Imagine being glued to your phone or computer, unable to even go to the bathroom without it, afraid to scrub in to the operating room lest you miss a call, email, or text message. That's what one group of doctors feels every year from September to March: the graduating medical students waiting to get interview invitations from residency programs.
"The stress has become so much that it's a cause for concern for our wellness, and could leave a residual effect and cause burnout for residents," said Salomeh Salari, MD, a recent graduate of the University of Michigan Medical School in Ann Arbor. Salari, who is now starting her ob/gyn residency at Case Western Reserve University in Cleveland, about the degree of pressure graduating seniors are facing when it comes to securing interview slots.
Once, when she was about to go to one residency interview, Salari dutifully trained her mother to watch the computer in case another email invitation came while she was in the interview -- only to miss an invitation that came in during a single 15-minute period when her computer was unattended. She was waitlisted, but did eventually get the interview.
Concerns About the Match Process
"There are some broadly held concerns about the match that are driving people to think about whether some reforms are necessary," John Andrews, MD, Vice President of Graduate Medical Education Innovations at the American Medical Association (AMA), said during a phone interview at which a public relations person was present.
"I was a program director from 2006-2012 at the University of Minnesota pediatric residency program," Andrews said. "For 23 spots we'd get 250-300 applications; the same program is now receiving 600-700 applications a year. The larger number is not representative of a specific interest -- more of the swarming anxiety applicants have [about the competition] and how many programs they need to apply to."
A specialty such as ob/gyn, which Salari chose, "is among the specialties that are not the most competitive ... And yet a specialty like that used to have people applying to 25-30 programs a year now has an average of 60 programs per applicant," Andrews continued. "Over 80% of applicants in the match -- certainly where U.S. applicants are concerned -- are matching to one of their top three choices, so it shouldn't be necessary to apply to 60 programs and engage in the expense and anxiety over the interviews to do that, yet people are being encouraged to do that by their peers, and in some cases, by the programs."
The residency programs, however, don't really have time to review all those applications, "and the process gives a disadvantage to students of lower socioeconomic status because they don't have the money to apply and go to interviews," he said.
One Possible Solution
Maya Hammoud, MD, MBA, chief of women's health and associate chair for education at the University of Michigan Medical School in Ann Arbor, has seen the problems too. "The match started because [residency] programs were trying to get students to come to their programs, and they would out-bid other programs," Hammoud, who is also president of the Association of Professors of Gynecology and Obstetrics (APGO), said in a phone interview. "They did the match to avoid this piece of it. But it's no longer working out because of ."
"If I apply to 60 programs and a student next to me only applies to five or six, then I'm in good shape," she said. But now everyone is applying to lots of programs, and programs have to find ways of screening them, so they end up using students' U.S. Medical Licensing Examination (USMLE) scores, only interviewing applicants with top scores, and missing out on very good students in the middle. At some programs that 14 of her students applied to, only the two with the highest USMLE scores were offered interviews. "This is why the students are very frustrated."
"I found myself calling other programs and saying, 'You didn't look at this student who's really good; why didn't you offer them an interview?' And they missed [those students] because they didn't fit the screening criteria. We accomplished lot of matches by doing this and I thought, 'Why do I have to call these people -- what did they miss? We can't keep doing this, and what about students who don't have someone to call for them?'"
So Hammoud put together a team of 20 physician educators representing APGO and the Council on Resident Education in Obstetrics and Gynecology (CREOG). They came up with the idea of an "Early Result Match" under which students would apply early to a maximum of five programs, and the programs would decide early whether or not to take them. Students would have to agree to go to the program that accepted them; those that didn't get selected could go into the general match. The programs that would participate in this program -- initially, only ob/gyn programs -- could fill up to half their slots using the Early Result Match.
"Right now, students apply in July, the applications go to the programs in September, the interviews are October through January, and the Match occurs in March and students start in July," she said. "What we'd do is have two matches -- the Early Match applicants would apply in July, and the ones who match would know in October whether they matched already." This would also give them several more months to prepare for the move to their new city -- in cases where that's what's required -- as opposed to finding out their match in March and then having only 3 months to get ready and move.
