Friday, January 1, 2016

The Residency Application Process suffers from Misaligned Incentives

Doctors who wish to practice in the United States must apply for and undergo a residency in a particular specialty in order to practice medicine.  Some residencies are considered more desirable and competitive than others.  I am a fourth year medical student, applying for a General Surgery residency, and I have to say the process of applying to residencies has gotten somewhat out of hand.

To be clear, I'm not talking about the Match- which is a beautiful, Nobel Prize-winning application of  a solution to the stable marriage problem.  I'm talking about interviewing for residencies in the first place.

At a time when medical students are graduating with unprecedented amounts of debt, I have already been forced to spend thousands of dollars on application fees, flights, and accommodations to travel to and interview at programs; though I must thank many family and friends who have graciously allowed me to crash on their couches and air mattresses for multiple nights.  And I must thank fate for not letting me crash on long drives done on too little sleep in lieu of flights to save money.

And what's more, the process of offering interviews has apparently gotten significantly more difficult.  Several places I interviewed at told me they received around 1500 applications- from which they offered less than 100 interviews, for around 5-10 spots.

Why has the system gotten this crazy?  Simple- incentives.  Medical students may face a cost of up to $1000 for traveling to a program and interviewing there.  But, if they don't match at all- they lose out on millions of dollars of income over the course of their career- and even worse lose the opportunity to work in their dream job, practicing the type of medicine they want to.  Reducing the risk of that outcome is worth a lot of money- especially to medical students who are notoriously risk-averse to begin with.

So they spend freely.  And to further minimize this risk, they apply to dozens upon dozens of programs- if not hundreds in some specialties to maximize their chances.  I know several ENT applicants who applied to every single ENT program in the country- the match is that competitive- even after all 100 of those programs under this deluge of applicants demanded that each applicant write a personalized personal statement specific to their institution.  I met a foreign medical graduate at my Step 2 CS session who applied to over 300 family medicine programs just to get a shot at something somewhere in the US.  And who's to blame him?  It's exactly what the system incentivizes him to do.

What can be done?  Here are several ideas:

1) A hard limit of being allowed to apply to 20 programs per specialty.  This would force more judicious applications and benefit everyone by reducing the incredible number of applications seen by many programs, allowing more reasonable and complete consideration.  Ultimately, it may result in more spots unfilled in the match- not necessarily a terrible thing, with the new supplementary match process that has been put in place that puts off the madness of the scramble.

2) More openness from programs about what kind of hard Step 1/Step 2 or other cut-offs they use.  Students who don't test well, don't have much research, or who otherwise don't meet the stated criteria but who are otherwise exceptionally strong should be allowed to send a message to the program.  They may emphasize their background and reasons for interest in the school- and then be given leave to send a full application if the program is interested- saving the students' money and the programs' time.

3) Interviews may be geographically and temporally grouped at a central location- possibly linked with specialty society meetings.  What this would look like: the American College of Surgeons Southern California Chapter could sponsor a scientific and educational meeting.  Residents and Faculty from every residency program in Southern California would take 2-3 days and come to a hotel in Anaheim, LA, or San Diego- as is done for many major academic conferences.  Then, over the course of that meeting, every applicant who received an interview at any Southern California residency would meet with residents and faculty from those programs.  While hardly ideal- it can be quite tough to get a feel for a program with only one day as is, let alone from an hour in a hotel- it will save everyone significant amounts of money and time.  Whether this trade-off is worth it for all involved is of course up for debate.

4) Alternately, combined video interviews.  Technology has advanced to the point that it may make sense to have students give answers to interview questions given live by one program, and have subsequent programs refer to those answers via a database shared by program directors.  If there is a new question they want to ask, they can do so by scheduling a video conference.  Of course, this would greatly restrict the subjective "feel" that many interviewers like to develop regarding applicants, though there is significant data that subjective, free-wheeling interviews significantly benefit applicants who share the same socioeconomic background as the interviewers.  In comparison some sources suggest empiric situational judgement tests or Multiple-Mini-Interviews - even done over video-conference - may be superior to traditional interviewing.

5) There is one aspect which is almost impossible to replicate cheaply- the pre-interview dinner/bar outing.  While it may not be able to get an applicant a spot, many a candidate has been crossed-off the list by a program director due to a terrible impression they make on residents at this "casual" get-together with the program's current residents.  And many medical students feel that this night can help them get a far better sense of how the residents at the program are than the interviews the next day.

But I truly wonder- are there other ways to obtain such information?  After all, anyone can be charismatic and put their best foot forward for one night.  Why not instead require students to provide 10-20 references for other medical students or residents they worked with?  Program directors or chief residents can randomly call one, and perhaps get a more unvarnished review of how the medical student works with colleagues over time rather than a snapshot for one night.  Of course, due to radical changes in medical education over the past decades not all medical schools put students into situations where a resident or fellow student can reasonably say that they are good to work with.1   But nonetheless, peers who have observed a medical student over time still may provide an alternate source of information to a program instead of one night at a bar, which many candidates on tight schedules due to too many interviews may not even be able to attend.  Helping medical students get a feel for the residents and their culture is far more difficult to replicate or replace, and I really don't have a good answer for it.

Overall, I don't know what the best answer is.  But the situation is reaching a breaking point: students spend so much that schools often make an extra $10,000-$25,000 in debt available for fourth year medical students to use on interviews.  And not to mention- it is not just money, but time.  With interview season going on as long as it does, fourth year medical students are effectively forced into taking months of light rotations on which they learn little to nothing in order to retain the flexibility to go on dozens of 2-day trips- sometimes on a moment's notice after a cancellation.  With medical knowledge expanding at an incredible rate, it may be  time to curtail the interview season and require fourth years to take more standardized electives geared towards preparing them for residency and beyond.

Ultimately, perhaps the ideas presented here will help, or perhaps others will- but I firmly believe something needs to change.

1 I am fortunate enough to go a school which is affiliated with a county hospital.  Different billing rules (the majority of hospitals that bill fee-for-service are only allowed to use medical student-obtained Family Histories, Social Histories, and Review of Systems, whereas we were allowed to write the entire note for the patient and have it be countersigned by a physician) and different customs borne of a total lack of resources allowed me the incredible privilege of actually being responsible for my patients and meaningfully working with a team for 24-30 hours straight.  This is no longer the case at the majority of medical schools in the United States