Nine graduates accepted fellowships and were excluded from this analysis. As with the class of 2019, most 2021 graduates (n = 104; 57.5%) accepted positions in the largest metropolitan areas, and few (n = 11; 6.1%) accepted positions in nonmetropolitan areas. Female residents were more likely to accept academic (48.9% vs 31.3%; P = .03) and academic main site (36.2% vs 21.6%; P = .05) positions than male residents. The distribution of jobs in both the 5 and 10 largest CBSAs was not significantly different from what would have been expected if jobs were equally distributed across the country on the basis of population (P = .81 and P = .87, respectively). However, the distribution was significantly different from what would have been expected if the distribution of such positions reflected the number of residents who graduated from residency programs in those CBSAs (P < .01 and P < .01, respectively).

CONCLUSIONS

As with the class of 2019, the majority of graduates in the class of 2021 accepted employment positions in large metropolitan areas. Relatively few graduates accepted positions in nonmetropolitan areas. How key RO stakeholders respond to the challenge of maintaining a stable supply of rural radiation oncologists while also ensuring that jobs available to graduating RO residents reflect their preferences will have a significant effect on the field going forward.

Composition of the Current Academic Radiation Oncology Workforce in Comprehensive Cancer Centers

PURPOSE

The landscape of the profession of academic radiation oncology is constantly changing. We sought to determine the demographic makeup of the current academic radiation oncology workforce.

MATERIALS AND METHODS

Internet web site searches of the 51 National Cancer Institute-designated Comprehensive Cancer Centers (CCCs) were conducted in September 2019. The Scopus database was subsequently searched in December 2019 to ascertain the h-index for each radiation oncologist. Geographic location was economically stratified (New York, California, Massachusetts, Illinois, and Washington DC) as previously reported. Race and binary sex were attributed by authors using publicly available information. Univariate analysis involved the chi-square test; a multivariable model considered several factors including rank and sex.

RESULTS

Of 993 radiation oncologists at CCCs, 53.6% are junior faculty, 24.8% associate professors, and 21.7% full professors. The average radiation oncologist at a CCC has been a physician for 19.7 (standard deviation = 11.3) years; 4.7% (47/993) are under-represented minorities. 24.6% of men and 15.5% of women were full professors, a statistically significant difference (P = .001). Of the 51 department chairs, 11.8% are women and 5.6% are under-represented minorities. There are fewer female than male program directors in the most economically stratified locations (P = .02). The mean h-index for all faculty is 17.6 (standard deviation = 16.9), and significantly differs between junior faculty (8.21), associate professors (18.46), and full professors (40.05; P < .0001). It also differs between men (19.35) and women (14.11). On multivariable analysis, sex, academic rank, and a secondary advanced degree were independently significant correlates of h-index.

CONCLUSION

Among academic radiation oncologists at CCCs, under 5% are under-represented minorities, men are significantly over-represented among senior faculty, and women have significantly lower h-indices than men.

Motivations, Well-Being, and Career Aspirations of Radiation Oncology Resident Physicians in Canada

Prior Pan-Canadian surveys of Radiation Oncology (RO) residents reveal a decrease in Canadian RO employment opportunities. Canadian RO resident levels increased from 130 in 2003, peaked at 209 in 2009, then decreased to 130 in 2017. Recognizing that RO has entered another period of transition, we re-examined resident motivations and perspectives on the job market and explored well-being and career aspirations among a contemporary cohort of Canadian RO residents. An online survey was distributed to residents at all Canadian RO training programs. Surveys consisted of 75 open-ended, Likert-scale, matrix-style, and multiple-choice questions. Student's t test compared subgroups, with statistical significance at p ≤ 0.05. Out of 128 eligible residents, 84 completed the survey (66% response rate) with representative sampling from each training year. Demographics reveal 53% male, and 85% Canadian registry-funded. Top training-related stressors were exam performance, job prospects, and physical/psychological demands of residency. Most intend to pursue fellowship post-residency (80%) and practice in Canada (88%). Few believe they can obtain staff positions treating preferred tumor sites (38%) or at preferred geographic locations (28%). Residents view job market being less competitive than 5 years ago (40%) and predict it will be less competitive in 5 years (60%). Canadian RO residents feel adequately trained, and most pursue post-residency fellowships. Current perceptions of the Canadian job market remain guarded, but appear more optimistic about the future. This update provides insights into current RO training and identifies areas that could be addressed by incoming competency-based medical education models for RO.

