Abstract
BACKGROUND:
The six-year Integrated Thoracic Surgery (I-6) residency programs have evolved over the past decade. Despite the rising number of programs, there is minimal data published about the criteria utilized by program directors to select candidates. We analyze the characteristics and qualities of successful matriculants using the American Association of Medical College’s (AAMC) data reports and survey responses from program directors.
METHODS:
Using a survey administered via the RedCap service, program directors were asked to rate the importance of a variety of factors in their evaluations of candidates. AAMC data reports from 2018–2020 provided information on the mean matriculant research productivity, United States Medical Licensing Examination (USMLE) Step 1 scores, and Step 2 Clinical Knowledge (CK) scores.
RESULTS:
Responses were received from 19 of 33 (58%) I-6 programs. Program directors consistently rated interview performance as a very important factor in their evaluation of applicants. Matching into the specialty is becoming more competitive, with mean USMLE Step 1, Step 2 CK, and research productivity increasing over the past few years; matriculants had mean Step 1 and Step 2 CK scores of 247.3 and 254.2, respectively, in the 2020 match.
CONCLUSIONS:
Thoracic surgery program directors place high value on applicant Interview Performance, Letters of Recommendation, and Professionalism. Program directors agree that a forthcoming pass/fail USMLE Step 1 score report will lead to closer scrutiny of other factors during the decision-making process and may cause future evaluation of applicants to be heavily reliant on letters of recommendation and medical school pedigree.
Graphical Abstract
The path towards becoming a cardiothoracic surgeon has evolved since its inception. The original training model dates back to 1928 when the University of Michigan began offering a two-year cardiothoracic surgery fellowship.1 Following this traditional pathway, physicians complete a residency in general surgery followed by a two- or three-year cardiothoracic surgery fellowship. In 2003, the American Board of Thoracic Surgery made it optional for cardiothoracic surgery trainees to be board certified in general surgery, thus enabling the development of the six-year integrated pathway. The program at the Stanford University School of Medicine was the first to begin training residents using this paradigm by accepting its first resident into the Integrated Program in 2007.2 The University of Pennsylvania and the Medical University of South Carolina quickly joined Stanford and in 2008 became the first 3 integrated thoracic residency programs to participate in the National Resident Match Program (NRMP).3 Since then, the number of integrated programs has grown to 33 accredited sites in 2021.4
The Joint Thoracic/ General Surgery (also known as the 4/3, 4+3, or Fast Track) pathway is a third pathway to board eligibility in Thoracic Surgery; it consists of four years of general surgery training followed by three years in cardiothoracic surgery. Trainees that complete this pathway are eligible to sit for both the General Surgery and Thoracic Surgery boards.2 The majority of 4/3 programs select internal applicants from the general surgery resident cohort.
The National Residency Matching Program’s (NRMP) “Charting Outcomes in the Match” 2020 report is the latest in the series of biennial reports that highlights the characteristics of successful residency applicants.5 The report is organized by specialty and includes the mean USMLE Step 1 and Step 2 CK scores as well as the mean number of research publications for both matched and unmatched applicants. Despite the inclusion of other surgical subspecialties that have adopted an integrated training model (e.g., plastics and vascular surgery), thoracic surgery is not included, as this report only includes specialties with at least 50 positions and Thoracic Surgery only offered 38 positions at the time of publication.
The “Program Directory Survey” is another report produced by the NRMP. It provides a unique insight into the factors program directors use when selecting applicants to interview and rank.6 This survey includes responses from program directors of 22 different specialties, however, the latest edition in 2018 only includes data from a survey of programs directors performed in 2014. The lack of recent information represents a gap in knowledge for prospective applicants that requires clarification. This void of information has only grown after the recent announcement from the National Board of Medical Examiners (NBME) that the USMLE Step 1 score report will change no sooner than 2022 from providing a 3-digit numerical value to pass/fail.7
Furthermore, despite the increasing number of accredited institutions and a growing number of applicants vying to fill a limited number of residency positions,8 there remains minimal data on program websites9 or published reports pertaining to the criteria utilized by program directors to select candidates. The aim of this study is to analyze the characteristics and qualities of successful matriculants of I-6 training programs and elucidate how the change in the USMLE Step 1 score report will influence the criteria used by program directors when evaluating candidates. Furthermore, we seek to determine which application components are deemed to be most critical to an applicant’s success in the Match process.
MATERIAL AND METHODS
Approval of a Medical Exempt Protocol was first obtained by the Stanford University Institutional Review Board. Both program websites and the American Medical Association’s (AMA) Fellowship and Residency Electronic Interactive Database (FREIDA), were utilized to obtain the contact information of I-6 program directors. Surveys were distributed, in March of 2021, via email to program directors using the Redcap service inviting them to participate in a voluntary survey. To increase our response rate, program coordinators were copied on the email. In cases where no response was received, we followed up with a call to the program coordinator and asked them to remind the program director to fill out the survey when able.
