Shifting the Surgical Residency Match to a 100% Virtual Interview Format During the COVID-19 Pandemic, How has It Affected Placement Into Surgical Training Programs?

Abstract

Introduction

The AAMC transitioned to virtual interview formats for the 2020-2021 residency match. This study aims to examine the impact of the 100% virtual interview format for the 2020-2021 residency match on both application and match changes for multiple surgical specialties, including neurosurgery (NS), orthopedic surgery (OS), plastic surgery (PS), general surgery (GS), thoracic surgery (TS), and vascular surgery (VS).

Methods

Cross-sectional study comparing application and match changes between the in-person 2019-2020 and virtual 2020-2021 residency match cycles for different surgical specialties.

Results

There was an overall increase in the number of applicants for 5 of the surgery specialties but not VS, and an overall increase in the number of applications per residency program across all specialties. The average number of applications per applicant also increased, except in TS. There were no major match changes except in TS, which saw an increase in number of spots filled by MDs to nearly 100% from 84.2% in the previous cycle.

Conclusion

The switch to the 100% virtual 2020-2021 residency match interview format was associated with an overall increase in the number of applications per program and number of applications per applicant across multiple surgical specialties. There was a decrease in the number of applicants to VS and an increase in the number of applications per applicant. The switch to a virtual interview format in 2020-2021 was also associated with an increase in TS spots filled by MDs to almost 98%, increasing the already concerning TS match disparity for DO and IMG applicants.

Background

The COVID-19 pandemic has created unprecedented challenges for graduate medical education and disrupted many critical components for successful residency matching. The National Residency Matching Program (NRMP) and Electronic Residency Application Service (ERAS) collaborate annually on the pairing of medical students with residency programs through a system commonly referred to as “The Match.” Due to the pandemic, ERAS opened over a month later than usual, shortening the residency application cycle considerably. The Association of American of Medical Colleges (AAMC) switched to a 100% virtual interview format for the 2020-2021 residency match. Many applicants had their United States Medical Licensing Examination (USMLE) testing dates interrupted or were unable to take entire portions. Additionally, rotations shifted to a virtual format, away rotations were cancelled, volunteering opportunities were limited, and research projects were interrupted for many medical students. These changes may have impacted opportunities for applicants to obtain meaningful letters of recommendation, indicate interest in specific programs, and build competitive applications. ¹

It is unclear what impact the switch to a virtual interview format has made on the match for surgical specialties. This study aims to examine the impact of the 100% virtual interview format for the 2020-2021 residency match on both application and match changes for 6 surgical specialties including neurosurgery (NS), orthopedic surgery (OS), plastic surgery (PS), general surgery (GS), thoracic surgery (TS), and vascular surgery (VS).

Methods

This is a cross sectional study comparing the application and match changes between the in-person 2019-2020 and virtual interviews 2020-2021 residency match cycles for surgical specialties (NS, OS, PS, GS, TS, and VS). Application data for the 2019-2020 and 2020-2021 residency cycles for surgical specialties were publicly available and extracted from ERAS statistics ² and assessed for the total number of applicants, total number of MD, DO, and international medical graduate (IMG) applicants, average number of applications per applicant, and average number of applications per MD, DO and IMG applicant. Match data for the 2019-2020 and 2020-2021 residency cycles for surgical specialties were extracted from NRMP databases ³ and assessed for number of positions offered, unfilled positions, number of positions filled by MD, DO, and IMG seniors and graduates. Only publicly available data were collected and analyzed. This study was conducted in compliance with ethical standards and reviewed by our Institutional Review Board (IRB) and deemed exempt.

Results

Application Statistics

There was an overall increase in the number of applicants for all surgical specialties from 2019-2020 to 2020-2021 except for VS, which decreased by nearly half (472 vs 266). However, there was only a moderate increase in the number of spots offered for each specialty. The amount of MD, DO, and IMG applicants remained approximately the same or increased for NS, OS, PS, and GS. Thoracic surgery saw a large increase in MD (95 vs 145), DO (17 vs 40), and IMG (63 vs 148) applicants, while VS saw a large decrease in MD (250 vs 128), DO (54 vs 23), and IMG (168 vs 115) applicants. The average number of applications per NS, OS, PS, and GS applicant increased moderately overall and across MD, DO, and IMG categories, except for DO applicants for NS which nearly doubled (49.84 vs 80.61). The average number of applications per TS applicant decreased overall (19.61 vs 12.81) and substantially decreased for DO (17.94 vs 7.83) and IMG (17.87 vs 9.42) applicants. There were increases in average number of applications per residency program across all specialties. Application statistics are reported in (Table 1) (Figures 1A and 1B).

