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    Report urges major reforms in the transition to residency

    The residency application, selection, and transition process has become increasingly complex and stressful for all those involved. Now, a committee of key stakeholders proposes dramatic changes.

    A group of masked doctors look at an x-ray

    Each year, tens of thousands of medical students face a flood of potentially life-changing questions.

    After many years of a demanding education, how do they nab a coveted residency slot to complete their training? How do they determine whether a residency program — where they could spend the next three to seven years — is the right fit? What can they do to stand out among dozens of applications? And most concerning, what happens if they don’t get a spot?

    “The process is so stressful and all-consuming,” says Juhee Patel, DO, a recent graduate of Rowan University School of Osteopathic Medicine in Stratford, New Jersey. “You focus so much on the next step, and the next, that you can forget that you’re still a student trying to learn.”

    Medical school advisors who guide students through the complex process feel the strain as well. And residency program directors who may receive a thousand applications for a dozen positions struggle to pinpoint the candidates who will best suit their programs.

    “The system is broken,” notes Karen Hauer, MD, PhD, an associate dean at the University of California, San Francisco (UCSF), School of Medicine.

    Now, for the first time, key stakeholders have come together to tackle the many thorny problems that hobble the process of transitioning from medical student to resident.

    On Aug. 26, the Coalition for Physician Accountability — the organization that brings together all the major players in the transition to residency process, including the AAMC, the National Resident Matching Program®, the American Osteopathic Association, and the Educational Commission for Foreign Medical Graduates — released 34 recommendations that some hope will shake up the entire process.

    The Coalition-convened Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) penned the report after nine months of extensive debate, drafting, and public feedback.

    The final recommendations touch nearly every aspect of the transition to residency. They range from decreasing the stress and expense of applications to increasing diversity, equity, and inclusion in medicine.

    “These recommendations are a comprehensive set of ideas on how to make the process better. Now the hard work starts on which ones are most helpful to applicants and programs and whether they can be implemented.”

    Janis M. Orlowski, MD, MACP
    AAMC chief health care officer

    “Taken together, these recommendations are transformational,” says Elise Lovell, MD, UGRC co-chair and emergency medicine residency program director at Advocate Christ Medical Center in Oak Lawn, Illinois.

    Still, the road ahead is not simple. For one, each member organization of the Coalition — there are 13 of them — is autonomous and will need to decide which recommendations it can act on and when. In addition, the United States is home to hundreds of residency programs and medical schools, each with their own missions and resources to consider as they contemplate change.

    “These recommendations are a comprehensive set of ideas on how to make the process better. Now the hard work starts on which ones are most helpful to applicants and programs and whether they can be implemented,” explains Janis M. Orlowski, MD, MACP, AAMC chief health care officer. “In the end, we’ll have some really good, winning ideas and some that will not work out.”

    Looking ahead, leaders say they are committed to the necessary work. “All of the members of the coalition are committed to ongoing collaboration with each other and with medical schools and residency programs to improve the system,” says Alison J. Whelan, MD, AAMC chief academic officer and the association’s representative on the coalition.

    Other leaders are hopeful as well. “Even if all the recommendations are not implemented seamlessly, I believe good things will occur,” notes George Mejicano, MD, UGRC co-chair and senior associate dean for education at Oregon Health & Science University School of Medicine.

    “For the past 10 years or more, we've been stuck in the same place,” says Grant Lin, MD, PhD, a pediatric resident at Stanford Health Care in California and a member of the UGRC committee. “The recommendations are a monumental step in breaking through that.”

    Ending the applications arms race

    Worried that they won’t win a slot, residency candidates have been filing more and more applications. Between 2016 and 2020, the average number of applications that candidates submitted rose more than 8% from 87.7 to 95. International medical school graduates, who often face additional hurdles in the quest for a residency slot, have hit an average of 136 submissions.

    “This year, we received 5,800 applications for 24 positions. It’s just not possible to thoroughly review most of them,” explains Richard Alweis, MD, a UGRC committee member and associate chief medical officer for medical education at Rochester Regional Health in New York.

    Candidates might apply to fewer programs if they better understood where they had a shot at acceptance, the UGRC suggests. The Residency Explorer™ tool and Careers in Medicine® program already provide some information, but the committee wants more. For instance, the authors note that such data as the test scores or geographic regions of applicants who were interviewed or ranked in the Match® by a program would be edifying.

    Programs looking to winnow their applicant pool need better information, too. The recommendations therefore advise making the Electronic Residency Application Service® (ERAS®) more searchable — say, for students who volunteered at a rural clinic or researched COVID-19.

    “This year, we received 5,800 applications for 24 positions. It’s just not possible to thoroughly review most of them.”

    Richard Alweis, MD
    Associate chief medical officer for medical education at Rochester Regional Health in New York

    But better information is hardly enough, the report notes. The community needs well-supported pilot programs that explore innovative ways to shrink application numbers.

    Some efforts, like accelerated pathways — ones that seamlessly move students from an institution’s medical school to its residency program — already exist. Other recommendations, such as capping the number of applications allowed per person, would be more dramatic departures from existing practices.

