COMMENTARY

Fixing the Match Crisis Starts With Capping Interviews

Helen K. Morgan, MD

Disclosures

March 01, 2021

Concern over the so-called "Match crisis" increases every cycle. This year, pandemic-related changes have shined a spotlight on the skewed distribution of interviews. Thanks to the shift from in-person to virtual interviews, applicants were no longer limited by travel and financial concerns. According to some experts, this has resulted in "top" candidates taking additional slots and subsequently reducing opportunities for others.

Worry about residency interview distribution has surged, with letters of concern posted by the Association of American Medical Colleges and the American College of Surgeons. Before the start of this season, my colleagues and I modeled the potentially dire consequences of ob/gyn applicants "hoarding" too many interviews in an article published in the Journal of Surgical Education.

The residency application problems exposed by the pandemic aren't going anywhere without action. Establishing a cap on interviews is now clearly necessary. Critics against this shift often point to unlikely, mostly theoretical concerns, as well as key anxieties. This is understandable, given that fundamental change is always hard and that inertia is difficult to overcome when the stakes are so high for all parties involved. Still, these obstacles can, and should, be overcome.

The idea that one solution can end this "crisis" is tempting, if likely false. Although capping residency interviews may not be a cure-all, it does represent one key step in a long- overdue overhaul.

Why Cap Now?

The argument against an interview cap often relies on the very small chance that applicants may fall in love with a program ranked low (16-18) on their initial program preference list. Even allowing for this unlikely scenario, interviews simply do not represent the best means for applicants to actually determine their compatibility.

My colleagues and I described a framework for applicants to assess their compatibility with a program. Our suggestion was based on the domains of clinical and academic training, practice setting, residency culture and personal life, and professional goals. Approaches such as this one would enable applicants to make informed decisions about where to apply. The move to capping residency interviews remains the most logical first step in addressing a distribution of interviews that is increasingly uneven.

A 2016 examination of National Resident Matching Program (NRMP) charting outcomes data revealed that 6% of general surgery applicants accounted for 28% of all interviews, and 25% of neurosurgery applicants accounted for 55% of all interviews. The past decade has seen a marked increase in the average number of applications submitted per applicant, a phenomenon that has been termed "application inflation."

For example, in ob/gyn, applications grew from 28.5 per applicant in 2010 to 64.2 in 2020. As a result, programs are inundated with large numbers of applications for a small number of residency spots. Each ob/gyn residency program received an average of 492 applications for 4.8 first-year residency positions.

The sheer volume of applications makes it challenging to perform a holistic review of each application. Thus, programs are forced to rely on flawed metrics, such as United States Medical Licensing Examination (USMLE) scores, Alpha Omega Alpha (AOA) medical honors society status, and clerkship grades. These metrics are simply not predictors of residency performance and threaten diversity; however, because they are easy to filter, the same applicants with favorable metrics receive many interview opportunities.

Capping the number of interviews that an applicant is allowed to schedule is the easiest, best way to create a broader distribution of interviews.

Costs Are High for All Involved

Critics of moving to a capped system often encourage applicants to self-limit as an alternative to changing the system. However, the current system is obviously not working. Students are fundamentally insecure about their probability of successfully matching. In addition, they worry that interview days are networking opportunities for postresidency fellowship or faculty positions and are understandably concerned that they may be viewed negatively for declining an interview.

Implementing a residency cap will create a new model, in which restraint and limitations are accepted as the new normal, as opposed to the current system of inefficiency and insecurity. We must use data to reassure concerned applicants that they can choose to interview only at their top programs without fearing negative consequences. Furthermore, we can show them how a broader distribution of interviews is beneficial for applicants as well as residency programs.

To start, the old adage that "more is better" does not ring true for interviews. To continue to use ob/gyn as an example, having 12 ranked programs in that specialty is associated with a more than 95% chance of matching. Thus, having more than 12 interviews does not improve an applicant's chance for a successful Match. However, given that the number of interviews a residency program can conduct is finite, interviewing at more than 12 programs takes interviews away from other applicants.

Many applicants who are not currently receiving many interviews will thrive as residents and ultimately become great physicians. Studies have shown time and again that key competencies, such as leadership, professionalism, and communication, are not easily assessed in our current system. Racial, gender, and ethnic biases have been demonstrated in such metrics as USMLE Step 1 Score, AOA status, and clerkship grades. Many applicants simply need the opportunity to shine during an interview, and these applicants are being filtered out right now.

