Reply to Letter to the Editor: Does “Hoarding” Impact Interview Distribution Among Orthopaedic Surgery Residency Applicants? A Modeling Study Based on a Large Database

To the Editor,

We thank Mr. Posner and colleagues [4] for their close reading of our work and for their thoughtful response, especially given the personal relevance of the topic to a group of medical students interested in pursuing a career in orthopaedic surgery.

A goal of our research on the orthopaedic residency application process was to balance the subjective nature of most information currently available on the application process against robust non-survey-based data. We think this can be helpful to medical students, as well as to advisors and policymakers. Critical in the interpretation of our data, however, is the differentiation between population-level and individual-level analysis. The dataset and redistribution modeling represent the effects on the overall applicant pool. As the authors of the letter [4] correctly point out, any changes to the process are likely to have effects for at least some individual applicants. Importantly, our paper [2] does not allow for an analysis of the ultimate match rate into residency positions, although a higher number of interviews is associated with a higher probability of matching successfully [3].

Although the adage that “you only need one” interview to match is technically true, as long as the number of applicants to orthopaedics remains higher than the number of available positions, a 100% match rate is impossible. The successful match of one applicant may indeed mean another applicant goes unmatched, although to date, we know of no analysis that can confirm or refute the contention that if one applicant gets an additional offer it will result in another person failing to match. It would be ideal to assess how potential or actual reforms influence the odds of an applicant’s match, including the effect of one additional interview.

We believe that applicants and medical schools can take specific steps to increase the odds of successful matches. Although we agree it is necessary to understand the match process early in medical school to prepare and curate a competitive application, we encourage avoiding excessive subspecialization to ensure a well-rounded medical education. We believe this helps future physicians, preparing medical students for clinical rotations, including orthopaedic subinternships. On an institutional level, high-quality, individualized advising from senior peers, residents, and attendings is critical in helping an applicant entering the pool to be well-positioned to apply strategically. We are glad to hear that a strong mentoring program is in place for the medical students who wrote the letter, and we hope that all medical students interested in orthopaedics have similar opportunities. We have worked to create such a system at our own institution, and to share advice openly about how to do so [1].

Our study [2] relied on data from before the introduction of preference signaling to orthopaedic surgery residency applications. Preference signaling may be acting as a functional cap on applications, although a more data-driven analysis is needed to quantify these effects [5]. At Oregon Health & Science University, we have not interviewed any nonsignaling candidates in the two cycles that have occurred. We encourage regulatory bodies to continue evaluating the application process and strive for an equitable system that will allow us to continue to recruit, retain, and educate highly qualified applicants to be the next generation of orthopaedic surgeons.