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1
Department of Diagnostic Radiology, Yale University School of Medicine, 333
Cedar St., SP2-332, New Haven, CT 06520
2
Department of Pediatrics, Massachusetts General Hospital, 14 Fruit St.,
Boston, MA 02115.
3
Research Department, American College of Radiology, 1891 Preston White Dr.,
Reston, VA 20191-4397.
Received August 20, 1999;
accepted after revision September 10, 1999.
Address correspondence to H. P. Forman.
Abstract
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SUBJECTS AND METHODS. All jobs advertised in Radiology and the American Journal of Roentgenology from January 1991 through December 1998 were tracked according to three separate parameters: academic versus private practice, subspecialty, and region. Statistical comparison was made between the first and second 48-month subperiods to identify changes.
RESULTS. Thirteen thousand seven hundred one advertised positions were coded. A dramatic decrease in job advertisements was noted after December 1991, with advertisements falling to one eighth of their late 1991 peak. A recovery has occurred, with advertising now approaching peak levels. Shifts were seen toward more private practice, midwestern location, vascular and interventional, and mammography positions. Declines occurred in the share of positions in California, the Southwest, and several radiology subspecialties. Other trends were noted but were statistically less significant. A strong correlation (R = 0.98) was found between the annual number of positions advertised and radiologists' median incomes relative to those of all physicians.
CONCLUSION. The job market in radiology, much as in other fields, can be tracked in a coincident manner with the use of a help wanted index. Changes in the makeup of radiology practice are important and are identified in a well-constructed index. These findings have validity and can be useful as an adjunct to other information for policy and planning purposes.
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Since 1991, many articles seeking to explain or survey the job market have been published. Hypothetic models that attempt to predict intermediate and long-range shifts have been proposed [5, 6]. Surveys have been used to quantify the current market [7,8,9,10,11,12,13,14,15,16]. All surveys, however, measure findings at a certain time, with little predictive value. At best they are mildly lagging in their measure because of the time needed to enter and tabulate data as they are acquired. By publication, the data are typically 6 months to 1 year old.
A predictive, or at least coincident, indicator of the job market would hold great value to planners, policy makers, medical students planning careers, job seekers, and radiology groups interested in hiring [17, 18]. It is a common practice among economists to use help wanted indexes (HWIs) as a measure of relative supply-demand imbalances in the job market. This practice dates back at least to the 1960s [19]. HWIs are compiled through measurement of column inches or actual column inches or actual counts of positions advertised in newspapers, trade journals, or other postings. Most notable is the "Conference Board" national HWI that is referenced monthly in the business section of the New York Times, Wall Street Journal, and many other similar publications [20].
In 1996, a study by Seifer et al. [21] describing a pilot evaluation of such an index for medical specialties was published; it tracked changes that seemed to match the overall market of the time. No group has compiled an index with a view toward planning and policy. We sought to create an HWI based on advertisements in the two leading radiology journals in an attempt to provide a proxy for relative supplydemand imbalances and to help track changes over time and across subspecialties.
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Rules in coding each advertised position were followed in our study. Advertisements for part-time positions were listed as such but coded as jobs in the overall index. Locum tenens positions were not included in this study. Positions with terms of less than 1 year were similarly excluded from the analysis. Veterans Affairs hospitals were coded as academic centers because most have academic affiliations. If a university-affiliated group described itself as private or partnership track, it was listed as such. Otherwise, university affiliation with academic rank implied academic coding. If a position was distinctly advertised as being split evenly between two subspecialty areas, it was entered as two positions. Otherwise, it was listed under the dominant subspecialty or as "general" if multiple fields were listed. Chair positions were listed as "other" in the category of subspecialty. Chief of service positions at a Veterans Affairs hospital or a smaller hospital affiliate of a larger program were listed according to the subspecialty requirement of the job or "general." If a radiology job was administrative, albeit with a small clinical component, it was listed as "other." Nonradiology jobs were not entered in the database. With the exception of a chair position, jobs that did not include a clinical component were excluded from the database. No attempt to screen for repeated jobs in the same issue was made. If an ad was identified as a duplicate, it was included to remove a potential source of bias.
As shown in Figure 1, the regions of the country used for coding were Northwest (six states), Southwest (seven states), Midwest (13 states), Northeast (10 states), Southeast (13 states and the District of Columbia), and California (separate region). Few positions outside the United States were advertised in these journals.
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The subspecialties that were specifically coded were the following: mammography, thoracic imaging, abdominal and cross-sectional imaging, vascular and interventional imaging, neuroradiology, pediatric imaging, emergency radiology, musculoskeletal imaging, nuclear medicine, and general. Technique-defined positions such as sonography or MR imaging were coded as abdominal and cross-sectional. When an individual position was not clearly definable, then consensus of two of the three coders, one of which was the senior author, was reached. Each coder was first trained by the senior author for intercoder concordance. This training was performed by having 3 months of advertisements in both journals coded and compared with the senior author's coding.
