Domestic and foreign medical residents in the U.S.

 From the Health Affairs blog:

Graduate Medical Education Positions And Physician Supply Continue To Increase: Implications Of The 2021 Residency Match  by Edward S. Salsberg Candice Chen

"With the merger of the Accreditation Commission for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) accreditation system between 2015 and 2020, the “NRMP Main Match” now covers an estimated 96 percent of the physicians entering GME in the US. This post looks at some of the major takeaways from the 2021 NRMP Match including the implications for the physician workforce.

"Serious concerns have been expressed that there are too few residency training positions in the US and that this is contributing to a gap between the number of medical school graduates and the number of training slots, often referred to as the “GME squeeze,” and that this shortage of residency positions is also contributing to a potential future physician shortage. In 2020, the Association of American Medical Colleges (AAMC) released their annual report projecting primary and non-primary care physician shortages between 55,100 and 141,900 physicians over the next decade.

...

"In this piece, we focus on the 35,194 first-year positions offered in the 2021 Match, and the 26,967 US MD and DO seniors actively participating in the Match for a first-year position.  

...

"Key Takeaways

"The Number Of Entry GME Positions Continues To Grow 

"There were 35,194 first-year positions offered in the 2021 Main Residency Match representing an increase of 2.7 percent from 2020. Comparing the combined number of ACGME- and AOA-accredited first-year positions in 2013 with the 2021 data indicates a 24.5 percent increase in positions over the eight years for an annual increase of 2.8 percent (exhibit 1). The net increase of 6,930 first-year positions over such a short period will be surprising to many given the absence of a major new federal funding initiative or change in GME policy.

...

"There Are No Signs Of A Major GME Squeeze For US MD And DO Seniors

"The number of new first-year GME positions is growing more rapidly than the annual number of graduating US medical school seniors. As noted above, the number of first-year positions grew by 6,930 positions at a 2.8 percent annual rate between 2013 and 2021.

...

"International Medical Graduates Continue To Be A Major Source Of Residents And Physicians For America 

In 2021, there were 13,238 active IMG applicants in the NRMP Match of which 7,508 IMGs were matched to first-year positions (excluding SOAP). Overall, IMGs represented 22.5 percent of all applicants who matched to first-year positions. IMGs include two very different cohorts: US IMGs, US citizens who have gone to medical school outside of the US, mostly at for-profit schools in the Caribbean; and non-US citizens who attended medical school in a foreign country, usually their home country.

...

"The numbers of both types of IMGs matched in the Main Match has been increasing slowly (exhibit 2), with 4,356 non-US IMGs and 3,152 US IMGs matching to first-year positions in 2021 (excluding SOAP). Interestingly, while the number matched went up 22.5 percent for non-US IMGs and 17.1 percent for US IMGs between 2013 and 2021, the number of active applicants was more consistent, rising only 5.0 percent and 3.9 percent over the same time period for each group."

How can medical residency candidates be evaluated more reliably?

 Standardized tests as measures of physician aptitude are falling into disrepute and disuse.  Consequently the medical profession needs to develop better ways for evaluators (e.g. med school professors) to communicate information about applicants to residency programs.

Here are two reflections on the current state of afairs in Orthopaedic surgery.

Are Narrative Letters of Recommendation for Medical Students Interpreted as Intended by Orthopaedic Surgery Residency Programs?  by Egan, Cameron R. MD; Dashe, Jesse MD; Hussein, Amira I. PhD; Tornetta, Paul III MD

Clinical Orthopaedics and Related Research: February 25, 2021 - doi: 10.1097/CORR.0000000000001691

"Background: Narrative letters of recommendation are an important component of the residency application process. However, because narrative letters of recommendation are almost always positive, it is unclear whether those reviewing the letters understand the writer’s intended strength of support for a given applicant.

"Questions/purposes: (1) Is the perception of letter readers for narrative letters of recommendation consistent with the intention of the letter’s author? (2) Is there inter-reviewer consistency in selection committee members’ perceptions of the narrative letters of recommendation?

"Methods: Letter writers who wrote two or more narrative letters of recommendation for applicants to one university-based orthopaedic residency program for the 2014 to 2015 application cycle were sent a survey linked to a specific letter of recommendation they authored to assess the intended meaning regarding the strength of an applicant. A total of 247 unstructured letters of recommendation and accompanying surveys were sent to their authors, and 157 surveys were returned and form the basis of this study (response percentage 64%). The seven core members of the admissions committee (of 22 total reviewers) at a university-based residency program were sent a similar survey regarding their perception of the letter.

...

"Conclusion :Our results demonstrate that the reader’s perception of narrative letters of recommendation did not correlate well with the letter writer’s intended meaning and was not consistent between letter readers at a single university-based urban orthopaedic surgery residency program.

"Clinical Relevance: Given the low correlation between the intended strength of the letter writers and the perceived strength of those letters, we believe that other options such as a slider bar or agreed-upon wording as is used in many dean’s letters may be helpful."

**********

CORR Insights®: Are Narrative Letters of Recommendation for Medical Students Interpreted as Intended by Orthopaedic Surgery Residency Programs? by Zywiel, Michael G. MD, MSc, Clinical Orthopaedics and Related Research: April 29, 2021 - doi: 10.1097/CORR.0000000000001780

"With the upcoming transition of the USMLE Step 1 to a pass/fail score, and as we continue to gather more evidence calling into question the current selection criteria used for surgical training, programs are increasingly left to wonder how they can select learners that are most likely to succeed. Similarly, learners are increasingly left wondering how they can appropriately determine whether they are likely to succeed in a chosen specialty.

...

