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Editor’s Spotlight/Take 5: How Did Coronavirus-19 Impact the Expenses for Medical Students Applying to an Orthopaedic Surgery Residency in 2020 to 2021?

Wongworawat, M. Daniel MD1

Author Information
Clinical Orthopaedics and Related Research: March 2022 - Volume 480 - Issue 3 - p 439-442
doi: 10.1097/CORR.0000000000002108

Applying to and getting into orthopaedic surgery residency is hard enough. In this last cycle, 1289 individuals applied for 868 positions [7]. In a typical year, on average, applicants sent out more than 80 applications, and programs received more than 120 applications per position. Stated another way, the competition has approximately doubled over the last 25 years [5].

The COVID-19 pandemic has upended most aspects of our lives, and its effect on the residency application cycle has reverberated through medical schools and training programs. In our specialty, which relies heavily on personal interaction for selection decisions, the limitations on away rotations and in-person interviews have all but taken that aspect away. In the 2020-2021 application cycle, no away rotations were permitted. With easing restrictions, this year’s applicants are allowed one away rotation, although this still has been discouraged [3]. Importantly, interviews remain limited to virtual platforms.

Even prior to the pandemic, there has been a national conversation on containing costs of residency applications. The Association of American Medical Colleges has aggregated data to help applicants plan in a campaign called “Apply Smart.” For each specialty, stratified by test scores, applicants can see the point of diminishing returns of application numbers [2]. This effort did little to stem the trajectory of the skyrocketing number of applications each student sends out. Another strategy involves something as simple as giving the students enough time to make travel plans and buy tickets before prices go up [8]. Then, the pandemic forced us to throw in another strategy to limit costs—go virtual.

Transitioning to virtual rotations and interviews jumpstarted this experiment on controlling application costs. A group led by Afshin Razi MD from Maimonides Medical Center, New York, NY, USA, reviewed residency application data, comparing expenses of two application cycles: 2019-2020 and 2020-2021. Between those two datasets, insert the COVID-19 pandemic with its patchwork of restrictions. Uniformly, however, all in-person travel to interviews were halted. Dr. Razi’s team found that the total cost for applications and interviews dropped by USD 5000, with the greatest drivers being the elimination of away rotations and travel to interviews [4].

We can applaud the nearly 70% discount on application costs. On the other hand, there are intangible benefits that can’t be replaced by a virtual experience. For instance, the American Orthopaedic Association’s Council of Orthopaedic Residency Directors (AOA CORD), in its Recommended Guidelines on 2021-2022 Residency Recruitment, emphasized that the in-person away rotation experience allows for mentorship and exposure, creating more opportunities for students, such as those from lower-tier schools, students who are of nonbinary genders, and students from schools where there are no orthopaedic rotations at their home institution [1].

The restrictions imposed in response to the pandemic challenge us to think carefully about reining in residency application costs while balancing unintended consequences, benefits, and harms. Please join me as I explore these themes with Dr. Razi, author of “How Did Coronavirus-19 Impact the Expenses for Medical Students Applying to an Orthopaedic Surgery Residency in 2020 to 2021?” in the “Take 5” interview that follows.

Take 5 Interview with Afshin E. Razi MD, senior author of “How Did Coronavirus-19 Impact the Expenses for Medical Students Applying to an Orthopaedic Surgery Residency in 2020 to 2021?”

M. Daniel Wongworawat MD:Congratulations on this important and very timely study. Previously, the number of interviews an applicant might have accepted were mainly limited by the number of places to which an applicant can realistically travel. That results in some self-selection and narrowing. How might decreased interview costs and ability to go to an unlimited number of interviews change the selection process? And specifically, how much might this favor individuals who look good on paper compared to those who might overcome on-paper deficits with strong in-person performances?

Afshin E. Razi MD: Historically, the time and expense associated with interview traveling was a major factor when deciding on which interviews to accept. Whereas applicants may have struggled to interview on back-to-back days if the time zones differed, with a virtual format, some applicants may even interview at multiple places on the same day. The virtual format does seem to favor individuals who look stellar on paper, and it limits our ability to evaluate applicants on qualities beyond the so-called objective metrics. It is reassuring that with the evolution and implementation of a universal interview offer day weeks after initial application submissions, programs can holistically evaluate applicants to promote a diverse, equitable, and inclusive environment and recruit those who may be an excellent fit for their program. The financial cost of traveling to interviews may have a disproportionally negative impact on first-generation college students and students from low-income backgrounds, this should be explored in future studies.

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Afshin E. Razi MD

Dr. Wongworawat:I wonder about the hidden costs and the unintended consequences. For example, interview hoarding might now be possible. What are the possible harms of a less expensive and more virtual process? How about benefits other than cost savings?

Dr. Razi: The virtual process does offer some benefits, but a less expensive virtual process also poses some harms. From an applicant’s perspective, there may be an opportunity cost related to the inability to experience a program first-hand. The ability to immerse oneself in a program’s city, community, and work environment is lost. Even with video simulation, this important aspect is absent. Additionally, resident and faculty interactions at in-person interviews are more organic, and applicants may have a better sense upon the conclusion of the interview about their sense of “fit” within a program. An immediate advantage of virtual interviews for applicants is the lack of travel costs, which can be cost-prohibitive to some applicants. Airfare, rental vehicles, and lodging in multiple cities quickly add up, sometimes requiring students to budget interview travel into student loans. With the virtual format, not only are the cost savings noticeable, but travel time is no longer an obstacle to interviewing at multiple programs. With a virtual format, it’s possible to schedule multiple interviews back-to-back in ways that have never been possible before. But yes, this may lead to interview hoarding among the top applicants.

