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Invited Commentary
Medical Education
October 11, 2021

Weighing the Benefits and Unintended Consequences of a 2-Phased Match

Author Affiliations
  • 1Family and Community Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
JAMA Netw Open. 2021;4(10):e2124400. doi:10.1001/jamanetworkopen.2021.24400

Over the past decade, the numbers of residency applications submitted by candidates have increased at an unprecedented rate, despite no evidence of benefit in the residency match.1 For US seniors, application rates increased by 87% over the period from 2009 to 2019 to an average of 64.9 applications per candidate.2 Regardless of this increase, no change occurred in the US senior match rate, which remains consistently in the 92% to 95% range. Only a slight increase in the match rate of international medical graduates (IMGs) occurred during this period, from 44% to 59%, despite a 44% increase in applications with an average of 136.5 per applicant.1,2 This increase in applications has resulted in escalating costs to both candidates and programs, a decrease in programs’ ability to conduct a holistic review of applications and an environment of mistrust between stakeholders.3

What are the drivers of this exponential increase in applications? Candidates experience peer pressure, advice from faculty, and an expansion of medical school graduates without concordant expansion in residency opportunities, limiting residency choice for applicants. Costs have not been a deterrent to overapplication. Many have suggested the economic reality of interviewing is such that even a $10 000 budget is a relatively small amount compared with already sunk educational costs and future earnings offset, especially considering the opportunity cost of not securing a residency position.3

Positive advances have been made in the past few years to mitigate the stress candidates experience. Some of these advances include releasing interview offers in a standardized window and limiting the number of offers to the available interview opportunities. Major stakeholders have developed tools to illustrate the point of diminishing returns by specialty application, although concerns have been expressed about several flawed assumptions in these tools.4,5

Winkel et al6 conducted a stakeholder survey to determine the likelihood of participation in an obstetrics and gynecology (OB-GYN) early result acceptance program (ERAP) pilot whereby a limited number of applications and residency positions would constitute a first pass match with results announced prior to the traditional September opening of the main match. The aims of the study were to explore stakeholder opinions in OB-GYN to determine interest in an ERAP, to determine ideal parameters for the pilot in terms of application numbers and available positions, and to use these data to estimate the potential impact of ERAP on the overall application process.6

Their findings were based on a 36% (n = 1167) overall response rate to a survey conducted in March 2021. Of respondents, the majority indicated they would be somewhat or extremely likely to participate in ERAP, including 70.7% of applicants, 60.8% of PDs, 74.7% of clerkship directors and 66.7% of student affairs deans. Respondents suggested the optimal number of applications per applicant should be limited to 3 and the program should make 25% to 50% of positions available in the first stage of the match based on expert opinion. The authors calculated that if 365 to 730 applicants match using ERAP, this would save $1 314 000 to $2 628 000 overall and would save 6570 interviews in OB-GYN with an estimated cost savings of $1 282 500.6

This study highlights the well-known escalation in numbers of applications to residency and offers one approach to reducing congestion in the match. The use of median data in the analysis, however, does not accurately portray the reality of individual candidate behavior in the application and interview process. If the goal of a 2-phased match is to reduce applications, this result is unlikely in the described pilot because of the right-tailed distribution of the application volume curve. More qualified candidates already submit fewer applications, accept more interviews, and are the most likely to be selected in the proposed first phase at the expense of the rest of the applicant pool. For example, in 2018, 25% of internal medicine residents who graduated from US medical schools submitted less than 15 applications each. At the same time, 7% of internal medicine residents from US medical schools submitted more than 75 applications each.7 Eliminating the initial cohort of highly qualified candidates and reducing available positions by 25% to 50% in ERAP will likely drive the remaining applicants to submit more applications based on previously demonstrated scarcity mindset behavior. The impact on osteopathic and international medical school graduates is likely to be more severe.

Economically, program directors will be faced with additional administrative and cost burden in conducting the recruitment cycle twice in the same year with no reduction in the interview to open position ratio. Candidates not selected in the first phase will incur the expense and psychic burden of a second round of applications and interviews, increasing stress and saving neither time nor money. Essentially, the majority of their final year of medical school will be spent pursing a residency position. For those who fail to match in the initial round, concerns about confidentiality, equity of opportunity, and the perception of being less competitive are not adequately addressed.

Residency application is a complex process involving multiple stakeholders. The most vulnerable group are the applicants who bear a disproportionate burden of cost and potentially negative implications for career opportunity. Limiting available positions through a preferential first-pass selection risks further exacerbating fear and mistrust, resulting in an increase in applications and a potential worsening in process integrity and equity. More concerning is basing recommendations solely on a recruitment cycle skewed by pandemic-related changes. A data-driven approach based on simulation modeling may be more effective in demonstrating potential success and adverse consequences, reducing candidates’ anxiety and overapplication in an environment of perceived scarcity.

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Article Information

Published: October 11, 2021. doi:10.1001/jamanetworkopen.2021.24400

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Clements DS. JAMA Network Open.

Corresponding Author: Deborah S. Clements, MD, Family and Community Medicine, Northwestern University Feinberg School of Medicine, 710 N Lake Shore Dr, Abbott Hall, 4th Floor, Chicago, IL 60011 (dclements@northwestern.edu).

Conflict of Interest Disclosures: Dr Clements reported she is a member of the NRMP Board of Directors. No other disclosures were reported.

References
1.
National Resident Matching Program. Results and data: 2020 main residency match. Accessed July 12, 2021. https://www.nrmp.org/report-archives/
2.
Association of American Medical Colleges. ERAS statistics. residency specialties summary by applicant, 2010-2020. Accessed July 12, 2021. https://www.aamc.org/data-reports/interactive-data/eras-statistics-data
3.
Antono  B, Willis  J, Phillips  RL  Jr, Bazemore  A, Westfall  JM.  The price of fear: an ethical dilemma underscored in a virtual residency interview season.   J Grad Med Educ. 2021;13(3):316-320. doi:10.4300/JGME-D-20-01411.1PubMedGoogle ScholarCrossref
4.
Zastrow  RK, Burk-Rafel  J, London  DA.  Systems-level reforms to the US resident selection process: a scoping review.   J Grad Med Educ. 2021;13(3):355-370. doi:10.4300/JGME-D-20-01381.1PubMedGoogle ScholarCrossref
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Carmody  JB.  Applying smarter: a critique of the AAMC Apply Smart tools.   J Grad Med Educ. 2020;12(1):10-13. doi:10.4300/JGME-D-19-00495.1PubMedGoogle ScholarCrossref
6.
Winkel  AF, Morgan  HK, Akingbola  O,  et al.  Perspectives of stakeholders about an early result acceptance program to complement the residency match in obstetrics and gynecology.   JAMA Netw Open. 2021;4(10):e2124158. doi:10.1001/jamanetworkopen.2021.24158Google Scholar
7.
Angus  SV, Williams  CM, Kwan  B,  et al.  Drivers of application inflation: a national survey of internal medicine residents.   Am J Med. 2018;131(4):447-452. doi:10.1016/j.amjmed.2018.01.002PubMedGoogle ScholarCrossref
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