Results of the 2012 Survey of theAmerican Association of Academic

Chief Residents in Radiology

Steven Sauk, MD, MS, Clinton Jokerst, MD, Jennifer Gould, MD, Ronald Evens, MD

Ac

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32

Rationale and Objective: Every year, the American Association of Academic Chief Residents in Radiology conducts a survey of the chief

residents in accredited radiology training programs in North America. The survey serves as a tool for gathering information, sharing ideas,

and voicing opinions.

Materials and Methods: An online survey was made available to the chief residents from 187 training programs in North America. Ques-

tions were presented in multiple-choice and free response formats, designed to address many issues ranging from program structure to

on-call policies, changes for the new board examination format and fellowships, and the effects of health care reform on radiology prac-

tices. The results of the survey were tabulated and responses to the repeated questions were compared with those from earlier surveysdating to 2003.

Results: Among those surveyed, 185 individual responses representing 135 unique programs were completed, yielding a 73% response

rate. Thirty-eight percent of programs responded from the northeast and 17% of programs responded from the southeast. Nineteen per-cent of responses were from central United States, 14% of responses were from western United States, and 12% of responses were from

Canada.

Conclusions: There is an increasing number of programs, which cover more hospitals, during the past decade. There are more programsproviding ultrasound and magnetic resonance services after hours, with an associated increase in after-hours attending physician cover-

age. Many changes are being made for the future board examination format. Health care reform is affecting how residents are preparing

themselves for their future practices.

Key Words: Resident education; staffing; call; health care.

ªAUR, 2013

he American Association of Academic Chief Resi- Mallinckrodt Institute of Radiology. Questions are added or

T dents in Radiology (A3CR2) includes chief residents

from all accredited radiology programs, including uni-

versity, community, and military hospitals. The organization

meets annually to discuss issues related to the training of diag-

nostic radiology residents. In addition, the A3CR2 conducts

an annual survey of resident training programs and presents

the data at the annual A3CR2 meeting held in conjunction

with the Association of UniversityRadiologists meeting (1–11).

The survey has been conducted since 1971, and the database is

maintained at the Mallinckrodt Institute of Radiology (11). The

survey is intended to not only to analyze trends regarding resi-

dency programs but also address the current issues that radiology

programs face and provide information regarding the changes

that many programs are making in the future (12–15). Survey

questions are generated by the chief residents at the

ad Radiol 2013; 20:320–331

om the Department of Radiology, Mallinckrodt Institute of Radiology atashington University, 510 South Kingshighway, Campus Box 8131, Stuis, MO 63110. Received May 12, 2012; accepted September 3, 2012.esented at the A3CR2 Meeting, San Antonio, TX, April 18, 2012. Addressrrespondence to: S.S. e-mail: sauks@mir.wustl.edu

AUR, 2013tp://dx.doi.org/10.1016/j.acra.2012.09.024

0

changed by the chief residents and several faculty members of

Mallinckrodt to address residency program issues that are

discussed at A3CR2 throughout the year. These questions are

then proposed to the Steering Committee of the A3CR2 for

final changes. Programs with more than one chief resident

were asked to select one representative to state their institution’s

name and answer program-specific questions. Any duplicate

answers from the same institution were removed after responses

were collected. The following data represent the results from

the survey conducted from February 14–24, 2012, discussing

trends in program characteristics, resident benefits, chief resident

roles, call structure, the effects of the changing board examina-

tion, fellowships, the impact of the current economy and health

care reform, and performance and quality improvement projects.

In the following sections, unless otherwise noted, there are no

changes in the data compared to the previous year’s data.

PROGRAM INFORMATION

Program structures were assessed to characterize the increas-

ing volume of studies that hospitals face in the current era of

rapidly advancing technology and the current trends in radiol-

ogy resident demographics.

Figure 1. Percentage of programs per-

forming a given number of studies per yearin 2004, 2009, and 2012. (k indicates 1000.)

