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1
Research Department, American College of Radiology, 1891 Preston White Dr.,
Reston, VA 20191.
2
Boston University School of Public Health, T3-W, 715 Albany St., Boston, MA
02118.
3
Department of Diagnostic Imaging, Brown University Medical School, Box G,
Providence, RI 02912.
4
Department of Diagnostic Imaging, Rhode Island Hospital, 593 Eddy St.,
Providence, RI 02902.
5
Commitee on Radiologist Resources, American College of Radiology, Reston, VA
20191.
Received March 21, 2000;
accepted after revision March 31, 2000.
Address correspondence to J. H. Sunshine
(jonathans{at}acr.org
).
Abstract
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MATERIALS AND METHODS. In early 1998, questionnaires were mailed to all graduates; 65% responded. Results were compared with similar surveys of 1995 and 1996 graduates.
RESULTS. Much as in past years, immediately after graduation 4% of residency graduates and 9% of fellowship graduates spent some time working as a locum tenens, working outside radiology, or unemployed, but by 6-12 months after graduation, 2% or fewer were not employed. The median fellowship graduate's salary was 5% greater than in 1996. Twelve percent of fellowship graduates were in nonownership-track jobs, much the same as in earlier years. Thirty-two percent had one or more of 12 possibly undesirable job characteristics, down from 39% in 1996; 14% not only had, but actually disliked, one or more of these characteristics, much the same as in 1996, but down from 23% in 1995. Multivariate analysis showed that women graduates were more likely than men to have had serious employment difficulties in the immediate postgraduation months; and that graduates having a spouse who also had to find a job in the same area were more likely than others to be in a putatively "seriously undesirable" location or in "holding pattern" employment while looking for something better or more permanent.
CONCLUSION. Unemployment remained very low. Some other indicators of the employment market showed improvement. Factors expected to affect employment outcomesfor example, training program quality or having major nonspouse-related restrictions on job locationhad surprisingly little effect.
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The initial employment experience of newly trained physicians is widely viewed as a bellwether for changing employment opportunities in the profession. This article presents detailed information on the characteristics of the initial employment situation of diagnostic radiology residents and fellows graduating in 1997. We describe employment outcomes and examine the extent of underemployment or unemployment that residents and fellows experienced in the months immediately after graduation. As in the past two surveys of graduates, we focus on circumstances that may affect employment outcomes and initial job satisfactionnotably, graduates' perceptions of training program adequacy, geographic preferences or constraints, and personal characteristics of the graduate. We compare our findings regarding 1997 graduates with findings of previous years and comment on marketplace trends.
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In 1997, as in 1995, all graduates of radiology programs were surveyed approximately 6-12 months after the usual June graduation date. After as many as three remailings, the response rate was 65% for both residency and fellowship graduates (767/1172 and 540/834, respectively), which was similar to the response rates in 1995 and 1996 [13, 16]. In surveys of previous years' graduates, we found no significant response rate differences between men and women. For these reasons, we did not test for gender differences in response rates of 1997 graduates. The small percentage of respondents who said they had not graduated in June were deleted from the data set because they might be at a different stage in the job-seeking process. Data from 731 residency graduates and 509 fellowship graduates were included in the analysis.
Findings are generally reported as percentages. In our discussion, we focus on patterns and differences that are statistically significantthat is, those in which there is at least a 95% probability that observed findings do not arise simply by chance. Table 1 presents estimates of standard errors for findings that are expressed as percentages. Standard errors often are the basis for calculating statistical significance. If no bias results from who responded to the survey, a general rule is that the true percentage of a characteristic for all graduates lies within two standard errors of the percentage found for respondents.
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The item response rate (i.e., the proportion of respondents who provide usable answers to a specific survey question) was quite highgenerally more than 90%. Numbers presented in this article are based on respondents who answered a particular question. Item response rates for questions pertaining to incomes and for follow-up questions that inquire about satisfaction with a job attribute (e.g., "If your job has this feature, do you now like it, dislike it, or feel neutral about it") were lower, approximately 75-85%.