    Battling bias and inequities

    The report makes several suggestions to improve diversity, equity, and inclusion in medicine.

    For one, it recommends that all members of the medical education community receive professional development on anti-racism, avoiding bias, and improving equity. Without such steps, physicians risk perpetuating health inequities — and even mistreating learners, according to the report.

    In addition, specialty societies should develop and disseminate best practices to help programs recruit a diversity of candidates.

    And because clinical clerkship grades can be subjective — and therefore require close monitoring — the report authors recommend that medical schools review their clerkship grade distributions each year to root out bias based on such characteristics as race, ethnicity, gender, and sexual orientation.

    Those involved with the UGRC process note that the committee considered diversity, equity, and inclusion throughout, not just in guidance focused specifically on those issues. The goal, they say, was to prevent recommendations from inadvertently having an uneven toll on any particular group.

    Making the interview process more equitable

    Aside from hoping to ace a residency interview, the interview-invitation system itself can be intensely stressful on candidates since it puts pressure on them to respond almost immediately to interview openings.

    “A friend asked me to watch their email account for offers from 4 a.m. to 10 a.m. so they could go to their clerkship. That’s pretty common practice,” notes Lin. “If you don’t respond to an interview request within about five minutes, that slot could be taken.”

    The report therefore recommends creating better platforms, policies, and procedures for offering and accepting interviews. While all those possibilities are being sorted out, the authors call for temporary measures for this application season, such as programs extending only as many invitations as available interviews and allowing students 24 to 48 hours to respond to invites.

    And then there’s another significant interview issue: Worried that they won’t land a slot elsewhere, some applicants hoard appointments at many programs further down their priority list.

    To address that problem, the report advises specialty-specific caps on the number of applicant interviews.

    “An electronic system could automatically prevent a candidate from taking too many interviews,” explains UCSF’s Hauer, who served on the committee. “Then those many extra interviews you didn’t need could go to other applicants who did really need them.”

    Getting residents ready

    The difficulties with the transition to residency are not only with the application process. Among the other issues is ensuring that students are ready when they hit the hospitals’ halls.

    You don’t really know exactly what you’re going to see when someone shows up on Day 1 of residency,” Alweis says.

    That’s mostly because there’s no agreed-upon set of skills that every medical school graduate must possess, according to the report.

    “We want all of medical education to start speaking the same language when we describe and assess a learner’s abilities,” Lovell says. Having such recognized competencies could offer many benefits. Among them are letters of recommendation built around core skills rather than more free-ranging, subjective assessments.

    Another key recommendation proposes creating standardized ways that programs can provide feedback to medical schools on their graduates’ readiness for residency. Those observations could help schools improve their curricula and learner handovers.

    “We want all of medical education to start speaking the same language when we describe and assess a learner’s abilities.”

    Elise Lovell, MD
    Undergraduate Medical Education to Graduate Medical Education Review Committee co-chair

    “Imagine if the feedback loop facilitated more open communication about the needs of programs,” explains Donna Lamb, DHSc, MBA, president and CEO of the National Resident Matching Program®, which runs the Match®, the process that allows candidates and programs to rank each other and thereby fill residency slots. “We could see great improvement in the collaboration and trust between schools and programs, and as trust increases, programs will become more willing to conduct holistic review” based on schools’ evaluations.

    Will all this work?

    Rolling out the recommendations will be complicated and certainly will take time, say those involved.

    At the AAMC, for example, a work group has been exploring options to improve the application process. “We’ll build on existing initiatives, consider new ones, and be as evidence-informed as possible,” says Whelan. “Importantly, before we act on any recommendations, we’ll get additional input from our constituents and communities.”

    Projects already underway include upgrading the technology behind the searchability of the ERAS application and trying out supplemental ERAS questions that could aid programs’ decision-making, explains AAMC chief services officer Gabrielle V. Campbell, MBA, LLM. The organization has also gathered extensive resources for students, schools, and programs to improve the transition to residency.

    Still, some report suggestions — capping the number of applications per candidate, for instance — must be approached with caution, Campbell notes. “For this to work in practice, candidates must have sufficient opportunities when applying, so the AAMC is studying the equity implications of caps.”

    “We’ll build on existing initiatives, consider new ones, and be as evidence-informed as possible.”

    Alison J. Whelan, MD
    AAMC chief academic officer

    The groups involved also want to contemplate possible unforeseen consequences of various steps, committee members say. In fact, Recommendation #1 is to establish a unified body to monitor the impact of changes and champion continuous quality improvements.

    But such united efforts are not so simple.

    “This work is going to require a level of collaboration never seen before in medical education,” says Lovell.

    So, what will motivate individual organizations to collaborate despite their sometimes differing perspectives?

    Mejicano has thoughts: “It’s a combination of altruism, compromise, peer pressure, and providing a compelling argument about how big the problem is.”

    If efforts pan out, Lin believes that thousands of people will benefit. “We want to be creating an effective physician workforce for patient care because, at the end of the day, that’s what this is all about.”