"Going forward, we need more research within the domain of selection criteria for training. This includes identifying more reliable predictors of technical skill, nontechnical skill, as well as performance in independent practice. The failure of most current selection criteria to adequately predict performance suggests that novel, specialty-specific instruments may need to be developed, evaluated, and ultimately incorporated at the medical student level to better predict future performance."

Signals and interviews in the transition from medical school to residency

Late last year I was interviewed by Dr. Seth Leopold, who is a Professor in the Department of Orthopaedics and Sports Medicine at the University of Washington School of Medicine, and Editor-in-Chief of the journal Clinical Orthopaedics and Related Research.   That interview has just appeared ahead of print on the journal's website: 

A Conversation with … Alvin E. Roth PhD, Economist, Game Theorist, and Nobel Laureate Who Improved the Modern Residency Match  by Leopold, Seth S. MD, Clinical Orthopaedics and Related Research: April 7, 2021 - Publish Ahead of Print - doi: 10.1097/CORR.0000000000001758

Here's one part of our Q&A:

Dr. Leopold:You once commented in a Not the Last Word column in CORR® that the Match might be improved if a bit more room could be made for candidates to send “signals” to programs that indicate particular interest[5]; if you could make one change to the Match right now to make it fairer all around, what would that change be?

Dr. Roth: I don’t yet know enough about the whole pre-Match process of applications and interviews to answer that confidently. I’m hoping to gain access to data that will illuminate more clearly how applications lead to interviews, and how interviews interact with other kinds of information to influence what rank-order lists are submitted by applicants and programs. Some of that process is surely in flux, between the pandemic causing interviews to be conducted remotely and the United States Medical Licensing Examination Step 1 going pass/fail. Signaling is a way to address miscoordination in interviewing (such as whether too many interviews are concentrating on too few candidates), but there are other ways the interview process might be broken that might better be addressed by other tweaks in how interviews are organized.

Dr. Leopold:I believe the study you’re proposing here would find a very attentive audience, both in medical schools and residency programs across the country, especially competitive ones like orthopaedic surgery. Based on other kinds of markets you’ve evaluated—I recognize I’m asking you to speculate—what do you think you might find here?

Dr. Roth: Presently, in at least some specialties, many interviews are conducted for each residency and fellowship position. It could be that interviews play a critical role in allowing programs and applicants to assess each other, regardless of the other information they may have. But it could also be that at least some interviews are being conducted “defensively,” because all the interviews that others are participating in make it hard for each program or applicant to predict how likely any interview will lead to a position being offered and accepted in the Match. So, it is possible that there is “too much” interviewing, in the sense that in perhaps predictable ways, some programs are interviewing some candidates they can virtually never hire, and some candidates they would never want to hire. Conversely, applicants are interviewing for some jobs they have hardly any chance of being offered, and some they sensibly think they won’t need to take. Of course, some things can be predictable even if they can’t be predicted by individual applicants and programs with the information they now have available. It might therefore be possible to suggest institutional reforms that would help reduce the uncertainty in deciding which interviews to offer. That might also reduce the number (and costs) of interviews. (In just such a way, the Match helped solve the problem of uncertainty involved in offers and acceptances, back when offers were exploding.) And there’s a possibility that fewer interviews could make everyone better off in terms of expectations, particularly if participants on both sides of the market will feel a reduced need to do so many interviews if everyone else reduces the number they do. But as you say, until we can look into this carefully, I’m just speculating.

The market for radiation oncologists

 Dr. Wes Talcott at Yale points me to some contemporary discussion of the labor force in radiation oncology.  As with a number of other medical specialties, there's a tension between the number of staff needed to prep a patient for treatment and the number of new board certified specialists needed to supervise such treatment. Residents fill the first kind of position, and time and training transforms them into the second.

The contemporary discussion seems to focus on proposals that individual residency programs should reduce the number of residency positions they need to fill, in a decentralized manner, either by offering fewer positions in the Match, or declining to fill positions that aren't filled in the main Match. There is a concern that a coordinated reduction in positions would invite antitrust scrutiny, although other specialties (such as gastroenterology*) have managed that.

Here's an article from the International Journal of Radiation Oncology*Biology*Physics:

Chicken Little or Goose-is-Cooked? The State of the US Radiation Oncology Workforce: Workforce Concerns in US Radiation Oncology by Chirag Shah, MD and Trevor J. Royce, MD, MS, MPH, Published:March 11, 2021 DOI: https://doi.org/10.1016/j.ijrobp.2020.11.056  

"oversupply worries have reached a fever pitch among trainees, with the job market being the primary concern and 52% perceiving an increasingly competitive market10; these concerns have manifested in a precipitous decline in student interest, with 14% of RO residency positions unmatched in the 2020 Match (compared with previous rates of near 0%) and worse numbers expected for the 2021 match."

#####################

Here's a reply, suggesting that the current situation presents an opportunity for the RO profession to remake itself in various ways:

When in a Hole, Stop Digging: In Reply, Workforce Concerns in US Radiation Oncology  Louis Potters, MD, FASTRO, FACR,  Published:March 11, 2021, International Journal of Radiation Oncology*Biology*Physics, DOI: https://doi.org/10.1016/j.ijrobp.2020.12.024

#####################

A different kind of reply is that fewer U.S. medical graduates are applying for RO residency positions in the Match:

