Resident Selection in the Wake of United States Medical Licensing Examination Step 1 Transition to Pass/Fail Scoring

Evaluating the Factors Influencing Residency Match for Surgical Specialty Applicants and Programs: Challenges and Future Directions

INTRODUCTION

We aim to evaluate the impact of recent changes in the residency matching process on surgical specialties' applicants and programs to offer recommendations on residency selection and matching processes.

METHODS

We utilized five databases while employing a Boolean query to search for studies from 2015 to March 2024. The search selection focused on factors and recent changes influencing residency match results across surgical specialties, including USMLE Step 1 pass/fail, research productivity, interview structure, and preference and geographic signaling.

RESULTS

The shift of the USMLE Step 1 to a pass/fail scoring system revealed a consensus among surgical program directors (PDs) and applicants not in favor of the change due to the emphasis on additional application elements. Research productivity was identified as a significant factor, especially in neurosurgery (with an average of 18.3 publications per applicant) and vascular surgery (8.3 publications), indicating a positive correlation between the number of publications and match outcomes. The adoption of virtual interviews has been well-received by both applicants and PDs, leading to an increase in the number of interviews offered and applicants. The implementation of preference and geographic signaling mechanisms has improved interview rates for applicants who utilize them.

CONCLUSION

The transition to a pass/fail USMLE Step 1 has raised concerns among surgical specialties, necessitating a greater focus on Step 2 scores and research productivity. Virtual interviews and signaling have improved the accessibility and reach of the residency application process, however, the full impact of these changes on the perception of applicant-program fit remains unclear.

Perceptions and Expectations Regarding the Step 1 Score Change Among Surgical and Non-Surgical Program Directors: A Systematic Review and Meta-Analysis

There are currently no studies examining differences in perceptions and expected impact of the Step 1 score change to pass/fail between surgical and non-surgical program directors (PDs). We conducted a systematic review in May 2023 of PubMed, Scopus, Web of Science, and PSYCInfo to evaluate studies examining PDs' perspectives regarding the Step 1 score change. We performed random-effects meta-analyses to determine differences in perspectives among surgical and non-surgical PDs. Surgical PDs (76.8% [95% CI, 72.1%-82.0%], I2 = 52%) reported significantly greater rates of disagreement with the score change compared to non-surgical (65.1% [95% CI, 57.9%-73.1%], I2 = 69.7%) (P = .01). Surgical PDs also reported significantly greater rates of agreement that the score change will increase the difficulty in objectively comparing applicants (88.1% [95% CI, 84.6%-91.7%], I2 = 16.4%), compared to non-surgical (81.0% [95% CI, 75.6%-86.8%], I2 = 72.6%) (P = .04). There was less heterogeneity among non-surgical PDs (88.7% [95% CI, 86.2%-91.2%], I2 = 0%), compared to surgical (84.7% [95% CI, 79.0%-90.8%], I2 = 67.3%), regarding expected increases in emphasis on Step 2, although the difference in rates of agreement was not statistically significant. Overall, there is significant heterogeneity in the literature regarding expected changes in the residency application review process. Most PDs reported significant disagreement with the score change, greater expected difficulty in objectively evaluating applicants, and greater emphasis on Step 2, with surgical PDs reporting greater rates of disagreement, greater expected difficulty, and heterogeneity regarding expected increases in emphasis on Step 2, compared to non-surgical. Additionally, there is significant heterogeneity in the overall literature regarding expected changes in the residency application review process. Further research is needed to establish evidence-based guidelines that improve the overall residency application process for all stakeholders.

The Impact of United States Medical Licensing Examination Step 1 Transitioning To Pass/Fail on Medical Student Perception of Research Needed to Match Into One's Preferred Specialty

Purpose To evaluate how the transition of United States Medical Licensing Examination (USMLE) Step 1 to a pass/fail scoring influenced medical student perceptions of the importance of research required to match into their preferred residency specialty. Methods A 14-item survey was distributed by e-mail to medical students at one medical school in the southeastern United States in November of 2021. Responses were compared between medical students taking USMLE Step 1 pass/fail in the future and medical students taking USMLE Step 1 for a three-digit score. Results A total of 168 medical students responded to the survey with 98 respondents who planned on taking USMLE Step 1 pass/fail (45 first-year medical students (MS1) and 53 MS2) and 70 respondents who took USMLE Step 1 for a numerical score (37 MS3 and 33 MS4). There were no differences in how each cohort scored the level of importance of research in matching into their preferred residency specialty (p=0.10); however, those taking USMLE Step 1 pass/fail believe an average of 4.6 research experiences are necessary to match into their preferred residency, compared to only 3.4 research experiences for those who took it for a numerical score (p=0.04). Conclusion No statistically significant difference in the perceived importance of research in matching into one's preferred residency specialty was found between cohorts. However, the pass/fail cohort believes they will need more research experiences to match their chosen specialty than the numerical score cohort. Results could indicate that students participate in more research and extracurricular activities to be more competitive for residency applications.

