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How Did Coronavirus-19 Impact the Expenses for Medical Students Applying to an Orthopaedic Surgery Residency in 2020 to 2021?

Gordon, Adam M. BS1; Conway, Charles A. MD1; Sheth, Bhavya K. MD1; Magruder, Matthew L. MD1; Vakharia, Rushabh M. MD1; Levine, William N. MD2; Razi, Afshin E. MD1

Author Information
Clinical Orthopaedics and Related Research: March 2022 - Volume 480 - Issue 3 - p 443-451
doi: 10.1097/CORR.0000000000002042

Abstract

Introduction

Orthopaedic surgery residency is one of the most competitive specialties for residency applicants [27]. In 2020, 1192 students applied for 849 positions; among United States medical school seniors, only 81% matched [27]. Given the reported increase in the number of programs each student applies to as a result of this competitive process, most medical student applicants participate in multiple away rotations to enhance their chance of matching [4]. During the past decade, the number of programs to which each US orthopaedic surgery residency applicant has applied has nearly doubled [9, 25]. In 2020, the coronavirus 2019 (COVID-19) pandemic added an unforeseen complication to the orthopaedic residency match [1, 7]. Although much of the application process remained unchanged, including the importance of board examination scores (this is scheduled to change in January 2022, when the United States Medical Licensing Examination [USMLE] Step 1 will convert to pass-fail scoring), clinical grades, and letters of recommendation, away rotation and in-person interview performance were not available during 2021 [5, 8, 18, 21, 25, 31, 33, 34, 37]. During the pandemic, the Association of American Medical Colleges [2] and Council of Orthopaedic Residency Directors [6] recommended that orthopaedic surgery residency programs cancel away rotations and in-person interviews for the 2021 residency application cycle. For program directors, chairpersons, and applicants, the financial and nonfinancial ramifications of this modified application cycle are still being investigated [15, 16].

Although prior studies have broadly evaluated the financial expenditures of applying to orthopaedic surgery residency [4, 10, 11], expenses for students applying in the year immediately before and during COVID-19 have not been compared. These expenses are important to evaluate because they have implications for candidates, medical schools, and training programs. Although decreasing the expenses associated with this process may make it possible for less affluent candidates to afford to be fully competitive, the reduced expenses associated with a virtual process may cause a high proportion of candidates to apply to many more programs than they might have when in-person visits would have been part of the process [3]. This may favor a small number of top candidates and could cause a higher proportion of candidates not to match [3]. Considering this gap in what we now know about the expenses associated with the process, it is important that we quantify the savings to medical students applying during this unprecedented time and that we consider the potential implications of those savings as the orthopaedic community strives for greater diversity and inclusion [1, 5, 17, 22, 23, 24, 30].

Given that in 2021 students did not attend away rotations and all interviews were held virtually, we asked (1) What were the financial savings associated with this change? (2) Was medical school geographic region associated with differences in expenses when applying to residency?

Materials and Methods

Study Design and Setting

We performed a retrospective, cross-sectional analysis of the 2020 and 2021 Texas Seeking Transparency in Application to Residency Dashboard database. The Texas Seeking Transparency in Application to Residency Dashboard is an online survey generated from a nationwide pool of applicants from 123 medical schools upon conclusion of the match. The database is available to US medical schools that agree to provide data to it; data within this database can be sorted by specialty. We chose this database because it represents an anonymous nationwide sample of applicants and prior studies have used these data to examine the trends in applicant characteristics and expenses in the transition from medical school to residency [12-14, 20]. The database is the only source for all the associated applicant expenses (application, away rotation, interview, total) to residency, and it provides data by medical school region, making it useful for geographic comparisons, which we felt was important. We believe this nationwide dataset represents the largest and most current data for this group of applicants.

For this study, responses from applicants applying to orthopaedic surgery residency in the year before the COVID-19 pandemic (2020) and during COVID-19 (2021) were queried.

Representativeness of the Dataset

The data were derived from an online survey shortly after concluding the residency match. The data consisted of a nationwide pool of applicants from 87% (123 of 141) of US allopathic medical schools. The response percentage was 29% (521 of 1794). Osteopathic and international medical graduates were not available for inclusion in the study. Although a minority of students responded to the survey, those who did seemed comparable with published data from the National Residency Match Program in terms of objective applicant characteristics including USMLE Step 1 and Step 2 scores, research output, leadership experiences, volunteer experiences, and the percentage of applicants achieving Alpha Omega Alpha honors [27]. To protect the anonymity and encourage participation from medical schools and applicants, both gender and race are not available at the student level.