Participants were first asked to verify the training model offered at their institution. Program directors were then asked to rate the importance of the following twenty variables when evaluating an applicant: 1) Pre-Clerkship Grades, 2) Clerkship Grades, 3) Clerkship Grades in Surgery, 4) USMLE Step 1 Scores, 5) USMLE Step 2 CK Scores, 6) Research Involvement, 7) Interest in Academic Career, 8) Class Ranking, 9) Awards or other Special Honors, 10) MSPE/ Dean’s Letter, 11) AOA, 12) Extracurricular Activities, 13) Personal Statement, 14) Completion of Away Rotation at your Institution, 15) Performance while on an Away Rotation at your Institution, 16) Letters of Recommendation, 17) Evidence of Professionalism, 18) Interview Performance, 19) Perceived ability to Operate, and 20) Perceived Commitment to the Specialty. Participants were asked to select from the following options when rating importance: Not at all Important, Somewhat Important, Important, and Very Important. The scoring metric for survey responses was a four-point Likert scale. The numerical weighting ascribed to survey responses is as follows: Not at all important = 1 point, Somewhat Important = 2 points, Important = 3 points, Very Important = 4 points. These weighted scores were summed up for each variable and divided by the number of respondents to determine the mean.
In the next section, participants were asked how the change in the USMLE Step 1 scoring system (to pass/fail) will influence their evaluations of candidates. They were given the following options to select from: a) Greater emphasis will be placed on all other factors, b) Greater emphasis will be placed on only the Step 2 CK score, c) This will not influence my evaluation of applicants, and d) Other (“other, please explain below”). This section allowed participants to select more than one option. Respondents were then asked to provide additional comments on how the USMLE Step 1 score report policy change may influence their evaluation of future applicants. In the final section, participants were asked to provide any additional comments or information about the qualities they are looking for in an ideal candidate.
Mean matriculant USMLE Step 1 and Step 2 CK scores as well as number of abstracts, presentations, and publications were obtained from the AAMC Table B1 2018–2020 data reports. Demographic information of active integrated thoracic residents was obtained from the AAMC Table B3 and B5 2018–2021 data reports.
RESULTS
Survey results provide insight into desirable candidate traits and establish the most (and least) important qualities sought by thoracic surgery programs across the nation. Responses were received from 19 of 33 (58%) I-6 programs; this data is shown in (Figure 1). Figure 2 shows the calculated scores for each variable after the survey results were tabulated.
FIGURE 1:
Free text responses from survey respondents to the question, “Please provide any additional comments or information about the qualities you are looking for in an ideal candidate”
FIGURE 2:
Free text responses from survey respondents to the question, “If you have additional comments about how the changing of the USMLE STEP 1 score report to a pass/fail outcome may influence your evaluation of applicants, please provide these comments below”
Respondents rated Interview Performance (Mean = 3.89, SD = 0.32, Median = 4) as the most important variable, followed by Evidence of Professionalism (Mean = 3.63, SD = 0.50, Median = 4), Letters of Recommendation (Mean = 3.63, SD = 0.50, Median = 4), and Clerkship Grades in Surgery (Mean = 3.58, SD = 0.69, Median = 4). USMLE Step 1 Score, (Mean = 3.37, SD = 0.76, Median = 4), Clerkship Grades (Mean = 3.3, SD = 0.73, Median = 3), Performance on service during an away rotation (Mean = 3.26, SD = 1.05, Median = 4), Research Involvement (Mean = 3.05, SD = 0.62, Median = 3), and Personal Statement (Mean = 3.05, SD = 0.78, Median = 3) were given moderate consideration. Less importance was attributed to applicant Interest in an Academic Career (Mean = 2.95, SD = 0.91, Median = 3), Extracurricular Activities (Mean = 2.85, SD = 0.81, Median = 3), Perceived Ability to Operate (Mean = 2.84, SD = 0.90, Median = 3), and Awards or other Special Honors (Mean = 2.74, SD = 0.87, Median = 2). The five variables identified as least significant were MSPE/ Dean’s Letter (Mean = 2.68, SD = 1.00, Median = 3), AOA (Mean = 2.68, SD = 0.89, Median = 3), Class Ranking (Mean = 2.6, SD = 0.94, Median = 3), Pre-Clerkship Grades (Mean = 2.47, SD = 0.84, Median = 2), and Completion of Away Rotation at Your institution (Mean = 1.79, SD = 0.92, Median = 2, ranked 20th) (Figures 3, 4). When asked to respond to how the USMLE score report change to a pass/ fail outcome will influence their evaluation of future applicants, 14 out of 19 (71%) I-6 program directors selected Greater emphasis will be placed on all other factors. Only 4 out of 19 I-6 directors (21%) selected Greater emphasis will be placed on only the Step 2 CK Score. This was reflected in the survey results, as the USMLE Step 2 CK Score ranked as the tenth most important variable (Mean = 2.95, SD = 0.91, Median = 3).