Identification of Factors Associated with Orthopaedic Surgery Residency Programs That Preferentially Match Students Who Performed an Elective Rotation Before the Interview Process

Introduction

The role of elective rotations in the orthopaedic residency selection process varies between programs. Our study aims to identify factors associated with residency programs that interview and match a greater proportion of applicants who have completed an elective rotation with their program.

Methods

Data were collected through the American Orthopaedic Association's Orthopaedic Residency Information Network database. Bivariate correlations and multivariate regression models were used to identify independent predictors of programs with a greater proportion of interviewees or residents who completed an elective rotation at the respective program.

Results

One hundred seventy-eight of the 218 existing residency programs were included in this study. Programs that offered fewer interviews and more away rotation positions per year were associated with a greater odds of its interviewees (OR = 0.36, p = 0.01; OR = 4.55, p < 0.001, respectively) and residents (OR = 0.44, p = 0.04; OR = 4.23, p < 0.001, respectively) having completed an elective rotation with the program. In addition, programs with fewer attendings (OR = 0.39, p = 0.03) and in-person interviews (OR = 3.04, p = 0.04) matched a greater proportion of their rotators. However, programs that interviewed applicants during the elective rotation were less likely to match their rotators (OR = 0.35, p = 0.04).

Conclusion

Certain program characteristics independently predict the likelihood of a program interviewing and matching their rotators. These findings may provide information for applicants and programs regarding the rotation process.

Level of Evidence

III.

Preference Signaling Survey of Program Directors-After the Match

INTRODUCTION

The 2022 to 2023 orthopaedic residency cycle implemented a preference signaling program (PSP), allowing applicants to send "signals" to up to 30 programs to demonstrate their genuine interest. With the conclusion of the 2022 to 2023 cycle, the primary purpose of this study was to analyze program director (PD) perceptions of the PSP after the match cycle and provide a retrospective evaluation of the effects of the PSP on the orthopaedic resident selection process.

METHODS

A 21-question survey was distributed to 98 PDs (32.7% response rate). Contact information was obtained from a national database.

RESULTS

Most respondents (96.9%) participated in the American Orthopaedic Association's PSP. The majority (93.7%) view preference signaling as a positive change. Most PDs (56.2%) reported a decreased number in applications received compared with previous years. Receiving a preference signal was ranked among the most important factors in resident selection, and most PDs agreed that preference signaling should be used to screen applicants (84.4%) and differentiate similar applicants (96.8%). Moreover, 65.6% of PDs indicated that they would not rank or invite applicants to interview without a signal or completion of a formal away rotation. PDs report that in the 2022 to 2023 cycle, 98.5% of applicants who matched at their program had sent a preference signal.

DISCUSSION

Preference signaling was one of the most important factors assessed during its inaugural application cycle and is anticipated to remain a key tool for screening and differentiating candidates. Applicants should strategically select signal recipients to enhance their success in the match.

Advising Orthopaedic Hopefuls in the Wake of a Pass/Fail US Medical Licensing Examination Step 1: A Proposed Method for Predicting US Medical Licensing Examination Step 2 Clinical Knowledge Outcomes

INTRODUCTION

Matching into orthopaedic residency has become difficult, and the US Medical Licensing Examination Step 1 transition to pass/fail scoring has complicated the process. Advisors' ability to mentor students has decreased, and program directors may rely on Step 2 Clinical Knowledge (CK) scores in selecting which candidates to interview. This study aims to offer a method to predict Step 2 CK outcomes based on preadmission and preclinical performance.

METHODS

The study investigated 486 students from a US medical school who enrolled in 2017 and 2018. Data on demographics, preadmission, and preclinical performance were collected. Before model creation, it was found that sex, Medical College Admission Test scores, Comprehensive Basic Science Examination performance, and preclinical curriculum performance produced optimal models. Multivariate ordinal logistic regression models were built to predict probabilities of four outcome levels of Step 2 CK: <235, 235 to 249, 250 to 265, and >265. Finally, nomograms were created to visualize probability calculations.

RESULTS

Each model's odds ratios revealed that female sex, higher MCAT scores, and better Comprehensive Basic Science Examination and preclinical performance were associated with an increased likelihood of being in higher Step 2 CK scoring groups. Preclinical performance had a profound effect, especially for those in the top 1/3. Models were successful in assigning higher probabilities to students in higher Step 2 CK scoring groups in more than 80% of instances. Nomograms presented provide examples of how to apply these models to an individual student.

DISCUSSION

This study presents a novel method for predicting probabilities of Step 2 CK outcomes that can be used to mentor students at a time point when Step 1 previously filled this role. It may assist in identifying orthopaedic hopefuls at risk of performing poorly on Step 2 CK and can foster the development of individualized guidance and mitigation strategies.

Predictive value of medical school ranking in the academic scholarship of ophthalmology residents

Objective

To determine whether a resident's medical school ranking predicts their scholarship during residency.

