Navigating the medical physics education and training landscape

Abstract Purpose The education and training landscape has been profoundly reshaped by the ABR 2012/2014 initiative and the MedPhys Match. This work quantifies these changes and summarizes available reports, surveys, and statistics on education and training. Methods We evaluate data from CAMPEP‐accredited program websites, annual CAMPEP graduate and residency program reports, and surveys on the MedPhys Match and Professional Doctorate degree (DMP). Results From 2009–2015, the number of graduates from CAMPEP‐accredited graduate programs rose from 210 to 332, while CAMPEP‐accredited residency positions rose from 60 to 134. We estimate that approximately 60% of graduates of CAMPEP‐accredited graduate programs intend to enter clinical practice, however, only 36% of graduates were successful in acquiring a residency position in 2015. The maximum residency placement percentage for a graduate program is 70%, while the median for all programs is only 22%. Overall residency placement percentage for CAMPEP‐accredited program graduates from 2011–2015 was approximately 38% and 25% for those with a PhD and MS, respectively. The disparity between the number of clinically oriented graduates and available residency positions is perceived as a significant problem by over 70% of MedPhys Match participants responding to a post‐match survey. Approximately 32% of these respondents indicated that prior knowledge of this situation would have changed their decision to pursue graduate education in medical physics. Conclusion These data reveal a substantial disparity between the number of residency training positions and graduate students interested in these positions, and a substantial variability in residency placement percentage across graduate programs. Comprehensive data regarding current and projected supply and demand within the medical physics workforce are needed for perspective on these numbers. While the long‐term effects of changes in the education and training infrastructure are still unclear, available survey data suggest that these changes could negatively affect potential entrants to the profession.


| IN TR ODUCTION
The past decade has been a period of unprecedented change in medical physics education and training. This period of change followed the widespread implementation of specialized, physics-intensive procedures such as image-guided radiation therapy and intensity-modulated radiation therapy, contributing to a demand for medical physics graduates that was much higher than supply. 1 In a time of increased demand on the quantity of qualified medical physicists required to handle these new technologically complex tasks, an accompanying concern regarding the quality of new entrants to the profession emerged. This concern was, at least in part, spurred by reports 2,3 of relatively low pass rates (53%) on the Part 3 (oral) component of the American Board of Radiology (ABR) exam (www.theab r.org/ic-rp-landing).

A proposed solution was published in a 2000 Medical Physics
Point/Counterpoint article suggesting that graduation from an accredited graduate or residency program should be a prerequisite for board certification. 4    creation of a suitable number of clinical residency positions. In doing so, this report introduced two initiatives that would become accredited alternative training procedures: a professional degree, the Doctorate in Medical Physics (DMP), which contains both didactic and clinical training, and the certificate program, which provides core didactic elements of a graduate degree in medical physics for students with a PhD from a related outside field. The potential impact of the DMP was discussed in a white paper submitted in 2008 by the AAPM Working Group on a Professional Doctorate for Medical Physics. 7 Controversy surrounding the creation of this new degree was summarized in a Point/Counterpoint article published in Medical Physics in 2008. 8 The first DMP program was accredited by CAM-PEP in 2010, and a total of four such programs have been accredited as of June 2017. 9 Furthermore, the models presented in TG-133 suggested the concept of what has become the CAMPEP-accredited certificate program, although the report does not explicitly mention the concept of a program to provide appropriate didactic education for PhD holders in disciplines other than medical physics. AAPM Report 197S, published in 2011, describes the essential didactic elements of medical physics graduate training for those entering through this alternative pathway. 10 The first certificate program was accredited by CAMPEP in 2011, and as of March 2017 there were 24 such programs. 11 In contrast to the situation 10 yr ago, the supply of graduates of CAMPEP-accredited graduate programs is now greater than the clinical demand. 12 While the number of accredited residency positions has increased dramatically in response to the new ABR exam eligibility requirements (Fig. 1, Table 1), so has the number of graduates from accredited graduate programs. 13 There is a significant mismatch between the number of clinically inclined graduates seeking residency positions and the number of positions available. Few question the need for a standardized didactic and clinical training structure, but one might question the process by which we, as a profession, have implemented this standardization. The long-term consequences are still unclear. Collection and analysis of comprehensive data surrounding these issues is required to begin to evaluate their effects, and this effort is now underway by the combined efforts of the AAPM, CAMPEP, the Society of Directors of Academic Medical Physics Programs (SDAMPP), and the ABR.
The purpose of this work is to summarize the relevant statistics and reports addressing the recent changes in the medical physics education and training landscape and to investigate their effects on various aspects of medical physics education, training and clinical practice. Specifically, we present the current statistics regarding medical physics graduate student matriculation, degree types, graduation rates and demographics of initial placement, with emphasis on residency placement. Additionally, we present these statistics in the form of trends in supply and demand of graduates of CAMPEPaccredited programs, the state of the conventional residency pathway, and modern alternatives to conventional residency for clinically oriented graduates. We also suggest standardization of data to clearly communicate this information to prospective students interested in the field of medical physics. We hope the data presented here will help elucidate the current and potential future effects of these recent developments on the medical physics education and training infrastructure and on the profession as a whole.
To corroborate and elaborate upon the above data, statistics from each CAMPEP-accredited graduate and residency program were acquired from every individual program website. 30 Per CAM-PEP Graduate Standard 2.10, 31 accredited programs must "publicly describe the program and the achievements of its graduates and students, preferably through a publicly accessible web site." This information is to be updated annually, and must include admissions statistics for each degree program. In addition, information on the destinations of graduates must be provided, specifically regarding residency and industry positions. 31 A template is provided to programs at http://www.campep.org/GraduateProgramSampleDisclosure Statement.pdf as a courtesy, but programs are free to present the data as they choose, which has led to inconsistencies in the way these data are presented. The vast majority of programs binned initial placement of their graduates into residency, industry, advanced LOUGHERY ET AL.
| 277 degree, and either clinical or academic positions. Placements into research or postdoctoral positions were allocated to "academic" for this report. Those few who were counted as both "academic" and "clinical" were also considered "academic." CAMPEP recently began providing comprehensive program-to-program statistics, collected as survey data for their annual graduate and residency program reports, two provided no data on their websites despite being accredited for several years, and one did not bin its residency placements separately from its clinical placements, prohibiting analysis of its data.
Admissions, graduation, and graduate placement data from the remaining 44 programs were analyzed.
T A B L E 1 Condensed statistics from CAMPEP annual reports, [15][16][17][18][19][20]26,34 lists, 5 and surveys. 14 Source data for these reports were used to track matriculation. Missing data (-) are unavailable due to lack of collection.   15 The residency placement percentage among graduates from accredited programs rose substantially from 2009 (14%) to 2011 (29%), due primarily to an increase in the number of residency spots and also likely due to the widespread acceptance among students that the clinical residency is the best route of preparation for a career in clinical medical physics.

