CORR Insights^®: What Factors Influence Applicants’ Rankings of Orthopaedic Surgery Residency Programs in the National Resident Matching Program?

Where Are We Now?

As Huntington and colleagues note in their study, there is a dearth of literature regarding the experiences and perceptions of applicants to orthopaedic residency programs. Traditionally, residency programs have grown accustomed to a certain “buyer’s market” when it comes to applicants. Thanks to a surplus of qualified candidates, programs are not required to “sell” themselves. As a result, our profession has invested little energy in discovering what medical students are actually looking for in their residency programs. As the current study shows, we may finally be seeing some cracks in the status quo.

The current study confirms what other studies about millennials have shown: Millennials place a high premium on happiness, balance, and interpersonal relationships [2, 3]. While congeniality is typical of many orthopaedic residencies, those values have not traditionally been of primary importance compared to the main goal of teaching residents to be orthopaedic surgeons.

Residency programs are being urged to achieve more diversity, as per the goals of the American Academy of Orthopaedic Surgeons (AAOS). The AAOS established a Diversity Advisory Board with a mission “to educate our fellows on the impact of diversity and culturally competent care in their practice and society (and to promote the growth of diversity among orthopaedic surgeons)” [1]. Working with both the Ruth Jackson Society and the Gladden Society, the Diversity Advisory Board created an advertising campaign directed towards qualified medical students with diverse backgrounds. The board also published several diversity themed articles in AAOS Now [5–7].

Our profession is only beginning to understand that the goals and interests of medical students from the Millennial Generation are different than those of the previous Baby Boomer and Generation X age group.

Where Do We Need To Go?

The present study confirms that interactions with a program’s current residents are a primary source of information for applicants. Clinical rotations also are an important means for students to experience the culture of a residency. This seems to be particularly important for women.

Surprisingly, almost 15% of women applicants perceived gender bias in the interview process and more than half (57%) were asked gender-related questions during interviews. In fact, it is illegal to ask most such questions, including those about a prospective employee’s marital status, plans to have a family, or whether or not gender will affect the candidate’s performance or ability to adapt to the workplace. These proscriptions are based on Title VIII of the Civil Rights Act of 1964 and the Pregnancy Discrimination Act of 1978 [8]. That a majority of female candidates are reporting encountering such questioning in the second decade of the 21st century is sobering. Moreover, 68% of women eliminated an institution from consideration based on their perception of gender bias in the residency program. As a profession, we still have a long way to go towards leveling the playing field for women and minority applicants, and in shifting our attitude toward more diversity in our specialty [4]. If our profession fails at leveling the playing field, we are going to dilute our ability to attract the best medical students.

How Do We Get There?

Continued monitoring of students’ values, interests, and goals will be needed going forward. Currently, the AAOS Diversity Advisory Board conducts a biennial demographic survey of residents, which could be expanded or duplicated to include residency applicants. This would not only provide a valuable picture of the evolving face of our specialty, but could also be used to pinpoint institutions at which bias is being perceived, and provide an opportunity for remediation where problems are uncovered. The efforts towards diversity by organizations like AAOS, Ruth Jackson Society, and Gladden Society need to be reinforced. All three groups have cooperated on mentoring programs, outreach, and advertising campaigns aimed at women and minorities. The fact that respondents in the study reported experiencing gender-based questioning, or blatant gender or minority bias confirms that our practitioners still need education in cultural competence and gender sensitivity. There are numerous avenues available for such training. The AAOS has a Culturally Competent Care Guidebook and online, interactive Cultural Competency Challenge, for which continuing medical education credit is available. At the University of Nebraska, my institution, all practitioners are required to take an online cultural competency training module and exam. Perhaps such training should be made a component of Maintenance of Certification. Finally, since the current residents were the applicants’ most valued source of information, ample time to interact with residents, informally and without attendings present, may be a vital component in conveying residency culture and attracting prospective candidates. Undoubtedly, both positive and negative aspects of a residency will arise in these interactions. However, a well-educated, well-informed applicant with easy access to honest discussion about his or her concerns is more likely to build a rank list, and ultimately obtain a residency, that accurately reflects his or her educational and social needs.