Using multivariate analysis, we investigated factors that may be associated with more or less desirable employment outcomes. Previous research has suggested that the following five physician and training program characteristics might affect employment choice and outcomes: having a spouse-related geographic constraint; having a nonspouse-related geographic constraint; having (by self-report) a major element of the just-completed training program that was "inadequate"; sex; and quality of the training program. This last was assessed subjectively by radiologists who had played a prominent role on the residency review committee, the committee that periodically evaluates each diagnostic radiology residency program. We used multivariate regression analysis (or logit analysis in the case of dichotomous outcome variables) to identify the extent to which each of these five factors independently affected the likelihood of nine specific employment outcomes.
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Status 6-12 Months After Graduation
More than three quarters of radiology residents (77%) went into fellowship
programs after graduation (Table
2). Most others (14%) found employment in a private radiology
group. When asked the most important single reason they took a fellowship
(Table 3), residents evenly
identified that they thought it was necessary to get a suitable job (47%) and
that they wanted additional specialized training (47%). Of the fellows who
graduated, 60% were employed in private radiology practices and 26% took
academic positions (Table 2).
Fellows who graduated predominantly cited wanting additional specialized
training (51%) and necessity in order to obtain a suitable job (40%) as the
most important reasons they had taken a fellowship
(Table 3). These numbers are
virtually unchanged from prior years.
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Overall, graduates' satisfaction with their jobs was quite high, with 81% of fellows and 90% of residents indicating that in general their employment situation "reasonably matched" their training and job goals (Table 2). (For some graduates, the employment situation is a fellowship, and for others it is a job.) Twentyone percent of fellows indicated that, 6-12 months after graduation, they were in "holding-pattern" employment, defined as "a position taken just to be employed while seeking something permanent or a better position." Among residency graduates, 24% indicated that they were in holding-pattern employment. The 1997 figures for holding-pattern employment for residents are significantly better than those reported in 1996, when 36% indicated they were in holding-pattern employment. Part of this difference is possibly attributable to the timing of the survey, however. The 1997 survey captured status 6-12 months after graduation, whereas the 1996 survey reflected employment at 3.5-6.5 months after graduation. By surveying graduates 3-6 months later, it is possible that some graduates who were initially in holding-pattern employment had moved to more satisfactory employment by the later survey date.
Detailed Characteristics of Graduates' Posttraining Employment
Graduates who took posttraining jobs (but not those in fellowships) were
asked detailed questions about the characteristics of their jobs; whether they
initially had sought these characteristics; and given the characteristics,
whether they liked, disliked, or felt neutral about them
(Table 4). The 12 job
characteristics that graduates were asked about were selected because some
observers believe that they are undesirable, although not all would agree. One
example is employment by health maintenance organizations (HMOs). We were
particularly interested in capturing characteristics of jobs that might be
leading indicators of declining employment opportunities, such as a part-time
job or a job at which there are too few patients to remain busy.
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Almost one quarter (24%) of fellowship graduates in posttraining jobs indicated that they had at least one of the first 11 job characteristics listed in Table 4. When being in a location "many people consider seriously undesirable" was added to the list, the proportion of fellowship graduates with one or more of the 12 characteristics was 32% (12% of fellowship graduates in posttraining jobs reported their location was seriously undesirable). This 32% statistic was lower than the corresponding 39% reported in 1996 and the 44% reported in 1995.
There is a fair bit of subjectivity in characterizing what is a location "many people consider seriously undesirable." Almost every location is on someone's undesirable list. Common responses included cold climates, rural or small towns, not on East (or West) Coast, not near (or occasionally near) particular family members. Few graduates in an "undesirable" location sought it, but once in such a location, only half of those there reported disliking it.
The most commonly cited nonlocation job characteristics that were reported by fellowship graduates were "not on a partnership track" in a job in which the concept of being a partner or an owner is relevant (12%), employed by an HMO (5%), part-time job (5%), and too few patients to remain busy (5%). The "not on a partnership track" statistic was 12% in 1996 and 16% in 1995. The number reporting too few patients to remain busy was 9-10% in 1995 and 1996, which was higher than in 1997. In 1997, 2% of fellows reported their job was mostly nights, weekends, or other off-hours. Almost none reported being employed by an equipment manufacturer or by a nonradiology practice.
