A Program Director’s Perspective: Advanced Positions versus Physician-Only Positions - What’s the Best for My Program?

Dear Editor

As the program director in a new anesthesiology residency program now in place for the past five years, my learning curve continues in a parabolic fashion. Although it has been five years, it seems like not that long ago I got the exciting confirmation from the Accreditation Council for Graduate Medical Education (ACGME) that our program was green-lit to participate in our first match. Since then, I have had our inaugural class of three residents successfully graduate with two residents match into their top fellowship choices and the third was hired on by our group as an attending. Two years ago, the program again got the approval to increase our future class size from three to four residents per class, and just recently, I have submitted a formal request to again increase the resident class size to six residents per class.

I continue to learn the intricacies of guidelines set forth by the different educational committees including the ACGME, American Board of Medical Specialties (ABMS), graduate medical education committees (GMEC) and National Residency Matching Program (NRMP).

Our institution and department chose to start our program without offering a clinical base year (CBY).  We thus placed ourselves in the NRMP as an advanced track program, recruiting trainees that would join our program as post-graduate year (PGY) 2 residents after completing a transition year or preliminary year PGY-1 year.  Thus, candidates coming for interviews would mostly include fourth year medical students.

 The advanced track is designed for programs to interview prospective candidates a year in advance. The prospective residents will require a CBY before initiating their PGY-2 position with our department. In my opinion, the inherent problem with this recruitment track is two-fold. Prospective residents must be interviewed elsewhere for their clinical base year, requiring extra interviewing expenses and the possibility of matching with an advanced track while not obtaining an CBY position or vice versa ( 1 , 2 ).

 The advanced track, in our opinion, does not benefit our departments offering as we are unable to assist with a clinical base year.  This year we offered 54 interviews for 4 positions and had 19 candidates decline.  The response from the candidates that declined their interview focused on the expense of interviewing and the lack of offering a clinical base year compared to a four-year all-inclusive program.

After much discussion within our department and with our designated institutional officer (DIO), we plan to modify our recruitment to the physician’s track (R) in the NRMP match.  Physician (R) positions are PGY-2 positions starting in the year of the Match that are reserved for applicants who have had prior graduate medical education. Physician positions are not available to senior medical students. In previous Results and Data Books (published by the NRMP), the numbers of R positions were small and they were included in the categorical position counts. In 2014, NRMP began listing R positions separately (NRMP policy). We believe this will increase our programs advantage with recruitment more than we currently experience as an advanced track program.

The advantage of the physician track will allow our department to interview a more mature candidate that is already in the practice of medicine, as they have completed or are in the process of completing at least one year of residency at the time they are interviewed. Furthermore, in 2017, only 5.7 percent of anesthesiology positions (100 R track/1743 total positions) are offered in the physician track, thus improving our competitive advantage for recruitment with these odds.  

We believe that medical students get very small windows into our specialty through their required and elective rotations forcing medical students to choose other specialties.  They are often forced to make impulsive decisions about their career path based on a few weeks of experiences. Many terrific candidates will be available from medical residents that did not have the exposure prior to their clinical base year and initially attempted to match within other areas of medicine or had a change of heart after their first year in that other specialty.

Given these reasons, I’ve decided to change our programs recruitment tactics. The next recruitment year will be different as our program transitions.  We will remain in a "not participating" status for “All-In” compliance purposes next year. Furthermore, we will not be interviewing medical students for the following academic year. As residency programs have sprouted over the last few years, maintaining a competitive recruiting advantage is paramount in maintaining a successful residency program.  I believe the Physician track (R) is the path lesser known but an oasis of talent to be explored.  As I set to enter the next five years of our program’s existence, I hope on the back end I can look back as that dust has settled and say that this change was for the better.