Academic Radiology, Vol 20, No 3, March 2013 A3CR2 2012 SURVEY RESULTS

Seventy-six percent of programs report that a medical

school or university is responsible for the residency pro-

gram. Twenty-five percent and 26% of programs cover

one and two hospitals, respectively, whereas 21% of

programs cover three hospitals. There is an increase in the

percentage of programs that cover more hospitals, with

15% of programs covering four hospitals and 13% of pro-

grams covering five or more hospitals (respective 2005 val-

ues were 9% and 9% in 2005). This year, 82% of programs

are a part of Level 1 Trauma centers and dedicated Stroke

Centers, 53% are National Institutes of Health–designated

cancer centers, and 54% have separate pediatric emergency

departments, covered by residents. When asked about the

number of radiologic studies performed per year, which

includes radiographs, fluoroscopic studies, nuclear medi-

cine, ultrasound, and magnetic resonance (MR) and com-

puted tomographic (CT) studies, 2% of programs perform

<100,000 studies (8% and 1% in 2004 and 2009, respec-

tively), 14% perform between 100,000 and 250,000 studies

(45% and 21% in 2004 and 2009, respectively), 33% per-

form 250,000 to 500,000 studies (30% and 42% in 2004

and 2009, respectively), 23% perform 500,000 to 750,000

studies (5% and 15% in 2004 and 2009, respectively), and

29% of programs perform >750,000 studies (12% and

21% in 2004 and 2009, respectively) (Fig 1).

A number of studies have looked at the differences between

the genders in radiology. Data from the Association of Amer-

ican Medical Colleges show an increase in the number of

women residents entering radiology, from 24% in 1999 to

27% in 2009 (16). Based on the A3CR2 Survey, among the

radiology residents in 2012, 29% are women, increased from

23% in 2003. In 2012, the average number of residents per

training program is 27 residents, increased from 21 residents

in 2003.

RESIDENT BENEFITS

Information regarding resident compensation and benefits

was gathered in an attempt to better understand the financial

obligations and constraints on residents, which are important

in future discussions regarding resident career choices (17).

The median first-year radiology resident salary for the

2011–2012 academic year is $50,344 ($47,211 in 2009), rang-

ing from $42,000 to $100,000 (ranging from $38,000 to

$65,000 in 2009). The median fourth-year resident salary

for the 2011–2012 academic year is $56,652 ($52,944 in

2009), ranging from $48,000 to $100,000 (ranging from

$42,000 to $100,000 in 2009). Resident salaries have

increased 6.6% and 7% for first- and fourth-year residents

between 2009 and 2012, respectively. The average inflation

rate from 2009 to 2012 is estimated at 6.9% (18) (Fig 2).

Ninety-four percent of programs provide paid family leave

for residents who are pregnant during their residency (80% in

2008), but 54% require them to be taken from the pool of vaca-

tion or ‘‘sick’’days (in whole or in part). Seventy-six percent of

programs offer up to 9 weeks of family leave for residents who

are pregnant. For residents who are significant others of

spouses who had just undergone delivery (also known as

‘‘paternity’’ leave), 79% of programs offer family leave, with

57% programs taking these days from the pool of vacation or

‘‘sick’’ days (in whole or in part). Sixty-one percent of pro-

grams offer up to 2 weeks of family leave for these residents.

Regarding resident benefits this year, 86% of programs offer

book funds, 76% provide travel stipends for conferences, 68%

reimburse for conference fees, and 71% allocate time for con-

ferences (2008 values were 76%, 76%, 7%, and 7%, respec-

tively). The survey reports that 94% residents attend the

course offered at the Armed Institute of Radiologic Pathology

(AIRP), formerly known as the Armed Forces Institute of

Pathology. Ninety-one percent of programs offer tuition

reimbursement for residents attending AIRP, whereas 77%

programs offer reimbursements for housing and/or travel

costs (in 2008, 93% and 78%, respectively). The average

amount allotted to residents in the country is $1793 (range,

$300 to $6000). Forty-three percent of programs offer per-

sonalized lead aprons for their residents. Forty-seven percent

of programs reimburse residents for oral boards review course

tuitions and/or travel costs (Fig 3).

Internet resources have become almost invaluable to resi-

dents and their education. Ninety-three percent (146 of 157)

of programs are subscribed to STAT Dx (www.amirsys.com/

statdx.php, Amirsys Inc., Salt Lake City, UT), 34% (54 of

321

Figure 2. The median salaries (and inter-

quartile ranges) of first- and fourth-year radi-

ology residents (postgraduate year 2 and 5,respectively), in 2009 and 2012.

Figure 3. The percentage of programs that offered specific benefits to radiology residents in 2008 and 2012. ABR, American Board of Radi-

ology; AFIP, Armed Forces Institute of Pathology; AIRP, Armed Institute of Radiologic Pathology; e-Anatomy, e-Anatomy (www.imaios.com/en/

e-Anatomy); RAD, RAD Primer (www.radprimer.com); STAT Dx, STAT Dx (www.amirsys.com/statdx.php).