Participants’ Data

The 2020 to 2021 Texas Seeking Transparency in Application to Residency Dashboard database had 521 responses from applicants applying to an orthopaedic surgery residency program (n = 263 in 2020 and n = 258 in 2021). Applicant characteristics were comparable between 2020 and 2021, including mean USMLE Step 1 and 2 scores, Alpha Omega Alpha honors membership, number of clerkships honors, research experiences, number of publications, number of presentations, number of leadership positions, and number of volunteer experiences (Table 1). Most applicants were from schools in the South, followed by the Northeast, Central, and West.

Table 1. - Demographics of orthopaedic surgery residency applicants by year
Parameter 2020 application year (n = 263) 2021 application year (n = 258) p value
Applicants from the CGSA 21 (54) 25 (65) 0.28
Applicants from the NEGSA 27 (72) 31 (80)
Applicants from the SGSA 42 (110) 36 (93)
Applicants from the WGSA 10 (27) 8 (20)
USMLE Step 1 score 247 ± 11 245 ± 12 0.43
USMLE Step 2 score 255 ± 12 255 ± 12 0.83
AOA membership 46 (121) 39 (101) 0.11
Number of applications 81 ± 24 73 ± 29 0.35
Number of interviews attended 12 ± 4.7 12 ± 5.8 0.65
Number of clerkships honored 4.4 ± 1.9 4.3 ± 2.4 0.57
Number of research experiences 5.6 ± 3.2 6.2 ± 2.8 0.77
Number of publications 4.6 ± 3.4 5.1 ± 3.5 0.54
Number of presentations 7.2 ± 3.8 7.3 ± 3.8 0.92
Number of volunteer experiences 7.0 ± 3.1 7.3 ± 2.9 0.79
Number of leadership positions 4.4 ± 2.7 5.1 ± 2.9 0.83
Data are presented as % (n) or mean ± SD; CGSA = Central Group on Student Affairs; NEGSA = Northeast Group on Student Affairs; SGSA = Southern Group on Student Affairs; WGSA = Western Group on Student Affairs; USMLE = United States Medical Licensing Examination; AOA = Alpha Omega Alpha.

Variables

The database was queried to record the total expenses, application costs, away rotation expenses, and interview costs for medical school seniors applying to orthopaedic surgery residency. Information for applicants including USMLE Step 1 and Step 2 scores, number of applications, number of interviews, and supporting applicant characteristics including medical school region was compared between years. The four medical school regions and the states in their respective regions are shown (Table 2). More information regarding the database and data collection can be found at: https://www.utsouthwestern.edu/education/medical-school/about-the-school/student-affairs/texas-star.html [36].

Table 2. - Geographic breakdown of student affairs groups in the United Statesa
Central Group on Student Affairs: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin
Northeast Group on Student Affairs: Connecticut, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
Southern Group on Student Affairs: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia
Western Group on Student Affairs: Arizona, California, Colorado, Hawaii, Nevada, New Mexico, Oregon, Utah, Washington
aMissing states do not have an allopathic medical school; medical schools in these states are grouped into these student affairs groups and this designates the region.

Primary and Secondary Outcomes

The data studied included a comparison of applicant characteristics in the year before (2020) and during COVID-19 (2021). The primary evaluation compared individual and total expenses between application cycles. Our secondary study outcome was the association of medical school region with total expenses, application costs, away rotation expenses, and interview expenses.

Ethical Approval

The publicly available data from this study are deidentified; therefore, this study did not require approval from our institutional review board.

Statistical Analyses

Median expenses and interquartile ranges (IQR) are reported with percentile distributions for each type of expense incurred. The dependent variable (USD) was analyzed to determine the normality of distribution. A Mann-Whitney U test or Kruskal-Wallis H test was used to determine whether there were statistically significant differences in median expenses between years and between medical school regions. For multiple comparisons, Dunn pairwise tests were performed, followed by adjustment using a Bonferroni correction. A p value of < 0.05 was considered statistically significant.

