2012 A 3 CR 2 Annual Chief Resident Survey Steve Sauk, MD Mallinckrodt Institute of Radiology

St. Louis AKA The Lou, Mound City, Gateway to the West

Survey Format Confidential online survey (surveymonkey.com) Multiple choice questions (single and multiple answer), free text for additional comments

Survey Purpose Share facts and information about the structure of training programs Use information about resident benefits to increase benefits at individual programs Share opinions of fellow chief residents about important issues facing radiology training Share ideas for how to deal with these important issues

Survey Topics Recurring – Basic Program Information and Resident Benefits – Chief Resident Responsibilities – Call and Outside Hospital Studies – New Board Exam Format and its Impact On: Curriculum, Call System, Fellowships New in 2012 – Ultrasound and MR interpretations on call – Healthcare Reform and its Economic Impact on Residency Programs, Fellowships, and the Job Market – Quality Improvement

Limitations Opinions and estimations Sampling bias (only chief residents included) Duplicate responses from programs with multiple chief residents – We tried excluding them from the data

PROGRAM DETAILS

Participation Results will be available to A 3 CR 2 members by on request Results will also be available to A 3 CR 2 members in the newsletter and on the website THANK YOU FOR PARTICIPATING! Year Individual Responses Unique Programs Number of Responses * Out of approximately 218 programs in the US

Program Size Changes in Size Increase in program size over 9 years – Total # residents increased 29% from 2003 to 2012 – # women residents increased 16% from 2003 to 2012

Hospital Coverage Decrease since 2011 (85%) and ‘09-’10 (80%) More residency programs are increasing # hospitals they cover for training Type of Institution

Volume % Programs with Varying # Radiologic Studies on Selected Years Annual # CT scans (millions) per year* * Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med Nov 29;357(22):

RESIDENT BENEFITS

Resident Benefits Average Amount = $1793 ($300-$6000) % Residents that attend AIRP = 94% Other Benefits: iPads, No healthcare co-pay, Gym membership, Meals

Vacation and Salary Average Resident Salary per Class % Programs vs. # weeks of Vacation Resident Salaries have increased 2.6 % for PGY-2 and 0.7% for PGY-5 since % of programs offer 4 weeks of vacation 34% of programs offer 3 weeks

Family Leave % Programs offering Family Leave % Programs with Family Leave taken from All, Some, or None of Vacation/Sick Days % Programs offering Family Leave % Programs with Family Leave taken from All, Some, or None of Vacation/Sick Days For Pregnant Residents For Significant Others of Pregnant Residents

Family Leave 5/129 programs report that residents can take more weeks of family leave, unpaid. Restrictions Negotiated for programs needs Medical Necessity % Programs Offering # Weeks of Family Leave for Pregnant Residents % Programs Offering # Weeks of Family Leave for Significant Others

CHIEF RESIDENT

Chief Resident Selection % Programs with Varying # Chief Residents Other All attendings Education Committee

Chief Resident Responsibiltities Others Budget management Banquet Planning Serving on Hospital and GME boards “Keeping everybody happy”

Chief Resident Benefits Average Salary Bonus $1932 (0-$7500)

CALL, WEEKENDS, AND ATTENDING COVERAGE

Call and Weekend Coverage Type of Reports while On-Call Short Prelim for Neuro studies only Full Report on Radiographs only Junior resident gives complete prelim report Senior resident gives short prelim report. Depends on time of day, or day of the week

Ultrasound Coverage After Hour Ultrasound Coverage Specific Situations Ob-Gyn Service performs Pelvic US Vascular Surgery Service performs DVT US Resident performs certain studies (RUQ, Scrotal, Renal) In-house Sonographer depending on time, hospital, and day of the week US Studies Performed After Hours

MRI Coverage % Programs Performing MRI Exams After Hours Specific Situations Emergent MR Examinations only “STAT” Examinations only ER or Inpatient MR Exams only Who Reads the MR Examinations After Hours? Specific Situations Residents provide Prelim Reports Telerad service reads MR exams Read only by request (i.e. if clinician calls) Complex cases read by attending only Depends on study (i.e. Cardiac read only by fellows)

Weekend Coverage % Programs Covering Routine Radiology Services Over the Weekend

Readout Process Specific Situations Face-to-face readout for Neuro Studies only Face-to-face readout for junior residents only Face-to-face readout only if there is a question on the study How often are face-to-face readouts performed?

