Job shortages over the past 5 years prompted 95% of radiology graduates to opt for fellowship by 2014, with 6% endorsing a desire to pursue multiple fellowships . The increased interest in fellowships by applicants exacerbated the so-called fellowship arms race whereby programs, unregulated due to a lack of a common application process, offered positions earlier and earlier to secure desirable applicants . With frustrations mounting over the process and competition for breast imaging fellowships escalating, the Society of Breast Imaging reinstituted participation in the Match in 2017 for the first time since 2006.
The results of the 2017 Breast Imaging Fellowship Match were eye-opening. Previously thought to be a competitive option with few unfilled programs in the previous cycle, only 64% of the breast imaging programs filled and 21.6% of the total positions were unfilled . If one radiology society decides that its affiliated fellowship programs will use a match system after the majority of prospective fellows have already committed to other programs, residents who are not completely committed to the discipline or fear that they would not be competitive enough to earn a position in that match will choose a different fellowship early in the year to secure a position and avoid the risk of not matching. Breast imaging bore the brunt of this program in 2017. With few prospective fellows available so late in the PGY-4 year, these programs struggled to find fellows. A rebound effect is now plausible in which an excess of residents wait for the breast imaging match only to have the pendulum swing back to a state of applicant oversupply.
Radiology fellowship programs had used the Specialties Matching Service much more liberally until 2006 , but concerns over programs not abiding by the rules eventually contributed to the Match falling largely out of favor. As radiologists, we must unify on this issue. We should have a common application system and give our residents proper exposure to all of their options before we require them to make this important decision. If we are going to use the National Resident Matching Program, it needs to be an all-in system across radiology. Breast imaging is an example of a particularly vulnerable discipline, as it is neither recognized by the American Board of Radiology as a subspecialty nor accredited by the Accreditation Council for Graduate Medical Education. As such, the programs can be heterogeneous. An all-in system would provide some stability by allowing applicants to rank breast imaging programs among other radiology disciplines after they have evaluated a wider variety of programs.
On the larger scale, radiology must come together regarding the “subspecialty” concept. Radiology is experiencing a bit of an identity crisis. Are we generalists, or are we subspecialists? It is nearly impossible to build a curriculum that strengthens both philosophies simultaneously, especially when the largest residency program is nine times the size of the smallest residency program . The curriculum structure established by the new radiology board examination seemed to be an endorsement of subspecialties. Stakeholders must assess the plausibility of developing subspecialty certificates and standardized requirements for each of the fellowships. The “mini-fellowships” during the PGY-5 year must be recognized in some way, even if it involves innovative means of incorporating elements of fellowship training or requiring a “mini-fellowship” as a prerequisite to fellowship, as had been informally discussed in 2017.
It is counterproductive to have each of the radiology subspecialties playing by its own rules. There was an attempt made by program directors and department chairs to adhere to a common application system 5 years ago, but this handshake agreement never materialized into a formalized plan. The 2018 Association for University Radiologists meeting would be a great time to assess the disappointing results of the breast imaging match and refocus on a common fellowship application system.
The 2017 Breast Imaging Match highlights the need to develop a common ground regarding the fellowship applications, definitions, accreditations, and certifications of all radiology subspecialty trainees and practitioners. Until we achieve that, the radiology identity crisis will continue.
References
1. Shetty A., Hammer M., Gould J., et. al.: Results of the 2014 survey of the American Alliance of Academic Chief Residents in Radiology. Acad Radiol 2014; 21: pp. 1331-1347.
2. Glover M., Patel T.Y.: The radiology fellowship arms race cannot be won. J Am Coll Radiol 2016; 13: pp. 461-464.
3. National Resident Matching Program : Radiology match results statistics in the specialties matching service® for 2018 appointments. Washington, DC: National Resident Matching Program; Available at: http://www.nrmp.org/wp-content/uploads/2017/06/Radiology-Match-Results-Statistics-AY2018.pdf
4. Pfeifer C.M.: The fellowship arms race revisited. J Am Coll Radiol 2016; 13: pp. 891-892.
5. Shetty S.K., Resnik C.S.: Fellowship directors’ perceptions of the 2005 NRMP radiology fellowship match. Acad Radiol 2006; 13: pp. 121-130.
6. Pfeifer C.M.: Radiology resident supply and demand: a regional perspective. J Am Coll Radiol 2017; 14: pp. 1161-1168.
7. Pfeifer C.M.: Changes to radiology: simpler is better. Acad Radiol 2015; 22: pp. 1326-1327.