Mixed Responses
The AMA is supporting Hammoud's idea with a $50,000 planning grant to APGO as part of the AMA's . "People have been saying there's a problem with the match for a very long time, and no one is finding a solution to it," Hammoud said. "The new process would help because everyone would be more focused on where they apply."
"Hers is an interesting idea -- it's attractive because it's a single discipline [involved] and [yet] it's national," said Andrews. "And with the backup of national organizations, we'd ideally get all ob/gyn programs to [go along]. It's almost like a college Early Decision program ... The thinking is that if the number of programs you'd apply to is limited, you would be really selective about which program is the best fit for you. Likewise, the programs would really invest in the applicants because the number of applications they'd receive are very small."
The American College of Obstetricians & Gynecologists (ACOG) is also supportive. "The residency application and matching process has become much more difficult for students and program directors in ob/gyn," Marc Jackson, MD, ACOG's vice president of education, said in a statement. "The increase in the number of applications that each student submits also has increased students' cost, time, and anxiety. This has changed negatively the landscape for interviews, especially for students below the top tier. At the same time, residencies' administrative time and cost to accommodate the increased number of applications has increased dramatically, making the candidate selection and interview process that much harder."
"Although there would be many logistical details to be worked out ... a program like this could benefit all students choosing ob/gyn and ob/gyn residency programs, leading to improved medical student and residency training," he said.
A spokesman for the Association of American Medical Colleges said the organization had not been contacted about the idea, but that it has developed resources to help medical students decide which programs to apply to, including a pilot tool called , which allows medical students to look at residency programs in 11 specialties and compare their profiles to applicants who matched at each program.
The National Resident Matching Program (NRMP), which runs the Match, also said it had not been contacted about the proposal, and expressed some doubts about it. "The NRMP's All In Policy requires any program participating in the Main Residency Match to register and attempt to fill all positions through the Main Residency Match or another national matching plan," Mona Signer, MPH, president and CEO of NRMP, said in a statement emailed to 51˶. "The other matching plans have been the Urology Match, the Ophthalmology Match, and -- -- the American Osteopathic Association (AOA) Match."
"The urology and ophthalmology matches are single-specialty and therefore those programs place no positions in the NRMP. The AOA Match offered positions accredited by the AOA, and programs that were dually-accredited by the AOA and the ACGME [Accreditation Council on Graduate Medical Education] could participate in both matches ... It is doubtful the NRMP Board of Directors would approve a policy to allow ob/gyn programs, all of which would now be ACGME-accredited, to participate in an early match and the NRMP."
Helping Students Narrow Their Choices
The NRMP is concerned about the rising number of applications, Signer said, and partnered with the AAMC to develop the Residency Explorer tool to help address the issue. Along similar lines, a second part of Hammoud's proposal is a MatchHelper app that helps students find out which programs match their interests.
"Because we want to encourage students to apply to fewer programs, we want as much information available to students as possible, so they can input their information and the app would say, 'This [program] is a really good match for you, based on what you're looking for' ... For instance, if someone is looking for a program with patients of diverse backgrounds and they're applying to a program where 90% of the patients are white, that's not going to meet their requirements."
Hammoud is hoping to get the pilot program started fairly soon. "We're spending this year as a planning year -- we're getting buy-in from all stakeholders and make sure we have all the elements we need in the application," she said. "I hope next year we can start our pilot; it's a little ambitious timeline but I think we can do it."
"I think the main thing we have to do is get people to apply to a more thoughtful number of programs," Andrews said. "If we tomorrow said, 'Hey, the match is broken; you can only apply to 20 programs,' there'd be a peasant revolt. The attractive part of her program is to limit programs to apply to in the early phase but then a larger number of programs you can apply to in the later part of the match. I think that will garner support from the students."