September 29, 2022

On September 28, residency programs across the United States will begin scouring vast numbers of applications to find next year’s class of medical residents. So, after years of intense coursework and demanding rotations, tens of thousands of medical students are staring down an extremely unnerving question: Will they land a coveted residency slot to complete their training?
“Naively, I thought getting into medical school was the last big hurdle, but people start talking about getting into a residency during first year,” says Rachel Kudrna, a fourth-year student at Elson S. Floyd College of Medicine of Washington State University (WSU) in Spokane. “There’s tons of anxiety. It feels like after working so hard to become a physician, it could all still fall apart.”
Such fears are fueled partly by some basic statistics. While the number of U.S. medical school matriculants has increased by 23% in recent decades, residency slots have not kept pace because of caps on government funding for them. There has been some progress around slots, with Congress approving funding for 1,000 new ones, but the AAMC and other institutions continue to urge additional expansion.
Meanwhile, although most applicants land a residency position — 93% of MD seniors did so in the National Resident Matching Program® Main Match last year, for example — some do not.
That has candidates filing a growing number of applications. In 2021, U.S. medical school graduates submitted 72.8 applications on average per person, up 24% from 2017.
“It’s heartbreaking because this involves so much money and effort. Even though we advise students not to do it, they do it anyway,” says Leila Harrison, PhD, WSU senior associate dean for admissions and student affairs.
On their end, programs are deluged with applications, often receiving upward of a thousand for 30 spots.
Those numbers make it hard for program directors to identify which applicants are truly serious about joining their institution, and it impedes holistic review. “Decreasing the number of applications can help improve equity in recruiting by making it more feasible for all programs to holistically review applicants,” says Becky Blankenburg, MD, MPH, immediate past president of the Association of Pediatric Program Directors and assistant dean of graduate medical education at Stanford School of Medicine.
“There’s tons of anxiety. It feels like after working so hard to become a physician, it could all still fall apart.”
Rachel Kudrna
Fourth-year medical student
Elson S. Floyd College of Medicine of Washington State University
And the number of applications isn’t the only issue. Applicants hoping for crucial residency interviews face additional stresses, including a need to respond almost immediately to invitations for fear that someone else will grab them.
To address such application-related concerns, experts have been researching, drafting, and debating numerous possible solutions. In one prominent effort, the Undergraduate Medical Education-Graduate Medical Education Review Committee (UGRC) released a 276-page report last year after 10 months of in-depth discussions with varied stakeholders.
Given the many goings-on, it can be tough to sort through the various application-related reforms. Below, we describe three efforts that have been getting significant attention — “preference signaling,” interview-related reforms, and possible application caps — their prospects, and what they may mean for all involved.
Amid a wave of applications, a residency program wants to invest its interview capital in applicants who are seriously thinking about training there. And students crave a way to signal such interest.
Enter preference signaling. Begun in 2020 in otolaryngology, the approach is fairly straightforward. Applicants receive a certain number of signals — it varies by specialty, but usually around five — to indicate interest in particular programs.
Last year, the Electronic Residency Application Service® (ERAS®) also began offering preference signaling, through its new supplemental ERAS® application. It started with three fields — dermatology, general surgery, internal medicine — and now has expanded to 13 more.
“Initially, a lot of students were groaning about having one more thing to do,” says Yoel Benarroch, a Boston University School of Medicine (BUSM) student applying in internal medicine. “But overall, anything that increases transparency is beneficial.”
Some observers worry that such transparency is too one-sided, though. “Students are signaling, but programs aren’t sharing enough information to help candidates decide where it makes the most sense to apply and signal,” says Angela Jackson, MD, BUSM associate dean for student affairs.
Some involved also argue that asking applicants to choose signals before attending interviews is akin to choosing a spouse before having a first date. “Students often don’t know much about a program until they interview. I worry there will be students who would be a fabulous match for a program but don’t signal it because they don’t know that it will be fabulous,” says Jackson.
Yet early signaling makes perfect sense, says David Chang, MD, a professor of otolaryngology at the University of Missouri School of Medicine in Columbia who has been involved in implementing and studying otolaryngology’s signaling effort. “The greatest narrowing of candidates occurs at the interview selection phase, so you need to impact the interview offer,” he says.
So far, otolaryngology’s signaling effort is clearly having an impact, research indicates. “By signaling an institution, you improve your chances of getting an interview by 260%,” says Chang.
AAMC research on the ERAS® signaling effort also has yielded interesting results.
For example, more than half of responding programs said signals helped highlight candidates they might otherwise have overlooked, notes Dana Dunleavy, PhD, director of the AAMC’s admissions and selection research and development program. What’s more, the data showed that signaling increases the likelihood of an interview invite for all applicants — regardless of race, gender, or applicant type such as graduates of international medical schools.
In fact, preference signaling looks so promising that ERAS® is moving it from the supplemental application to the main one in 2023 and is inviting all specialties to participate.
“By signaling an institution, you improve your chances of getting an interview by 260% [research in otolaryngology suggests].”
David Chang, MD
University of Missouri School of Medicine
Looking ahead, experts hope to identify the best number of signals for each specialty. Provide too few signals, and some programs won’t receive enough to help with their selection process. Too many, and signals start to become meaningless.