Dr. Wongworawat:How can we maintain the advantages of lower costs without those potential harms? Which organization(s) have the levers to throw here, and what changes should they make to achieve those goals?

Dr. Razi: Every year, the average number of applications per applicant increases, and this is true across all the surgical subspecialties. To try to keep application costs more modest and the process fair, some other surgical subspecialties are trialing a common application system outside of the Electronic Residency Application System. I believe those charged with minding the process in our specialty will watch the results of that trial with interest. As for prompting change in orthopaedic surgery, I think the AOA may be best equipped to take on such a challenge. With the AOA CORD implementing successful away rotation and in-person interview recommendations beginning in 2020 and 2021, the AOA CORD is the one most likely to oversee a successful transition in the application process in our specialty. Talk of capping the number of applications or interviews has been around for some time. This will force some self-selection, much as choosing a limited number of away rotations in the pre-COVID years did; applicants and mentors had to evaluate the candidate’s relative competitiveness. Intuitively, an application cap would result in the number of applicants per program to decline and thus allow for a more manageable cohort of applicants to holistically choose from. Not only would an application cap serve applicants by receiving a more holistic review of their application, but programs should have fewer applicants in total to select from. In terms of an interview cap and the perceived benefit, there is diminishing returns once an applicant reaches a certain number of interviews. Historically, applicants have good success once reaching over 10 interviews and great success once reaching 15 [6]. This is potentially helpful for programs to target and receive interviewees who are truly interested in their program. As the application system is currently constructed, with no involvement of an orthopaedic leadership body, the ability to trial new ideas is a challenge. Should AOA CORD eventually design an application system strictly for orthopaedic surgery applicants, they would be able to enforce application numbers and only allow for the acceptance of a certain number of interviews. These are just two potential possibilities of an orthopaedic surgery–specific application.

Dr. Wongworawat:If those organizations make changes that limit an applicant’s ability to apply to more than a certain number of programs, or to take more than a certain number of interviews, to what degree does that expose them to the potential for anti-competitive litigation or litigation of other kinds?

Dr. Razi: The idea of anticompetitive litigation is challenging and it is a consideration. Certainly, before making any big moves, I suspect that the entities overseeing the process—specifically, the AOA CORD—would perform a specific legal review on that very question. Indirectly, the 2022 application cycle has forced a limit on away rotations for applicants to promote an equitable experience and, to date, it seems to be accepted without significant push back from program directors or applicants. But it’s one thing for external circumstances like a pandemic to force restrictions on the process; it may be quite another for programs or oversight bodies to engage in what may be perceived as anti-competitive collusion.

I think before implementing any limit on applications or interviews, an understanding of the behaviors of applicants and their motives for accepting or declining an interview would be important. For example, it would help to know whether there is any realistic limit on how much the typical applicant would spend on this process, or is there no upper bound on what candidates will spend to try to ensure a match into orthopaedic surgery? Furthermore, what percentage of applicants match at a program they would not have applied to if applications were capped. Secondarily, where in their rank list do most orthopaedic residency applicants match at the present time? Both of these questions are vital if any capping were to be performed. Related to this, we also need to understand to what degree any increased costs would have on limiting applicants with fewer financial means from applying to more programs.

Dr. Wongworawat:What are some cost-saving strategies that might be considered for future application cycles? With your findings about regional differences, could there be strategies for different parts of the country?

Dr. Razi: Some programs already have implemented strategies on these themes. One is the ability for candidates to interview virtually if they’ve participated in an away rotation. This may provide additional cost savings and time savings for applicants and programs during the interview season. Another option involves a similar process employed by certain subspecialty fellowships. For example, the shoulder and elbow fellowship interviewing process has grouped programs into geographic pods. Applicants may maximize their interview time by attending interviews with multiple programs in the same state or geographic region.

References

1. American Orthopaedic Association. AOA/CORD recommended guidelines: 2021-2022 residency recruitment. Available at: https://www.aoassn.org/aoa-cord-recommended-guidelines-2021-2022-residency-recruitment/. Accessed December 15, 2021.
2. Association of American Medical Colleges. Apply smart: data to consider when applying to residency. Available at: https://students-residents.aamc.org/apply-smart-residency/apply-smart-data-consider-when-applying-residency. Accessed December 15, 2021.
3. Association of American Medical Colleges. Final report and recommendations for medical education institutions of LCME-accredited, U.S. osteopathic, and non-U.S. medical school applicants. Available at: https://www.aamc.org/system/files/2020-05/covid19_Final_Recommendations_05112020.pdf. Accessed December 15, 2021.
4. Gordon AM, Conway CA, Sheth BK. How did coronavirus-19 impact the expenses for medical students applying to an orthopaedic surgery residency in 2020 to 2021? Clin Orthop Relat Res. 2022;480-443-457.
5. Nasreddine AY, Gallo R. Applying to orthopaedic residency and matching rates: analysis and review of the past 25 years. J Bone Joint Surg Am. 2019;101:e134
6. National Resident Matching Program. Charting outcomes in the match: senior students of U.S. MD medical schools; 2020. Available at https://www.nrmp.org/wp-content/uploads/2020/07/Charting-Outcomes-in-the-Match-2020_MD-Senior_final.pdf. Accessed December 15, 2021.
7. National Resident Matching Program. Results and data. 2021 main residency match. Available at: https://www.nrmp.org/wp-content/uploads/2021/05/MRM-Results_and-Data_2021.pdf. Accessed December 15, 2021.
8. Ruckle D, Wongworawat MD. Do orthopaedic residency programs have the least time between invitation and interview? J Grad Med Educ. 2021;13:548-552.
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