Most fellows with any given one of the 11 nonlocation characteristics reported that they did not initially seek this attribute in a job, but only about half reported disliking the characteristic. A few exceptions to this pattern are notable. Fellows with part-time jobs predominantly sought part-time employment (85%) and were largely satisfied with the outcome. Also, about half of all fellows who were not in a partnership or ownership track had not been seeking partnership or ownership track employment.
Fourteen percent of fellowship graduates not only had one or more of the 12 job characteristics we studied (including undesirable location), but also disliked one or more of these characteristics that was present in their job. In 1996, the percentage was similar, but in 1995 it was higher: 23%.
Fewer than one quarter of all graduates of residency programs go straight to posttraining employment, so the posttraining employment outcomes for this group might be expected to be less desirable than for fellows. Compared with the fellowship graduates, a larger percentage of residents in posttraining employment (i.e., not in fellowships) report having any of the 11 nonlocation job characteristics (31%), and almost half (49%) reported having any one of the 12 location or nonlocation characteristics. In 1995 and 1996, the corresponding statistics were essentially identical to the 49% in 1997.
In 1997, 19% reported not being on a partnership or ownership track although they were in a practice in which the concept of ownership was relevant. However, as with the fellows, only half of those not on a partnership or ownership track were originally seeking such employment. Nine percent of residency graduates in posttraining jobs were working for an HMO; few of these disliked the situation. Nine percent were in part-time jobs; as with fellows, most had sought this. Nine percent had a temporary job; approximately 90% of these disliked this situation. More than one quarter (28%) of residents reported practicing in what might be labeled a seriously undesirable location; this number is significantly higher than for fellows.
Seventeen percent of residency graduates in posttraining employment both had and disliked one or more of the 12 job characteristics we studied, which was much the same as in prior years.
Specialties
Training in a specialty field is an important part of radiology training.
As in prior years, approximately three quarters of residency graduates
reported that they went on to fellowships.
The most common diagnostic radiology specialty fields (for either graduates of fellowship programs or for those who began a fellowship) were angiography/interventional radiology, neuroradiology, and general body imaging (Table 5). These were also the fields that had been most frequently chosen in 1996. Overall, the distribution of graduates among specialty fields has not markedly changed in recent years.
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We asked radiology graduates how much of their work time they had desired to spend in their specialty field when they began searching for their posttraining jobs and how much time they were actually spending in their field (Table 5). Overall, graduates responded that they had desired to spend 61% of their time in their specialty field but were actually spending, on average, 50%. Although there is some variation in both the desired levels of time and the actual levels across different fields, desired time exceeded actual time in all fields and for virtually all individual respondents. When asked if they were dissatisfied with the actual time they were spending in their fields, however, only 19% reported dissatisfaction.
Salary
Salary trends may reveal important shifts in employment opportunities for
diagnostic radiologists. Salaries typically rise as the demand for physician
services grows, and salaries tend to decrease if the number of trained
specialists exceeds employment opportunities. Salary is an important dimension
in its own right in choice of employment setting and location. Differences
between expected and actual salaries may be indicative of rapidly changing job
opportunities, or of general lack of information about job prospects during
training.
We asked graduates who had a full-time job after training to check off both their expected starting salary and their actual starting salary from a set of categories, with each category generally consisting of a $10,000 range.
Median starting salaries for diagnostic fellows were almost exactly equal to the median expected salary. The 1997 medians were an increase of just more than 5% from 1996 levels for the actual salaries and an increase of 4% for the expected salaries. Inflation between 1996 and 1997 was quite modest; the consumer price index rose approximately 2%. In inflation-adjusted terms, therefore, the initial earnings of just-graduated diagnostic fellows rose by 3%, which is slightly greater than the income increases enjoyed by physicians overall. According to the American Medical Association, inflation-adjusted physician earnings rose by just less than 2% between 1996 and 1997 [25].
The percentage of diagnostic residents going directly into posttraining employment is small; this is not the usual career pathway. Residents' reported median earnings were virtually unchanged from those reported for 1996. Thus, inflation-adjusted median earnings decreased by approximately 2%. Residents' median earnings were 90% those of fellows.