Table 1.

Residency Application Statistics for Surgical Specialties 2019-2020 (In-Person) vs 2020-2021 (Virtual).

Surgical specialty	Total number of applicants	MD - # of applicants	DO - # of applicants	IMG - # of applicants	Average number of applications per applicant	Average number of applications per MD applicant	Average number of applications per DO applicant	Average number of applications per IMG applicant	Average number of applications per residency program
Neurosurgery	492, 506	339, 331	25, 23	128, 152	65.4, 73.14	70.79, 79.69	49.84, 80.61	54.16, 57.74	279.81, 321.80
Orthopedic surgery	1699, 1766	1154, 1231	287, 265	258, 270	65.83, 66.88	78.32, 77.74	47.92, 50.61	29.93, 33.33	594.96, 615.13
Plastic surgery (integrated)	358, 416	269, 299	25, 31	64, 86	57.80, 58.67	65.00, 66.17	32.84, 38.39	37.33, 39.91	252.37, 297.63
General surgery	6844, 7543	3228, 3438	901, 999	2715, 3106	47.35, 50.65	47.01, 49.53	52.67, 54.64	45.99, 50.56	1009.56, 1186.45
Thoracic	175, 333	95, 145	17, 40	63, 148	19.61, 12.81	21.05, 17.65	17.94, 7.83	17.87, 9.42	127.07, 129.27
Vascular	472, 266	250, 128	54, 23	168, 115	14.77, 30.24	16.44, 39.09	12.15, 22.48	13.14, 21.93	114.31, 125.67

Figure 1.

(A) Average number of applications per surgical residency program for 2019-2020 and 2020-2021 (B) Average number of applications per applicant for surgical specialties for 2019-2020 and 2020-2021 (C) Percentage of surgical residency spots filled by MDs for 2019-2020 and 2020-2021(D) Percentage of surgical residency spots filled by DOs for 2019-2020 and 2020-2021(E) Percentage of surgical residency spots filled by IMGs for 2019-2020 and 2020-2021.

Match Statistics

The number of positions offered across all specialties increased between 2019-2020 and 2020-2021, with the largest increase seen in OS (755 vs 868). The percentage of TS spots filled by MDs increased from 84.2% vs 97.8%. Conversely the percentage of TS spots filled by IMGs decreased from 10.5% to 2.2% while the percentage filled by DOs did not change. Additionally, the percentage of VS positions filled by IMGs doubled (5.3% vs 11.4%) and the percentage filled by DOs nearly halved (6.7% vs 3.8%) in the most recent cycle. The number of unfilled positions did not change greatly, other than a decrease in unfilled GS preliminary spots (591 vs 524). Orthopedic surgery and GS categorical saw an increase in number of spots filled by MD and DO graduates. Spots filled by non-US IMGs increased for GS preliminary (160 vs 191) but remained the same or decreased for all other specialties. No major changes were observed in the number of US MD seniors and DO seniors who matched across all surgical specialties. Match statistics are reported in (Table 2) (Figures 1C-1E).

Table 2.

Match Statistics for Surgical Specialties 2019-2020 (In-Person) vs 2020-2021 (Virtual).

Surgical specialty	Positions offered	Unfilled positions	Filled MD seniors	Filled MD grads	Filled DO seniors	Filled DO grads	Filled US IMG	Filled Non-US IMG	% filled MD	% filled DO	% filled IMG	% of MD seniors matched	% of DO seniors matched
Neurosurgery	232, 234	0, 0	203, 198	8, 11	3, 6	0, 2	6, 6	12, 11	87.5, 84.6	1.3, 3.4	7.8, 7.3	1.1, 1.1	.1, 0.1
Orthopedic surgery	755, 868	5, 2	686, 699	28, 40	112, 107	6, 12	5, 5	7, 3	80.8, 80.5	15.6, 13.7	1.6, 1.0	3.8, 3.8	1.9, 1.7
Plastic surgery (integrated)	180, 187	0, 0	165, 167	5, 9	0, 2	1, 1	3, 2	6, 6	91.7, 89.3	.6, 1.6	5.0, 4.3	.9, 0.9	.0, 0.0
General surgery (categorical)	1536, 1569	4, 5	1033, 1029	105, 133	202, 228	13, 18	98, 83	80, 73	67.3, 65.6	14.0, 15.7	11.6, 9.9	5.7, 5.6	3.4, 3.6
General surgery (preliminary)	1174, 1136	591, 524	290, 272	15, 17	31, 47	5, 6	82, 78	160, 191	24.7, 23.9	3.1, 4.7	20.6, 23.7	1.6, 1.5	.5, 0.7
Thoracic	38, 46	0, 1	32, 43	1, 0	1, 1	0, 0	0, 1	4, 0	84.2, 97.8	2.6, 2.2	10.5, 2.2	.2, 0.2	.0, 0.0
Vascular	75, 79	1, 0	61, 65	2, 2	5, 3	0, 0	0, 2	4, 7	81.3, 82.3	6.7, 3.8	5.3, 11.4	.3, 0.4	.1, 0.0