Design

The authors stratified ophthalmology residents in ACGME accredited programs into tiers based off their medical school background's US News & World Report ranking: T1 (schools 1-20), T2 (21-50), and T3 (51-90). Investigators queried PubMed and Scopus for number of total publications, first/second author publications, publications in the top 10 impact factor journals in ophthalmology, and publications with the senior author affiliated with the resident's residency program/medical school. Authors collected data from start of ophthalmology residency to December 5th, 2021, and performed Pearson chi squared, ANOVA, Eta squared, Tukey, and multivariable logistic regression tests.

Results

1054 residents were included for analysis, with 370 from T1 schools, 296 from T2 schools, and 388 from T3 schools. T3 residents had a significantly decreased likelihood of publishing at least one (OR = 0.659;95%CI = 0.481,0.905;p = .010), two (OR = 0.643;95%CI = 0.436,0.949;p = .026), or five (OR = 0.407;95%CI = 0.187,0.886;p = .024) total publications compared to T1 residents. T3 residents also were partially predicted to publish fewer first author works, high impact journal articles, and articles with senior authors affiliated with their medical school. T2 residents were more likely to publish at least one second author work than T1 residents (OR = 1.604;95%CI = 1.101,2.337;p = .014). There was no significant difference between tiers in publications with senior authors affiliated with the same residency program.

Conclusions

The authors observed little difference in scholarship between residents from T1 and T2 schools, but some differences may exist between T3 and T1/T2 residents. Merit of rankings should be further explored.

Differences in the Academic Attributes of Matched and Unmatched Orthopaedic Surgery Residency Applicants are Narrowing

Orthopaedic surgery remains one of the most competitive residency specialties, with the number of applicants outpacing the availability of residency positions each year. The purpose of this study was to analyze present-day orthopaedic surgery match data, identify differences between matched and unmatched applicants, and compare our findings to previous trends.

Methods

Applicant data from the National Resident Matching Program from 2016 to 2022 were analyzed. The number of matched and unmatched US allopathic senior orthopaedic applicants relative to the number of available positions was used to determine respective match rates. Performance metrics and applicant characteristics were compared by match status. Trends were compared with those of previous analysis from 2006 to 2014.

Results

The number of applicants increased from 863 in 2016 to 1,068 in 2022. The match rate decreased from 75% in 2016 to 66% in 2022 (p < 0.0001). Matched applicants had a higher number of contiguous ranks (12.3 vs. 6.5; p < 0.001), United States Medical Licensing Examination (USMLE) Step-1 score (248 vs. 240; p < 0.001), USMLE Step-2 score (255 vs. 247; p < 0.001), Alpha Omega Alpha (AOA) membership (38% vs. 13%; p < 0.001), and enrollment at a top 40 National Institutes of Health (NIH)-funded medical school (34% vs. 24%, p < 0.001). Compared with 2006 to 2014 data, a smaller percentage of matched applicants were enrolled in a top 40 NIH-funded medical school (34% vs. 37%, p = 0.013). The mean differences in USMLE Step-1 score (16 vs. 8.25 points, p < 0.001) and USMLE Step-2 score (16 vs. 8.25 points, p = 0.002) in favor of matched applicants nearly halved compared with that in 2006 to 2014. In addition, there was no longer a significant difference in the number of research products (abstracts, presentations, posters, and publications) between matched and unmatched applicants (p = 0.309).

Conclusions

Differences in the academic attributes of matched and unmatched orthopaedic surgery applicants have become less profound over time, making it increasingly difficult to predict a successful match based on USMLE Step scores, AOA membership, research productivity, and medical school research reputation. Future studies should evaluate differences in subjective metrics (e.g., away rotation and interview performance and letters of recommendation) by match status.

The Scholarly Impact of Student Authorship in Ophthalmology

Purpose  The H-index (H i ), an author-level metric of scholarly impact, is predictive of future scientific achievement. We sought to analyze the scholarly impact of student authorship on the H i of corresponding authors (CAs) within a major academic journal in the specialty of ophthalmology. Materials and Methods  We compared the H i of all unique CAs for manuscripts published in Ophthalmology (Journal of the American Academy of Ophthalmology) in 2008, 2012, and 2016. Data abstraction was completed twice: in October 2018 and March 2021. We further grouped published articles for CAs into those with student authors (StA) and those without (nStA). Primary analysis involved a linear regression analysis with change in H i from October 2018 to March 2021 as the outcome variable, CA groups as the predictor variable, adjusting for the covariates of baseline H i , the year when the CA published his or her article, number of research items published in October 2018, and the academic appointment of the CAs. Secondary analysis involved a linear regression analysis with change in H i from October 2018 to March 2021 as the outcome variable, total number of student authors per CA as the predictor variable, adjusting for the covariates of baseline H i , the year CA published his or her article, number of research items published in October 2018, and the academic appointment of the CAs. Results  The number of student authors increased from 168 in 2008 to 192 in 2016. Of the 902 articles, 316 articles were co-authored by one or more student authors. The average change in H i of CAs publishing with student authors (StA, 11.0 ± 14.7) was significantly greater ( p  < 0.0001) than the change in H i of CAs publishing without student authors (nStA, 6.2 ± 6.2). As the total number of student authors increased, the change in H i of CAs increased linearly for all years combined (regression coefficient = 1.70, p -value < 0.0001). Conclusion  CAs publishing with students in the field of ophthalmology have a higher scholarly impact than those publishing without students. The development of programs to integrate students into ophthalmology research early on may encourage their pursuit of a career in ophthalmology, while advancing the careers of their mentors.