FIGURE 3:
Survey participants were program directors, and assistant program directors. Participants were asked to rate the level of importance they attribute to the following: Pre-Clerkship Grades, Clerkship Grades, Clerkship Grades in Surgery, USMLE Step 1 Scores, USMLE Step 2 CK Scores, Research Involvement, Interest in Academic Career, Class Ranking, Awards or other Special Honors, MSPE/ Dean’s Letter, AOA, Extracurricular Activities, Personal Statement, Completion of Away Rotation at your Institution, Performance while on an Away Rotation at your Institution, Letters of Recommendation, Evidence of Professionalism, Interview Performance, Perceived ability to Operate, and Perceived Commitment to the Specialty. Respondents were asked to select from the following options when rating importance: Not at all Important, Somewhat Important, Important, and Very Important. More respondents rated Interview Performance as “Very Important” than any other variable. Completion of away rotation at your institution has the most “Not at all important” responses
FIGURE 4:
The numerical weighting ascribed to survey responses is as follows: Not at all important = 1 point, Somewhat Important = 2 points, Important = 3 points, Very Important = 4 points. These weighted scores were summed up for each variable and divided by the number of respondents to determine the mean. Interview performance received that highest mean score (3.89). Completion of away rotation at your institution received the lowest mean score from respondents (1.79).
Figures 1 and 2 display free text responses from survey respondents to the prompts “Please provide any additional comments or information about the qualities you are looking for in an ideal candidate” and “If you have additional comments about how the changing of the USMLE STEP 1 score report to a pass/fail outcome may influence your evaluation of applicants, please provide these comments below”
In the 2018 AAMC Table B1 report, the mean USMLE Step 1 score for thoracic surgery matriculants was 242.3, rose to 244.1 in 2019, and increased yet again to 246.3 in 2020. The mean USMLE Step 2 score was 246.2 in 2018, 253.7 in 2019, and 254.2 in 2020. The mean number of abstracts, presentations, and publications was 10.1 in 2018, 10.7 in 2019, and 14.7 in 202010. In 2018 AAMC Table B3 report, 50/202 (24.8%) active residents were said to be female, that number increased to 59/217 (27.2%) in 2019, 65/223 (29.1%) in 2020 and 74/242 (30.6%) in 202111. The 2020 AAMC Table B5 report revealed that of active integrated thoracic M.D. residents, 3.2% identified as Black/African American, 6.9% Hispanic, 19.4%, Asian, 61.3% White/Caucasian and 4.2% Other/Unknown. In 2021 the percentage of Black/African American decreased to 2.5%, and to 5.5% for Hispanics, 22.9% of residents identified as Asian, 60.6% White/Caucasian and 3.8% Other/Unknown12.
COMMENT
This study has several limitations. The scoring metric used to report survey responses was a noncontinuous four-point Likert scale. This approach assumes that the intensity of the respondents’ attitude towards each variable is categorical. Our results are also limited to responses from program directors who responded to our survey and may not reflect the opinions of all integrated thoracic surgery residency directors. Free text survey responses are difficult to quantify and therefore objectively compare furthermore the impact of the COIVD-19 pandemic on the match process is still ongoing and its full impact may not be apparent as of yet. Finally, we chose to survey only program directors, but we acknowledge that other faculty members play an important role in the evaluation of applicants and candidate selection. A future survey that includes the opinions of department chairs and assistant program directors may yield more comprehensive findings.
CONCLUSIONS
Despite the growth of thoracic surgery residency programs, relatively little is known about the characteristics of a competitive applicant. In 2018, a roundtable of prominent thoracic surgery program directors, led by Dr. Joseph Woo, examined how residency candidates are evaluated and discussed factors important during the process.13 In that discussion, the program directors reported using objective data, such as surgery clerkships grades, AOA, and USMLE scores to create an initial list. Once that list was created, they relied on factors such as letters of recommendation and interview performance to allow for further gradation of applicants and to create a more holistic picture of the candidate. Results from an NRMP survey of integrated thoracic surgery residency program directors conducted in 2014 echoed this sentiment. They revealed that the factors weighed heavily in the evaluation of applicants, at that time, included: USMLE Step 1 and Step 2CK scores, passing USMLE Step 2 CS and AOA, interactions with faculty and house staff during the interview and visit, interpersonal skills and leadership qualities.5
In our study, I-6 program directors placed high value on Interview Performance, Letters of Recommendation, and Evidence of Professionalism. Surprisingly, I-6 program directors placed relatively little value on Perceived Ability to Operate, Research Involvement, and Perceived Commitment to Specialty. In comparison to general surgery residents that apply internally to 4/3 programs, I-6 applicants are mainly fourth-year medical students. As a consequence of the limited clinical experience of most medical students, program selection committees have limited insight into how an applicant functions in a hospital team setting. This could explain why respondents to our survey weighed Clerkship Grades in Surgery more heavily than Pre-Clerkship Grades. One I-6 program director remarked that clerkship grades and evaluations are an important indication of performance in a “real-world” setting. In response to the question asking about the qualities found in an ideal candidate, one program director succinctly responded, “a track record of sustained success and accomplishment.”
