Medical schools across the specialty spectrum are reporting increasing numbers of student applicants, overwhelming residency programs and heightening anxiety among graduates. In response to growing competition for limited spots, more individual students are applying to multiple programs, often with fit as a secondary consideration—which, in turn, increases the number of annual applicants for each program to review and consider.
What are today’s residency programs doing to counteract this challenging snowball effect? They’re getting innovative, developing recruitment tools with an eye toward achieving high-performing residency classes whose trainees are a suitable fit for their programs’ culture and mission.
Although such steps have been needed for some time, COVID-19 seems to have sped up development. “The medical education environment was already evolving and changing, and COVID presented an opportunity to improve the system. Many medical and surgical specialties explored and implemented unique programs or initiatives,” said Sonya Malekzadeh, MD, residency program director and professor of otolaryngology–head and neck surgery at Georgetown University Medical Center in Washington, D.C. Moreover, these specialties are taking cues from each other, incorporating numerous practices to employ in their own programs to everyone’s benefit. The common goal is to achieve the best matches by providing less stressful and more promising pathways to placement for applicants, and a more effective and holistic recruitment review process for programs.
Supplemental and Specialized Applications
Today’s high volume of applications means more time and money spent, not to mention increased stress. But that’s not all, said Ilana Rosman, MD, associate professor in internal medicine (dermatology) and pathology and immunology, and dermatology residency director at Washington University School of Medicine in St. Louis. “The volume also contributes to suboptimal outcomes, particularly related to applicant–program fit and medical education,” she noted. “Students often feel pressure to pursue activities they perceive as more valuable to programs to match at the expense of following their own passions and interests. Programs have difficulty determining which applicants have a genuine interest in their program.”
To help address these challenges, the dermatology specialty participated in the supplemental Electronic Residency Application Service, or ERAS, application pilot program offered through the Association of American Medical Colleges. “Completed in addition to the traditional MyERAS application, the supplemental application asked applicants to describe their five most meaningful activities or experiences and allowed them an opportunity to provide additional information about their journey to residency,” Dr. Rosman explained. “They were also able to denote up to three preferred programs and three preferred geographic regions.”
Students often feel pressure to pursue activities they perceive as more valuable to programs to match at the expense of following their own passions and interests. Programs have difficulty determining which applicants have a genuine interest in their program. —Ilana Rosman, MD
According to Dr. Rosman, the supplementary application proved useful. “Certain qualities, including sustained engagement in activities, leadership experience, and commitment to diversity and inclusion are important to us,” she said. “It was easier to identify applicants with these elements.”
The plastic surgery specialty applied a different application approach to residency recruitment through a piloted process called the Plastic Surgery Common Application (PSCA). Built separately from the ERAS, the PSCA was administered at no cost to applicants. “We believe that applying to residency shouldn’t be prohibitively expensive,” said Brian C. Drolet, MD, an associate professor and vice chair of education in plastic surgery and program director of integrated plastic surgery residency at Vanderbilt University School of Medicine in Nashville. “Cost is a major barrier to many residency applicants, and there are major equity issues inherent in the current process. The PSCA seeks to eliminate these financial barriers.” The goal, he added, is to ultimately use the PSCA only, “and save applicants an average of $1,500 in application fees.”
The PSCA was strategically designed to focus on quality over quantity. “ERAS applications can be 50 pages or longer, and many plastic surgery programs will get more than 300 applications for one or two positions,” Dr. Drolet said. “There’s no way that programs can look holistically at applicants; instead, they’re screened by arbitrary and often inappropriate metrics. We think that students should focus on depth of engagement and demonstrate truly meaningful accomplishments.” He believes the best way to find a good match is to “interview a group of applicants who demonstrate a strong likelihood upfront, and that only happens when applications are reviewed holistically rather than screened based on Step scores or number of publications.”