SAUK ET AL Academic Radiology, Vol 20, No 3, March 2013

157) are subscribed to RAD Primer (www.radprimer.com,

Amirsys Inc., Salt Lake City, UT), and 17% (26 of 157) are sub-

scribed to e-Anatomy (www.imaios.com/en/e-Anatomy,

IMAIOS SAS, France). Other benefits not included in the sur-

vey questions but commented on by those surveyed include

iPads (Apple, Cupertino, CA) for residents, gym memberships,

coverage for insurance co-payments, and meals.

CHIEF RESIDENT

Sixty-one percent of programs in the country have two chief

residents, with a range of one to six residents simultaneously

holding the position. Chief resident selection varied greatly

322

between programs and consisted of input from residents,

faculty, program directors, and the department chair. Chief

residents are offered a variety of responsibilities and benefits,

all of which have not changed dramatically since 2007.

Chief resident responsibilities remain largely administrative

(Fig 4). Ninety-five percent of chief residents are responsible

for creating the call schedule, and 80% of programs have their

chief residents create the resident rotation schedule. Seventy-

three percent of programs will designate the chief residents to

create the vacation schedule. Seventy-nine percent of pro-

grams involve the chief residents for resident recruiting and

selection. Teaching duties are less common, with 62% and

48% of programs asking chief residents to teach residents

Figure 4. The percentage of chief resi-

dents with specific responsibilities in 2012.

Figure 5. The percentage of programs that provided certain typesof reports while on-call in 2011 and 2012. Prelim, preliminary.

Academic Radiology, Vol 20, No 3, March 2013 A3CR2 2012 SURVEY RESULTS

and medical students, respectively. Regarding the curriculum,

62% programs have chief residents develop and evaluate the

training program curriculum, and 49% of programs have chief

residents create the attending lecture/conference schedule.

Chief residents were responsible for organizing the institu-

tion’s board review schedule at 42% of programs. Miscellane-

ous duties including social events and managing disputes are

handled by the chief residents in 73% and 93% of programs,

respectively.

Survey respondents reported several benefits associated

with the chief resident position. Fifty-three percent of chief

residents are allotted extra time away from clinical duties to

attend national conferences and meetings. Conference fees

and travel costs were reimbursed by residency programs for

60% of programs surveyed. Forty-three percent of programs

offer their chief residents time off-service to perform chief res-

ident duties, something that many participants in the survey

indicated would help them better fulfill their obligations as

chief resident and make the position more attractive.

Thirty-seven percent of respondents had either their own

office or a shared office with the other chief residents.

Seventy-five percent of programs offer their chief residents a

salary bonus, with a median of $1500 per year, which has

increased from $1000 in 2008.

CALL STRUCTURE

Call structures are varied and complex across all programs,

intertwining the higher demands for imaging in today’s med-

ical practices with the schedules of the technicians, residents,

and attending physicians.

On-call residents are responsible for previewing and/or

dictating studies from numerous locations, from both the

emergency department and inpatient services performed

overnight. Sixty percent of programs provide complete pre-

liminary reports to clinicians while on call (unchanged from

2011) (Fig 5). Twenty percent of programs provide abbrevi-

ated preliminary reports, answering only the clinical question

and/or incidental findings that impact the patient’s immediate

management (19% in 2011). There has been a decrease in the

programs that provide oral reports from 5% in 2009 to 1% in

2012, with an increase in final reports provided by the resident

and attending or the attending alone, from 16% in 2011 to

19% in 2012. There are several programs that have variability

in the type of report given, depending either on the type of

study (ie, only neuroradiology studies are provided with a

short preliminary report), the level of training of the on-call

resident (ie, the junior resident provides a complete

preliminary report while the senior resident provides a short

preliminary report), and the time of the day or week.

Since 2009, there has been a general trend for more ultra-

sound coverage throughout the country (Fig 6a). This year,

323

Figure 6. (a) The percentage of programs

in 2009 and 2012 that offered 24-hour so-nographers, home-call sonographers, and

residents who perform the ultrasound (US)

examinations and those programs that

have nonradiologists perform the examina-tion and that do not offer after-hours ultra-

sound examinations. (b) The percentage of

programs in 2012 that offered ultrasoundexaminations for the emergency depart-

ment (ED), inpatient services for emergent

indications, and inpatient services for rou-

tine indications.