Several variables commonly identified as less important include Class Ranking, Pre-Clerkship Grades, and AOA. The criteria for high achievement in these categories is variable and often differs depending on where an applicant attended medical school. Interestingly, Completion of Away Rotation at Your Institution ranked as the least important factor amongst I-6 programs directors. The completion of away rotations is often regarded by medical students and program directors of other competitive specialties to be a vital component of a strong residency application.14–16 Our survey results might reflect a recent change in opinion due to travel restrictions caused by the COVID-19 pandemic. Nonetheless, the survey responses suggest that if applicants do go on away rotations, their performance while on service is weighed heavily and ranked relatively important by program directors as this likely provides the insight into how the applicant functions in the hospital setting. One program director remarked that the quality sought after in an ideal candidate is “grit.” Another answered the same question with “commitment, and someone who is trainable.”
The importance of the USMLE Step examination scores is evident in the survey responses, with USMLE Step 1 scores ranked as the fifth most-important variable. Although this rigorous examination aims to test one’s knowledge of a wide breadth of detailed material, our survey indicates they are not just viewed as a standard measure of an applicant’s intelligence. One I-6 program director commented that although Step 1 is often derided for only measuring test-taking ability, this deduction misses the fact that the exam is primarily a test of memorization, and thus, tests commitment rather than aptitude. The director argues that it measures an ability to recognize a necessary goal, study for that goal, and achieve it. It is then no surprise that the recent changes by the NBME moving to transition the USMLE Step 1 exam to a pass/fail scoring system has sent many programs and applicants scrambling to figure out what should be the new objective measuring stick. There is concern that this change will disadvantage candidates from lesser distinguished medical schools.17,18 Some believe that the USMLE Step 2 CK exam will simply replace Step 1 for the use of score cutoffs. We asked program directors how this change will influence the evaluation of applicants in the future. Many felt that this change would result in more emphasis placed on clerkship grades in an effort to make objective comparisons. One I-6 program director felt that the change was a step in the wrong direction and represents a progressive elimination of evaluation metrics that power and reward excellence and achievement. The director expressed concern that this move leaves the residency application process more vulnerable to bias and could widen existing resource disparities. This sentiment was echoed by another program director who thought the change would lead to more emphasis being placed on “the school of medical training and who you know as evidenced by letters of recommendations.” All in all, most program directors acknowledged that it would lead to closer scrutiny of other factors, and that at least for now, more applications would need to be reviewed due to the absence of score cutoffs.
Another interesting finding was that Research Involvement was ranked only the 8th most important factor by survey respondents when evaluating an applicant. A 2013 survey of thoracic surgery applicants found that a large majority were interested in academic careers and just over half were interested in dedicated research time.19 A more recent study found that early involvement in cardiothoracic surgery research is associated with increased research productivity and other academic achievements over the course of their careers as cardiothoracic surgeons.20 Significant research involvement is an essential component of most academic cardiothoracic surgeon’s careers, which is reflected in the fact that first-year thoracic surgery residents have one of the highest mean number of abstracts, presentations, and publications amongst all residency specialties. This number has increased between 2018 and 2020; the mean number of abstracts, presentations, and publications in 2018, 2019, and 2020 were 10.1, 10.7, and 14.7, respectively.10
As of 2020, the reported USMLE scores of thoracic surgery matriculants ranked amongst the best even as the number of applicants continued to increase. Despite the impressive scholastic achievements among matriculants, diversity amongst active residents is still relatively low; female representation has increased over the years but the number of African Americans remains below other surgical subspecialties making up 3.2% and 2.5% of thoracic surgery residents in 2020 and 2021 respectively.11,12 While many programs are working hard to address the lack of diversity in thoracic surgery training, one survey respondent expressed concern that the “eradication of the medical school evaluation system will only make it harder for talented, hard-working, deserving students who may belong to groups at risk of bias … to be recognized and rewarded.” Information regarding the characteristics and qualities of thoracic surgery residency matriculants will empower programs to streamline their application process, help set realistic score cutoffs, and work to eliminate bias. Future studies on this topic should deliver more insightful applicant and matriculant demographic data and provide match metrics that will inform candidates and programs on the landscape of the thoracic surgery match process
Footnotes
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