| RESULTS
However, it has remained stagnant since, averaging 27% from 2010-2014 before a sharp rise to 36% in 2015. The growth of CAMPEPaccredited residency programs is also presented in Table 1, with the  reports. 20, 30 We found that program websites accounted for 106 residency spots in 2014, compared with 120 graduate placements reported in the 2014 CAMPEP graduate report. 13 It should be noted that the lack of standardization in reporting makes program website data difficult to interpret. For example, eight residents have been identified as entering industry over the last 2 yr (2013-2014), and four of these were graduates from one residency program, however, it appears from the program website that these graduates are in clinical consulting practice, which most would not consider "industry." Also, only about half of graduate programs sorted their placement data by degree, which makes it difficult for a prospective student to determine whether data are representative of the degree they seek.
Placement from such programs is included in the "All Graduates" row of Fig. 2 but not the rows sorting MS from PhD. Thus, the MS and PhD rows are incomplete data sets.
The percentage of graduates from each CAMPEP-accredited graduate program that placed into a residency program is presented in   Table 3).
Eight of the ten programs with very high placement percentages (placement percentage > 50%) had been accredited for at least 5 yr.
Seventeen of the 21 programs with a placement percentage greater than 30% had been accredited for at least 5 yr.

| DISCUSSION
Whereas these statistics provide a snapshot of the recent changes in the medical physics education and training landscape, further discussion is necessary to put these data into context, to anticipate how they might change in the future, and to determine whether there are potential unintended consequences associated with these changes.  34 To resolve the shortage in nuclear medicine physics residency programs, CAMPEP has agreed to allow a "2 + 1" residency program, which allows for imaging physics and nuclear medicine physics residencies to offer an additional twelve months of training of the other discipline to its residents. 34 Outside of residency program websites, the only data that sort incoming residents into therapy or imaging comes from CAMPEP graduate program reports ( Table 1) The residency placement data per institution presented here must be interpreted with caution as it does not take into account the career objectives of the graduates from that institution. For example, if most of the graduates from a particular program intend to enter non-clinical careers and therefore do not apply for residency positions, the placement percentage for that program will obviously be relatively low. The percentage of graduates who obtained a residency position out of those who applied for them would be a more appropriate indicator of the success of a program that is striving to place its graduates into board certified clinical practice. Unfortunately, we do not currently have these data. We therefore encourage the collection of these data in the future.