Both residents and fellows had reasonably accurate expectations of their salaries37% of residents and 30% of fellows stated their actual salary was in the same bracket as expected (Table 6). (Recall that brackets generally encompass a $10,000 range.) On average, however, salary expectations somewhat exceeded actual salaries for residents. Only 27% had salaries in a bracket higher than expected, but 36% found starting salaries lower than expected, and fully 30% reported the actual salary was two brackets or more below the expected.
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Although 36% of fellows' actual salaries were lower than expected, this was almost exactly balanced by the 34% who reported earning more than expected. Both women residents and women fellows were more likely than their male counterparts to report that their actual earnings were less than expected.
Rating of Training Programs
The quality of graduates' training programs may affect employment
opportunities. We asked graduates to evaluate the training program they had
just completed on three dimensionsthe quantity of patients or
procedures, the variety of patients or procedures, and the quality of
instructionrating each dimension as good, adequate, or inadequate
(Table 7).
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Responses were similar to prior years, with most graduates satisfied with the quality of programs. However, 11% of residents and 6% of fellows indicated some feature of their program was not adequate, predominantly the quality of instruction. There were no significant differences in these responses between men and women. Graduates who rated any aspect of their training program as inadequate were asked to describe specific inadequacies. Although responses varied substantially, recurring comments suggested lack of attention to teaching, lack of interest in teaching on the part of attending staff, and "menial" tasks delegated to residents.
Employment Searches
The employment search processhow broadly graduates are looking, how
many offers they receive, and so forthcan shed light on the changing
job market. The typical (median) diagnostic radiology graduate made a
reasonably large number of inquiries into employment possibilities (13 for
residents, 20 for fellows), attended approximately four interviews, and
received two offers of employment (Table
7). As these statistics indicate, fellows tended to search more
extensively than residents. In contrast, there was no difference in the
typical number of interviews attended or in the typical number of offers
received between the two types of graduates.
Search patterns were unchanged from previous years for fellows. However, evidence indicates that residents' searches were more successful in 1997 than in 1996. For residents, on average, the number of employers actively recruiting the graduate, number of interviews received, and number of offers received rose in 1997. However, in spite of increased success in job search activities, there was no evidence in the salaries received that the job market for residents had strengthened in 1997.
Geographic constraints are frequently thought to be an underlying factor in explaining differences in salary, job satisfaction, and other characteristics among graduates in any field. With the rise of women in medicine and the growth of professional households, some observers believe that constraints are increasing. We inquired both about needing to find a job for a spouse or companion and about other geographic constraints. This year, for the first time, we asked graduates who indicated they had a nonspouse-related geographic constraint to describe it. Answers varied: not in the Midwest, in the same town as my family, and so forth. Although these types of responses are qualitative and interpretation is subjective, we classified the extent of the constraints into one of four simple categories: small, moderate, extensive, or location-specific. Classification was based on whether the graduate indicated (roughly) that she or he was excluding fewer than 10% of all job markets, 10-50% of all job markets, more than 50%, or that he or she had a specific (single) location where employment was required.
Forty-one percent of residency graduates and 34% of fellowship graduates said they had the constraint of a spouse or companion needing to find a job in the same area. This was the situation for about two thirds of women, but only 32% of male residents and 21% of male fellows. Overall, 64% of residency program graduates and 69% of fellowship graduates indicated that they had some nonspouse-related geographic constraint. All these percentages are similar to those for 1996 graduates. Most (51-54%) of those with nonspouse-related geographic constraints ruled out more than half the United States, roughly 20% (10-50%) ruled out a moderate part of the country, and just fewer than 20% had a specific location where they desired employment. Contrary to the situation with spouse-related constraints, men were more likely to indicate they had nonspouse-related constraints than were women. However, among those with nonspouse-related constrants, the women were slightly more likely to have more extensive geographic limitations (either rated extensive or citing a specific location).
Findings of Multivariate Analyses
We investigated factors that may be associated with employment outcomes
that are more or less desirable. Previous research has suggested that the
following five characteristics of the graduate and his or her training program
might affect employment choice and outcomes: having a spouse-related
geographic constraint; having a nonspouse-related geographic
constraint; having (by self-report) a major element of the just-completed
training program that was "inadequate"; sex; and quality of the
training program, as assessed by experts in the field
[13,
16].