From a residency program perspective, the need to host increasingly large numbers of interviews is becoming a significant burden. Just as applicants are feeling the need to apply to more programs, institutions are feeling pressure to interview more applicants. They believe that the stigma of not properly filling residency positions is too risky to limit interviews. So they continue the "arms race," furthering current inefficiencies.

Again, to use ob/gyn as an example, although NRMP data suggest that programs only need to rank four applicants per position, each program interviewed 18 applicants for each position. This inefficient system is financially costly for residency programs. A ceiling must be put into place.

The financial cost isn't limited to institutions. Although the pandemic has restricted travel and related considerations in the short term, those concerns are not gone. They will need to be taken into account in future cycles, once in-person interviews return. Allowing applicants to overinterview provides further inequity into a system already rife with biases.

A survey of neurosurgery residency applicants found that the average cost per applicant was $10,255, with interviews comprising most of the expense. Another survey of senior medical students found that 70% of respondents borrowed money to cover interview expenses, and 41% of applicants turned down an interview secondary to financial concerns. Because medical students are disproportionately from families of high socioeconomic status, financial costs unfortunately are often not a limiting factor. Because applicants with financial means are able to overinterview, it creates a culture and pressure for everyone else to follow suit.

All told, substantial reasons support moving away from the current system. Although the precise nature of the cap would need to be determined, identifying a reasonable limit would seem possible, given the ample data available.

Beyond Caps

Capping interviews is an easily identified solution, but it should not be the only one. It does not address the fundamental problem behind application inflation. The onus cannot rest solely on applicants to change their behaviors, because they are the ones who have the most to lose.

Medical schools must provide further support, through career advising and student services, to help students clarify their values and priorities as they approach the residency application process. This will help students select fewer residency programs and discern where to interview. Residency programs must also provide transparency about the metrics they value in their interview selection and rank processes, so that applicants can make informed decisions.

This is an opportune time for specialty societies to provide much-needed leadership to address these issues. The field of otolaryngology opted to offer a preference signaling "token" system this year, organized through the Otolaryngology Program Directors Association. Applicants could signal interest to programs with five tokens before the release of interview offers. For their part, the Association of Professors of Gynecology and Obstetrics and the Council on Resident Education in Obstetrics and Gynecology have implemented numerous interventions, including the Recommended Standards for the Ob-Gyn Application and Interview Processes . These standards include two set dates for interview offer release. Pilot data from 2020 demonstrated that this intervention alone mitigated excess interview scheduling. Applicants were able to weigh all of their available options before accepting interviews.

In addition, ob/gyn is investigating the possibility of an Early Result Acceptance Program (ERAP), similar to early decision in undergraduate admissions. Applicants could apply to a small, set number of programs before the regular application cycle, and programs could fill a percentage of their positions through ERAP.

Other concerns do remain. Individuals participating in the couples match have unique circumstances. Thoughtful consideration and possible exceptions are needed to prevent disadvantage to those applicants. The lack of centralization of interview scheduling is another key impediment to interview caps. Residency applications are centralized through the Electronic Residency Application Service, and the Match is centralized through the NRMP. Residency interviews are scheduled through an array of platforms. Interview cap supporters have suggested an electronic ticket system to circumvent this lack of centralization.

Hurdles such as these show that the move to a capped system requires 100% buy-in from all residency programs. This will require intentional leadership and coordination from specialty societies. To be clear, the time is now for this to finally be pursued.

Although it is tempting to hope that this alone will fix things, one intervention will not be able to unravel the complex and inefficient knot that tangles the residency application process. Each stakeholder group bears responsibility for our current quagmire. Thus, each group must work to implement solutions to unravel the "crisis" we find ourselves in.

Helen Kang Morgan, MD, is director of residency preparation courses and clinical associate professor of obstetrics and gynecology and learning health sciences at the University of Michigan Medical School. She is a co-investigator of the Association of Professors of Gynecology and Obstetrics (APGO)/American Medical Association initiative Reimaging Residency grant "Right Resident, Right Program, Ready Day One" and is a member of the APGO Undergraduate Medical Education Committee.

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