Discussion

Overall, our study identified a moderate increase in the total number of positions offered for all surgical specialties except for GS preliminary between the in-person 2019-2020 and the virtual interviews 2020-2021 match cycles. There was an associated overall increase in the number of applicants for all surgical specialties, except for VS which nearly halved. There was an overall increase in the number of applications per residency program for all specialties. The average number of applications per applicant increased as well, except for TS which decreased substantially. There were no major changes in the match statistics from 2019-2020 to 2020-2021, except for TS which saw an increase in percentage of spots filled by MDs to almost 98%, which was accompanied by a decrease in percentage of spots filled by IMGs.

The switch to a virtual format due to the COVID-19 pandemic has disrupted much of the residency match process. After the transition to a virtual format for the 2020-2021 residency application cycle, there were concerns that applicants would respond by applying to more programs, particularly for competitive surgical specialties, stressing the already challenged system. ⁴ Our study identified an overall moderate increase in the number of applications per residency program across all surgical specialties, confirming this concern. One concern with the virtual format is that a smaller pool of highly competitive candidates will apply more broadly and subsequently interview more broadly. This could have potentially led to an increase in the number of unmatched applicants and programs.

Generally, the costs to apply increase from $10 per application to $26 per application as applicants increase the number of programs on ERAS. Combined with the prohibitive expenses of traveling, these costs can limit the number of programs applicants apply to. ⁵ However, the transition to a 100% virtual interview format removed the need for expensive travel, perhaps justifying the comparatively small cost of applying to additional programs for the 2020-2021 cycle. The decreased opportunities for applicants to express their interests in specific programs due to the cancellation of away rotations and switch to virtual interviews brought on by COVID may provide an additional potential explanation for the increase in the average number of applications per applicant. The increasing number of applications, interviews, and ranked programs has been associated with an increased chance of matching into residency. ⁶ Applicants may have tried to mitigate the impact of these decreased opportunities by applying to a larger number of programs for their specialty of interest. ⁴

Other than the increase in number of applicants, applications per program, and applications per applicant, there were no other overarching changes across the surgical specialties between the in-person 2019-2020 and the virtual 2020-2021 match cycles. There were, however, substantial changes for VS and TS specialties. The percentage of positions filled by IMGs did not change between the 2 cycles for most of the surgical specialties, so the reason for the increase in the percentage of VS positions filled by IMGs in the 2020-2021 cycle (5.3% vs 11.4%) is unclear. Likewise, the cause of the decreased percentage of DO matches in VS (6.7% vs 3.8%) is also undetermined. The decrease in number of VS applicants (472 vs 266) may be associated with the substantial disparity between the number of applicants and the number of VS spots offered in the previous 2019-2020 cycle (472 applicants for 75 spots). The more than 6-fold number of prospective applicants to the number of available spots may have dissuaded 2020-2021 applicants from applying to the specialty. Additionally, several of the key factors that influence medical student decisions to apply to VS such as exposure to vascular procedures, influence of mentors, and program culture were negatively impacted by virtual format which may have decreased interest in the specialty for the 2020-2020 cycle. ⁷ Those that did choose to apply to VS may have increased the number of programs they applied to in order to increase the likelihood of matching in such a competitive specialty. The impact of these factors may have been compounded by the switch to a virtual format, as opportunities to build competitive applications were severely limited.