After Hour Attending Coverage Only Neuro studies read by attendings after hours Depends on the day of the week 10% programs plan to implement extended in-house attending coverage (5-10pm) within the next year 7.5% programs plan to implement overnight in- house attending coverage within the next year 55% programs do not plan to implement extended in- house attending coverage

CHANGING BOARD EXAMINATION

Changing Board Examination Sentiment re: New Board Exam Format Disadvantages Expressed  Decreased emphasis on Verbal Communication, an invaluable skill  15 month wait period post- graduation to be board-certified, making it more difficult to find a job Advantages Expressed  Incorporates physics into clinical knowledge  Removes 4 th year hiatus for oral boards prep  Encourages more trainees to pursue fellowships  Allows more focused training during 4 th year

Changing Board Examination Plans to change to the new 3 yr “core” curriculum

Changing Board Examination Plans for 4 th year (Pgy-5) once the new examination is in place Other Plans Continue fulfilling Mamms and Nucs requirements Remediation in sections of poor performance “Mini-fellowships” are optional

Plans for 3 rd years (PGY-4) preparing for the “core” examination Specific Management Issues  2-3 months off the call-pool  Placed on lighter rotations  Afternoons off for 1-3 months  No nightfloat 3-6 months prior to exam  Negotiations with faculty  Any combination of the above Changing Board Examination

Plans for board reviews for the new board exam structure Current Oral Boards Plans for “Core” Exam

FELLOWSHIPS

Fellowships How are fellowship applicants interviewed?

Fellowships What fellowships are the 4 th years (PGY-5) going into?

Fellowships Distribution of Internal vs. External Fellowships (2012) ED Combined Private practice

Fellowships How is your institution planning on dealing with the expected increase in fellowship applicants once the new board format is in place?

Fellowships Sentiments re: Change to limit interviews starting Feb. and offers to external candidates starting May of the R3 year Preference for the fellowship application process Comments: “Encourages residents to stay at their program” “Collides with ‘core’ exam prep”

HEALTHCARE ECONOMICS AND THE JOB MARKET

Healthcare Economics and the Job Market Sentiments about Current Job MarketHave you started looking for a job?

Healthcare Economics and the Job Market SHORT-Term Plans After Graduation LONG-Term Plans After Graduation

Healthcare Economics and the Job Market How the Current Economic Environment and Current Job Market Influences Career Plans* * Similar trend in 2011 What are you willing to compromise to obtain a job?** ** Some not willing to compromise anything for a job

86% feel practices will try to increase their volume to maintain a similar salary despite the lower reimbursement rates 65% feel it will discourage top-tier medical students from choosing radiology – 5% feel it will encourage top-tier medical students to choose radiology 36% feel that practices are going to be looking for radiologists trained in more than one fellowship “Worst possible effect. Game over. Medicine as we know it is done.” Healthcare Economics and the Job Market What effects do you think healthcare reform will have on radiology? Does your program offer some training in healthcare economics and radiology business?

Healthcare Economics and the Job Market 51% programs with # trainees = training “cap” 13% programs with # trainees > training “cap” 16% programs planning on increasing # trainees 4% programs planning on decreasing # trainees 44% programs not planning on changing # trainees Poor economic climate has lead to budget issues at some programs, esp. programs that have more trainees than its training “cap,” paying for a certain # trainees out of pocket.  such programs may need to downsize # trainees

QUALITY IMPROVEMENT AND AUDIENCE RESPONSE SYSTEMS

Quality Improvement How many PQI projects have you taken part in? What does your program do to support residents on PQI projects? How well does your training program prepare you for ABR’s PQI requirements? ABR requires radiologists to document participation in 3 successful PQI projects every 10 years to maintain board certification

Audience Response How often are Audience Response Systems used? How useful are Audience Response Systems?

DISCUSSION

Discussion Program Details Interval decreased number of responses compared to 2011, but increased since 2009 – likely related to shorter time frame to complete the survey this year Total # residents increased 29% from 2003 to 2012, with a proportionately smaller increase in percentage (16%) of women residents from 2003 to 2012 Decrease in university affiliation from 85% to 76% since 2011 Hospital Coverage and Volume – Overall increase in the number of programs which cover 4 or more hospitals since 2005 (44% increase) – 140% increase in programs which read > 750k radiologic studies Reflective of the general trend of higher volume of radiologic studies in the US

Discussion Resident Benefits Interval increase in overall benefits since 2008 – Book funds, conference fees, ABR examination fees, Lead aprons, oral board review course tuition/travel stipend – AIRP coverage varies from %300-$6000 (average $1793), with ~94% residents attending AIRP 2.6% and 0.7% increase in resident salaries since 2009 for PGY- 2 and PGY-5, respectively 90% programs offer 3-4 weeks of vacation Family Leave – 94% and 79% programs offer family leave for pregnant residents and significant others, respectively – 46% and 43% programs offer family leave without taking from some/all vacation/sick days Vast majority of programs offering 6-7 weeks and 1-2 weeks of family leave for pregnant residents and significant others

Discussion Chief Residents 49% programs choose their chief residents by a combination of program director/chair + resident 81% programs have 2-3 chief residents Responsibilities managed by majority of programs – Call schedule*, Rotation Schedule, Vacation Schedule, Curriculum development and evaluation, resident recruiting/selecting, social events, managing disputes*, and teaching residents Responsibilities managed by a minority of programs – attending lecture / conference schedule, medical student teaching, boards review organization, budget management, banquet planning, and serving on hospital/GME boards Majority of programs offer extra time/paid fees for conferences and salary bonus (average = $1932)