Preference Signaling for Orthopaedic Surgery Applicants: A Survey of Residency Program Directors

INTRODUCTION

On March 30, 2022, the American Orthopaedic Association's Council of Orthopaedic Residency Directors announced its endorsement for a preference signaling program (PSP) for the 2022 to 2023 orthopaedic residency application cycle. The purpose of our study was to assess orthopaedic surgery residency program director (PD) perceptions of the PSP and analyze potential effects of the PSP on the residency application process.

METHODS

A 19-question survey was distributed to 98 PDs (40.8% response rate). Contact information was obtained from a national database.

RESULTS

Most programs plan to participate in the PSP (87.5%). Preference signaling is highly regarded for residency selection, with PDs ranking its relative importance just below away rotation performance and personal knowledge of the applicant. Most PDs agreed that applicants will have increased chances of receiving interviews at programs they send a preference signal (65%). Most PDs also do not think that the PSP will help improve diversity (42.5%) and combat the overapplication phenomenon (67.5%). A majority think that an application cap limiting the total number of applications submitted should be initiated in future application cycles (85%).

CONCLUSION

Preference signaling will be one of the most important factors considered during orthopaedic residency selection. A signal will likely improve applicants' chance of receiving an interview. Thus, students should be selective about where they send their preference signals and invest time in creating strong, personal connections with a few, select programs to increase their success in the orthopaedic residency match.

Analysis of Current Orthopedic Surgery Residents and Their Prior Medical Education: Does Medical School Ranking Matter in Orthopedic Surgery Match?

OBJECTIVE

The purpose of this study was to determine the strength of the association between medical school ranking and orthopedic surgery residency ranking using the current cohort of orthopedic surgery residents.

DESIGN

We obtained a list of accredited programs from Doximity for orthopedic surgery residency programs and U.S. News & World Report for medical schools. Each orthopedic surgery residency program webpage was evaluated for the presence of an orthopedic surgery residency roster. For each resident, the medical school attended, allopathic or osteopathic degree, and year of post-graduate training was recorded. Orthopedic surgery residency programs and medical schools were assigned to one of four tiers for each based on their respective ranking. Descriptive statistics, Chi squared tests and Pearson residuals were used to analyze the association of orthopedic surgery residency tier and medical school tier. Post-hoc pairwise comparisons were performed utilizing the Bonferroni correction to account for 16 tests, correcting the significance level to p = 0.003.

SETTING

187 orthopedic surgery residency program webpages.

PARTICIPANTS

4123 orthopedic surgery residents.

RESULTS

There was a significant association between medical school tier and orthopedic surgery residency tier (X² [9] = 1214.78, p < 0.001). The post-hoc residual values were statistically significant for 75% (12/16) of tests performed. The majority of Tier 1 orthopedic surgery residents 50.5% (800/1585) attended a Tier 1 medical school. The strongest positive association exists between Tier 1 medical students attending Tier 1 residencies (residual = 23.978, p < 0.001). The strongest negative association with Tier 4 residencies was with Tier 1 medical schools (residual= -15.656, p< 0.001).

CONCLUSIONS

Medical school ranking is an important consideration for prospective orthopedic surgery applicants and may become more important with less objective measures of academic performance such as United States Medical Licensing Examination Step 1.

LEVEL OF EVIDENCE

Observational.

Medical Schools as Racialized Organizations: How Race-Neutral Structures Sustain Racial Inequality in Medical Education-a Narrative Review

In 2021, The American Association of Medical Colleges released a framework addressing structural racism in academic medicine, following the significant, nationwide Movement for Black Lives. The first step of this framework is to "begin self-reflection and educating ourselves." Indeed, ample evidence shows that medical schools have a long history of racially exclusionary practices. Drawing on racialized organizations theory from the field of sociology, we compile and examine scholarship on the role of race and racism in medical training, focusing on disparities in educational and career outcomes, experiences along racial lines in medical training, and long-term implications. From the entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics negatively impact the careers of trainees of color, particularly those underrepresented in medicine (URiM). Indeed, in addition to structural biases associated with otherwise "objective" metrics, there are racial disparities across subjective outcomes such as the language used in medical trainees' performance evaluations, even when adjusting for grades and board exam scores. These disadvantages contribute to URIM trainees' lower odds of matching, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. Additionally, hostile racial climates and less diverse medical schools negatively influence White trainees' interest in practicing in underserved communities, disproportionally racial and ethnic minorities. Trainees' mental health suffers along the way, as do medical schools' recruitment, retention, diversity, and inclusion efforts. Evidence shows that seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, may reproduce and sustain racial inequality among medical trainees. Medical schools whose goals include training a more diverse physician workforce towards addressing racial health disparities require a new playbook.