Preference Signaling
Otolaryngology is among the specialties dealing with more applicants for residency positions than there are positions available, said Marc Thorne, MD, MPH, associate chair for education and quality, clinical professor in otolaryngology–head and neck surgery, and division chief of pediatric otolaryngology at the University of Michigan Medical School (UMMS) in Ann Arbor, as well as the current chair of the Otolaryngology Program Directors Organization (OPDO). “Our specialty has led in attempting to innovate and improve in the residency recruitment process over the last several years. Otolaryngology–head and neck surgery was the first specialty to institute the process of preference signaling, in which the OPDO serves as a trusted source for prospective otolaryngology residents who wish to signal their special interest in a small number of programs,” he explained.
The preference signaling process was introduced in the 2021 residency application cycle. At the time of submission, otolaryngology applicants were permitted to signal up to five programs of interest. The programs then received a list of applicants who submitted signals to consider during interview offer deliberations (Acad Med. Published online October 5, 2021. doi:10.1097/ACM.0000000000004441). According to Dr. Thorne, preference signaling has resulted in applicants receiving significantly more interview offers from programs in which they were most interested. The practice has since been adopted by several other specialties. The program has been so successful, in fact, that the ERAS “is exploring incorporation of signaling into the formal application system,” noted Dr. Malekzadeh, who, as immediate past chair of the OPDO, was among the leaders who developed the process.
Maya Hammoud, MD, MBA, research professor of obstetrics and gynecology, professor of learning health sciences, chief of the women’s health division, and associate chair for education at UMMS, described her specialty’s plans for a variation on preference signaling. “Instead of signaling five or fewer programs, we would use a two-tiered signal in which the applicant gets three gold tokens and 15 silver tokens for a total of 18 programs signaled because we’re a much bigger specialty,” she explained. “We think that this might help eventually reduce the number of applications; now, students are applying to as many as 70 programs.” The token process would be implemented for the 2023 Match, she added.
Standard Interview Date
Residency application is stressful enough without adding the uncertainty of not knowing when or if an interview offer might be on the way. By establishing a common or standard interview date, specialties such as otolaryngology and OB-GYN have created a finite window of time in which residency applicants can expect to receive an interview offer (J Surg Educ. 2021;78:1091-1096).
“Prior to the common interview date, otolaryngology applicants would anxiously hover over emails waiting for interviews to trickle in,” said Dr. Malekzadeh. “It wasn’t uncommon to hear of students asking parents and friends to monitor their emails or pulling off to the side of the road to respond to an invitation. It created a lot of unnecessary anxiety.”
“We set the standard interview offer date to about three to four weeks after applications open to give the programs opportunity to holistically review and discuss the applicants,” said Dr. Hammoud. “We found that when we offer interviews on only one day, the applicants don’t over-interview. They have all the offers at once and can decide which program they really want.”
Technology-Based Tools
The COVID-19 pandemic expanded the use of technology-driven communication in residency recruitment. “There has been much more intentional effort to expose applicants to programs through social media and other virtual events,” noted Dr. Hammoud. “Our national organization, the American College of Obstetrics-Gynecology (ACOG) and CREOG [Council on Resident Education in Obstetrics and Gynecology] sponsored a virtual residency fair largely driven by interns and medical students. They highlight programs and offer best practices on social media platforms like Twitter and Instagram.”
Through the combination of changes, we were able to interview more applicants and allow them to learn more about our program before deciding to spend additional money to visit. —Cheryl O’Malley, MD
In 2018, the internal medicine residency program at the University of Arizona College of Medicine–Phoenix started conducting all-virtual interviews. Then-program director Cheryl O’Malley, MD, associate professor and associate dean of graduate medical education at the university, found inspiration from the 2015 book Work Rules by Lazlo Bloch, former senior vice president of people operations at Google. “He described Google’s approach to recruitment, and I realized that young professionals are looking for a program that aligns with their values,” she said. “One of our values is innovation, so having a new, thoughtful approach to interviewing that was also creative and responsive to evolving challenges and opportunities aligned with our values. I’d always interviewed all applicants and found it an important time to highlight our family-feel and personal interest in them, so we needed to maintain that, while minimizing the impact of interviews on patient care and education. It was a risk, but through the combination of changes, we were able to interview more applicants and allow them to learn more about our program before deciding to spend additional money to visit.”