Discussion Call, Weekends, Attending Coverage Slight increase in the number of final reports given while on-call with decline in number of oral reports since 2011 Ultrasound Examinations – Who performs them? 59% increase in programs with 24-hour sonographer coverage – may depend on hospital, time, and day of the week 14% decrease in programs with home-call sonographer 23% increase in programs with residents performing ultrasounds while on-call Specific Situations – Ob-Gyn performs Pelvic US – Vascular surgery performs DVT studies – What kinds of studies? all programs perform ED ultrasounds, and 88% perform emergent inpatient ultrasounds

Discussion Call, Weekends, Attending Coverage MRI Examinations – Majority of programs performing Neuro and Body MRs – 54% performing musculoskeletal and vascular studies What indications? Are these read overnight or read the next day? – 95% progams have the on-call resident read the MR examinations over night Type of report variable  prelims, depends on the study Weekend Coverage – Minimal change in % programs covering services over the weekend Majority of programs working full day Saturday 49% programs provide services on a full day Sunday – Why? Increase in radiologic studies would be too overwhelming for the following Monday? Higher demands from clinical services for imaging over the weekend? How much of these examinations change the management over the weekend?

Discussion Call, Weekends, Attending Coverage Read out Process – % programs doing face-to-face readout hasn't changed since 2011 Attending Coverage – 67% increase in 24/7 in-house attendings since 2009 (12%  20%) – 41% increase in extended hour in-house attendings since 2009 (32%  45%) – ~18% programs plan to implement either 24/7 or extended hour attending coverage next year – Why? A result of clinical services demanding final reads during the night? How much resident variance is there?

Discussion Changing Board Examination How do people feel about the new board exam format? – Majority = mixed + negative – Major disadvantages = decreased emphasis on verbal communication and delay in being board-certified Will this affect the clinicians interactions with radiologists? Will this affect the job search after several years? Implementing the 3 year "core" curriculum – # programs with 3 year curriculum have increased 7-fold since 2010 – 17% programs do not plan to change to a 3 year core curriculum – What will 4th years do? Selectives / mini-fellowships Continue normal rotations Less common: start fellowship, fill in deficits from the first 3 years

Discussion Changing Board Examination How will you manage 3rd years preparing for the "core" examination? – 75% programs plan to have them take time out of the call pool or time off-service (increased since 2011) Variable amount of time (1-3 months) – How will they make up for the time off-service or off-call, if at all? – Who will cover for their call?  4th year class? 2nd year class? How will 3rd years study for their "core" examination? – 67% programs are not sure – 15% programs keeping the same internal board review, while there is an general increase in % programs stopping internal board review, to allow time for external review

Discussion Fellowships Large majority of fellowship programs has an early acceptance policy for internal candidates – disadvantage for those applicants in programs without specific fellowships % applicants going into fellowships since 2009: – Decreased: Breast (13%  11%), MSK (19%  14%) Neuro IR (2%  0%) – Increased: Neuro (15%  20%), Peds (2%  5%), VIR (15%  22%) For these fellowships, there is a larger percentage of fellows from outside institutions than from within the same institution

Discussion Fellowships Once the new board format is in place, an increase in fellowship applicants is expected – majority of programs do not plan to expand their programs or are not sure Fellowship interviews will start Feb 2013 with offers given starting May 2013 – Majority agree that the change is more fair, but may be difficult to enforce – strong sentiment about interviews occuring the same time during "core" exam prep – Majority would prefer a common deadline for all fellowship applications (increased in number since 2011)

Discussion Healthcare Economics and the Job Market Increased concern about attaining a job since 2011 – People willing to compromise lower salary over vacation time, location, and call/weekend shifts to obtain a job Majority have not start looking for a job – Short-term, 92% going into fellowships – Long-term, split nearly evenly between academics, private practice, and undecided Similar impact of the economic environment and current job market on residents this year, compared to 2011 – Majority feel little/no influence on career plans – Majority feel that the economy increases the interest in doing fellowship

Discussion Quality Improvement and Audience Response Systems 62% programs feel their training program prepares them for the ABR's PQI requirements – May be reflective of the 75% those surveyed who have taken part of a PQI project this year 36% those surveyed feel audience response systems is valuable

Future Directions Continued impact of new board exam format Continued impact of evolving ACGME duty hour restrictions New ideas for the upcoming academic year in light of the new “core” examination

Thanks! Chief Resident Participants Laurie May at RSNA Gautham Reddy and the A 3 CR 2 Leadership Jennifer Gould and Ron Evens Clint Jokerst, Amy Fowler, Doug Kitchin, Elizabeth Sheybani, and Colin Thompson To Request Data from this Survey: