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The otolaryngology residency application problem

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March 24, 2017
by Robert T. Sataloff, MD, DMA, FACS


The challenges of gaining acceptance to an otolaryngology residency are familiar not only to those of us in academics, but also to anyone who has tried to help a medical student gain entrance to one of our training programs. The pressures and cost of applying to otolaryngology residency are increasing, and the large number of applications submitted by each applicant makes it challenging for residency programs to figure out who is really interested in a specific institution.

In August 2016, Wong proposed a solution that involved organizing residency programs into consortia, based on similar characteristics such as geography and a supported research year.1 Graboyes and Goebel offered commentary and critique on the same issue.2 We can always count on Joel Goebel and his group for thoughtful insights, and this commentary is no exception.

Graboyes and Goebel enumerated potential problems with Wong's innovative suggestion. The critiques included bias that might be created in residency reputation based on exclusion from consortia, or self-exclusion from consortia by elite programs; bias against residents who applied but were not invited for interviews by consortia for early match (the consortia concept provided for early match, with those failing to match entering the current National Resident Matching Program [NRMP] match); problems in choosing meaningful criteria on which to base the aggregation of programs into consortia; challenges in selecting the best candidates for invitation to interview for a consortia match; and the likelihood that the NRMP would not allow such a system.

Both Wong and his critics raise valid concerns, but the problems remain unsolved.

The Society of University Otolaryngologists-Head and Neck Surgeons and the Association of Academic Departments of Otolaryngology-Head and Neck Surgery are sensitive to the problems facing our applicants and discuss them routinely. Electronic residency application service data revealed that there was a median of 46 applications per applicant in 2015.3 Those data also revealed that in 2014, otolaryngology residency applicants who were members of Alpha Omega Alpha (AOA) submitted a median of 59 applications for otolaryngology residency, and in 2015 they submitted 63. Of all applicants, the median number in 2015 was 46 applications. The costs associated with each application include not only monitory requirements but also time and stress.

Suggestions for easing this situation have included limiting the number of applications permitted,4 using standardized letters of recommendation,5-7 guiding otolaryngology program directors to counsel students to apply to a carefully chosen group of 10 to 20 programs,8,9 and requiring that a portion of each personal statement include specific information about why the applicant is interested in that specific program. In my opinion, while all these suggestions have merit, they also have shortcomings.

For example, forcibly limiting the number of applications that an applicant is permitted to submit not only seems somewhat contrary to the basic principles of freedom of choice, but it also has potential disadvantages for both applicants and programs. Setting aside the difficulty of figuring out how to select the correct number of programs at which to set the limit, limiting the number of applications could potentially hurt not only weaker applicants, but also the strongest. Weaker applicants probably would be forced to eliminate most or all their “reach” programs. This would be troublesome not only for the applicants, but also for the programs.

We have all seen students who were not our best applicants on paper do so well on “away rotations” that they were accepted into and thrived in elite programs that no one would have predicted would take them. Not only have such training opportunities benefited the applicants, but the applicants also often have provided diversity that strengthened the programs. If the number of applications were limited, these applicants probably would not “waste” away rotations at programs that were unlikely to accept them.

Program directors and otolaryngology medical student advisors already should be advising applicants to focus on a relatively small number of programs that are their top choices, selected from programs at which they appear competitive. I advise my students to select their top 3 to 5 choices and an additional 10 to 15 at which they would be happy. However, while they choose their away rotations and focus their efforts on these programs, they all know there is no guarantee that they will be accepted to one of them, and they apply to many more. In the current system, I would not advise them to do otherwise. So, this approach alone will not decrease the number of applications.

Much can be said in favor of standardized letters of recommendation. However, although they have been discussed for several years, they have yet to be adopted uniformly in otolaryngology, and opinions and experiences in other specialties vary.10-13 Moreover, unless these standardized letters include or are supplemented by free-form commentary, much of the most valuable, personal information about applicants may not be conveyed well enough. In addition, it seems unlikely that this approach will reduce the number of applications per candidate.

Many applicants already have been writing paragraphs within their personal statements that are specific to each program, and now this is required. The requirement is reasonable. However, that paragraph is often pro forma, and it increases the amount of work they need to do to complete their 50 or 60 applications. Moreover, while program directors certainly read such statements, they also know they are being written for each program, and that may hamper the credibility of the program-specific paragraph. Also, there is no convincing evidence that adding this requirement will decrease the number of applications significantly. There also is a new requirement for an online survey that must be taken by all applicants, but its effect on the number of applications submitted is unknown.

So, we have medical students applying to an oppressive number of programs, and programs receiving a burdensome number of applications from which it is often difficult to cull applicants with a genuine interest in any specific institution. I do not have a perfect solution, but I have a thought for a simple approach that might help.

The matching program was instituted for good reasons, including protecting applicants from being placed under undue pressure. I am personally familiar with the old system. At the end of my first day of an away rotation at the Massachusetts Eye and Ear Infirmary, I received a phone call and was given 10 seconds to accept or decline a residency position at the University of Michigan. I accepted gratefully, but I would not have minded the option (which I requested and was denied) to defer that decision until I had spent a month at Harvard. Nevertheless, there seems to be room for a happy medium between the old, unregulated system and the current, richly regulated NRMP.

For example, in college admissions, early-decision programs work well. Students who are accepted are spared the arduous task of applying to multiple colleges in which they are less interested, and colleges can select from applicants whom they know are committed to their institution. Applying early decision to one college has no demonstrated adverse effect on applications at other colleges; and people who are rejected during the early-decision process commonly are accepted to their early-decision school later during the regular application process.

While a similar early-application option for otolaryngology residency would not solve all our problems, it is a simple, time-tested approach that might help, especially if it were timed with an ample period between the decision and the match-application deadline, so that early-decision applicants would not have to fill out their 60 additional applications and wait to “push the button” in case they were rejected from their early-decision program.

Since there is so much academic precedent for early-decision models, it seems possible that the NRMP would be willing to discuss such an option, with the early-decision program either separate from and well before the match, or possibly administered through the match. If 20% of residency positions were filled by early decision, assuming many of these candidates would be AOA-level applicants, that would not only put those students into their first-choice programs and help programs fill with applicants who really want to be there, but it also would decrease by about 3,600 the number of applications through which other programs had to sift.

Early decision is only one simple, partial solution to our current problems. There are undoubtedly others. However, it seems clear that it is time for us to not just think about this issue, but also to act. We have recognized for years the difficulties that the current system poses for applicants and programs, and they are only getting worse. It is past time to start improving our system.



References

  1. Wong BJ. Reforming the match process-early decision plans and the case for a consortia match. JAMA Otolaryngol Head Neck Surg 2016; 142 (8): 727-8.
  2. Graboyes EM, Goebel JA. Reforming the otolaryngology-head and neck surgery match: Should we embrace a consortia match? JAMA Otolaryngol Head Neck Surg 2016; 142 (8): 728-730.
  3. Association of American Medical Colleges. Otolaryngology: using ERAS since ERAS 2006.https://www.aamc.org/download/358802/data/otolaryngology.pdf. Published 2015. Accessed July 3, 2016.
  4. Naclerio RM, Pinto JM, Baroody FM. Drowning in applications for residency training: A program's perspective and simple solutions. JAMA Otolaryngol Head Neck Surg 2014; 140 (8): 695-6.
  5. Perkins JN, Liang C, McFann K ,et al. Standardized letter of recommendation for otolaryngology residency selection. Laryngoscope 2013; 123 (1): 123-33.
  6. Messner A, Teng M, Shimahara E ,et al. A case for the standardized letter of recommendation in otolaryngology residency selection. Laryngoscope 2014:124 (1): 2-3.
  7. Kominsky AH, Bryson PC, Benninger MS, Tierney WS. Variability of ratings in the otolaryngology standardized letter of recommendation. Otolaryngol Head Neck Surg 2016; 154 (2): 287-93.
  8. Baroody FM, Pinto JM, Naclerio RM. Otolaryngology (urban) legend: The more programs to which you apply, the better the chances of matching. Arch Otolaryngol Head Neck Surg 2008; 134 (10): 1038.
  9. Christophel JJ, Levine PA. Too much of a good thing. JAMA Otolaryngol Head Neck Surg 2014; 140 (4): 291-2.
  10. Nallasamy S, Uhler T, Nallasamy N ,et al. Ophthalmology resident selection: Current trends in selection criteria and improving the process. Opthalmology 2010; 117 (8): 1505.
  11. Diab J, Riley S, Overton DT. The Family Education Rights and Privacy Act's impact on residency applicant behavior and recommendations: A pilot study. J Emerg Med 2011; 40 (1): 72-5.
  12. Love JN, Deiorio NM, Ronan-Bentle S ,et al. SLOR Task Force. Characterization of the Council of Emergency Medicine Residency Directors' standardized letter of recommendation in 2011-2012. Acad Emerg Med 2013; 20 (9): 926-32.
  13. Diab J, Riley S, Downes A ,et al. A multicenter study of the family educational rights and privacy act and the standardized letter of recommendation: Impact on emergency medicine residency applicant and faculty behaviors. J Grad Med Educ 2014; 6 (2): 292-5.
Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Senior Associate Dean for Clinical, Academic Specialties, Drexel University College of Medicine, Philadelphia
Ear Nose Throat J. 2017 March;96(3):91-93