No Longer a Match: Trends in Radiation Oncology National Resident Matching Program (NRMP) Data from 2010-2020 and Comparison Across Specialties  by Chelain R.GoodmanM.D., Ph.D.aAustinSimM.D., J.D.hElizabeth B.JeansM.Ed, M.D.dJustin D.AndersonM.D.bSarahDooleyM.D.cAnkitAgarwalM.D., M.B.A.gKarenTyeM.D., M.S.eAshleyAlbertM.D.fErin F.GillespieM.D.iRahul D.TendulkarM.D.kClifton D.FullerM.D., Ph.D.aBrian D.KavanaghM.D.jShauna R.CampbellD.O. Available online 11 March 2021,In Press, Journal Pre-proof International Journal of Radiation Oncology*Biology*Physics https://doi.org/10.1016/j.ijrobp.2021.03.006

"In the 2020 NRMP, 122 US MD senior graduates preferentially ranked radiation oncology, a significant decrease from 2010-2019 (Median [Interquartile Range],187 [170-192], p<0.001). Across all specialties, radiation oncology experienced the greatest declines in the 2020 NRMP cycle relative to 2010-2019 in both the number of ERAS applicants from the US and Canada (-31%) as well as the percentage of positions filled by US MD or DO senior graduates (-28%). Of 189 available positions, 65% (n=122) were filled by US MD senior graduates who preferentially ranked radiation oncology as their top choice of specialty, a significant decrease from 2010-2019 (Median=92% [IQR, 88-94%], p=0.002). The percentage of radiation oncology programs and positions unfilled prior to the SOAP was significantly increased in 2020 compared to 2010-2019 (Programs: 29% versus 8% [5-8%], p<0.001; Positions: 19% versus 4% [2-4%], p<0.001). Despite >99% (n=127 of 128) of US senior applicants successfully matching in the 2020 NRMP, 16 of 24 remaining unfilled positions were filled via the SOAP. Radiation oncology was the top utilizer of the 2020 SOAP, filling 15% of total positions versus a median of 0.9% [0.3-2.3%] across all specialties (p<0.001).

Conclusions

Supply of radiation oncology residency positions now far exceeds demand by graduating US medical students. Efforts to nullify a market correction revealed by medical student behavior via continued reliance on the SOAP to fill historical levels of training positions may not be in the best of interest of trainees, individual programs, or the specialty as a whole."

##################

*The reduction in gastroenterology residency positions was combined with an increase of a year in required training, and this combination contributed to the unraveling of the gastro Match, which has since been restored. See the background discussion in

McKinney, C. Nicholas, Niederle, Muriel and Alvin E. Roth, "The collapse of a medical labor clearinghouse (and why such failures are rare)," American Economic Review, 95, 3, June, 2005, 878-889.

***************

Update: here's a discussion of the RadOnc situation by the Rad Onc Virtual Visiting Professor Network

Match Day 2021 for medical residents

 Yesterday was Match Day, during Covid Year, and the aggregate data are reassuring that virtual (instead of in-person) interviews left the Match, in aggregate, much as before. The NRMP reports on match results, and Thalamus reports on interviews among the largest specialties.

Here's the NRMP press release:

Press Release: NRMP Delivers Strong Residency Match During Uncertain Times

"The 2021 Main Residency Match was the largest in NRMP history. There were 38,106 total positions offered, the most ever, and 35,194 first-year (PGY-1) positions offered, an increase of 928 (2.7%) over 2020. The growth in positions was supported by continued growth in the number of Match-participating programs. A record-high 5,915 programs were part of the Match, 88 more than 2020. In five years, the number of Match-participating programs has increased by 845 (16.7%), spurred in part by the completion of the transition to the single accreditation system for allopathic and osteopathic programs.

"Rather than faltering in these uncertain times, program fill rates increased across the board. Of the 38,106 total positions available, 36,179 filled, representing a 2.6 percent increase of filled positions over 2020. Of the 35,194 first-year positions available, 33,535 filled, representing a 2.9 percent increase of first-year filled positions. Those fill rates drove the percent of all positions filled from 94.6 to 94.9 percent and the percent of PGY-1 positions filled from 94.6 to 94.8 percent in 2021. There were 1,927 unfilled positions after the matching algorithm was processed, a decline of 71 (3.6%) compared to 2020.

...

"Percent of Applicants Matched to PGY-1 Positions Declines Slightly for Seniors; Rates Remain High. With all applicant groups demonstrating increases in the number of applicants submitting rank ordered lists of programs and ultimately matching to first-year PGY-1 positions, the overall percent matched declined modestly for some groups. Specifically, the percent of U.S. MD seniors matched to PGY-1 positions declined from 93.7 to 92.8, and the percent of U.S. DO seniors matched to PGY-1 positions declined from 90.7 to 89.1 percent. Non-U.S. citizen IMGs saw the largest decline, from 61.1 percent in 2020 to 54.8 percent in 2021. The unavailability of medical licensure examinations in the early stages of the pandemic coupled with permanent changes to the scoring and administration of those examinations by the end of 2020 created significant challenges for IMGs this year and likely contributed to the decline. Additionally, changes in clinical rotations may have affected match rates. The overall percent of applicants matched to PGY-1 positions declined from 80.8 to 78.5 percent."

***********

And here's a post from Thalamus, the interview managing service whose motto is "connecting the docs."

Explaining COVID’s Impact on the 2020-2021 Virtual Recruitment Season and NRMP Match Outcomes  March 19, 2021 by Team Thalamus

Here are their concluding remarks:

"1. The number of interview invitations stayed the same.

"2. The number of interviews completed by both applicants and programs went up. 

"3. The rate of interview cancellations decreased. 

"4. And while the candidates receiving the top 20% of interview offers completed more interviews than other candidates, overall applicants and programs both completed more interviews, thereby lengthening rank lists and providing each greater opportunity to match.

"While the slight decrease in match rates is due to a disproportionally larger number of applicants entering the match in comparison to the growth rates of the number of available residency positions, more candidates matched than ever before, because significantly more unique applicants received opportunities to interview.