This raises some concern for VS residency programs since there is a high demand for vascular surgeons that is not adequately met by the current supply. ⁸ Arous et al note that recent development of integrated VS programs with decreased training time may assist in increasing the current physician supply in the field of VS, yet the number of programs only increased by 4 in the past year. ⁸ There is an obvious interest in VS among residency applicants evidenced by the disproportionate amount of applicants for the amount of spots offered, but the supply of available residency programs does not match the demand from both aspiring surgeons and the medical needs of the nation. Efforts should be made to further increase the number of new VS residency programs to meet this demand. Although the reason behind the large decrease in VS applicants in 2020-2021 is unknown, efforts can be made to increase interest in VS among medical students to expand the pool of highly qualified VS applicants for future residency cycles. ⁹

Interestingly, TS saw the opposite changes compared with VS. The decrease in the number of applications per applicant seen in TS is in stark contrast to the changes seen in all the other surgical specialties. Considering the competitive nature of the TS specialty, we would expect this number to increase in response to the limited opportunities available to applicants due the lack of away rotations and switch to virtual format. There is no clear explanation for the decrease seen in this measure; however, survey data from the 2020-2021 applicants, which are not currently available, may shed light on the reasons behind this observation.

Additionally, the 2021 match statistics revealed that the percentage of TS residency positions filled by MD degree holders increased from 84.2% to 97.8% although MD applicants only constituted 43.5% of total TS applicants. This was accompanied by a decrease in spots filled by IMGs from 10.5% to 2.2%. These changes raise a concerning disparity that despite an increase in the percentage of DO and IMG applying to TS residencies. This may be due to the marked decrease in the average number of TS applications per DO applicant (17.94 vs 7.83) and IMG applicant (17.87 vs 9.42) compared to MD applicants (21.05 vs 17.65), thus increasing the likelihood of an MD applicant matching into the program. The reason for this decrease in applications per applicant among DO and IMG students is unknown and is most likely multifactorial.

Graduation from US allopathic medical schools has been associated with increased likelihood of successful matching into TS residencies in the past. ¹⁰ The switch to a virtual format for the 2020-2021 match was associated with the largest disparity in TS spots filled by MDs since at least 2008. ¹¹ DO and IMG have statistically been at a disadvantage compared to their MD peers for matching into competitive residencies, which seems to have been exacerbated by the switch to a virtual format. ¹² The switch to a virtual format and shortened length for the 2020-2021 cycle may have increased the difficulty of evaluating applicants via traditional metrics such as interview performance and in-person competence during rotations, resulting in reliance on less valuable metrics such as school reputation. ¹³ Regardless of the reason for the increased match discrepancy between MDs and their DO and IMG peers, program directors should consider strategies to address the concerning disparity during the residency match process.

Additional studies should be conducted to investigate what specific factors from the 2020-2021 residency cycle contributed to the changes observed by our study. Analyzing the NRMP program director survey may identify changes in applicant characteristics valued by programs, while analyzing the NRMP applicant survey may illustrate factors influencing applicants’ program selection and ranking. When demographic data for the 2020-2021 surgical residency become available, trends should be analyzed to determine what impact the switch to a virtual format has made on racial and gender disparities for both application statistics and match statistics. The NRMP and ERAS should consider providing additional data in terms of MD, DO, and IMG unmatched applicants by specialty to improve reporting and assessment of unmatched individuals within these subgroups across specialties.

There were several limitations. The data regarding the gender and race of all applicants and the matched individuals have yet to be released for both the 2019-2020 and 2020-2021 application cycles. Without this demographic data, we were unable to explore any possible disparities that may have been precipitated by the switch to a virtual interview format. ¹⁴ In addition, the most recent NRMP applicant survey data available are from the 2018-2019 cycle. This data set discusses the factors influencing applicants’ program selection and ranking, the number of applications per specialty, and the number of interviews offered and attended by applicants in each specialty. The unavailability of data regarding program selection reasoning and interview statistics for both our in-person 2019-2020 cycle and the virtual 2020-2021 application cycles further limits our investigation into the various changes that the virtual interview format may have caused. Currently, the data provided by the NRMP regarding the unmatched pool of applicants are very limited and do not include specialty-specific statistics on MD, DO, or IMG unmatched applicants. We were, therefore, unable to explore the consequences that may arise given the strong likelihood that the virtual format enabled a subset of extremely competitive applicants to apply and interview more broadly.

Conclusion

The switch from the in-person 2019-2020 to the 100% virtual interviews 2020-2021 residency match format was associated with an overall increase in the number of applications per program and number of applications per applicant across many surgical specialties. There was a major decrease in the number of applicants to VS and an increase in the number of applications per applicant to the specialty. These changes may be due to a number of factors that were compounded by the disruption of the COVID-19 pandemic, but presents a troubling prospect for the specialty’s future. The switch to a virtual format in 2020-2021 was also associated with an increase in TS spots filled by MDs to almost 98%, increasing the already concerning TS match disparity for DO and IMG applicants.