Reasons for Declining Applicant Numbers in Radiation Oncology From the Applicants' Perspective: Results From the Applicant Concerns and Radiation Oncology Sources Survey (ACROSS)

PURPOSE

Applications to radiation oncology in the United States have decreased the past 3 years, resulting in unfilled residency positions (30 [14.5%] in 2019 and 35 [18.5%] in 2020). The aim of this study is to understand the concerns among radiation oncology applicants and whether these concerns may have led to a decline in applications.

METHODS AND MATERIALS

An Internet-based survey was e-mailed to all radiation oncology applicants participating in the 2020 National Resident Matching Program Match for whom e-mail addresses could be obtained (n = 145, 78.8%). The survey was open from May to September 2020.

RESULTS

Survey responses were received for 98 applicants out of 145 (67.6%) available applicant e-mails. Applicants' top-rated concerns were location of practice restrictions and residency expansion/oversupply of practicing physicians. Applicants were less concerned about a lack of exposure to the field of radiation oncology, competitiveness of the match, and the content of residency training. The sources of information which applicants used most, which applicants trusted most, and which promoted the most optimism among applicants were radiation oncology attending and resident physicians. The sources of information which applicants used least, which applicants trusted least, and which promoted the most pessimism among applicants were online resources. As a result of their concerns, 27 (28%) respondents strongly considered choosing a different field of medicine. Applicants identified 93 fellow graduating medical students who were interested in radiation oncology but chose not to apply; applicants reported that potential applicants chose not to apply most often due to concerns about location of practice restrictions and residency expansion/oversupply of practicing physicians.

CONCLUSIONS

Applicant concerns about residency expansion and location of practice restrictions are prevalent and may have led to declining applications to radiation oncology. To assuage applicant concerns, radiation oncology stakeholders must address these concerns by mitigating underlying problems.

United States Radiation Oncology Fellowship Growth From 2010 to 2020

PURPOSE

To provide a comprehensive analysis of radiation oncology (RO) fellowship growth from 2010 to 2020.

METHODS AND MATERIALS

A collated database of RO fellowship programs and matriculants was created using (1) RO residency program (n = 92) and graduate (n = 2082) web searches, (2) prospective American Society for Radiation Oncology (ASTRO) Career Center postings database, (3) Association of Residents in Radiation Oncology Fellowship Directory, (4) RO fellowship survey data, (5) ASTRO Membership Directory, and (6) direct e-mail contact with fellowship program directors. Linear regression was used to assess the statistical significance of RO fellowship program, position, and matriculant growth over time.

RESULTS

From 2010 to 2020, the number of RO fellowship programs and annual positions significantly increased from 20 to 37 (1.60 increase per year; 95% confidence interval, 1.32-1.89; P < .001) and 20 to 39 (1.81 increase per year; 95% confidence interval, 1.52-2.10; P < .001), respectively. The most commonly offered fellowship disciplines were proton therapy (n = 10), brachytherapy (n = 7), stereotactic radiosurgery/stereotactic body radiation therapy (n = 6), general RO (n = 5), and customizable to trainees' interests (n = 3). Only 10 (27%) fellowships had a formal curriculum. All fellowships were unaccredited. Four (10.8%) programs were offered at institutions without an Accreditation Council for Graduate Medical Education-accredited RO residency training program, all established within the past 2 years. In addition, 54.8% (171 of 312) of available fellowship positions were filled between 2010 to 2020. Of these, 94 (55.0%) were graduates of US RO residency programs. The mean number of total fellows and US-residency trained fellows per year was 15 (range, 5-23) and 8 (range, 2-20), respectively. There was no significant increase in the number of annual matriculated fellows over time (P = .077). Among US-residency trained fellows, 27 (28.7%), 37 (39.4%), and 29 (30.9%) were from small (≤6), medium (7-12), and large (>12) residency programs, respectively. Twenty-eight (29.8%), 13 (13.8%), 25 (26.6%), and 27 (28.7%) trained in the Northeast, Midwest, South, and West, respectively.

