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September 21, 2018

Matching for Fellowship Interviews

Author Affiliations
  • 1Department of Surgery, Stanford University, Stanford, California
  • 2Department of Management Science and Engineering, Stanford University, Stanford, California
JAMA. Published online September 21, 2018. doi:10.1001/jama.2018.13080

Surgical fellowships have proliferated over the last 2 decades. Recent data suggest that the application process has become inefficient and costly, especially for candidates and programs in competitive surgical specialties.1 Although the Accreditation Council for Graduate Medical Education (ACGME) accredits many programs, other organizations, such as the Foundation for Surgical Fellowships, the Society of Surgical Oncology, and the American Society of Transplantation, certify non-ACGME fellowships. Of 3354 graduating general surgery residents from 2009 to 2013 who responded to a survey by the American Board of Surgery, 74% (n = 2478) sought surgical specialty training.2 Candidates for surgical fellowships are matched to programs following the “deferred acceptance” matching algorithm similar to the one used by the National Resident Matching Program (NRMP).3 This algorithm assigns each candidate to a program such that if an applicant ranked another program over the one to which they were assigned, then that program must have ranked all their assigned trainee(s) over this candidate.

Residents interested in competitive fellowships, such as pediatric surgery, are often compelled to apply and interview in as many programs as possible. The shift toward centralized electronic applications enables fellowship candidates to apply to numerous programs with low incremental costs and little discrimination.4 Most surgical training programs interview many candidates because the consequences of not matching harms the reputation of the program and affects the work force of their services.5 Surveys of pediatric surgery program directors in 2011, 2012, and 2014 revealed that they interviewed a median of 24 to 30 candidates per year. However, the median rank at which the programs matched was less than 4, and programs never matched beyond their 12th choice, suggesting that they did not need to interview as many residents as they did.5

Hence, candidates and programs spend considerable resources on a process in which the ratio of interviews to positions is high. Few published data are available on the number of invitations and interviews extended to fellow candidates, so the magnitude of the problem is unclear and may be substantial. These interviews are expensive. Moreover, the absences that are a result of interviews may disrupt training during the senior years of residency, adversely affecting the clinical services.1,6 When residents interview, the burden of clinical coverage may shift to co-residents. In a 2014 survey of 72 general surgery residents seeking fellowships, 57.7% missed at least 1 week of work, not counting residents who used vacation time to travel to those interviews, 21.7% spent more than $8000 on interviews, and 32.3% acquired more debt to pay for interviews.1

Given the complexities of this matching market, instituting an interview match may be one approach to help improve the interview selection process by reducing the large numbers of unfruitful and costly fellowship interviews. For example, Ashlagi et al7 found in a theoretical matching model that when candidates and programs each have highly heterogeneous preferences, limiting the number of interviews improved the efficiency of the matching process. Thus, fellowship interview matches represent an opportunity to reduce the excessive number of interviews and optimize the selection of applicants.

A practical strategy that may achieve this goal is an interview match that precedes the existing match. After applications are submitted, candidates and programs submit rank lists that could be used to fill limited interview slots. Mechanisms that enable applicants and training programs to signal interest in each other have been proposed.4,7 By ranking candidates and programs highly, both essentially are respectively signaling their strong preference for each other.4 Therefore, fewer interviews might be sufficient for candidates and programs to identify mutually desirable matches and reduce the number and costs of interviews. If the program and candidate interview slots remain unfilled, a secondary match could be performed to fill unmatched interview slots.

The mathematical algorithm that could be used for the interview match would be based on the deferred acceptance matching algorithm used for the final fellowship (and residency) matches, with 2 differences: (1) candidates would match to more than 1 interview, and (2) the number of interviews per candidate and per program could both be capped. This approach might allow programs and candidates to rank each other in tiers, instead of having to submit strict rank-order lists. The goal would be to determine an optimal number of interview slots, adjusted for the number of positions available at each program, while also minimizing unnecessary interviews without harming either programs or candidates. Tiered ranking differs from ordered ranking in that tiers could allow for multiple entries of candidates or programs of similar desirability. Tiered ranking might provide greater flexibility for the matching algorithm to maximize mutually desired interviews.

This type of interview match could be piloted in 1 or more surgical specialty fellowship programs using the same organizations that run their matches. Although this pilot may successfully limit the number of interviews, there may be unintended consequences. For example, candidates who are most likely to be challenged by a limit on the number of interviews may be those who do not appear desirable based on their application materials but perform well at interviews (which they might not be invited to if interviews are limited in number). Conversely, the programs most likely challenged may be those that do not enjoy a top reputation but are able to favorably impress candidates during the interview and therefore change how candidates rank them. A pilot could be adjusted to reduce the number of interviews incrementally over time, as experience with this model is gained.

The extent to which the reduction of interviews will affect the final match assignments depends on (1) the competitiveness of that specialty, (2) the heterogeneity of the rank lists that candidates and programs submit, and (3) on the importance of face-to-face interviews in forming those rankings.

In conclusion, a well-designed interview match may help reduce excessive costly interviews while more efficiently pairing candidates and programs, so that both achieve as many highly ranked choices as possible. This strategy could be applied broadly to matching programs in other medical specialties and may be attractive at earlier career stages such as residency interviews.

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Article Information

Corresponding Author: Irene Wapnir, MD, Department of Surgery, Stanford University, 300 Pasteur Dr, H3625, Stanford, CA 94305-5655 (wapnir@stanford.edu).

Published Online: September 21, 2018. doi:10.1001/jama.2018.13080

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank Alvin Roth, PhD, Erling Skancke, MS, and Akhil Vohra, BS (all from Stanford University), for in-depth conversations on these topics.

References
1.
Watson  SL, Hollis  RH, Oladeji  L, Xu  S, Porterfield  JR, Ponce  BA.  The burden of the fellowship interview process on general surgery residents and programs.  J Surg Educ. 2017;74(1):167-172. doi:10.1016/j.jsurg.2016.06.008PubMedGoogle ScholarCrossref
2.
Klingensmith  ME, Cogbill  TH, Luchette  F,  et al.  Factors influencing the decision of surgery residency graduates to pursue general surgery practice versus fellowship.  Ann Surg. 2015;262(3):449-455. doi:10.1097/SLA.0000000000001435PubMedGoogle ScholarCrossref
3.
Roth  AE.  The origins, history, and design of the resident match.  JAMA. 2003;289(7):909-912. doi:10.1001/jama.289.7.909PubMedGoogle ScholarCrossref
4.
Bernstein  J.  Not the last word: want to match in an orthopaedic surgery residency? send a rose to the program director.  Clin Orthop Relat Res. 2017;475(12):2845-2849. doi:10.1007/s11999-017-5500-9PubMedGoogle ScholarCrossref
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Gadepalli  SK, Downard  CD, Thatch  KA,  et al; Association of Pediatric Surgery Training Program Directors.  The effort and outcomes of the pediatric surgery match process: are we interviewing too many?  J Pediatr Surg. 2015;50(11):1954-1957. doi:10.1016/j.jpedsurg.2015.06.008PubMedGoogle ScholarCrossref
6.
Niesen  MC, Wong  J, Ebramzadeh  E,  et al.  Orthopedic surgery fellowships: the effects of interviewing and how residents establish a rank list.  Orthopedics. 2015;38(3):175-179. doi:10.3928/01477447-20150305-05PubMedGoogle ScholarCrossref
7.
Ashlagi  I, Braverman  M, Kanoria  Y, Shi  P.  Communication Requirements and Informative Signaling in Matching Markets. New York, NY: ACM Press; 2017:263-263. doi:10.1145/3033274.3084093
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