SAUK ET AL Academic Radiology, Vol 20, No 3, March 2013

46% of programs have a trained sonographer in-house 24

hours, 7 days a week, which has increased from 29% in

2009. Thirty-eight percent of programs have a trained sonog-

rapher who is on-call but is contacted while at home, which

has decreased from 44% in 2009. Having the sonographer

take call in-house or while at home can vary depending on

the hospital covered and the day of the week. Sixteen percent

of programs will have the on-call resident perform the ultra-

sound study, increased from 13% in 2009. Every program in

the country performs emergency department ultrasound

studies after hours, including gallbladder, appendix, and scro-

tal examinations. Eighty-eight percent of programs provide

emergent inpatient studies after hours such as transplant organ

Doppler studies, and 29% of programs provide routine inpa-

tient studies after hours (Fig 6b). There are exceptions to

the ultrasound examinations performed overnight; where

many programs have the obstetrics/gynecology service per-

form and interpret pelvic and pregnancy-related ultrasound

examinations and have the vascular surgery service perform

and interpret venous Doppler studies in the evaluation for

deep venous thromboses.

324

With more clinicians aware of the increased risks of radia-

tion in medical imaging and with advances in its technology,

MR imaging (MRI) has increased in volume during the past

decade. Within those hospitals that do provide MR services

after regular business, there is variability in the types of exami-

nations performed and, depending on the urgency and

whether the patient is from the emergency department, in

whether they are performed in an outpatient or inpatient set-

ting. Ninety percent of programs provide neuroradiology

(brain and spine) services after regular business hours (after

5:00 PM). Body, musculoskeletal, and vascular studies are per-

formed in 65%, 54%, and 47% of programs, respectively,

across the country (Fig 7a). Four percent of programs do

not provide MRI studies after regular business hours. The

interpretations of MR examinations are made by the on-call

residents in 95% of programs (Fig 7b). Fourteen percent of

programs have the fellows interpret the MR examinations

with or without the resident. Twelve percent of programs

have the attendings interpret the MR examination with or

without the resident. Six percent of programs do not interpret

the MR examinations overnight. The reports given to the

Figure 7. (a) The percentage of programs

in 2012 that offered specific types of mag-

netic resonance (MR) examinations afterhours. (b) The percentage of programs in

2012 that provided interpretations for MR

examinations performed after hours, by

on-call residents, fellows, and/or attend-ings, and those that did not interpret MR ex-

aminations performed overnight.

Academic Radiology, Vol 20, No 3, March 2013 A3CR2 2012 SURVEY RESULTS

clinician may vary depending on the type of examination (ie,

only body cases are given in oral report form), on the com-

plexity of the study, and on whether the clinician calls for

the results.

The process for reviewing studies at the end of the call shift

varies across the country and may depend on the type exami-

nation performed and the level of training of the resident. The

face-to-face readout gives the opportunity for the attending

and resident to discuss each case and its findings in person.

Forty-nine percent of programs perform face-to-face read-

outs with an attending or fellowmost or all of the time. Fifteen

percent of programs perform face-to-face readouts some of

the time. No face-to-face readouts are performed in 21% of

programs.

Throughout the United States, training programs are

pressured to provide more final reports, thereby requiring

attendings to cover radiology services after hours (Fig 8).

This may depend on the type of study and the day of the

week or on some combination of being in-house and at

home depending on the time of the day. Currently, 46%

of programs have the attendings go home at the end of

the work day, which is decreased from 54% in 2010. Attend-

ings remain in-house for extended hours (ie, from 5:00 to

10:00 PM) to read out the on-call studies in 45% of programs,

previously 46% in 2010. Twenty percent of programs have

an attending in-house overnight to finalize studies, which

is increased from 15% in 2010. Attendings review cases

from home in 3% of programs, which is unchanged from

2010. Attendings review cases after hours only if the on-

call resident calls them for a specific question in 35% of

programs, which is decreased from 52% in 2010. Twelve

percent of programs hire an external teleradiology service

to read out the studies read by the on-call resident

(previously 10% in 2010).

325

Figure 8. The percentage of programs

from 2009 to 2012 that have attending

physicians go home at the end of the workday, stay in-house for extended hours (ie,

5:00 to 10:00 PM), stay in-house overnight 7

days a week, review cases at home, reviewcases that residents call about in the middle

of the night, and have external teleradiology

services read on-call studies. Other meth-

ods include having attendings read onlyneuroradiology studies after hours and hav-

ing attendings read studies after hours on

different days of the week.