"And therefore, overall, the match rate held steady as it has had in recent years, driven by its Nobel Prize winning application of the stable marriage algorithm.  

"Of course, there are several factors at play here including where applicants and programs enter preferences of where or whom they would like to match, respectively.  Similarly, given visa restrictions "IMGs were particularly disadvantaged this year more than usual, which lead to their larger resultant drop in their match rate.  There are continued challenges here including increasing the number of positions of available training positions to match a continued acceleration and growth of the applicant pool, and data can help expand upon this work. "

"Overall, the challenges of over-interviewing in GME was not greatly affected by the virtual interview process, and the greatly hypothesized “match crisis” appears to have been avoided.  Yet, this process shed significantly light on a continued systemic problem: Due to a lack of transparency, applicants continue to overapply, and residency programs continue to over-interview, creating a costly and anxiety-ridden process for all.  Data and technology can help change this for the future as COVID leaves its recognizable mark on the medical residency recruitment and match process."

A call for capping residency interviews

 One clear symptom that the marketplace for medical residents is in crisis is the persistent drumbeat of suggestions for how to modify it.  The transition from medical school to residency has become congested, with many applications and interviews preceding the centralized clearinghouse known as the Match (which will yield its results on March 19).  

One way to treat a disease is to treat some of its most obvious symptoms. Here's the latest such proposal, to put a cap on the number of interviews. (Readers of this blog will wonder how those will be coordinated, and a number of proposals have been made including signaling, or a centralized interview match.)  

I'm hoping that data will become available to allow these proposals to be better evaluated, and perhaps to allow a market design that will deal with causes as well as symptoms.

Here's the latest, from Medscape.

Fixing the Match Crisis Starts With Capping Interviews  by Helen K. Morgan, MD

"Concern over the so-called "Match crisis" increases every cycle. This year, pandemic-related changes have shined a spotlight on the skewed distribution of interviews. Thanks to the shift from in-person to virtual interviews, applicants were no longer limited by travel and financial concerns. According to some experts, this has resulted in "top" candidates taking additional slots and subsequently reducing opportunities for others.

"Worry about residency interview distribution has surged, with letters of concern posted by the Association of American Medical Colleges and the American College of Surgeons. Before the start of this season, my colleagues and I modeled the potentially dire consequences of ob/gyn applicants "hoarding" too many interviews in an article published in the Journal of Surgical Education.

The residency application problems exposed by the pandemic aren't going anywhere without action. Establishing a cap on interviews is now clearly necessary...."

HT: Mike Rees

A shortage of medical residency positions

 Rising numbers of American medical graduates, combined with more constant numbers of medical residencies (which are required for medical licensure), leave more graduates of international medical schools unmatched and underemployed, including many Americans who studied medicine overseas.

The NY Times has the story:

‘I Am Worth It’: Why Thousands of Doctors in America Can’t Get a Job.  Medical schools are producing more graduates, but residency programs haven’t kept up, leaving thousands of young doctors “chronically unmatched” and deep in debt.   By Emma Goldberg

"Dr. Cromblin is one of as many as 10,000 chronically unmatched doctors in the United States, people who graduated from medical school but are consistently rejected from residency programs. The National Resident Matching Program promotes its high match rate, with 94 percent of American medical students matching into residency programs last year on Match Day, which occurs annually on the third Friday in March. But the match rate for Americans who study at medical schools abroad is far lower, with just 61 percent matching into residency spots.

...

"The pool of unmatched doctors began to grow in 2006 when the Association of American Medical Colleges called on medical schools to increase their first-year enrollment by 30 percent; the group also called for an increase in federally supported residency positions, but those remained capped under the 1997 Balanced Budget Act. Senator Robert Menendez, Democrat of New Jersey, introduced the Resident Physician Shortage Reduction Act in 2019 to increase the number of Medicare-supported residency positions available for eligible medical school graduates by 3,000 per year over a period of five years, but it has not received a vote. In late December, Congress passed a legislative package creating 1,000 new Medicare-supported residency positions over the next five years."

Economics envy: signalling proposals for the radiation oncology match (to reduce congestion and coordination failure)

 Here's a call to introduce signaling into the resident match for radiation oncologists, explicitly modeled after the signaling used in the job market for economists.

I Need a Sign: The Growing Need for a Signaling Mechanism to Improve the Residency Match

Wesley J. Talcott, MD, MBA , Suzanne B. Evans, MD, MPH, 

Int J Radiation Oncol Biol Phys, Vol. 109, No. 2, pp. 329-331, FEBRUARY 01, 2021, DOI:https://doi.org/10.1016/j.ijrobp.2020.09.008

"Increased attention has been directed toward the radiation oncology interview application process, as the COVID19 crisis threatens to exacerbate its many longstanding inefficiencies.1,  2,  3 A signaling mechanism, by which applicants can send a signal indicating strong interest to a strictly limited number of programs, has been discussed in other specialties to remedy similar inefficiencies4,  5,  6 and will be implemented this application cycle by otolaryngology residency programs. We strongly believe our field should similarly take a leading role on this initiative this application cycle.

Such a system is not novel. A signaling mechanism was introduced in the Economics postdoctoral job market match, which has resembled the Radiation Oncology market in terms of applications submitted per applicant and interview invitations per application. Candidates submitting applications have the option to signal to employers with up to 2 “signals of interest.” These signals are sent through a secure portal associated with the American Economic Association,7 rather than through an extrinsic third party. The instructions for the portal encourage applicants not to send signals to their top 2 programs, but instead to programs who would be likely to factor the signal into their interview invitation decision. 

...

