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