SAUK ET AL Academic Radiology, Vol 20, No 3, March 2013

Routine services are sometimes performed over the week-

end, depending on the hospital and program and the available

faculty (Fig 9). Nineteen percent and 16% of programs pro-

vide half-day coverage on Saturdays and Sundays, respectively.

Full-day coverage is provided on Saturdays and Sundays in

58% and 49% of programs, previously 55% and 49% in

2010, respectively. There has been a decrease in the number

of programs that do not provide weekend routine services

(originally 27% in 2010, now 23% in 2012).

Figure 9. The percentage of programs that provide routine service

coverage for half- or full-day Saturdays and Sundays, as well as the

percentage of programs that do not provide routine service coverageover the weekend.

CHANGING BOARD EXAMINATION

In 2008, the American Board of Radiology (ABR) issued a

change in the way diagnostic radiology residents are board

certified, moving from the three-examination model (includ-

ing a physics examination, clinical examination, and oral

examination) to a two-examination model, where a ‘‘core

examination’’ is given at the end of the third year of radiology

training and a certifying examination is given 15 months after

the completion of residency (19). With this, the ABR has

determined that mastery of the core components of diagnostic

radiology must be demonstrated at the qualifying step at the

end of the third year of training, leading to many programs

switching to a ‘‘three + one’’ curriculum, where the trainee

finishes all of the core requirements for board certification

at the end of the third year of training, allowing the fourth

year of training to be dedicated to focus on subspecialties.

Ten percent of those surveyed thought this change was pos-

itive, expressing that this new board format incorporates

physics into clinical knowledge, removes the block of time

off-service for studying in the fourth year of radiology,

encourages more trainees to pursue fellowships, and allows

more focused training during the fourth year. Thirty

percent of those surveyed thought this change to be negative,

326

expressing that the new board format decreases emphasis on

effective verbal communication skills and makes it more diffi-

cult to find a job because board certification cannot be

attained until 15 months after graduating residency. The

majority of those surveyed, 62%, had mixed sentiments

regarding the new board format.

Since 2010, there has been a dramatic increase in the num-

ber of programs that have established a ‘‘three + one’’ curric-

ulum, from 5% to 41% (Fig 10). Thirty-five percent of

programs plan to have a ‘‘three + one’’ curriculum established

by 2013, increased from 19% in 2010. Seven percent of pro-

grams plan to have this new curriculum established after

2013, decreased from 18% in 2010. There is no change in

the number of programs that do not plan to change to a ‘‘three

+ one’’ curriculum, accounting for 17% of programs.

Figure 10. The percentage of programsfrom 2010 to 2012 that already have, plan

to have, or do not plan to have a 3-year

‘‘core’’ curriculum in place for the newboard

examination planned for 2013.

Figure 11. The percentage of programs in 2011 and 2012 that are

making changes for preparing radiology residents for the future‘‘core’’ board examination.

Academic Radiology, Vol 20, No 3, March 2013 A3CR2 2012 SURVEY RESULTS

Although 23% of programs have not yet decided what the

fourth-year residents will do once the new board examina-

tion is in place, 26% of programs plan to continue normal

rotations. Sixty percent of programs plan to implement

selectives, or ‘‘mini-fellowships,’’ in which residents are

allowed several months to concentrate on specific subspecial-

ties of interest. Seven percent of programs are allowing

residents who plan to matriculate into fellowships at the

same institution of their residents to begin their fellowship

training earlier and for 2 years, as opposed to the conven-

tional 1 year (ie, ‘‘three + two’’ curriculum). Twelve percent

of programs will use the fourth year to fill in deficits from

the first 3 years, and 17% of programs plan to use a combi-

nation of implementations.

In preparation for the new ‘‘core’’ examination, many

programs are offering a variety of ways for residents to study

(Fig 11). Twenty-five percent of programs are allowing those

studying for the examination time off-service to study,

which is increased from 21% in 2011. Residents will be

taken out of the call pool for a varying amount of time

(�2 to 3 months) in 50% of programs, which is increased

from 40% in 2011. Thirteen percent of programs will not

give residents any protected time, and 36% of programs

are not sure how they will structure their curriculum for

the class taking the ‘‘core’’ examination. Some programs

are planning to place those studying for the examination

on rotations that demand less time on-service or allowing

afternoons off to study.