"To improve the interview application process, we recommend granting applicants a strictly limited supply of free virtual “signals of interest” that can be submitted via a monitored online portal. An applicant would be allowed to submit up to 2 signals from this portal to programs of interest. Signals must be limited, as value of these virtual signals comes from their scarcity; strict enforcement of a 2-signal limit means received signals convey credible interest, whereas the absence of an accompanying signal (the case with the vast majority of submitted applications) conveys essentially no information. This system should be free for applicants, to not introduce more financial inequities in this process. The cost to set up the online portal would be minimal given its simplicity, with little overhead once established, and could be shouldered by programs or radiation oncology organizations."

Should college admissions be organized like the medical residency match?

 The Chronicle of Higher Ed asks why not organize college admissions the way we organize the match for residency positions in medicine. (It considers the benefits and glides over the difficulties):

Can Algorithms Save College Admissions?  We’ve tried a system based on competition long enough. It isn’t working.  By Brian Rosenberg

"competition manifests itself in several ways, including large admissions staffs, growing marketing budgets, costly “yield management” consultants, the proliferation of programs, and what some refer to as an arms race in building construction. By far the most expensive and problematic effect of competition has been increasing reliance on what is euphemistically referred to as “merit aid,” which in fact means the awarding of tuition discounts to low- or no-need students in order to persuade them to attend a particular institution.

...

"What if we replaced the current and longstanding admissions process among private colleges with a match process, similar to what has for years been used to match medical-school graduates with residency and fellowship positions? What if, in other words, we used data and algorithms instead of travel, merit aid, and free food to drive college admissions?

...

"A similar system is used by the QuestBridge program, which asks applicants to rank 12 choices among the 42 colleges in the program and then matches qualifying students with a college. In order to qualify for the QuestBridge scholarship, students must enroll in the college with which they are matched.

...

"is the selection of a college on the basis of the friendliness of the tour guide or the cleverness of the marketing truly less random than being matched on the basis of priorities and interests?"

Concerns about remote interviewing for the surgery match

 I don't doubt that every year people are nervous about the residency Match, and worries this year are related to the special situation of the Covid pandemic, in which interviews will be remote.

Irene Wapnir forwards the following:

From the AM College of Surgeons Bulletin: Interview crisis:

It May Be Too Late toAvoid a Crisis in the Surgery Match This Year

Ronald J. Weigel, MD, PhD, FACS; Steven C. Stain, MD, FACS; and L. Scott Levin, MD, FACS, FAOA

Are you hearing that outstanding medical students applying for surgical residencies are being wait-listed for an interview at top training programs? The problem may be yet another unfortunate consequence of the COVID-19 pandemic.

In normal years, programs have cancellations because there is a physical limitation for how many interviews a student can do. This year, the pandemic forced programs to go to virtual interviews, and a small group of top students nationally appear to be filling all the interview slots for the top programs. If this is true, then many of those programs may go unfilled in the match.

For example, if the average number of interviews offered by a program is 100, and these programs are all competing for the same pool of 100 intern applicants, the pool of top students interviewed may be too small to fill all the slots in these programs. Additionally, the current interview process may create disadvantages for minority applicants and students from schools that are not considered "top tier."

With virtual interviews allowing students to interview at a larger number of programs, we may need a different system nationally for the allocation of interview slots, such as rolling acceptances for interviews with students being required to commit only to a set number of programs, which would allow additional students the opportunity to be interviewed. The solution will require program directors and surgical leaders nationally to discuss this issue. It may be too late to avoid a crisis in the match this year.

Surgery Match: Considerations and Possible Solutions

In their article, "It May Be Too Late to Avoid a Crisis in the Surgery Match," Drs. Weigel, Stain and Levin highlight challenges with this year's surgery match. Regarding this, the ACS proposes that program directors, deans and chairs, as well as candidates, consider the following to ensure as fair and equitable a process as possible during this extraordinary time:

Program Directors, Deans, Chairs

• Review the consequences that oversubscribing to slots has to programs and other candidates with students
• Don't offer slots to more candidates until those offered have a reasonable time to respond
• Make lists of candidates of interest who are not interviewed to ensure slots are offered when available

Candidates

• Consider limiting the number of interviews scheduled to a reasonable amount. Consider the impact on your colleagues of taking up too many interview slots—be fair to other applicants
• Release interview slots if you know you will not use them
• Release slots when you have completed enough interviews and experienced reciprocal interest that you are confident you have a well-prepared rank list

 

Unraveling of neurology fellowships

 From the journal Neurology:

Current controversies in neurology subspecialty education: Insight from clinical neurophysiology  by Heidi M. Munger Clary, Michelle Bell  Neurology® 2020;95:669-670. doi:10.1212/WNL.0000000000010754

"Juul et al. help elucidate factors contributing to the unraveling of neurology’s fellowship application market. There has been mounting discontent among neurology residents and residency leadership regarding the timing of fellowship applications. Seventy-eight percent of residency program directors believe that the fellowship application cycle occurs too early, and 87% of residents believe that the process should start no earlier than the second half of postgraduate year 3.4,5 With each subsequent year, it appears that the application process occurs progressively earlier, a phenomenon described in economics as unraveling. This phenomenon is seen in unstable markets and has been described in fellowship applications for other specialties before the establishment of a match."

Preference Signaling for the Otolaryngology Interview Market

 From the journal The Laryngoscope, a thoughtful description of the growing interest in signaling for medical residency interviewing (which I believe will be implemented for Otolaryngology residency positions in the coming year).

