Discussion
Between 2014 and 2018, there was a steady decline in the number of
medical students applying into otolaryngology, with a 20% decline in
applicants from 376 in 2014 to 299 in 2018.2 The
underpinnings of this phenomenon are likely multifactorial, with
contributions from both applicant and program-specific factors. Previous
studies have focused on specialty competitiveness, with filters
pertaining to USMLE board score, AOA membership, and research experience
as key factors in the decline in
applicants.4,5,13However, as these application qualifications are longstanding, we
hypothesized that the pre-match PSP and ORTA contributed to the downward
trend observed in applicant numbers.
Both the PSP and ORTA were added with good intent – for candidates to
convey serious intentions to specific programs and for programs to
identify excellent, “best-fit,” future residents. However, contrary to
their intended purpose, this study suggests that both the PSP and ORTA
were perceived as barriers to application and led to declines in
applicant numbers (and consequent increases in match rate success). When
examined individually, however, only the PSP (and not the ORTA) led to a
statistically significant decrease in applicant numbers. This effect has
been seen previously: when the PSP was first trialed at Duke in the 2014
Match, the program received 25% less applications than in years
prior.9Further, the PSP may have had a more negative influence than the ORTA
due to qualitative differences. The PSP entails additional research and
preparation for each application, a demanding task that compounds with
each additional program a candidate applies to, whereas the ORTA is a
one-time 2-3 hour time commitment that does not require preparation.
One consequence of declining applicant numbers is the risk of losing
high quality applicants. Increasing competitiveness (assessed via
average USMLE Step 1 score, percent AOA membership, and number of
research experiences) may discourage candidates with unique
circumstances, and/or potentially excellent clinicians with
below-average Step 1 scores, who would otherwise make a valuable
contribution to the
field.4,5,9Further, there is evidence to support that academic achievements like
high USMLE Step 1 scores and noteworthy research experience may not
predict successful residency
performance.5,14,15Although otolaryngology applicants are high-achieving in each of these
domains, more than 90% of programs report having to remediate residents
due to unprofessional behavior, insufficient medical knowledge, or poor
clinical
judgement.16Alternatively, qualities that otolaryngologists do highly value, such as
integrity, empathy, and surgical dexterity, are not captured by these
academic metrics.3
Perceived competitiveness motivates candidates to submit large numbers
of applications as a mechanism to increase the likelihood of a
successful
match.17As a result, over the past two decades, the mean number of
applications-per-candidate for otolaryngology has increased by nearly
250%.6Among 150 otolaryngology residents surveyed, 90.6% acknowledged
applying to programs in which they had no specific interest in order to
improve their chances of
matching.6Programs inundated by these application numbers are left grappling to
understand candidates’ genuine interest in specific programs.
In response to candidates’ shotgun approaches to the Match, limitations
on the number of applications-per-candidate to between 10 and 20
programs have been
recommended.17Such restrictions are suggested to enable candidates to focus only on
desired programs, decrease interview-associated travel expenses, and
minimize discrepancies in application numbers secondary to financial
burden or disadvantage. For residency programs, such constraints would
enable reviewers to evaluate applications in greater detail and
potentially eliminate selection criteria (such as USMLE score, AOA
status, and/or publication numbers) aimed at trimming inflated candidate
cohort numbers. With more time to review a smaller pool of applicants,
PDs could broaden evaluation of quantitative criteria (i.e., board and
clerkship scores, AOA status) to also include more “humanistic
criteria” (i.e., personal accomplishments, letters of recommendation,
and personal statements). Several studies have echoed sentiments to
implement application limits, albeit discordance remains concerning the
specific number that should be permissible; there is currently no method
available to limit application
numbers.8,18
Beyond instituting a limitation on applications-per-candidate, numerous
proposals have been made to improve the otolaryngology residency
application and selection
process.9A preference signaling system piloted in 2018 was successfully
implemented in the 2021 otolaryngology Match, and will be continued in
otolaryngology and appended to dermatology, general surgery, and
internal medicine in the 2022 Match
cycle.19,20Named “the Star System”, this approach provides each applicant a
predetermined number of “stars” or “signals” to send to programs of
particular
interest.9,19This enables applicants to easily and transparently indicate interest in
a select few programs and addresses the current system that leaves
programs grappling to understand candidates’ genuine interest. Another
signaling approach known as the Consortia Match utilizes a hybrid early-
and conventional-match system in which residency programs are grouped
into “baskets” based upon qualities including program caliber,
reputation, and geography, and applicants are limited to one program
“basket” in the early
match.1,9By limiting the number of programs a candidate can apply to in the early
consortium, this match structure would help reduce strategies such as
interview hoarding and improve the match between program and
applicant.1
In addition to application and selection process reform, pre-graduate
curriculum development and otolaryngology exposure and mentorship early
on in medical school, must be considered. Opportunities such as
shadowing, resident mentorship, and interest group
involvement21allow a greater breadth of students to explore otolaryngology as a
specialty and enable departments to identify who would be “best-fit”
for the specialty. Decreasing or supplementing the emphasis on
scholastic achievements in lieu of more holistic or non-cognitive
evaluations of applicants may attract an applicant pool better equipped
to provide improved, specialty-specific patient
care.22