Currently, 84% of programs offer internal board review for

the oral board examination. Thirteen percent do not offer an

internal board review but allow time off-service for external

board review. Three percent of programs do not offer internal

board reviews and do not allow time off for external board

reviews. With the new ‘‘core’’ examination, 15% of programs

plan to keep their internal board review with few or no

changes. Thirteen percent of programs plan to dramatically

change their internal board review format to match the style

of the ‘‘core’’ examination. Four percent of programs plan to

stop their internal board review, allowing time for external

review. Twelve percent of programs plan to continue allowing

time off-service for residents to attend external board reviews.

Two percent of programs plan to stop all board review ses-

sions. The majority of programs, representing 67% of those

surveyed, are not sure how they will prepare their residents

for the ‘‘core’’ examination.

With the advent of the new ‘‘core’’ curriculum format,

many programs are planning to adapt their teaching methods

to reflect the multiple-choice format of the examination. One

method includes the use of audience response systems (ARS),

which require audience members to use a clicker to enter the

answer to a multiple-choice question that the lecturer pro-

vides. At the end of a designated time limit, the results from

the polled audience are displayed, which allows the lecturer

to discuss explain the correct and incorrect answers. Nine per-

cent of programs frequently use ARS, whereas 35% rarely use

it. Fifty-two percent of programs do not use an ARS. Among

those programs that do use ARS, 36% of their residents find it

to be a valuable tool, whereas 6% find that ARS detract from

learning. Twenty-one percent of those surveyed have mixed

sentiments about the use of ARS.

327

Figure 12. The distribution of residents in

the United States who matriculated and

plan to matriculate into fellowships in 2009

and 2012, respectively. ‘‘Other’’ fellowshipsinclude emergency radiology and combined

fellowship programs. MRI, magnetic reso-

nance imaging; MSK, musculoskeletal;

NeuroIR, neurologic interventional radiol-ogy; Nucs, nuclear medicine; Peds, pedia-

trics; VIR, vascular interventional radiology.

SAUK ET AL Academic Radiology, Vol 20, No 3, March 2013

FELLOWSHIPS

Especially with the changes in the curriculum with the new

board examination format, more residents are planning to

pursue fellowship subspecialty training. Ninety-one percent

of the chief residents who were surveyed plan to enter a fel-

lowship after graduating residency, whereas 3% plan to enter

a private practice, 3% plan to enter an academic position,

and 3% plan to enter the military service.

Data from polling the rest of the chief residents throughout

the country show that interventional radiology is themost pop-

ular of fellowships, with 22% of residents in the country plan-

ning to go into it for the next year, which is increased from

15% in 2009 (Fig 12). Twenty percent of residents plan to go

into neuroradiology (increased from 15% in 2009); 14% plan

to go into musculoskeletal radiology (decreased from 19% in

2009); and 11% plan to go into breast imaging (decreased

from 13% in 2009). Pediatric radiology is planning to have

5% of this year’s fourth-year residents enter its fellowship

(increased from 2% in 2009); nuclear medicine is expecting

2% of the current fourth-year resident class to enter its fellow-

ship (increased from1% in 2009); and a stable 4% percent of res-

idents are entering a cardiothoracic imaging fellowship this year

compared with 2009. Body MR fellowships are seeing a

decrease, from 6% in 2009 to 4% this year. Seventeen percent

of residents are planning to enter either an abdomen or a

body fellowship, separate from a Body MR fellowship. One

percent of residents are planning to enter other fellowships

such as neurointerventional or emergency radiology.

There is also some variability in what percentage of the

fellowship positions are offered to external applicants. Data

from the chief resident survey show that within interventional

radiology, 25% of the fellows are from an outside institution;

within neuroradiology, 68%; within musculoskeletal

radiology, 47%; within breast imaging, 55%; within

328

abdomen/body and body MRI, 65% and 50%, respectively;

and within cardiothoracic, nuclear medicine, and pediatric

radiology, 50% of fellows are from outside institutions.

With input from the A3CR2 and the Association of

ProgramDirectors in Radiology, the Society of Chairs in Aca-

demic Radiology Departments has decided that, beginning

with radiology fellowships with start dates of July 2014, all fel-

lowships must limit their interviewing season from the begin-

ning of February of the resident’s junior year (which would

therefore correspond initially to spring 2013) and that offers

to external candidates not be made until May 1 of the third

year of residency (corresponding to May 1, 2013). Thirty per-

cent of those surveyed agree with the change as it will make

the process of interviewing for fellowships more fair.

Twenty-eight percent agree with the change but think that

it will be difficult to enforce these new limitations. Eight per-

cent disagreewith the change, and 35% of those surveyed have

no strong opinion either way. Several comments were made

that the interview season will occur at the same time as

‘‘core’’ examination preparation starting in 2014.