Preference Signaling for the Otolaryngology Interview Market

C.W. David Chang MD  Steven D. Pletcher MD  Marc C. Thorne MD, MPH  Sonya Malekzadeh MD

First published: 06 October 2020 https://doi.org/10.1002/lary.29151

"The impact of the coronavirus disease 2019 pandemic extends beyond patient care and into graduate medical education (GME). The pandemic has created disarray in the residency application process. Visiting rotations and residency interviews—two cornerstones of the application cycle—are gone.

"Just as the pandemic has exposed healthcare disparities in medical care, it also shines a light on inequalities with GME. Even before the pandemic, many residency specialties observed a meteoric rise in the number of applications submitted by each applicant. In 2019, otolaryngology applicants submitted an average of 72 applications, an 80% rise over 15 years.1 This increase drives a cycle of programs receiving more applications and students feeling the need to apply more broadly to maintain competitiveness. Students with monetary resources are better able to mitigate match risk through prolific residency application and by traveling for away rotations to cultivate faculty advocates. Financially disadvantaged applicants may find it more difficult to amass influential social capital.

"With the deluge of applications, applicants are unable to distinguish themselves from the crowd. Such dilution impairs the applicants' abilities to credibly convey interests to programs. Similarly, the program director has a hard time selecting candidates from a pool of excellent applicants for interview.

"The interview is a limited resource. Selection committees often react to this scarcity by declining to interview qualified candidates they think (but do not really know) are unlikely to choose their program and instead interview candidates who they think (but do not really know) are more likely to accept an offer. This approach is inefficient.

"Preference signaling is an intriguing solution. Since 2006, the American Economic Association has operated a signaling service to facilitate job interviews for graduate students. This applicant‐initiated concept aligns goals of interested applicants with programs. Students send signals to up to two employers to indicate their interest in receiving an interview. In reviewing their outcomes, signals were found to increase probability of interview, especially for niche scenarios (nongraduate applicants, applications to liberal arts colleges, and small city locations).2 Signaling has received interest among medical residency specialties as well.3, 4

...

"The Otolaryngology Program Directors Organization (OPDO) Council has worked diligently with stakeholders to incorporate their input throughout the development process. We thank members and leaders of the academic otolaryngology community, including the Association of Academic Departments in Otolaryngology (AADO), the Society of University Otolaryngologists (SUO), and the greater community of program directors for their support. We appreciate the guidance and valuable insight from the Association of American Medical Colleges (AAMC)—specifically the Group on Student Affairs (GSA), the Committee on Student Affairs (COSA), and the Electronic Residency Application Service (ERAS)—along with the National Resident Matching Program (NRMP). We are hopeful that signaling will improve the residency interview selection process by facilitating the successful pairing of applicants with programs."

NRMP conference on Transition into Residency: Oct 16-17

I'll be speaking  this morning at the opening session of the (virtual) NRMP conference on Transition into Residency: Conversations Across the Medical Education Continuum

My title will be "The Match as part of the larger system of transition to residency."

One of the topics I expect to discuss is the proliferation of applications and interviews, in the NRMP and also in many of the fellowship matches.

Trading truthfulness for efficiency in the Israeli medical internship market, by Ariel Rosenfeld and Avinatan Hassidim

Too smart for their own good: Trading truthfulness for efficiency in the Israeli medical internship market, by Ariel Rosenfeld and Avinatan Hassidim, Judgment and Decision Making, Vol. 15, No. 5, September 2020

Abstract: The two most fundamental notions in mechanism design are truthfulness and efficiency. In many market settings, such as the classic one-sided matching/assignment setting, these two properties partially conflict, creating a trade-off which is rarely examined in the real-world. In this article, we investigate this trade-off through the high-stakes Israeli medical internship market. This market used to employ a standard truthful yet sub-optimal mechanism and it has recently transitioned to an “almost” truthful, more efficient mechanism. Through this in-the-field study, spanning over two years, we study the interns’ behavior using both official data and targeted surveys. We first identify that substantial strategic behaviors are exercised by the participants, virtually eliminating any efficiency gains from the transition. In order to mitigate the above, we performed an intervention in which conclusive evidence was provided showing that, for most of the interns, reporting truthfully was much better than what they actually did. Unfortunately, a re-examination of the market reveals that our intervention had only minor effects. These results combine to question the practical benefits of “almost” truthfulness in real-world market settings and shed new light on the typical truthfulness-efficiency trade-off."

Here's their description of the prior, inefficient random serial dictatorship rule:

"For about two and a half decades, until 2014, each intern was asked to submit her ranking of the hospitals relevant for her graduation class, and the assignment itself was decided by the RSD mechanism (with a few minor house rules aimed at providing special treatment for special intern groups such as PhD students and parents of young children), which has come to be known as the Internship Lottery. Up until a few years ago when the system was finally computerized, interns physically gathered in a large auditorium and ID numbers were drawn out of a hat. The RSDT mechanism has been deployed since 2014 in an attempt to increase efficiency (Bronfman et al., 2015) (see (Roth & Shorrer, 2015) for a review and discussion on the transition choice)."

And here (out of the sequence in the paper) is a quick description of the new, efficient mechanism.

"To mitigate the fact that the probability vectors induced by the RSD mechanism may be far from optimal, the RSDT mechanism was proposed: First, after each intern submits a ranked list of hospitals, a large number of RSD simulations is performed to approximate the true probability vector for each intern. Then, using a fitted utility function over probability vectors (learned through structured surveys), probabilities are automatically traded between the interns though a Linear Program (LP) which optimizes social welfare. The LP guarantees that each intern’s expected utility (given the utility function) is no-worse than what she had before the trade."

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Related post:

Thursday, March 26, 2015

Redesigning the Israeli Medical Internship Match

Pandemic disruptions in the market for medical residents

 The coronavirus pandemic and associated lockdowns and limitations have stressed a number of labor markets, including the one for new physicians.  Here's an article from the Journal of Surgical Education that suggests that, in a world of online interviewing, the number of interviews might usefully be capped. They also recommend signalling...