4.B | Modern residency pathway
The It is incumbent upon us as a profession to determine whether these rates are acceptable and how current and potential students will interpret and respond to this reality. For the sake of comparison, the match rate for our American PGY1 (post-graduate year 1) physician colleagues historically ranges between 92% and 95%. 38 Many graduate students feel pressured to acquire a PhD to improve their chance of obtaining a residency position. 39 Thus, many clinically oriented graduate students may currently be pursuing or are considering a research degree that they might not want or need to be competitive for a residency position that prepares them for a purely clinical job. While this situation may be unfortunate for students, it is also disadvantageous for the research infrastructure. In  39 Our data suggest the situation is not necessarily unfavorable for an individual student who applies to specific programs, as Mills 40 and Beckham 42 suggest. Forty-six CAMPEP-accredited programs 6 (88%) offer a terminal master's degree that is designed to provide appropriate education for clinical practice. As mentioned above, MS students enrolled in four specific graduate programs have historically had a significantly higher chance (61%) of entering a residency program than their colleagues at the MS programs in the 42 other institutions that offer the degree (22%). Also, they have a much higher placement probability than that for all PhD graduates from CAMPEP programs; however, we are unsure of the percentage of these CAMPEP PhD grads that intend to pursue board certification. These data suggest that the MS degree is still a viable option for clinical practice, with LOUGHERY ET AL.
| 283 the caveat that the clinically oriented student should carefully evaluate the placement data from institutions to which they apply. 35 The "alternative pathway" to the profession, as described by TG-133, 1 has traditionally represented a mechanism for bringing valuable expertise from other disciplines into the field of medical physics. The certificate program was envisioned as a means to formalize the didactic training for such entrants and AAPM Report #197S recommends six areas of core coursework as a minimum requirement for such programs. While the certificate program has standardized the didactic preparation for the alternative pathway and has been rapidly adopted by academic institutions, we must assure that it continues to serve a valuable function for the profession. CAMPEP allows two courses in the topical areas described by Report #197S to be taken during the residency training. Furthermore, many programs have developed online certificate coursework, which may not be ideal for some of these topical areas. As a result, didactic and clinical preparation in medical physics for those entering medical physics residency from certificate programs is relatively modest in comparison to MS and PhD degree holders in medical physics. This is evident in the CAMPEP residency program director survey, to which 100% of respondents prefer graduates of CAMPEP-accredited graduate programs over those from CAMPEP-accredited certificate programs. 23 In December 2016, the AAPM approved the creation of TG-298 "Task Group on Alternative Pathway Candidate Education and Training" to address these issues.

4.C | Alternatives to residency for clinically oriented graduates
Graduates interested in entering clinical practice in medical physics who do not obtain a residency position are faced with either attempting to enter the workforce without board eligibility or finding another job where they can apply their medical physics skills (Fig. 2).
The number of graduates in the "Other" category, which includes unemployment, has risen from 9% before 2009 to 15% in 2015.
While industry is emerging as a proposed path for those who are   12,36,45 additional data will be required to answer this question.
We might expect a DMP program to be an attractive option given that it provides guaranteed clinical training and board eligibility since it incorporates the accredited residency training within the degree program. However, the DMP student typically pays tuition for their clinical training, in contrast to the traditional resident who is paid a salary. As a result, the DMP may be perceived as a wise investment for incoming students since it provides accredited residency training experience as required by the ABR, but the DMP may also be seen as a last resort for graduates who cannot obtain a competitive paid residency. The DMP might ultimately be perceived as simply a very expensive way to obtain a residency spot and ABR eligibility. Despite the increased financial burden, it has been suggested that the DMP graduate will reach higher financial status over a 7-yr plan than other professional doctorates in other fields. 46 Many have been and are currently considering whether the DMP is beneficial to the profession. 8,46 It may be a valuable pathway to the creation of a sufficient number of clinical training opportunities to meet clinical demand and a mechanism to produce more wellrounded entrants by requiring more graduate education than MS degree requirements. One could also argue that it could degrade the foundation of the training pipeline built on the competitive forces that weed out all but the best entrants into the profession, instead allowing those who are willing to pay a very large sum for tuition.
As it was previously noted that the path to a residency position is now largely facilitated by the MPM, it should be noted here that DMP programs exist exclusively outside the match. imagine that a prospective student would look at these data-and at our entire education and training landscape-and see a career path that may not seem worth the level of uncertainty it represents. This would be a serious and negative unintended consequence of the recent changes to the training requirements for ABR certification.
In summary, we, as a profession, should carefully consider the allocation of our training resources. We would be wise to determine approximately how many medical physicists we should be educating and training. Efforts focused on creating an education and training environment that both attracts and cultivates the highest quality trainees will result in the highest quality workforce that will provide the clinical care and create the scientific breakthroughs of the future.
We should also allocate research resources toward future researchers-not as a means to improve the chances of graduates to obtain a clinical residency spot, but to drive meaningful scientific advances. We should consider the effects of the current state of medical physics education and training on our future graduate students and trainees. Our students deserve honesty about the current residency and job market and their relative chances of doing what they want to do with a degree from our programs. They also deserve easily accessible information on potential career paths along with LOUGHERY ET AL.
| 285 data to facilitate their appraisal of the viability of their career plans.
Those of us involved in medical physics education and training should carefully consider the recent changes that have taken place and their effects on the future of the profession. We then need purposeful action to drive the education and training landscape to where we would like it to be. We are unlikely to get there by unguided chance.

| CONCLUSION
We present data from publicly available CAMPEP reports, program websites, surveys, and publications to illustrate and to discuss the wide-ranging changes to the education and training landscape in We have implemented new education pathways, but it is not yet clear how these might affect our training infrastructure. Finally, we have evidence that these uncertainties could influence prospective entrants to the profession and thus the future quality of our applicant pool.