Results

Expense Analysis

From 2020 to 2021, the median (IQR) total expenses (USD 7250 [USD 5000] versus USD 2250 [USD 2000]), application costs (USD 2250 [USD 500] versus USD 1750 [USD 1000]), away rotation expenses (USD 2750 [USD 3000] versus USD 250 [USD 250]), and interview expenses (USD 2250 [USD 3000] versus USD 75 [USD 100]), declined between application cycles (all p < 0.001) (Fig. 1). The median total savings for all applicants between application cycles was USD 5000, driven by the greatest decreases in away rotation and interview expenses (Fig. 1).

F1
Fig. 1:
A-B These box plots represent (A) individual and (B) total expenses of applying to orthopaedic surgery residency for all applicants from 2020 compared with expenses in 2021. The median value with quartiles is represented.

Regional Expense Comparisons

In 2021, median total expenses were lower in all geographic regions, with the greatest savings from applicants in the West (USD 6000); in addition, the difference in median total expenses between the geographic region with the highest total expenses and the lowest total expenses was lower in the pandemic year than it was in the year before (USD 1000 versus USD 1500; p < 0.001) (Table 3). Despite a decrease in total expenses in 2021 between regions, there were differences between the Northeast (USD 1750), West (USD 1750), and Central (USD 2750) regions (p < 0.001) (Fig. 2). From 2020 to 2021, only application fees from Northeast applicants differed (USD 2250 versus USD 1250; p < 0.001) (Table 3). In 2020, interview expenses did not differ between all regions (USD 2250 Northeast and West versus USD 2750 Central and South; p = 0.19); similarly in 2021, interview expenses were similar between all regions (USD 75 versus USD 75; p = 0.82) (Table 3). Finally, in 2020, Northeast (USD 3250) and Western (USD 3250) applicants spent more for away rotations than Southern (USD 2750) and Central (USD 2250) applicants (p = 0.01) (Table 3). In 2021, applicants from schools in the South and Central regions spent more than their counterparts (USD 250 versus USD 0; p = 0.028) (Table 3).

Table 3. - Comparison of application costs between geographic regions from 2020 to 2021
Expense in USD 2020 application year (n = 263) 2021 application year (n = 258) Difference of medians p valuea
Application fees
 Central 1750 (1750-2750) 1750 (1250-2750) 0 0.71
 Northeast 2250 (1750-2250) 1250 (750-2250) 1000 < 0.001
 South 1750 (1750-2250) 1750 (1250-2250) 0 0.21
 West 1750 (750-2250) 1250 (750-1750) 500 0.06
Interview expenses
 Central 2750 (1250-4750) 75 (25-75) 2675 < 0.001
 Northeast 2250 (1250-3250) 75 (25-125) 2175 < 0.001
 South 2750 (1250-4250) 75 (25-125) 2675 < 0.001
 West 2250 (1250-5250) 75 (25-125) 2175 < 0.001
Away rotation expenses
 Central 2250 (1250-3250) 250 (0-750) 2000 < 0.001
 Northeast 3250 (1750-4750) 0 (0-250) 3250 < 0.001
 South 2750 (1750-4750) 250 (0-250) 2500 < 0.001
 West 3250 (2250-5250) 0 (0-250) 3250 < 0.001
Total expenses
 Central 6250 (4750-10,250) 2750 (1750-3750) 3500 < 0.001
 Northeast 7250 (5750-10,250) 1750 (1250-2750) 5500 < 0.001
 South 7750 (5250-10,250) 2250 (1750-3250) 5500 < 0.001
 West 7750 (5750-12,250) 1750 (750-2750) 6000 < 0.001
Data are presented as median (IQR).
ap value is from a Mann-Whitney U test comparing values from 2020 and 2021 within each geographic region; costs are provided in USD.

F2
Fig. 2:
This box plot represents the total expenses of applying to orthopaedic surgery residency during 2020 compared with expenses in 2021 by applicant geographic region; CGSA = Central Group on Student Affairs; NGSA = Northeast Group on Student Affairs; SGSA = Southern Group on Student Affairs; WGSA = Western Group on Student Affairs.