Machine Learning for The Prediction of Ranked Applicants and Matriculants to an Internal Medicine Residency Program

Phenomenon: Residency programs throughout the country each receive hundreds to thousands of applications every year. Holistic review of this many applications is challenging, and to-date, few tools exist to streamline or assist in the process for selecting candidates to interview and rank. Machine learning could assist programs in predicting which applicants are likely to be ranked, and among ranked applicants, which are likely to matriculate.Approach: In the present study, we used the machine learning algorithm Random Forest (RF) to differentiate between ranked and unranked applicants as well as matriculants and ranked non-matriculants to an internal medicine residency program in northern New England over a three-year period. In total, 5,067 ERAS applications were received during the 2016-17, 2017-18, and 2018-19 application cycles. Of these, 4,256 (84.0%) were unranked applicants, 754 (14.9%) were ranked non-matriculants, and 57 (1.12%) were ranked matriculants.Findings: For differentiating between ranked and unranked applicants, the RF algorithm achieved an area under the receiver operating characteristic (AUROC) curve of 0.925 (95% CI: 0.918-0.932) and area under the precision-recall curve (AUPRC) of 0.652 (0.611-0.685), while for differentiating between matriculants and ranked non-matriculants, the AUROC was 0.597 (95% CI: 0.516-0.680) and AUPRC was 0.114 (0.075-0.167). The ranks of matriculated applicants were significantly higher using the algorithmic rank list as compared with the actual rank list for the 2017-18 (median rank: 98 versus 204, p < .001) and 2018-19 cycles (74 versus 192, p = .006), but not the 2016-17 cycle (97 versus 144, p = .37).Insights: The RF algorithm predicted which applicants among the overall applicant pool were ranked with impressive accuracy and identified matriculants among ranked candidates with modest but better-than-random accuracy. This approach could assist residency programs with triaging applicants based on the likelihood of a candidate being ranked and/or matriculating.

The US Medical Licensing Examination Step 1 Scoring Change: A Survey of Orthopaedic Surgery Residency Applicants From the 2019 to 2020 Match Cycle

INTRODUCTION

The USMLE Step 1 examination has been used as an objective measure for comparing residency applicants. Recently, the National Board of Medical Examiners and the Federation of State Medical Boards decided that the USMLE Step 1 examination will transition to a pass/fail result starting no earlier than 2022. The purpose of this study was to investigate the perspective of medical students who applied for orthopaedic surgery residency positions during the 2019 to 2020 interview cycle on the USMLE scoring change, and the potential effect this change may result in for future applicants and the residency selection process.

METHODS

A 15-item anonymous web-based survey was sent to 1,090 orthopaedic surgery residency applicants from four regionally diverse residency programs. The survey elicited attitudes toward the transition of the Step 1 examination to pass/fail and perspectives this change may or may not have on the residency selection process.

RESULTS

Responses were received from 356 applicants (32.7%). The majority (61.6%) disagreed with the change to pass/fail scoring, and 68.5% do not believe that the change will decrease stress levels in medical students. For interview invitations, respondents chose Step 2 clinical knowledge, letters of recommendation, and performance on away rotations as the most influential factors in the absence of a Step 1 score.

CONCLUSION

Most of the students surveyed who applied for an orthopaedic surgery residency position during the most recent application cycle disagreed with the National Board of Medical Examiner/Federation of State Medical Board decision to change Step 1 to pass/fail and feel that this change may have disadvantage in certain student groups while either increasing or having no effect on medical student stress.

LEVEL OF EVIDENCE

IV.

Formal Orthopaedic Surgery "Boot Camp" Curriculum to Optimize Performance on Acting Internships

Orthopaedic surgery is one of the most competitive residency specialties in the National Residency Matching Program. To improve the odds of matching, senior medical students applying in the field participate in orthopaedic surgery away rotations with programs across the country. Students who do well on these rotations have a higher likelihood of matching because clinical performance is a principal criterion used by admissions committees to rank applicants. On the other hand, these rotations can be physically and emotionally taxing on medical students because poor performance can negatively affect their application and, thus, chances of matching at that institution. Unfortunately, the resources provided by medical schools to prepare students for these high-stakes rotations are usually sparse and unstructured. To address this gap in training at our institution, we developed a formal "boot camp" offered through the university to prepare interested senior medical students for their orthopaedic surgery acting internships. This course focuses on building a solid foundation of musculoskeletal knowledge and exposing students to surgical and procedural skills that are fundamental to the practice of orthopaedic surgery. Over the 2 years, this course has been offered at our institution, and it has proven successful in outcome measures, such as student satisfaction and preparedness, student orthopaedic knowledge, program director evaluations, and match rate. This article describes the novel 1-month curriculum, which includes lectures, laboratory, and clinical experience.