So the experimentation continues. For example, OB-GYN is trying a two-tier system, with three gold and 15 silver signals. The hope is that providing more signals will reassure applicants that they’ll land interviews, allowing them to reduce the number of applications they submit, says Maya Hammoud, MD, MBA, an OB-GYN at Michigan Medicine in Ann Arbor. “At the same time, we want to give applicants the opportunity to highly focus on certain places within the larger range.”
Whatever the number of signals, Dunleavy cautions program directors not to overemphasize them. “This is just an indicator of interest,” she says. “It’s not an indicator of how likely someone is to be successful at or satisfied with your program.”
The quest for program interviews — without which applicants won’t move on to residency — is inherently stressful. But the interview invitation process itself often intensifies applicant anxiety.
Among the stresses are the first-come, first-served nature of the process.
“Applicants feel tied to their phones so they can respond immediately to invites, and that could go on for many weeks,” says Ilana Rosman, MD, dermatology residency program director at St. Louis’s Washington University School of Medicine. Often, Rosman adds, students sacrifice sleep or learning to monitor incoming invites.
Experts point to another concern: interview hoarding, in which applicants accept invitations from programs low down on their priority list. Doing so can waste a program’s time and take invitations away from other, less competitive applicants who need them.
All this has leaders rolling out various invitation-related innovations.
One popular experiment is common invitation release dates. This approach, which roughly half of large specialties are trying, means an applicant can weigh all invitations at once and choose the ones they truly want.
Several specialty organizations also have begun advising a standard, reasonable RSVP timeframe. Surgery recommends giving candidates a minimum of 48 hours, for example. So far, the guidance seems to be sticking: Last year, 97% of surgery programs implemented that response time.
In addition, many programs in surgery — as well as several other fields — have recently agreed to limit the number of interview invitations to the number of interviews actually available. “Some programs understandably have wanted to make sure all their spots for interviews fill, so they offer 30 invitations when they only have 20 spots,” says Hammoud. “It’s like airlines overbooking, which isn’t very considerate.” In this case, applicants often wind up on a waitlist, hoping they’ll eventually get a slot should someone cancel.
Then there’s the possibility of the most dramatic interview-related reform: caps.
So far, only ophthalmology has tried that approach. In 2020, concerned that virtual interviews — enacted as a COVID-19 precaution — would spark runaway interview acceptances, the specialty agreed to cap interviews at 20 per applicant.
“Prior data show that in ophthalmology, if you get at least 12 interviews, you can be confident that you’re going to match,” says Fasika Woreta, MD, MPH, ophthalmology program director at Johns Hopkins University School of Medicine in Baltimore. “And since starting caps, we’ve seen no negative impact on match rates.” In fact, this year, the cap was lowered to 15.
Woreta considers interview caps an obvious choice for ophthalmology since it has just one interview scheduling portal, but says other fields without such a platform might struggle to enforce caps. In addition, each specialty would have to assess their own Match® data to calculate the minimum number of interviews necessary to match in that field.
Whether or not caps are the answer, the interview process certainly needs reform, observers say.
“Programs spend six months of the year involved with some aspect of the interview process,” says Blankenburg. “We want to minimize that time so that programs can focus more on their current residents and helping them become the best physicians possible.”
Of the myriad possible changes to the residency process — last year’s UGRC report had 34 of them — one that gets a large chunk of attention is application caps.
The upsides seem obvious. Caps would halt the applications arms race, reducing effort and expense for candidates. They would also allow programs to conduct more thorough reviews of applications.
“Although preference signaling does help determine genuine interest in our programs, with caps, the application itself becomes the signal, which is what it should be,” says Rosman.
AAMC researchers have now spent a year exploring the possible effects of application caps. To do so, they used computer models and data on the number of applications a candidate submitted along with their likelihood of entering residency.
“We wanted to see if we could significantly reduce the number of applications without reducing residency entry rates while also remaining fair,” explains Dunleavy.
So far, the results point to some downsides. “Our research suggests that caps disadvantage international graduates, doctors of osteopathic medicine, and applicants with lower scores on their first major licensing exam, which for MDs is USMLE Step 1,” Dunleavy says.
In addition, other concerns arose during in-depth AAMC focus groups with applicants. Oddly, some conversations suggested that caps might not ultimately reduce the total number of applications.
“Say a student could afford 50 applications, and one specialty allows 20 maximum. To mitigate the perceived risk of fewer applications, that student might pursue an even more worrisome strategy. They might apply in an additional specialty that doesn’t genuinely interest them,” says Dunleavy.
“Another possible issue is that some candidates who would have applied below the cap would now feel pressure to meet it. Given such concerns, we need to tread carefully,” she adds.
“It’s great to recognize that we all have the same goals. We all want an effective process for everyone involved.”
Kathleen Kashima, MD
University of Illinois College of Medicine
Gabrielle Campbell, MBA, LLM, AAMC chief services officer, advises careful thought generally when it comes to application-related changes. “We want to make sure that interventions are evidenced-based and that they support the greatest number of people across all stakeholders,” she says.
Meanwhile, students, advisors, and residency directors plan to keep exploring various possible reforms. For example, the AAMC recently hosted a two-day brainstorming workshop that covered such topics as ways to provide candidates with more robust information about programs.
Many involved say they appreciate the opportunity to build mutual trust and seek solutions that work for both programs and applicants.
“It’s great to recognize that we all have the same goals,” says Kathleen Kashima, PhD, senior associate dean of students at University of Illinois College of Medicine in Chicago, who participated in the meeting. “We all want an effective process for everyone involved.”
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