Saturday, March 7, 2020

More proposals for reducing applications and interviews before medical resident matching

If the number of proposals for reform is an indicator of a brewing problem (and I think it is), it's time to think about the various application and interview processes that precede the NRMP resident match.  Here are three more...

J. Bryan Carmody (2020) Applying Smarter: A Critique of the AAMC Apply Smart Tools. Journal of Graduate Medical Education: February 2020, Vol. 12, No. 1, pp. 10-13.

"Medical students today submit more residency applications than ever before. This trend is costly for students and imposes a substantial burden on program directors. Yet, despite a steady increase in the number of applications submitted per applicant, overall match rates have not improved.1 Put another way, applicants could collectively apply to fewer programs than they do now—and enjoy essentially the same overall match rate.

To assist students in determining the optimal number of residency programs to which they should apply, the Association of American Medical Colleges (AAMC) unveiled Apply Smart in 2016. The website notes that “there is a point where the relationship between the number of applications submitted and the likelihood of entry into a residency changes,” and suggests that students should consider limiting their applications at this point of diminishing returns.2 Responses to Apply Smart have been positive, with deans and program directors praising the tools and encouraging their use in counseling medical students.3–6

At first glance, the Apply Smart analyses seem highly informative. Yet, closer inspection reveals methodologic issues that introduce bias and suggest the need for improvements.
"Overapplication is costly, for applicants and programs alike. Given the incentives for medical students to overapply, it is unclear whether informational strategies alone can curtail overapplication. Until graduate medical education leaders are willing to support application caps or a fundamental restructuring of the Match to better allow signaling between applicants and programs,13 it is imperative that informational strategies present unbiased data that can aid students in applying to an appropriate number of programs. We cannot be satisfied for students to Apply Smart—we need to help them apply smarter."


Joseph G. Monir (2020) Reforming the Match: A Proposal for a New 3-Phase System. Journal of Graduate Medical Education: February 2020, Vol. 12, No. 1, pp. 7-9.

"The National Resident Matching Program (NRMP) was originally devised in 1952 to bring order to the chaotic residency application process.1 It currently has 2 phases: The Match and the Supplemental Offer and Acceptance Program (SOAP). Applications are submitted through the Electronic Residency Application Service (ERAS). While this is a significantly superior system to its predecessor, it is not flawless. As both residency applicants and positions have become more competitive, the flaws of the current system are becoming increasingly problematic for all involved parties.

"Despite evidence that applying to a greater number of programs does not improve Match rates,2 applicants feel pressured to apply to more and more programs to avoid going unmatched. In 2018, each applicant submitted a mean of 90.6 applications (mean of 60.3 for US graduates and 136.4 for international graduates).3 Applicants feel forced to accept interviews at programs which they have minimal interest in attending, to the detriment of other genuinely interested students. This, in turn, pressures other applicants to do the same lest they be disadvantaged. Whipple et al confirmed this vicious cycle using their computer model for competitive residencies, where they found that applying to the maximum number of programs “led to a poor result for the majority of students when all applicants undertook the strategy.”4

"As a result of this vicious cycle, residency programs are inundated with an average of 996 applications per program5 and have few reliable methods of identifying which of those applicants would seriously consider training there. Interviewing applicants who have no desire to attend that program is a costly endeavor. Gardner and colleagues found that, when accounting for both material and personnel costs, programs spent on average $18,648 ± $13,383 per open position and $1,221 ± $894 per interviewee.6

"Applying so broadly is costly for applicants as well. Fogel et al7 found that 84% of applicants believed residency interviews were too expensive, with 64% of applicants spending at least $2,500, and those entering competitive fields spending considerably more. In a study of orthopedic surgery applicants, for example, interview costs averaged $7,119 (range $2,500–$15,000).8 These figures do not include the cost of the applications themselves or externships, making the total residency application cost significantly higher.

"It is clear that the current system is fraught with inefficiency and that all involved parties would be better served by a system where applicants only apply to the programs they would seriously consider attending.

"The 3-Phase System
Transitioning the Match to a 3-phase process as outlined below could address the aforementioned problems.

"Phase 1
This phase would run from September through December and would function the same as the Match is currently. However, applicants would be limited in the number of positions for which they could apply. The results of Phase 1 would be e-mailed to applicants in the beginning of January. Most interviews already occur within this time frame, so most programs could continue using the systems they have in place. The majority of positions would be anticipated to fill in Phase 1.

"Phase 2
This phase would run from January through March. Those who do not match in Phase 1 would proceed to Phase 2. This would again function like the current Match, with applicants applying to open programs, attending in-person interviews, and submitting a rank list. There would be no cap on the number of Phase 2 applications, allowing applicants to apply broadly. The results of Phase 2 would be e-mailed to applicants in March. The majority of unfilled positions from Phase 1 would be expected to fill in Phase 2.

Phase 3
This phase would be the current SOAP week, with daily rounds of interviews and offers. The number of applicants and positions entering the SOAP would likely decrease significantly."

Plast Reconstr Surg. 2019 Feb;143(2):634-639. doi: 10.1097/PRS.0000000000005254.
Solving Congestion in the Plastic Surgery Match: A Game Theory Analysis.
Molina Burbano F1, Yao A, Burish N, Ingargiola M, Freeman M, Stock J, Taub PJ.

Plastic and reconstructive surgery is among the most competitive specialties in the residency match. Applicants seeking to maximize their chances of a successful match often submit numerous applications to the National Residency Matching Program. It is not uncommon for those applying to plastic and reconstructive surgery to apply to every program. The high application volume imparts significant time and financial burden for applicants and programs alike. Furthermore, it makes distinguishing between applicants with a genuine interest in a specific program and those who are merely hoping to improve their chances vastly more difficult. The authors sought to characterize trends in the match rate, as the number of integrated plastic and reconstructive surgery programs continues to increase. Furthermore, they reviewed the literature on game theory for possible solutions to residency application congestion. The authors propose the use of the game theory model to explain the observed results and show why an application limit is the most reasonable approach to address this issue.

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