CONCLUSIONS

There has been significant growth in unaccredited RO fellowship programs and annual positions during the past decade, although the number of matriculants has remained stable. We report for the first time the recent establishment of fellowships at institutions without an Accreditation Council for Graduate Medical Education-accredited RO residency program. The impact of fellowship programs on the training of RO residents should be studied.

Quantitative Analysis of Practice Size Consolidation in Radiation Oncology: A Trend Toward Bigger and Fewer Practices

PURPOSE

There is evidence of practice consolidation in US health care in recent years. To our knowledge, a detailed quantitative study of recent changes in radiation oncology practice size has not been performed. We aim to evaluate radiation oncology practice size changes between 2012 and 2020 in the United States.

MATERIALS AND METHODS

Using the Medicare Physician Compare Database, we identified practices employing radiation oncologists using their taxpayer identification number and individual radiation oncologists using their national provider identifier. We grouped individual radiation oncologists into categories by practice size (which includes the number of physicians of all specialties) and compared the number of radiation oncologists in each category between 2012 and 2020. Further analyses by US geographic census region, single-specialty practice, academic practice, and high- and low-population density areas were performed.

RESULTS

Between 2012 and 2020, the total number of practicing radiation oncologists increased by 9%, and the number of practices employing radiation oncologists decreased by 11.5%. The number of radiation oncologists in practices of size 1 to 2, 3 to 9, 10 to 24, and 25 to 49 decreased by 3.7%, 4.7%, 4.9%, and 2%, respectively, and the number of radiation oncologists in practices of size 50 to 99, 100 to 499, and 500+ increased by 1.4%, 2.1%, and 11.8%, respectively (all 500+ practices are multispecialty groups). The increase in practice size was significant in all regions, for single-specialty and multispecialty practices, academic and nonacademic practices, and for practices in high-, middle-, and low-population density areas (P < .05 for all comparisons). The proportion of single-specialty practices has decreased significantly (P < .001), and the proportion of academic practices increased significantly (P = .004). Additionally, the proportion of practices and physicians in high- and low-population density regions remained stable during this period (P > .05).

CONCLUSIONS

Our analysis suggests that practice size consolidation has occurred within the US radiation oncology workforce from 2012 to 2020. The impact of this consolidation on quality, cost, and patient access deserves further attention.

The Geography of Employment Outcomes for Radiation Oncology Graduates in 2019

PURPOSE

The geographic distribution of practicing radiation oncologists is of concern for multiple stakeholders within the field. Employment outcomes of graduating residents can affect that distribution, and they are of major concern to current residents. Data investigating employment outcomes of recent graduates are sparse. We aimed to analyze the employment outcomes of the radiation oncology residency class of 2019.

METHODS AND MATERIALS

Using publicly available information, we identified the employment of 179 of 183 graduating residents in the class of 2019. For each, the place of employment, residency program, and medical school were geocoded using Google Maps. We used the rural-urban continuum code (RUCC) published by the United States Department of Agriculture to determine the rurality of each location and compared employment outcomes by RUCC and program size.

RESULTS

Two thirds of graduates (66%) took a position in a county within a metropolitan area with a population greater than 1,000,000 people; only 3.4% took a position in a county outside of a metropolitan area. Graduates of smaller programs (≤6 residents) and those in smaller metropolitan areas were more likely to take positions in smaller metropolitan areas or nonmetropolitan areas. The geographic distance between location of employment and residency program did not significantly vary by program size or size of metropolitan area where a residency program was located.

CONCLUSIONS

Among the class of 2019, a small proportion took positions in nonmetropolitan areas. Smaller programs and those in smaller metropolitan areas may be more likely to produce graduates that practice in similar settings, but those graduates might not do so locally. We advocate for a centralized, prospective data collection of employment outcomes for graduating residents to refine these analyses and to reduce employment prospect information asymmetry for trainees.