Identifying Attitudes Toward and Acceptance of Osteopathic Graduates in Surgical Residency Programs in the Era of Single Accreditation: Results of the American College of Osteopathic Surgeons Medical Student Section Questionnaire of Program Directors

Purpose The purpose of this study was to quantify the number of surgical programs currently training osteopathic residents and to solicit advice for current osteopathic medical students who are interested in pursuing a surgical residency.  Methods A questionnaire was sent to all listed Electronic Residency Application Service® (ERAS®) email contacts for the following specialties: General Surgery, Neurological Surgery, Orthopedic Surgery, Otolaryngology, Urology, Integrated Vascular Surgery, Integrated Plastic Surgery, and Integrated Thoracic Surgery. The questionnaire was sent a total of three times. Results Two hundred sixty-four of the 1,040 surgical residency programs responded to the questionnaire. Of these responses, 19% were formerly American Osteopathic Association (AOA) accredited programs. About 47.3% of responding programs indicated they are not currently training an osteopathic physician. One hundred thirteen programs provided additional comments on how osteopathic medical students may improve the competitiveness of their residency applications. These comments included increasing volumes of research activities, performing well on the United States Medical Licensing Exam (USMLE), and completing a sub-internship in the desired field or at a specific institution.  Conclusion Osteopathic students still face many barriers to matching into surgical residencies. This study provides concrete steps students may take to increase the competitiveness of their application.

Trends in leadership at shoulder and elbow fellowships: a cross-sectional demographic review

OBJECTIVE

To determine educational characteristics, trends, and demographics among shoulder and elbow fellowship leaders (FLs).

BACKGROUND

Fellowship leaders in shoulder and elbow impart lasting impact on trainees and field development. Four previous studies have analyzed the characteristics and career path trends among orthopedic surgery subspecialty FLs (spine, adult reconstruction, trauma, and sports medicine). We characterized the educational backgrounds and demographic composition of all 40 FLs including fellowship directors (FD), fellowship co-directors (co-FD), and associate fellowship directors (associate FD) of 31 American Shoulder and Elbow Surgeons (ASES)-accredited shoulder and elbow fellowships in the United States. We additionally compiled the residency and fellowship institutions that trained FLs as framework for aspiring leaders in orthopedic surgery.

METHODS

Using the American Shoulder and Elbow Surgeons (ASES) directory website page "ASES-Recognized Shoulder and Elbow Fellowship Programs," we identified all active shoulder and elbow fellowships within the United States as well as associated FL identifiers. Compiled data points include age, sex, ethnicity, residency/fellowship training location, time since education completion until FL appointment, length in FL role, personal research Scopus H-index, and major society and journal leadership position history.

RESULTS

We analyzed data from all 40 active FLs across 31 ASES-accredited shoulder and elbow fellowships, encompassing 26 FDs, 13 co-FDs, and 1 associate FD. The majority of FLs (97.5%) were male whereas 2.5% were female, with racial/ethnic identification of 80.0% Caucasian, 10.0% Asian/Pacific Islander, and 10.0% Middle Eastern. The mean Scopus H-index of the FLs was 24.63 ± 16.43. The top residency programs for producing future FLs were the University of Pittsburgh, University of Pennsylvania, University of Nebraska/Creighton, Hospital for Special Surgery, and Brown University (all n = 2). The top fellowship programs for producing future FLs were Mayo Clinic (n = 6), Columbia University (n = 6), San Francisco/California Pacific (n = 4), and Washington University in St Louis (n = 4).

CONCLUSION

Shoulder and elbow fellowship leaders graduate with increased frequency from certain fellowship programs with lesser correlation to residency institutions. Programs demonstrate high retention of prior trainees as future FLs. All FLs are distinguished by high indices of research productivity; however, demographic diversity remains limited, which is comparable to prior orthopedic subspecialty FL investigations.

Current Views on the New United States Medical Licensing Examination Step 1 Pass/Fail Format: A Review of the Literature

INTRODUCTION

Residency programs have historically used numerical Step 1 scores to screen applicants, making it a career-defining, high-stakes examination. Step 1 scores will be reported as pass/fail starting in January 2022, fundamentally reshaping the residency application review process. This review aimed to identify opinions of physicians and medical students about the new format, identify arguments in support of or against the change, and determine the implications of this change on the residency selection process.

METHODS

A comprehensive PubMed review was performed in May 2021 to identify articles that discussed the new Step 1 format. Non-English and duplicate articles were excluded. Data collected from each article included publication year, specialty, subjects, and key findings.