Currently, only neuroradiology and interventional radiol-

ogy have their fellowship applicants apply using the National

Resident Matching Program, which enforces when residents

may apply, interview, and be ranked for the match, which typ-

ically occurs every June. With the new Association of

ProgramDirectors in Radiology and Society of Chairs in Aca-

demic Radiology Departments decision for when fellowships

applicants may interview regardless of the subspecialty,

residents were surveyed regarding their preference for the fel-

lowship application process. Twenty-three percent prefer the

same application process, with priority given to internal appli-

cants and with varying application deadlines. Forty-six

percent prefer a common deadline for all fellowships applica-

tions. Five percent prefer a match process for all fellowship

positions, beyond neuroradiology and interventional

Academic Radiology, Vol 20, No 3, March 2013 A3CR2 2012 SURVEY RESULTS

radiology. Twenty-six percent prefer a combination of a

match process and a common deadline.

HEALTH CARE ECONOMICS AND THE JOBMARKET

Health care reform, falling reimbursements, and a recent eco-

nomic downturn have contributed to large changes in radiol-

ogy, especially the job market. There is increasing concern

regarding the current job market for radiologists, with 95%

of chief residents feeling at least a little worried about finding

a job after residency or fellowship. Twenty-five percent of

chief residents have already started looking for a job and 8%

already have one before graduation. To obtain a job, 60%

are willing to accept a lower salary, 50% are willing to have

less vacation time, 48% are willing to move to a less ideal loca-

tion, 44% are willing to take more call shifts, and 36% are

willing to take more weekend shifts.

Chief residents were asked about career plans following

completion of their training in radiology. Despite the inherent

selection bias from polling only chief residents and the large

number of academic training programs represented in the

results, the motivations for pursuing a particular career path

are important to evaluate. After fellowship training, 27% of

chief residents plan to enter academics, 38% plan to enter

private practice, 3% plan to enter the military service, and

32% are undecided.

The current economic environment influences career plans

in a variety of ways. Forty-five percent of chief residents

believe that there is little or no influence. Twenty-five percent

think that academics has become more appealing as a result,

whereas 10% believe that private practice has become more

appealing. Forty-two percent and 3% believe that the envi-

ronment has increased and decreased interest in training in a

fellowship program, respectively. Sixteen percent think that

the current economic environment influences one’s

fellowship choice.

When asked about the effects health care reform will have

on the field of radiology, 86% think practices will try to

increase their volume to maintain a similar salary, despite

the lower reimbursement rates. Sixty-five percent believe it

will discourage top-tier medical students from choosing radi-

ology. Thirty-six percent think that practices are going to be

looking for radiologists trained in more than one fellowship.

As far as training residents in health care economics and

radiology business, 30% of residents think their programs offer

adequate training, 34% think that their training is inadequate,

and 36% of residents report there is no training given in this

area.

The poor economic climate has led to budget issues at

some programs, especially programs that have more trainees

than its training ‘‘cap,’’ paying for a certain number of train-

ees out of pocket. As a result, such programs are looking at

the need for downsizing the number of trainees. In 2012,

51% of programs have an equal number of trainees as their

training cap. Thirteen percent of programs have more

trainees than their training cap. In the 2012–2013 academic

year, 16% of programs are planning on increasing the num-

ber of trainees, whereas 4% are planning on decreasing the

number of trainees.

PERFORMANCE AND QUALITY IMPROVEMENTPROJECTS

During the past decade, the ABR has mandated that radiolog-

ists document participation in at least three successful per-

formance and quality improvement (PQI) projects every 10

years tomaintain board certification. Sixty-two percent of res-

idents find that their programs are adequately preparing them

for this requirement. Twenty percent think they are getting

inadequate training, whereas 18% of residents are finding

that they are not getting any training in PQI projects. Among

the programs that do support residents on PQI projects, 60%

provide faculty advisors, 48% provide resources such as data-

bases and research tools, 18% provide time off-service, and

2% provide financial support. Twenty-two percent of pro-

grams do not provide any of the aforementioned methods of

support for residents pursuing a PQI project.