Early Match, Early Acceptance
Spurred by its exploding number of applicants, obstetrics–gynecology has been at the forefront of recruitment innovation. In 2020, the Association of Professors of Gynecology and Obstetrics received a grant from the American Medical Association (AMA) dedicated to the purpose. Dr. Hammoud is the primary investigator for the grant.
Among the ideas that Dr. Hammoud and her colleagues explored was an early results acceptance program (ERAP). With ERAP, students apply to a limited number of programs; in turn, the programs allot a portion of residency openings to these applicants (JAMA. 2020;323:503-504). “We end up doing a quick first-stage match; that applicant doesn’t go into the regular match group,” said Dr. Hammoud. “We get these early matches out of the system using less money and fewer resources. It also encourages our programs to do the holistic review, because they have more time to look at applications.”
A 2021 survey study to gauge OB-GYN stakeholders’ interest in ERAP showed broad support for the program, and survey responses suggested that an ERAP in the specialty could reduce applications by approximately 33% (JAMA Netw Open. 2021;4:e2124158). Currently, the neurology, neurosurgery, ophthalmology, and urology specialties participate in an early match process for residency program applicants.
Situational Judgment Tests
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Professional and interpersonal skills are essential in a medical career but aren’t easily evaluated via standard applications or even interviews. In 2020, Michael Cullen, PhD, senior director of assessment, evaluation, and research in graduate medical education at the University of Minnesota Medical School in Minneapolis, along with a team of researchers, developed a 45-minute, online situational judgement test (SJT) designed to measure conscientiousness, integrity, accountability, teamwork, stress tolerance, aspiring to excellence, and patient-centered care as they would present in the residency setting (Teach Learn Med. 2020;32:508-521). In the test, the applicant is presented with situations they’re likely to encounter as a resident or fellow and then given lists of possible responses and/or actions, each of which must be rated on a scale of 1 to 7 (“completely ineffective” to “highly effective”). The SJT is automatically scored, requiring no input from faculty, and comes with a development report for matched trainees, which can be used for setting professionalism goals for trainees.
Applicants in dozens of residency and fellowship programs in psychiatry and other specialties took part in the SJT pilot. In their study paper, researchers concluded that the tests “show promise as a method for assessing noncognitive attributes in residency program applicants.” Dr. Cullen cited the SJT as another tool that could be used to achieve a more holistic review of candidates without adding the need for faculty input.
The Future of Recruitment
As the number of residency applicants continues to rise, medical education leaders are working on additional ways to improve and refine the recruitment process. Dr. Hammoud and her colleagues are working with the AMA on a proposed system alignment check index system that would help students pinpoint programs to which they are most aligned. Programs would apply “weights” in six key aspects of their offerings and applicants would use that information to self-evaluate their suitability. “It’s kind of like a dating app,” said Dr. Hammoud, “but because the applicant is self-evaluating, it’s to their advantage to be accurate. No one else sees it but them.”
Dr. Rosman would like to see continued collaboration between specialties to address the challenges of the application process. “Many of the pain points are similar across specialties,” she emphasized. “Working together, we can come up with innovative ways to solve problems within the current system.”
To encourage development of a system where applicants could apply to far fewer programs and reviewers could be more thoughtful, Dr. Thorne supports greater transparency among programs regarding their selection criteria and the attributes they value most highly. “Applicants may benefit from seeing data about their likelihood of matching at a limited number of programs they identify ahead of the process as their preferred destination,” he said. “This may support a cap on applications in the future.”
Linda Kossoff is a freelance medical writer based in California.