We used multivariate regression analysis (or logit analysis in the case of dichotomous outcome variables) to identify the extent to which each of the five factors independently affected the likelihood of nine specific employment outcomes. The outcomes studied were having spent time after graduation unemployed, working locum tenens, or working outside diagnostic radiology; working in a holding-pattern job; having any one or more of 12 job features (Table 4); working part-time; working for an HMO; not being on a partnership track; working in a seriously undesirable (by self-report) location; going into a fellowship; and going into academia. Note that for the last two outcomes, there is no better or worse outcome, only the hypotheses that various personal or program factors may lead to different patterns in employment choices.
We were unable to identify significant determinants for five of the outcome measures: going into a fellowship; going into academia; not on a partnership track; having any one or more of the 12 undesirable job features; and working part-time. We discuss the other outcome measures in order and discuss only those antecedents that were identified as statistically significant.
Controlling for all the other variables we studied, women were more likely than men to report having spent time unemployed, working locum tenens, or working outside of diagnostic radiology. This relationship held for both the fellowship graduates and the residency graduates. The reported quality of the training program was also independently related to this outcome, but only for fellowship graduates. Other things being equal, fellowship graduates who ranked their training program as having some inadequacies were more likely to have spent time unemployed, working locum ltenens, or working outside of diagnostic radiology. Similarly, graduates who had had one of these severe employment difficulties were more likely to have been in one of the training programs ranked in the lowest quality category by experts in the field, although the statistical significance of this result is marginal (p = 0.08).
Having a spouse-related constraint was the only factor that was significantly related to being in holding-pattern employment or to working in a seriously undesirable location. This relationship held for both residency graduates and fellowship graduates. Women fellowship graduates were marginally more likely than men to be employed by an HMO (p = 0.09).
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The characteristics of residents' and fellows' jobs have remained stable over the past few years. Few significant changes or trends are noted when 1997 responses are compared with those of prior years. The single prominent change from 1996 is that significantly fewer fellowship graduates reported having too few patients to remain busy in 1997. One cannot tell from the survey, however, whether this change reflects an actual increase in workload or more realistic expectations on the part of newly employed radiologists. Other research, however, has found the workload of radiologists has been increasing [26]. The proportion of residency graduates who indicated they had fewer patients than desired did not significantly change.
The employment patterns reported by diagnostic radiology graduates compare favorably on some dimensions when viewed relative to the physician marketplace overall. On the basis of American Medical Association surveys, approximately 8% of patient-care physicians were employed by HMOs in 1997, somewhat more than is true for radiology graduates. Although the number of physicians in the United States employed by HMOs has grown only 1-2 percentage points over the past 5 years, since 1990 the number of physicians starting out as employees of medical practices and remaining employees has significantly increased [27]. In contrast, the percentage of radiology graduates who report they are not on a partnership track decreased in 1997.
Fellowship graduates tend to receive higher salaries than residents who go directly into posttraining employment. Along with graduates' continued sentiment that fellowship training provides desired subspecialty expertise and is valued in the market, these findings suggest that there is significant returnboth intellectual and financialto completing a fellowship. Some observers question whether fellowships (as opposed to posttraining jobs) should count as "employment" for residency graduates. Table 3 shows, in this context, that only a small percentage of these graduates report taking fellowships primarily because they could not find a job. A fellowship has become very much a part of the usual career path.
As more women enter the field of medicine, interest in differences in training and employment patterns between men and women has continued. Among 1997 graduates, 27% of the graduated residents who responded to the survey and 30% of the graduated fellows were women. These percentages are similar to those seen in recent years and are less than the percentage of medical students who are women. Some notable differences in the responses and employment outcomes of men and women were detected in the survey. Female fellows and residents were more likely to report difficulties in employment after graduation. The percentage of female fellows who spent time as locum tenens, working outside radiology, or unemployed was more than three times as high as the percentage of male fellows. However, most women reported that their employment reasonably matched their training and goals (83%), and this number was no different from the response by male fellows.
Female fellows and residents working fulltime were also more likely than their male counterparts to report that actual earnings were significantly lower than expected. (Note that this finding excludes graduates working part-time, of which women make up a higher percentage.) Interpreting differences between expectations and actual salaries is not straightforward because there can be differences either when job markets are particularly good or bad or when graduates lack reasonable information on which to base expectations. Actual earnings of female fellows and residents on average trail those of male graduates. Because women are also more likely to take jobs in HMOs and outside private practice settings, further analysis is necessary to examine the source of differences between earnings and expectations.