Data were accumulated from each journal and then combined for analysis. Data were further summarized on an annual basis and plotted, for display, on a monthly basis with a 12-month rolling average superimposed to remove or decrease seasonal variation. Rarely, a position could not be coded with all three parameters. In this situation, totals would not sum to the grand total. Statistical analysis included chi-square and univariate linear regression, when appropriate, with p less than 0.05 considered significant.
Finally, we obtained publicly available compensation data from the American Medical Association and calculated the ratio of the radiologists' median incomes to physicians' median incomes. This comparison was intended to measure the change in relative income rather than reflect changes caused by domestic or health care inflation only, which would affect all physicians' incomes. We then tabulated the percentage of change in this ratio for each of the available years. Because of the lag in reporting, data on physicians' incomes are now available only through 1996.
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Figure 2 summarizes the data. On this graph, the jagged line represents monthly data for the two journals combined, and the smooth line is the rolling average. The initial drop in overall advertisements was statistically significant (p < 0.001) from peak to trough, and the resultant increase is similarly statistically significant (p < 0.05). Minor seasonal variation is apparent.
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Table 1 shows raw data and percentage data for the entire database, disaggregated according to academic versus private practice, region, and subspecialty. For this study, non-American positions include Canadian. The category "other" includes administrative and chair positions. Table 2 shows the statistically significant decrease in academic positions relative to private practice positions during the two time intervals. Academic positions decreased from 47% of the total in 1991-1994 to 36% in 1995-1998. Table 3 shows the comparison across the two time periods for each geographic region. Particularly prominent increases in relative job demand occurred in the Midwest, with conspicuous decreases in California and the Southwest. Table 4 is a similar comparison by each specialty. A statistically significant and prominent increase in the percentage of jobs in vascular and interventional radiology and mammography was seen, with a decrease in the percentage in the dedicated cross-sectional and chest positions.
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Table 5 shows the data from our income analysis. It is clear that radiologists' incomes, relative to other physicians' incomes, have varied according to job demand as noted in our HWI and the American College of Radiology (ACR) data on the physician job market. A simple linear regression of the ratio versus the HWI data has an R of 0.98 with a statistical significance of p less than 0.05. A similar regression of the HWI data with the ACR survey data has an R of 0.68 with p less than 0.01. This regression shows that the raw correlation is weaker but that the relationship is statistically significant although only five data points were available for sampling.
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The value of HWIs has been shown for nonphysician sectors of the labor market [22,23,24,25,26]. Their value as an indicator of a current or future job market derives credibility from their continued use over three decades and their strong theoretic underpinnings, including the seminal work by Cohen and Solow [22, 25].
Our data can be further validated in many ways. One of the most compelling is that salaries vary directly with the relative changes in the HWI. In the near future, the current HWI data would predict that, given the recent improvement in the index, radiologists' salaries will increase relative to other specialties. Further, our data have a strong statistically significant correlation (R = 0.68; p < 0.01) with the similar timed data of the ACR hiring survey [11]. This validation was initially used for the national HWIs, and similar confirmation was found in our sample.
Several factors might compromise the validity of this HWI. A change in classified advertising policy (either in fees charged or in formatting) could account for a sudden shift. No such evidence exists in this study for either journal. A sudden change in governmental policy demanding advertising of every position in a particular venue could cause advertising in the venues we examined to either increase or decrease suddenly. Again, this change was not found.
Methods of finding jobs could change in several ways. One obvious alternative is central job bureaus such as those run by the ACR. Another alternative is the movement toward electronic advertising and job searching. Certainly, some change in the role of various job-seeking channels took place in the course of the 8-year period that we studied. In addition, if a particular journal fell out of favor sufficiently, its advertising would be a poor means of finding candidates. This last possibility was clearly not the case in our data. Advertised jobs may not exist. For instance, internal candidates may be chosen ahead of publication of a job advertisement. However, this dynamic would be expected at all times in the job market, and thus the overall trend should not be affected.
These changes could only slowly affect the numbers and would not account for the largescale shifts that we identified. Moreover, no change should produce the pattern of decline and then growth that we found. Also, even if these factors affect the total amount of advertising, none should affect the balance between academic and private practice jobs or among regions or specialties.
Concern about the subjective nature of the coding process may develop. Though we did not seek to establish interobserver variability in our study, our initial experience showed good concordance among the three individuals who participated in the coding process. As previously mentioned, consensus was achieved by two of the three coders (one being the senior author) whenever a question about classification occurred. Any deficiencies in coding should affect the data uniformly and therefore not affect trends.
Our data show large trends and more subtle changes in the mix of jobs. The most prominent trend in the radiology job market was the dramatic decline in positions advertised in the early 1990s and the subsequent rebound. On a monthly basis, the number of jobs advertised decreased to one eighth of the peak level and then increased by the same factor of 8. Although the decline can be ascribed to the growth and fear of managed care, causes of the improvement are less obvious.