The Case for Capping Residency Interviews

Helen Kang Morgan, MD,*,1 Abigail F. Winkel, MD,† Taylor Standiford, BS,‡ Rodrigo Muñoz, MD,§ Eric A. Strand, MD,║ David A. Marzano, MD,* Tony Ogburn, MD,¶ Carol A. Major, MD,# Susan Cox, MD,⁎⁎ and Maya M. Hammoud, MD, MBA

J Surg Educ. 2020 Sep 14, doi: 10.1016/j.jsurg.2020.08.033 [Epub ahead of print] PMCID: PMC7489264

"As a result of the COVID-19 pandemic, residency programs will make an abrupt shift to virtual interviews in the 2021 residency application cycle.1 ... Medical students, medical schools, and residency programs have needed to react to sudden developments such as cancelled clinical electives, delayed or cancelled United States Medical Licensing Exams (USMLE),2 significant limitations on visiting student elective and sub-internship rotations,3 and changes in Electronic Residency Application Service (ERAS) timelines.4 Given this context, applicants may opt to increase their total number of residency applications as well as interviews accepted and completed, especially since they will no longer be limited by travel and cost deterrents.5, 6, 7 Likewise, residency programs are no longer logistically restrained to configure an applicant's interview schedule on a single day, and will have the ability to schedule interviews throughout multiple days and during non-business hours. In-person interactions provided by traditional interview day experiences have historically weighed heavily in determining mutual compatibility8 , 9; thus, both stakeholder groups will be looking to raise their chances of finding a match, including potentially increasing the number of interviews.

This is particularly troublesome given the current state of residency application processes, "fraught with misaligned stakeholder incentives.10, 11, 12, 13, 14, 15 Although the ratio of positions per applicant is higher now than ever before, the number of applications per applicant have risen.16 , 17 These numbers have increased rapidly in certain specialties, with the mean number of applications per applicant in obstetrics and gynecology (OBGYN) rising from 28 in 2010 to 66 in 2019.18 The consequences of application inflation are numerous and include decreased abilities for residency programs to perform holistic review of applicants with increased reliance on metrics such as USMLE scores. Residency programs also need to devote significant faculty and administrative time for the interview processes.19 The consequence of application inflation that will be of crucial importance this application cycle is the growing awareness that a small percentage of applicants has been receiving a disproportionate percentage of interview offers.20 , 21 In the era of virtual interviews, if these applicants choose to schedule all of their interview offers, there is a real potential for detrimental downstream effects to other applicants. This may also lead to a greater number of unfilled residency spots, with a larger number of programs and applicants required to enter into the Supplemental Offer and Acceptance Program. Given the paucity of data to inform best practices, there is a pressing need to model the potential effects of current application processes and applicant strategies in this disrupted application cycle."

...

"All stakeholders urgently need equitable solutions that address both individual and systems-level problems for this coming application cycle and beyond.30 Capping the number of interviews that an applicant can schedule could remedy 1 pressing flaw in current application interview processes. Implementing caps at the interview scheduling stage is preferable to capping at the application stage given the multiple complexities that must be considered such as DO and IMG status, and overall competitiveness. In addition, exceptions may need to be made for individuals participating in the Couples Match. The potential legal implications of mandatory interview caps are in the infancy of exploration. Capping interviews would likely not violate anti-trust laws given that applicants would still have the choice of where they would like to interview, however these issues would need to be further investigated. New measures such as preference signaling mechanisms30, 31, 32 need to be urgently considered in order for programs to be able to prioritize whom to offer interviews. The use of “tokens” would enable applicants to be able to convey interest to a set number of programs; this has been well-described in graduate PhD economics education literature.33 It will be imperative for “fit” to not become a proxy for decisions guided by unconscious bias,34 but instead, for principles of equity and inclusion to guide change during this time of accelerated change."

HT: Marc Melcher

Job matching under constraints by Kojima, Sun, and Yu in the September AER

 From the September AER, the latest in a distinguished string of papers initially motivated by aspects of the clearinghouse for new doctors in Japan:

Kojima, Fuhito, Ning Sun, and Ning Neil Yu. 2020. "Job Matching under Constraints." American Economic Review, 110 (9): 2935-47.  DOI: 10.1257/aer.20190780

Abstract: Studying job matching in a Kelso-Crawford framework, we consider arbitrary constraints imposed on sets of doctors that a hospital can hire. We characterize all constraints that preserve the substitutes condition (for all revenue functions that satisfy the substitutes condition), a critical condition on hospitals' revenue functions for well-behaved competitive equilibria. A constraint preserves the substitutes condition if and only if it is a "generalized interval constraint," which specifies the minimum and maximum numbers of hired doctors, forces some hires, and forbids others. Additionally, "generalized polyhedral constraints" are precisely those that preserve the substitutes condition for all "group separable" revenue functions.