RESULTS

A total of 81 articles were included, 26 of which discussed the impact of the new format within surgical fields (32.1%). Remaining articles discussed the implications within the medical community as a whole (n = 33, 40.7%) and nonsurgical fields (n = 22, 27.2%). Studies suggest Program Directors will rely on Step 2 Clinical Knowledge (CK) scores, medical school reputation, applicant familiarity, Dean's letters, recommendation letters, and research in lieu of numerical Step 1 scores. In addition, concerns have been raised that the new format will disadvantage international, osteopathic, and minority applicants while increasing stress surrounding Step 2 CK.

CONCLUSIONS

Within the medical community, there are concerns that Step 2 CK will be used to substitute Step 1 and that resident diversity will diminish due to the new Step 1 format. Holistic candidate consideration will be increasingly important.

The Orthopaedic Resident Selection Process: Proposed Reforms and Lessons From Other Specialties

INTRODUCTION

Proposals for substantive reforms to the orthopaedic resident selection process are growing, given increasing applicant competitiveness, burgeoning inefficiencies and inequities of the current system, and impending transition of Step 1 to pass/fail. The COVID-19 pandemic has further catalyzed the need for reforms, offering unprecedented opportunities to pilot novel changes. However, a comprehensive collation of all proposed and implemented orthopaedic reforms is currently lacking. Thus, we aimed to characterize proposed orthopaedic-specific resident selection reforms in the context of reforms implemented by other specialties.

METHODS

EMBASE, MEDLINE, Scopus, and Web of Science databases were searched for references proposing reforms to the orthopaedic resident selection process published from 2005 to 2020. An inductive approach to qualitative content analysis was used to categorize reforms.

RESULTS

Twenty-six articles proposing 13 unique reforms to the orthopaedic resident selection process were identified. The most commonly proposed reforms included noncognitive assessments (n = 8), application caps (n = 7), standardized letters of recommendation (n = 5), program-specific supplemental applications (n = 5), creation of a centralized database of standardized program information (n = 4), use of a standardized applicant composite score (n = 4), and a moratorium on postinterview communication (n = 4). Importantly, nearly all of these reforms have also been proposed or implemented by other specialties.

DISCUSSION

Numerous reforms to the orthopaedic resident selection process have been suggested over the past 15 years, several of which have been implemented on a program-specific basis, including noncognitive assessments, supplemental applications, and standardized letters of recommendation. Careful examination of applicant and program experiences and Match outcomes after these reforms is imperative to inform future directions.

Incidence of Research Gap Years in Orthopaedic Residency Applicants: The New Standard?

Introduction:

The purpose of this study was to (1) determine the incidence of a research gap year (RGY) in orthopaedic residency applicants at a single institution over a seven-year span; (2) compare applicant characteristics between applicants who did a RGY with those who did not, and (3) report variables associated with match success for RGY applicants.

Methods:

Applicants who reported taking a year out from medical school to pursue research on their Electronic Residency Application Service to a single institution from 2014 to 2015 through 2020 to 2021 were reviewed.

Results:

A strong positive correlation was noted between the percentage of applicants who participated in a RGY and time (Pearson correlation: r = 0.945 [95% confidence interval (CI), 0.666­0.992], P = 0.001). Over the study period, 11% of applicants had done a RGY, most commonly after their third year of medical school (82.7%). Most RGY applicants matched orthopaedics (72.8%) and 19.4% matched at the same institution they did their RGY.

Conclusion:

The percentage of RGY applicants to the study institution nearly doubled between 2014 to 2015 and 2020 to 2021. RGY applicants had a higher match rate than nationally published match rates. Further study is needed on a national level.

Predicting Osteopathic Medical Student Performance on the United States Medical Licensing Examination Step 2 Clinical Knowledge From Results of the Comprehensive Osteopathic Medical Licensing Examination Level 2-Cognitive Evaluation

Background To improve their standing in residency selection, many osteopathic medical students choose to take the United States Medical Licensing Examination (USMLE). Although scores on USMLE Step 1 and Level 1 of the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) are known to be highly correlated, scarce data exist on the association between COMLEX-USA Level 2-Cognitive Evaluation (CE) and USMLE Step 2 Clinical Knowledge (CK) scores. In this study, we aimed to determine the association between COMLEX-USA Level 2-CE and USMLE Step 2 CK scores and derive an equation to predict performance on USMLE Step 2 CK for applicants who have only taken COMLEX-USA. Methodology We reviewed COMLEX-USA Level 2-CE and USMLE Step 2 CK scores for all students at the Lake Erie College of Osteopathic Medicine from May 2020 to April 2021. Linear regression was used to evaluate the relationship between COMLEX-USA Level 2-CE and USMLE Step 2 CK scores. Results A total of 340 students took both COMLEX-USA Level 2-CE and USMLE Step 2 CK. There was a linear association between COMLEX-USA Level 2-CE and USMLE Step 2 CK scores such that every one-point increase in COMLEX-USA was associated with a 0.13-point increase in USMLE Step 2 CK score (standard error = 9.1; model R2 = 0.64). Conclusions Students or programs interested in predicting performance on USMLE Step 2 CK from performance on COMLEX-USA Level 2-CE can do so using the following equation: USMLE Step 2 CK = 0.13(COMLEX-USA Level 2-CE) + 163.5.

