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Die Herausforderungen des Spieltags

von NFI Redaktion

The player results are in. On Monday, March 11, students found out if they are suitable for a residency program; this Friday they will find out where. The past few days have been a battle for the 10% who couldn’t keep up this week. From Monday to Thursday, unmatched students are eager to secure one of the few remaining spots, even if it means changing their specialty.

The process is a strangely ritualistic and full of apprehensions. Students feel like their medical careers depend on this one week, spending tens of thousands of dollars on the selection process to reach this moment. Even if they match, more than half won’t get their top choice. Most will spend the week worrying about where they will soon train, what cities they will have to move to, and how this will impact their lives and families.

However, experts say that Match Week events represent deeper issues. The Match is just an algorithm – one that works pretty well. It’s the months-long process leading up to this week, the extremely expensive and time-consuming arms race for training spots that fourth-year medical students must go through, that is the real problem. It’s more systemic than this week-long madness. And students, residents, and programs are determined to change this.

Snowball Effect
The issues with the residency application process at least partially arose when medical schools in the 2000s began using a centralized application system, said Maya Hammoud, MD, director of women’s health and associate chair for education at the University of Michigan, Ann Arbor, Michigan. Over time, it has become easier to apply to more programs. Out of fear, and facing the average number of applicants ahead of them in the class, students felt the need to apply to additional programs, said Hammoud. The result is a snowball effect that in 2022 led U.S. medical students to submit an average of 78 applications, while international medical students submitted an average of 102 applications.

Meanwhile, students are spending thousands of dollars on application fees to complete 70, 80, or 90 residencies, most of which they have little real interest in and are underrepresented in medicine, said Dr. Bukky Akingbola, third-year obstetrics and gynecology resident at the University of Minnesota, Minneapolis, Minnesota.

Overlooked Talent
The more applications, the more personnel and money programs have to spend on the process – and the more likely they are to rely on filters like USMLE scores or Step 1 exam results to narrow down applications. „Part of the problem is that programs are not responsible for evaluating students in a multifaceted way,“ said Bryan Carmody, MD, a pediatric nephrologist and medical education blogger. „When you evaluate people in a certain way, you push them to show a certain type of talent.“

The problem with relying on metrics like test scores is that they do not select for better doctors or better care. As long as there are more applicants than residency spots, some students will always be left dissatisfied. But if the competition for these positions makes them better doctors, „that’s virtuous competition,“ said Carmody. Even those students who don’t match would benefit from it.

As it stands, that’s not the case. In the current application process, students who improve society are not considered. In fact, it stifles diversity and promotes outright fraud, as the recent scandal has shown, said Carmody.

The Lost Year
By the time the selection process is complete, students have devoted most of their fourth year to standardized tests, personal statements, securing interview spots, and meeting with programs. Some medical schools give students a few months off or a shorter rotation to focus on the process, said Akingbola. And while she appreciated the flexibility at the time, it cost her a fourth year of education – and tuition. „In hindsight, I would have wanted to be there for childbirth or major gynecological cases,“ she said.

Abigail Ford Winkel, MD, associate vice chair for education at the Grossman School of Medicine at NYU and professor in the Department of Obstetrics and Gynecology, agreed. „My only real criticism is that it prevents students and faculty from preparing these medical students for the profession of being doctors, which is top priority.“

A better option might be to shorten the application process, confine the entire application, interview, and match process to the fall, giving students back their final semester. But such a reform would require a „Herculean effort,“ said Akingbola.

Incremental Change
A significant portion of resident selection is steeped in tradition. But leaders and students are pushing back against the way things have always been. In 2019, the American Medical Association’s Reimagining Residency Initiative funded two grants to support medical students transitioning to specialty training.

For a grant awarded to the Association of Professors of Obstetrics and Gynecology, a separate application for Obstetrics and Gynecology residents was created. It will launch in 2025 and will be more cost-effective than the current system.

The team led by Hammoud also standardized the interview delivery date to prevent students from anxiously checking their inboxes for months. And they integrated a new feature into the application that allows students to indicate their preferred programs in applications. They introduced the signaling option in 2023, and last year the average number of applications per student for Obstetrics/Gynecology actually decreased, said Hammoud.

Since Obstetrics/Gynecology made these updates, seven more specialties have standardized their interview date and 20 have added signaling to the application. „People are hungry for better processes and see the improvements,“ said Hammoud.

Winkel at NYU is leading another grant-funded project to coach medical trainees. At NYU, first-year medical students receive individual coaching. They are now expanding their efforts to offer coaching to incoming residents after match day. After all the turmoil of match day, this is a way to ensure that trainees receive individual, holistic support during their first year of training. Since receiving the grant, other schools have been looking into the coaching structure, and Winkel has been invited to Grand Rounds, a special clinical training session, to present it.

„It’s not just about career counseling. It’s about helping these adults find the path to where they want to go,“ she said.

Realistically, no one will completely abolish the residency selection process. However, some are making real incremental changes to specialties and programs to alleviate students‘ fears.

Match week will likely always bring disappointment to some students, but match day emotions tend to even out, said Carmody. Surveys show that students who matched their top choice are happiest in March, but six months into their training, everyone is equally happy, he said.

„The person who is happy and successful in medicine will, in my opinion, be happy and successful with many different educational paths.“

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