One can look to radiology-use data nationwide to reflect on the possible cause of these trends. Although a significant decrease in reimbursement per procedure via Health Care Finance Administration-related Medicare reform and managed-care penetration was seen, the anticipated decrease in use that managed care portendeda phenomenon observers have called "managed cost without managed care" [27,28,29]did not occur. Thus, radiology groups could dramatically reduce hiring to maintain income and to anticipate reductions stemming from managed care. However, as workload per radiologist increased and managed care did not actually curb use, groups could increase hiring. This, anecdotally, is what appears to have happened.
Of course, one can also suppose that supply variables have contributed to the index fluctuations. For instance, changes in the number of radiologists seeking positions, working part-time, or retiring should affect the market substantially. In fact, a recent survey from the ACR found that retirement increased in 1996 although the other supply parameters did not change substantially [11]. Nevertheless, our study does not mean to differentiate among the forces governing supply and demand in the radiology job market but instead focuses on reliably tracking changes in the balance between them.
We have also identified trends in all three dimensions by which we measured the mix of jobs. A trend away from academic positions and to positions in private practice was seen. Our index is limited by the fact that job advertisements and not necessarily job offerings are being measured. The academic setting has a group of available applicants (residents and fellows), so less need exists to recruit outside (other than for equal opportunity purposes) when the job market is weak. This trend could account for a shift toward private practice advertising in radiology employment market downturns. Because fewer jobs, in total, were offered in the second 4-year period we studied than in the first, the apparent decrease in academic positions may reflect this behavior. Nevertheless, the private market in all industries is well known to be more responsive to cyclic changes than the academic [30], and, thus, one might hypothesize that during a cyclic downturn, the number of new jobs in the private sector would decrease more dramatically. Similarly, any rebound might be expected to be more dramatic in the private sector. Our data cannot differentiate among these forces. Informed inference is the best we can offer.
Geographically, several trends can be noted. A strong trend toward positions in the Midwest and a milder, but still pronounced, trend away from advertised positions in the Southwest and California were seen. The advent of managed care in the 1990s and the media-dispersed stories of jobless anesthesiologists likely provoked a national scare among radiologists, with a resulting generalized freeze on new hires. However, real use, reimbursement, and administrative burdens have disproportionately affected the Southwest and California health care markets [31]. Literature consistently suggests that managed care has a negative effect on hiring [31], which likely explains the relative decrease in job offerings in these regions while other less-affected regions rebounded more vigorously.
Across specialties, several trends were found. Easily explainable is the trend toward positions in vascular and interventional radiology and in breast imaging. A dramatic growth, perhaps partly driven by the need for a certificate of added qualification or other certification for performance of the specialty, has occurred in these fields (McClennan BL, personal communication). This need, however, would not explain the relative decline in positions in pediatric radiology. As with other findings in this study, many factors should be considered. Among them is a variation that we cannot quantify in the advertising of jobs by specialty. Pediatric radiology, for instance, relies heavily on nonclassified advertising [32]. The tremendous recruitment of pediatric radiologists in the early 1990s might have "over-stocked the pipeline" [33].
To our knowledge, no formal evaluation of HWIs that reflects on subtrends, such as our current study, has been undertaken. Our study of subtrends is certainly less reliable than the overall trend because of the smaller numbers. Our trends do tend to conform to general changes in the market, as noted previously.
The value of a coincident indicator of the medical job market is high. The demands on medical students to pay attention to the market and the need for policy planners to consider relative supply-demand imbalances when planning expansions or contractions of residency slots make forecasting in medicine as relevant as it is in other fields. The periods of dramatic growth in the health care industry are likely behind us as our country and others seek to contain health care spending and limit the supply-driven influences of physicians and technology [2, 17, 34]. Thus, it is incumbent on our specialty to have accurate information. However, since the publication by Seifer et al. [21] of their work in 1996, no similar studies that rigorously track the medical job market through measuring job advertisements have been performed.
In conclusion, HWI variation can be used to track the job market for physicians. We are not the first group to describe this application, but we are the first to create a long-term index for a single specialty. Substantial supporting data, including trends found by ACR surveys of hiring by radiology practices [8,9,10,11], validate our index. An HWI represents a substantial improvement over existing techniques used to track or approximate jobmarket changes in a medical field. What exists presentlymathematic models and survey instrumentsare variously simplistic, subjective, expensive, and available later than would be desirable. As with all indicators, however, only time can prove the value. In the future, we would like to expand the tracking to include Internet-based formats of advertising positions and to attempt to track real-time changes in regional job markets. With credentialing in institutions becoming more automated and trackable, jobs, and not merely job offers, may be measurable coincidentally, rather than in a lagging manner.
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