Here's the first paragraph:

"Hiring entities often face various types of constraints. In the United States, firms that receive favorable treatments from governments often promise to hire at least a certain number of workers (Byrnes, Marvel, and Sridhar 1999): floor constraints. In Chinese cities, the household registration system distributes quotas to employers for transferring  employees’ registrations from other places (Chan and Zhang 1999): type-specific ceiling constraints on hiring nonlocals. In rural India, a health subcenter is often required to be staffed by exactly one male and one female (Kapoor 2011): type-specific constraints with exact quotas. These are restrictions on the set of employees that an employer is allowed to hire. Inspired by a classical framework for studying job markets (Kelso and Crawford 1982), this paper studies how all possible restrictions of this type impact the substitutes condition on revenue functions of the employers, a condition known to be critical for the existence and certain regularity properties of competitive equilibria (Kelso and Crawford 1982; Gul and Stacchetti 1999; Milgrom 2000; Hatfield et al. 2019; Kojima, Sun, and Yu 2020a)"

and, from the Conclusions section:

"In a classical paper on the difficulty for rural hospitals in filling all of their positions in the National Resident Matching Program, Roth (1986) concludes that “this maldistribution seems unlikely to be changed by any system that does not involve some element of compulsion, or some change in the relative numbers of available positions and eligible students.” Our analysis suggests that in job matching with adjustable salaries, a compulsion in the form of floor or ceiling constraints may be a possible solution: one of the appealing properties of such a policy is that it preserves the substitutes condition and thus the existence of competitive equilibria under standard assumptions (Kojima, Sun, and Yu 2020a)."

The Canadian Resident Matching Service: a history

 Here's a brief history of the Canadian medical residency match:

Gallinger J, Ouellette M, Peters E, Turriff L. CaRMS at 50: Making the match for medical education [Les 50 ans du CaRMS: jumelage pour l’éducation médicale]. Can Med Educ J. 2020;11(3):e133-e140. Published 2020 Jul 15. doi:10.36834/cmej.69786

Abstract: "Entry into postgraduate medical training in Canada is facilitated through a national application and matching system which establishes matches between applicants and training programs based on each party’s stated preferences.

"Health human resource planning in Canada involves many factors, influences, and decisions. The complexity of the system is due, in part, to the fact that much of the decision making is dispersed among provincial, territorial, regional, and federal jurisdictions, making a collaborative national approach a challenge. The national postgraduate application and matching system is one of the few aspects of the health human resources continuum that is truly pan-Canadian.

"This article examines the evolution of the application and matching system over the past half century, the values that underpin it, and CaRMS' role in the process."

Should residency program rank order lists be kept confidential from the Dean?

Here's the report of a survey of residency program directors in radiology. One issue, not confined to radiology, is the confidentiality of their rank order list for the resident match--confidentiality from their own administrative hierarchy.  The problem with having to show your rank order list to your dean is that it interferes with program directors' incentives to rank candidates in order of true preferences:   Thirty-seven percent felt pressure to match applicants from the top of the rank list in order to improve the perceived “success” in the match."  That is, some of these programs are refraining from ranking the most desirable applicants they interviewed because they worry these people will match to other programs.  This will make their program look bad to the dean (who will ask "how come you have to go so far down on your list?")

“What Program Directors Think” V: Results of the 2019 Spring Survey of the Association of Program Directors in Radiology (APDR) Academic Radiology,  8 August 2020, In Press, Corrected Proof

by Anna Rozenshtein MD, MPH1 Brent D. Griffith MD2 Priscilla J.Slanetz MD, MPH3 Carolynn M.DeBenedectis MD4 Jennifer E.Gould MD Jennifer R.Kohr MD6 Tan-Lucien Mohammed MD, MS7Angelisa M.PaladinMD8Paul J.Rochon MD9 Monica Sheth MD10Ernest F.Wiggins III MD11 Jonathan O.Swanson MD12   Academic Radiology Available online 8 August 2020, In Press, Corrected Proof 

"The Association of Program Directors in Radiology (APDR) surveys its membership annually on hot topics and new developments in radiology residency training. Here we report the results of that annual survey.

...

"Radiology Residency Match: Forty-nine percent of respondents reported that the final rank list is known only to the program administration (PD/APD) and the selection committee, while 27% disclosed the rank list to the department administration and 24% to the institution. Thirty-seven percent felt pressure to match applicants from the top of the rank list in order to improve the perceived “success” in the match."

Gender distribution of medical residents

 Surgeons are still less likely to be women (particularly orthopedic surgeons):

Bennett CL, Baker O, Rangel EL, Marsh RH. The Gender Gap in Surgical Residencies. JAMA Surg. Published online July 29, 2020. doi:10.1001/jamasurg.2020.2171

HT: Irene Wapnir

More applications, from fewer applicants per position in Vascular Surgery residencies

Trends in the 10-year history of the vascular integrated residency match: More work, higher cost, same result
Katherine K.McMackin MD, Francis J.Caputo MD, Nicholas G.Hoell MD, JoseTrani MD, Jeffrey P.Carpenter MD, Joseph V.Lombardi MD
Journal of Vascular Surgery, Volume 72, Issue 1, July 2020, Pages 298-303

"During the last 10 years, the number of vascular surgery integrated residency spots rose from 9 to 60 per year. Most programs offer one spot per year; none offer more than two. The average number of applications received by programs rose from 17 applications in 2008 to 63.8 in 2017. The average rank list depth needed by programs to fill the spots has not increased (range, 2.5-5.1; standard deviation, 0.73). The proportional depth of the applicant pool decreased from 4.6 U.S. and Canadian applicants for every one residency spot in 2008 to 1.7 applicants for every one residency spot in 2017. Applicant quality metrics were available for 2 years (2014 and 2016). Step 1 scores (237/239), Step 2 scores (250/250), research experiences (3.7/4.2), and volunteer experiences (5.9/5.5) remained nearly unchanged. The number of contiguous ranks for matched applicants remained stable (12.3/12.8).

"Conclusions:
The current system promotes multiple inefficiencies, resulting in application glut. Fewer applicants are flooding programs with an increasing number of applications. More money is being spent on Electronic Residency Application Service applications without changes in the number needed to rank by applicants or programs to achieve a match. There is no improvement in the quality of the applicant. Should these trends continue, they represent an unsustainable model for resident selection."