Discussion

Orthopaedic surgery remains one of the most competitive specialties for residency applicants. With rising application volumes and recent changes to the application process that directly impact applicants and programs, a better understanding of the expenses in a traditional application cycle compared with the cycle that was necessarily modified by the COVID-19 pandemic are needed. Prior studies have surveyed applicants about the expenses of pursuing an orthopaedic surgery residency [4, 14]; however, the expenses in the year immediately before and during COVID-19 have not, to our knowledge, been compared. In our large-database survey, we found the median total expenses, application costs, away rotation expenses, and interview expenses declined in 2021 compared with 2020. In the COVID-19 interview year (2021), orthopaedic residency applicants saved a median of USD 5000 with the suspension of away rotations and with the use of exclusively virtual interviews. We found that applicants from the West benefitted from this more than those from other areas (the median savings in the western region was USD 6000). The benefits of financial savings are obvious; the potential harms—including the possibility of a large increase in the number of programs that applicants might apply to if they feel they do not need to visit those programs or interview in person—may be less obvious but are no less important.

Limitations

There are some limitations to this study. The expense data are limited to median and percentile distributions of application costs, away rotation expenses, interview expenses, and total expenses for US allopathic applicants. Using a voluntary, nationwide survey performed at the conclusion of the match prevented us from reporting more granular information with regard to expenses at each stage of the application process. But because many factors may influence the number of programs applied to, the away rotation site chosen, and the number of interviews completed, using broad categories allowed for a more homogeneous comparison. The survey used for the present study is administered shortly after conclusion of the match and therefore recall bias is a limitation; however, because the time span is short, we believe it is unlikely to have substantially influenced our findings. We could not correlate expenditures to match success or applicant demographics. Understanding the differences in expenses broken down by gender, race, socioeconomic background, and other demographics was not available because of privacy concerns and represents an area for consideration in future studies. Paradoxically, the lack of diversity that currently troubles our specialty makes it likely that an analysis by gender or race would not have changed our main findings; still, there may have been differences to individual applicants within different demographic and socioeconomic groups of applicants.

The low response proportion to the survey is also a limitation. The cohort in the present study represents only a fraction of the specialty-specific applicant pool. Our study data were derived from 87% (123 of 141) of US allopathic medical schools, including a response percentage of 29% (521 of 1794). Although a minority of students responded to the survey, the results from those who did seemed comparable with published data from the National Residency Match Program in terms of objective applicant characteristics including USMLE Step 1 and Step 2 scores, research output, leadership experiences, volunteer experiences, and the percentage of applicants achieving Alpha Omega Alpha honors [26], and the two year groups surveyed here did not differ from one another (see Table 1). Osteopathic applicants and international medical graduates were not included, potentially underestimating the true difference in cost expense savings observed in the study; however, most matriculating orthopaedic residents attend a US allopathic medical institution, and so our study group is broadly representative in that respect. There is the potential for nonresponse bias for programs and applicants, and we could not compare responders with nonresponders to the survey. Applicants who fared better during the application process may have been more likely to respond, and our data may be skewed to reflect higher-performing applicants. Finally, our results should be taken in the context of the recommendation from the American Orthopaedic Association Council of Orthopaedic Residency Directors in May 2020 for applicants with USMLE step 1 scores higher than 235 to apply to no more than 40 programs [6]. This may explain the lack of rise in application volumes and expenses from 2020 to 2021.

Expense Analysis

The median differential in expenses for orthopaedic surgery applicants was USD 5000 during the 2020 to 2021 application cycle, driven mostly by decreases in away rotation and interview expenses. Contrary to what was projected [3], the application costs in the present study remained similar in 2021. Prior studies have surveyed applicants regarding the expenses of applying to orthopaedic surgery residency [4, 10, 11, 14]. In a recent cost analysis study [3], the mean total expenses in 2020 were approximately 50% greater than expenses 5 years prior [4, 14]. The financial ramifications of our study may guide program directors and chairpersons as they pursue greater inclusion of underrepresented groups and strive to deliver an equitable match. Fogel et al. [10] surveyed applicants in 2015 regarding cost estimates for interviewing, and 72% of applicants borrowed additional money to finance the interview season, and 28% cancelled at least one interview because of financial concerns. The authors of that study could not determine whether the applicants who cancelled an interview felt comfortable doing so and/or had secured enough interviews to match. It would be worthwhile to understand the tradeoff between expenses and having an increased chance at securing a match. With medical school tuition increases coupled with the growing financial debt after professional school, the 2020 to 2021 year may catalyze future changes to the residency application process.