For the first time, for 1997 graduates, we undertook a detailed analysis of nonspouse-related geographic constraints in job searches. The results were rather striking, with more than half of graduates with such constraints ruling out more than half the job markets in the United States. Some observers have suggested that the growth of managed care and consolidation among health care providers will force physicians to shift practice locations from those urban areas that have historically been highly desirable to areas that historically have had fewer physicians. It will be interesting to examine whether graduates' perceptions of their geographic mobility will change over time and what trade-offs graduates are willing to make to establish themselves in specific localities.
Also for the first time, we undertook multivariate analyses of factors that contributed to less desirable employment outcomes. We continued to find that spouse-related geographic constraints were linked to less desirable employment outcomes and that graduates who rated training programs as inadequate experienced more employment-related difficulties than did those who were generally satisfied. Although previous simple descriptive analyses had suggested that being female contributed to less desirable employment [16], the multivariate analyses were less definitive, quite possibly because of the link between spousal constraints and gender. That is, the spouse-related constraint, rather than gender, appears to be the causal factor.
These multivariate results need to be viewed cautiously. Graduates rating their training program as inadequate may have their perceptions of inadequacy heightened by poor job outcomes. Moreover, there is a statistical issue: In all, we studied 90 relationshipsnine outcome variables for each of two types of graduates (residents and fellows) with five independent variables studied for each. If relationships were purely random, one would expect four or five of 90 to meet our test for statistical significance (p <0.05). We found seven met this test, which is only marginally more. Thus, most of the relationships we found may be purely statistical artifacts, not genuinely causal relationships. However, a spouse-related geographic constraint was significant in four relationships, and it is thus reasonably clear that the effect of such a constraint is real.
Our conclusion is that the market for radiology graduates remained reasonably stable. There was no indication of erosion in employment rates. Graduated fellows' salaries and job offers to residents were slightly up over prior years. Job characteristics were stable relative to 1996 and showed some improvement relative to 1995. Still, future market trends may be affected by some key changes in the structure of the job market. A significant number of graduates continue to report that they are not on partnership or ownership tracks, although the percentage is less than in 1995. Also, for residentsbut not fellowsactual starting salaries were slightly below expectations.
Data Strengths and Weaknesses
The data from this survey have several strengths. The major strength of the
survey is that it systematically collected extensive data on posttraining job
search and employment characteristics for a large, nationally representative
sample of diagnostic radiology graduates. The size and coverage of the survey
permit us to make reasonably precise statements about employment patterns and
changes, and help put anecdotal evidence on employment and earnings into a
broader perspective. Response rates to the survey and to individual questions
were high, lending credence to the findings. Furthermore, this is the third
successive year that the survey has been conducted in the same general form
and format. Continuity in survey design permits longitudinal analysis of the
changing employment market and gives us greater confidence that changes in
graduates' responses in fact reflect changes in the market environment.
Agreement is good between this survey's data on unemployment and data from a December 1997 survey of program directors [17]. This suggests that graduates who did not respond to this survey were not more likely to be unemployed than those who did, although it is possible that the unemployed were hiding from both surveys.
The data have important weaknesses as well. Some of the responses to questions are subjectivefor example, graduates' rating of the quality of their training programs. Moreover, interpretation of some of the quantitative questions is also open to debate. For example, receiving many job offers may reflect a particularly strong job market, or it may reflect a weak market if the reason for obtaining multiple offers is that many are unacceptable. Comparisons and tabulations require us to assume that the responses of different individuals can be meaningfully aggregated.
The survey was fielded 6-12 months after graduation. This is a few months later than the survey of 1996 graduates (although the same as for 1995 graduates), and the change in timing may account for the decline in the number of graduates who indicated being in holding pattern employment. Hence we are reluctant to suggest that this finding is indicative of a stronger job market. Fielding the survey later might also affect recall on some of the dimensions of the job search and employment expectations, although we found no striking differences in the quality of responses when compared with prior years' surveys.
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