Residency Match Trends, Racial Disparity, and Matching Amid a Pandemic

PURPOSE

Radiation oncology has been facing an evolving crisis in recruitment for several years, and the events of 2020 to 2021 will certainly add to that crisis with the urgency of addressing systemic racial injustice amid a global pandemic. The purpose of this study is to examine applicant data to gain insight on residency match trends and evaluate these findings within the backdrop of a novel match year.

METHODS AND MATERIALS

National Residency Matching Program (NRMP) data between 2009 and 2020 were assessed for the number of applicants, programs, and positions available, number of ranked applicants needed to fill positions, and successfully matched applicant data. Additionally, Electronic Residency Application Service data were evaluated for race/ethnicity identification among applicants.

RESULTS

The number of applicants who ranked radiation oncology as their preferred specialty has declined for 3 consecutive years from 223 in 2017 to 155 in 2020. In 2020 the applicant-to-position ratio was at an all-time low at 0.82, and the unmatched position rate increased to 18.5%. The percentage of Black or African American applicants applying to radiation oncology has also declined to 4.9%, and this population represents 7.2% of all applicants. The number of ranked applicants needed to fill the available radiation oncology PGY2 positions increased from 4.0 in 2010 to 6.0 in 2020.

CONCLUSION

Declining interest in radiation oncology among applicants, and an even further decline of black applicants, along with the challenges of interview and travel restrictions during the pandemic provide heightened concern for this year's match. Innovative efforts to expand the reach of radiation oncology to prospective applicants is needed to engage diverse, bright, and committed students for the continued progress of radiation oncology and most importantly, our patients.

US Radiation Oncologists (Re)Defined: An American Society for Radiation Oncology Scope of Practice Study

Purpose

To assess US radiation oncologists’ views on practice scope and the ideal role of the radiation oncologist (RO), the American Society for Radiation Oncology (ASTRO) conducted a scope of practice survey.

Methods and Materials

In spring 2019, ASTRO distributed an online survey to 3822 US RO members. The survey generated 984 complete responses (26% response rate) for analysis. Face validity testing confirmed respondents were representative of ASTRO’s RO membership.

Results

Nearly all respondents agreed that “ROs should be leaders in oncologic care.” Respondents indicated the ideal approach to patient care was to provide “an independent opinion on radiation therapy and other treatment options” (82.5%) or “an independent opinion on radiation therapy but not outside of it” (16.1%), with only 1.4% favoring provision of “radiation therapy at the request of the referring physician” as the ideal approach. Actual practice fully matched the ideal approach in 18.2% of respondents. For the remaining majority, actual practice did not always match the ideal and comprised a mix of approaches that included providing radiation at the referring physician’s request 24.0% of the time on average. Reasons for the mismatch included fear of alienating referring physicians and concern for offering an unwelcome opinion. One-fifth of respondents expressed a desire to expand the scope of service though interspecialty politics and insufficient training were potential barriers. Respondents interested in expanding scope of practice were on average earlier in their career (average years in practice 13.3) than those who were not interested (average years in practice 17.2, P < .001). Radiopharmaceuticals administration, medical marijuana and anticancer medications prescribing, and RO inpatient service represented areas of interest for expansion but also knowledge gaps.

Conclusions

These results provide insight regarding US ROs’ scope of practice and attitudes on the ideal role of the RO. For most ROs, to provide an independent opinion on treatment options represented the ideal approach to care, but barriers such as concern of alienating referring physicians prevented many from fully adhering to their ideal in practice. Actual practice commonly comprised a mixed approach, including the least favored scenario of delivering radiation at the referring physician’s request one-quarter of the time, highlighting the influence of interspecialty politics on practice behavior. Advocacy for open communication and meaningful interdisciplinary collaboration presents an actionable solution toward a more balanced relationship with other specialties as ROs strive to better fulfill the vision of being leaders in oncologic care and being our best for our patients. The study also identified interest in expanding into nontraditional domains that offer opportunities to address unmet needs in the cancer patient’s journey and elevate radiation oncology within the increasingly value-based US health care system.