Evidence-Based Selection of Surgical Residents

Residency programs should use a systematic method of recruitment that begins with defining unique desired candidate attributes. Commonly sought-after characteristics may be delineated via the residency application. Scores from standardized examinations taken in medical school predict academic success, and may correlate to overall performance. Strong letters of recommendation and a personal history of prior success outside the medical field both forecast success in residency. Interviews are crucial to determining fit within a program, and remain a valid measure of an applicant's ability to prosper in a particular program, even with many interviews being completed in the virtual realm.

Do Medical Students Who Participate in a Research Gap Year Produce More Research During Residency?

The research gap year has become increasingly popular among medical students. It is also a well-known factor in consideration for orthopaedic surgery residency programs. Although medical students who participated in a research gap year typically enter residency with more research experience than their counterparts, it is unknown whether this translates to increased research productivity during residency compared with their peers. The purpose of this study was to investigate (1) whether residents who participated in a research gap year during medical school publish more peer-reviewed publications than their peers during residency, (2) whether residents who participated in a research gap year during medical school publish more first-author publications than their peers during residency, and (3) which applicant characteristics are associated with a greater number of peer-reviewed publications produced during residency.

Rate of USMLE Step 2 CK Scores Included on Orthopedic Surgery Applications and Associations With Step 1 Score

Background At present, orthopedic surgery applicants do not universally include Step 2 Clinical Knowledge (Step 2 CK) scores on their applications and current inclusion rates are not yet reported. As Step 1 transitions to pass/fail scoring, we suspect more applicants will include Step 2 CK scores. We sought to identify what percentage of applications currently include Step 2 CK, if applicants who include Step 2 CK (Step 1+CK) score lower on Step 1 than those not including Step 2 CK (Step 1-CK), and what correlations exist between Step 1 and Step 2 CK scores among those who include the scores on their applications. Methodology Applicants to one residency program over two application cycles (2019-2020) were analyzed. The percentage including Step 1 and Step 2 scores was recorded. Step 1 scores were compared between Step 1+CK and Step 1-CK applicants. Differences between Step 2 CK and Step 1 scores were stratified by Step 1 score. Results A total of 1,688 applicants applied to our institution from 2019 to 2020. Of those reporting United States Medical Licensing Examination scores, 1,316/1,660 (79%) reported a Step 2 CK score. Step 1-CK applicants scored higher on Step 1 (250.7 ± 10.9) versus Step 1+CK applicants (244.3 ± 13.1) (p < 0.0001). More applicants who scored lower on Step 1 improved upon their percentile rank between Step 1 and Step 2 CK than those who scored higher on Step 1 (χ² _(8,1316) = 79.1, p < 0.0001). Conclusions From 2019 to 2020, 79% of applicants included Step 2 CK. Lower Step 1 scores were more likely to include Step 2 CK and improve upon their percentile score. It is unclear how Step 1 scoring change will affect current practice.

A comparison of orthopaedic surgery and internal medicine perceptions of USMLE Step 1 pass/fail scoring

BACKGROUND

United States Medical Licensing Examination Step 1 will transition from numeric grading to pass/fail, sometime after January 2022. The aim of this study was to compare how program directors in orthopaedics and internal medicine perceive a pass/fail Step 1 will impact the residency application process.

METHODS

A 27-item survey was distributed through REDCap to 161 U.S. orthopaedic residency program directors and 548 U.S. internal medicine residency program directors. Program director emails were obtained from the American Medical Association's Fellowship and Residency Electronic Interactive Database.

RESULTS

We received 58 (36.0%) orthopaedic and 125 (22.8%) internal medicine program director responses. The majority of both groups disagree with the change to pass/fail, and felt that the decision was not transparent. Both groups believe that the Step 2 Clinical Knowledge exam and clerkship grades will take on more importance. Compared to internal medicine PDs, orthopaedic PDs were significantly more likely to emphasize research, letters of recommendation from known faculty, Alpha Omega Alpha membership, leadership/extracurricular activities, audition elective rotations, and personal knowledge of the applicant. Both groups believe that allopathic students from less prestigious medical schools, osteopathic students, and international medical graduates will be disadvantaged. Orthopaedic and internal medicine program directors agree that medical schools should adopt a graded pre-clinical curriculum, and that there should be a cap on the number of residency applications a student can submit.

CONCLUSION

Orthopaedic and internal medicine program directors disagree with the change of Step 1 to pass/fail. They also believe that this transition will make the match process more difficult, and disadvantage students from less highly-regarded medical schools. Both groups will rely more heavily on the Step 2 clinical knowledge exam score, but orthopaedics will place more importance on research, letters of recommendation, Alpha Omega Alpha membership, leadership/extracurricular activities, personal knowledge of the applicant, and audition electives.