DISCUSSION

This year’s survey included a number of questions focusing on

the changes that are being made in anticipation for the new

board examination format. The majority of the programs

have already instituted or plan to institute a 3-year ‘‘core’’ cur-

riculum. To allow enough study time for the first class taking

the ‘‘core’’ examination, half of the programs in the country

are planning to take the class out of their call pool and some

programs are either taking residents off-service or putting

them on less time-demanding rotations, although how pro-

grams will balance this with the remaining residents remains

to be worked out on a individual program basis. Additionally,

most programs are not sure how they plan to prepare their res-

idents for the ‘‘core’’ examination, partly due to the uncer-

tainty of how the examination will appear. In June 2013,

the ABR is planning to administer a ‘‘pilot’’ examination for

the third-year residents who are eligible to take the ‘‘core’’

examination in October 2013, to provide performance feed-

back for residents and to make appropriate adjustments in the

content and scoring of the new examination. It is hoped that

after the administration of this pilot examination, programs

will have a better idea of how to prepare their residents for

passing their ‘‘core’’ examinations.

As shown in this survey, with the increasing volume of

radiologic studies in this era of rapidly advancing technology,

combined with the higher demands for attending coverage

beyond the regular work hours, programs are trying to

balance the needs for their individual hospitals without

compromising the experience of residents working inde-

pendently to train effectively for their future practices. There

has been an increase in the percentage of programs that offer

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SAUK ET AL Academic Radiology, Vol 20, No 3, March 2013

24-hour trained sonographer coverage after hours, which

may partly be due to current campaigns to reduce patients’

exposure to radiation to as little as reasonably achievable.

With the advent of faster and more efficient MR protocols,

it is expected that there will be an increase in the volume of

MR studies performed after hours as well. Currently, 95% of

residents are interpreting MR examinations while on-call.

With more clinicians being aware of the risks of exposing

patients to radiation from CT examinations, there may be

an increase in the volume of MR studies performed.

Combined with the pressures for final reads while on-call

throughout the country, many programs are considering

readjusting how examinations are read on-call. Already,

this survey has shown an increase in the number of programs

that are providing either extended-hour or 24-hour attend-

ing coverage for studies performed on-call from 2009 to

2012. It is uncertain up to what point programs will have

attendings cover the workflow after hours before resident

training is at risk for being compromised. Future survey

results will be needed to provide more information regarding

this trend.

Given the current economic environment and the contin-

ued evolution of health care reform, there is increasing

concern among residents in the United States regarding the

current job market, with nearly all residents in the country

seeking to train in a fellowship before practicing in an aca-

demic or private practice job. Although the impacts of the

economy on the business of radiology remain uncertain, the

majority of residents in the United States think they are either

inadequately or not trained in health care economics, some-

thing that can be considered for change in program curricula

in future years.

A study was conducted in 2007 that demonstrated an expo-

nential increase in the number of CT scans performed during

the past decade, with >62 million CT scans performed in

2007 (20). Hospital coverage and the volume of radiologic

studies are continually changing over the past decade. There

is an increase in the number of programs that cover four or

more hospitals, with an associated increase in the number of

programs that perform >750,000 radiologic studies per year.

This may be due to a combination of factors, including the

increasing use of imaging for patient management and

hospitals needing to support falling reimbursement rates by

merging to support their budgets given the current economic

environment.

The residency class sizes have increased by 29% since 2003.

There is an associated 16% increase in women residents enter-

ing radiology. The reasons behind this pattern are not clear.

However, data from the Association of American Medical

Colleges indicate an increase in the number of women

residents entering other medical specialties such as allergy

and immunology, medical genetics, surgery, and surgical

subspecialties, out of proportion to the small increase in the

number of women residents choosing to enter radiology (16).

Radiology resident benefits continue to increase since

2009. Resident salaries have increased 6.6% and 7% for

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first- and fourth-year radiology residents since 2009, respec-

tively, keeping up with the national inflation rate of 6.9%

and reflecting how sources of funding continue to adapt to

the changes in the economy. Residents are receiving increas-

ing benefits in regard to book and travel funds, conference

fees, and support for attending the AIRP conferences.

Most programs are offering support for residents who

request family leave, with more than half of the programs

taking at least some of the days of family leave from vacation

and/or sick days.

Chief residents continue to be largely responsible for

administrative duties such as schedule generation and curric-

ulum development.With the changes being made for the new

‘‘core’’ examination, chief residents will play an important role

in designing a schedule that matches the needs of residents

preparing for the examination with the program needs to

cover the various clinical services.

In conclusion, the A3CR2 survey provided data on chief

radiology residents’ perceptions concerning residency

training, changes in the curriculum with the new board

examination format, on-call policies, fellowships, and health

care economic trends. The responses provide a tool that allows

for comparison among various training programs and among

different time periods.

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