A National Survey of Radiation Oncology Experiences Completing Tele-Consultations During the Coronavirus Disease (COVID-19) Pandemic

Purpose

The emergence of the coronavirus disease (COVID-19) global pandemic has led to a significant shift in the delivery of health care, including an explosive growth of telemedicine services. This reverberated in the field of radiation oncology, with a recent American Society for Radiation Oncology (ASTRO) nationwide survey reporting 89% of surveyed clinics began to offer telemedicine programs to patients because of the pandemic. However, this survey did not study the perceptions and experiences of those clinicians delivering telemedicine services.

Methods and Materials

We investigated through a national physician survey the merits and limitations of radiation oncology tele-consultations. An anonymous web-based survey was distributed using SurveyMonkey (www.surveymonkey.com) via email.

Results

Seventy six respondents (16.1% overall response rate) completed the survey, with broad representation from both academic and community-based practices. Many respondents agreed that transitioning to tele-consultations was a needed step given the emergence of the pandemic, despite most having never previously offered this service. Despite many radiation oncologists having little prior experience with tele-consultations, a majority were satisfied in being able to explain the details of a medical diagnosis, provide results of imaging and bloodwork, and discuss recommendations around radiation treatments through this format. Nearly half of the respondents agreed that tele-consultations felt impersonal, with the inability to complete physical examinations noted as a contributor to the impersonality. Nevertheless, respondents still agreed that telemedicine will play an important role going forward, and almost 90% agreed that they would offer tele-consultations even after the pandemic has resolved.

Patient Radiation Exposure: Imaging During Radiation Oncology Procedures: Executive Summary of NCRP Report No. 184

The National Council on Radiation Protection and Measurements (NCRP) recently assessed patient radiation exposure in the United States, which was summarized in its 2019 NCRP Report No. 184. This work involved an estimation of the number of medical procedures using ionizing radiation, as well as the associated effective doses from these procedures. The NCRP Report No. 184 committee elected to not incorporate radiation dose from radiotherapy into its calculated population dose exposures, as the assessment of effective dose for the population undergoing radiotherapy is more complex than that for other medical radiation exposures. However, the aim of NCRP Report No. 184 was to raise awareness of ancillary radiation exposures to patients undergoing radiotherapy. Overall, it was estimated that annually, in 2016, approximately 800,000 patients received approximately 1 million courses of radiation therapy. Each of these treatments includes various types of imaging that may not be familiar to radiologists or others. Exposures from radiotherapy planning and delivery are reviewed in the report and summarized in this executive summary. The imaging techniques, use of this imaging, and associated tissue doses are described. Imaging can contribute a few percent to the planned treatment doses (which are prescribed to specified target volumes) as well as exposing patients to radiation outside of the target volume (in the imaging field of view).

A 15-Year Profile of U.S. Radiation Oncology Residency Growth by Geographic Region, Metropolitan Size, and Program Size

PURPOSE

The size and growth of U.S. radiation oncology (RO) residency positions have important implications for the RO workforce. There are no data on residency growth by geographic region, major urban centers, and program size. We aim to fill this gap.

METHODS AND MATERIALS

A database of all RO programs and positions from 2003 to 2018 was created using National Resident Matching Program data. Programs were categorized by U.S. Census Bureau geographic region, major metropolitan location (top 10 combined statistical area vs all other), and program size (small [≤6 trainees], medium [7-12], and large [>12 trainees]). Linear regression with interaction terms was used to determine the effect of region, major metropolitan location, and program size on RO program and position growth over time.

RESULTS

There has been a 69% (54-91) and 82% (106-193) increase in the number of RO programs and annual positions from 2003 to 2018. Differences in program and position growth, respectively, were seen in each category. Growth in the Northeast (92% and 83%), South (81% and 113%), and West (125% and 130%) has outpaced the Midwest (17% and 33%). Growth in top 10 metropolitan areas (77% and 92%) is higher than in all other areas (63% and 73%). Growth in medium (68% and 80%) and large (175% and 153%) programs is greater than in smaller (36% and 33%) programs.

CONCLUSIONS

There has been a major increase in the number of RO residency programs and positions over the past 15 years. Growth is occurring in every major category but there are differences in magnitude within each category. This information can inform future decisions about RO training programs in the United States.