The alternative should be taken into context, though, because the expense of applying to orthopaedic surgery residency represents approximately only 2.7% of the total of a typical medical education (USD 8179 and USD 300,000, respectively) [35, 39-41]. Although saving money is desirable, a study has shown that completing a rotation at another program increased an applicant’s chance of matching into that program by a factor of 1.5 [4]. Thus, the accrued expenses of away rotations and in-person interviews appear to be worthwhile because they can help students determine whether a program is a good fit and allow students to meet and assess a program’s current residents [29, 32]. Although reduced expenses in 2021 seem like a favorable finding, applicants and programs might have had a reduced ability to demonstrate their value to one another [38]. Although certain top applicants may not have been affected by a virtual interview season, the percentage of unmatched applicants who only ranked orthopaedic surgery increased from 18% in 2020 to 22% in 2021 [27, 28]. Additionally, the increased propensity for programs to match home students is also a concern with the adoption of a virtual format. We encourage the academic orthopaedic community to survey applicants regarding the perceived expenses and their association with behaviors related to applying to residency. For example, understanding whether finances prevented an applicant from applying to even more programs, performing an additional away rotation, or interviewing at additional programs would be valuable. Finally, the results of this study should be considered by national orthopaedic societies. When compared with other surgical subspecialties, orthopaedic surgery applicants spend the most on application fees but the least on interviews [12]. The remaining unmodified component to the traditional application would be for the orthopaedic surgery specialty to adopt their own application system. With greater control, they could evolve the application process if desired. There is also a need for more data evaluating the possibility of implementing application and/or interview caps for students and programs [19]. This would limit the financial burden to students and time burden for residencies to review applications.

Regional Expense Comparisons

In 2021, median total expenses decreased in all geographic regions with the greatest savings from applicants in the West (USD 6000), followed by South (USD 5500), Northeast (5500), and Central (USD 3500) regions. Despite a decrease in total expenses in 2021 between regions, differences remained among the Northeast, West, and Central regions. Another notable finding was the lack of difference in application fees between regions with the exception of Northeast applicants. Virtual interviewing substantially decreased interview expenses from 2020 to 2021, and region was not associated with any cost differences. In 2021, applicants from schools in the South and Central regions spent more than their counterparts for away rotations, perhaps suggesting more applicants without a home department in these regions. Previous cost studies are limited because they do not include geographic comparisons. Only two studies that we know of considered applicant medical school region when evaluating the expenses of applying to orthopaedic surgery residency, and none did so during 2021 [12, 14]. We found that in a typical application cycle, geographic region was not associated with differences in total expenses, interview expenses, or application fees. Only away rotation expenses differed in 2020, with Central US applicants spending less than applicants in the Northeast and West. The cost of living might be a primary driver of these differences. We found that the in-person interview is one of the most costly aspects of applying to residency, independent of geographic region. We suggest better coordination of regional residency interviews into “pods” similar to the shoulder and elbow fellowship match to limit back-and-forth travel for programs in the same geographic region of the United States. We strongly encourage the academic orthopaedic surgery community to consider gathering more granular data from students and residency programs to help address these and other important questions related to the transition from medical school to residency.

Conclusion

In the COVID-19 interview year, the median expenditures of orthopaedic residency candidates were USD 5000 lower than they were in the previous year; the difference can be attributed to the use of virtual interviews and the lack of away rotations. There are geographic implications, with applicants from western US medical schools saving the most. Despite the financial savings during the 2021 match, further study related to the long-term success of the current application process (both for applicants and programs) is needed. The recommendation in May 2020 by the American Orthopaedic Association Council of Orthopaedic Residency Directors to limit the number of applications submitted by candidates with USMLE Step 1 scores greater than 235 did not result in any considerable decline in applications submitted or expenses. A better understanding of how differences in these expenses may influence our specialty’s ability to attract diverse candidates would be important, and we need to explore perceived and actual financial obstacles to obtaining this diversity in the application process. Finally, program directors and chairpersons should explore avenues to reduce the expenses of the traditional application process while maintaining recruitment of top candidates.

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