Thu. Jul 29th, 2021

When “Madeline” decided that she wanted to stay in-state for residency, faculty from her medical school said her chances of matching at a program in her home state were high.

A recent medical graduate from the Midwest whose name has been changed for privacy purposes, Madeline was a competitive applicant. She was in the top quartile of her medical school class, and her mentors assured her that she had a good shot at matching in one of the ob/gyn programs in the state. Faculty encouraged her to apply to 20 programs (which Madeline acknowledged was low compared with other ob/gyn applicants). They assured her she’d match at one of her top three choices.

Matching at a program close to home was a high priority for Madeline. She had a 10-month-old son, and planned to live with her parents, who would assist with childcare — extra support that she was counting on during her intern year.

When Match Day rolled around in March, Madeline prepared to celebrate the start of her medical career with her parents, husband, and son. But when she opened her results, she could not believe it. Madeline matched at her fifth choice — at a program located several states away.

“I found out that I had to leave my family and my support,” Madeline told MedPage Today. “It was just a really shocking day and a really hard day.”

More applicants are reporting less optimal match results in recent years. According to 2021 match data from the National Resident Matching Program (NRMP), 43.1% of allopathic graduates matched at their top choice last cycle — the lowest percentage in almost 25 years. Additionally, more than a quarter in that group ranked at their fourth choice or lower.

Some experts say that worse match outcomes are the result of an increasingly congested, chaotic residency application landscape. Applicants apply to more programs each year to keep up with competition, multiplying their own costs and workload, as well as increasing the burden on programs to review more applicants for the same number of spots. This trend was exacerbated by the COVID-19 pandemic — but applications have been trending up for decades.

Medical education advocates have proposed solutions including a residency application cap, or an early match to ease congestion. But those solutions may require reimagining the match process.

‘Application Fever’

The average U.S. medical graduate applied to 70 programs in 2020, while the average international medical graduate applied to 139 programs. Last year, both of these groups applied to twice as many programs than they did 20 years ago.

Physician education groups have recognized that overapplication is an issue. Gabrielle Campbell, the chief services officer for the Association of American Medical Colleges (AAMC), told MedPage Today via email that “the AAMC is endeavoring to reduce residency application rates.” However, she added that data show the number of applications submitted by MD, DO, and international graduates has steadily increased in recent years.

This year, the number of residency applications submitted by allopathic graduates increased by 4% from last season, according to Campbell. The number of applications submitted increased by 5% among osteopathic graduates and 6% among international graduates.

Bryan Carmody, MD, an assistant professor at Eastern Virginia Medical School and an advocate for medical education reform, said that applicants’ desire to overapply — or as he calls it, “application fever” — is rational. Because residency slots are a scarce resource, applicants apply everywhere to avoid the dire consequence of not matching.

“[Overapplication] benefits individual applicants relative to each other,” Carmody said in an interview. “But when you consider all applicants, the same number of people match as they did 10 years ago. They just have to apply to twice as many programs and spend twice as much money doing it.”

Those increased costs for applicants are cause for concern. Hannah Hendrix, national president of the American Medical Student Association, told MedPage Today that her organization is worried about applicants who come from disadvantaged backgrounds, and may not be able to afford to submit the same number of applications as their peers.

“Folks who are going into debt to pay for medical school may or may not have credit to spend thousands of dollars to apply to these residency positions,” Hendrix said. While she recognized that overapplication compromises equity, she added that applying to a wide swath of programs often feels like an applicant’s only choice.

“From a student perspective, we know it’s not ideal,” she added. “But we’re stuck in a spot where we may be pretty decently in debt and without a way to practice if we don’t match.”

Application or Interview Caps

Advocates for medical education reform have suggested a few solutions to counter overapplication and ease congestion in the match. One proposed solution is putting a cap on applications and interviews.

In response to the COVID-19 pandemic, the Association of Professors of Dermatology published a statement encouraging allopathic graduates to apply to a maximum of 40 to 60 programs, and accept 12 to 15 interviews, citing NRMP data showing that the probability of matching plateaus after 12 ranked programs.

Dermatology is a competitive speciality, and this cap might not work across the board. But some proposals state that specialties should determine the optimal number of programs an applicant can apply to, adjusting based on specialty-specific data from past cycles.

“I think it’s the most practical solution,” said Hao Feng, MD, assistant professor of dermatology at the University of Connecticut Health Center. “It would allow [medical graduates] to apply to the ‘right’ number of programs.”

Feng said that an application cap would not only level the playing field for applicants, but also take a large burden off of programs. In the current system, programs get hundreds, or even thousands of applications for a limited number of spots. The influx of applications makes it difficult for full review — and it forces programs to resort to filtering based on metrics such as U.S. Medical Licensing Examination (USMLE) Step 1 test scores, or honor society status.

“You may eliminate people who could be great candidates, and are very qualified, but just didn’t check the right check marks,” Feng said.

An application cap would reduce the number of applications programs receive, allowing for a more individual review of each applicant. Ilana Rosman, MD, director of the dermatology residency program at Washington University School of Medicine in St. Louis, said that “overapplication and holistic review are very intimately tied,” and in the current system there isn’t room for both.

“If you institute an application cap, you will immediately see a change,” Rosman said. “It’s the surefire way to do it.”

Rosman added that in an application cap system, there may initially be a mismatch, where more applicants may go unmatched and more programs go unfilled. But over time, applicants will be more selective about choosing programs that fit their preferences and qualifications.

A separate proposed solution of an interview cap may prevent top candidates from hoarding interviews. However, it does not address the issue of an influx of applications for programs. Maya Hammoud, MD, associate chair for education at the University of Michigan, added that the number of applicants who take too many interviews is so small, that a cap would not make a significant impact.

An Early Match

As opposed to a cap on interviews or applications, Hammoud has proposed that an early match could ease crowding. An early match would consist of a two-stage application process. In the first stage, applicants would have the opportunity to apply to a maximum of five programs. They would receive results prior to the start of the normal application cycle, and could enter the match again if they did not match at one of their top five choices.

Hammoud said that an early match would allow program directors to view a smaller number of applications in the first round, giving them the chance to evaluate graduates on more than just test scores. For applicants, it would give them a chance to signal their preference to top programs, as opposed to being just another number.

“This is for people who know exactly where they want to be,” Hammoud said. “It’s going to remove a lot of people from the pool who know exactly what they want.”

In order for any of the proposed solutions to succeed in easing congestion and improving match outcomes, medical graduates will need to be more selective about where they want to apply, experts said. Greater transparency from programs, including access to program-specific data about prior match cycles, will inform graduates on where they should apply.

After matching outside of her home state, Madeline, the medical graduate from the Midwest, picked up her family and moved within just a few months. She acknowledged that the NRMP has come up with some solutions, such as the couples’ match, to support applicants’ lifestyle choices. But she added that there are no protections for people who have other reasons, such as family, that they want to be in a specific place.

“We are not just medical students, or young doctors,” she said. “We are people with lives.”

  • Amanda D’Ambrosio is a reporter on MedPage Today’s enterprise & investigative team. She covers obstetrics-gynecology and other clinical news, and writes features about the U.S. healthcare system. Follow