Update on the Selection Criteria of Plastic... : Annals of Plastic Surgery (original) (raw)

Background

Plastic and reconstructive surgery (PRS) is recognized as a highly competitive specialty. Since the first assessment of resident selection criteria in 2007, PRS residency programs have adopted holistic review processes and adapted to changes such as a decline in medical schools participating in the Alpha Omega Alpha Honor Medical Society as well as the recent transition to pass/fail grading for the United States Medical Licensing Examination (USMLE) step 1 examination (Schultz et al. Plast Reconstr Surg Glob Open. 2020;8:e2892; Tadisina et al. Plast Reconstr Surg. 2017;139:330e–331e). This study was devised to evaluate current PRS residency criteria in light of these changes.

Methods

An anonymous, 12-item, electronic survey was generated and distributed using Alchemer. An email was sent to 171 program directors (PDs) and associate program directors (APDs) of PRS residency programs. Survey questions were developed to collect data regarding respondent demographics and their desired criteria when assessing residency applicants. Complete responses were collected and analyzed with summary statistics and multivariate logistic regression using RStudio (version 1.3.109).

Results

In total, 44 (25.7% response rate) of the 171 PDs and APDs completed the survey. Of the 16 programs (36.4%) with a USMLE cutoff score, 7 (43.8%) reported a range of 230 to 239 and 6 (37.5%) reported a range of 240 to 249. Without a score for step 1, the majority (48.8%) of respondents believe that step 2 scores will replace step 1 scores in terms of assessment criteria, and the content of recommendation letters was selected as the criterion with the greatest increase in weight (66.7%). In addition, 27.3% of programs require a step 2 score at the time of interview. The top 3 academic criteria in order of decreasing importance were the content of recommendation letters, clinical grades, and letter writers, whereas the top 3 nonacademic criteria were subinternship performance, maturity, and interview performance.

Conclusions

Plastic and reconstructive surgery remains a highly competitive specialty for residency applicants. Our findings suggest that Alpha Omega Alpha membership remains diminished in importance, whereas USMLE cutoff scores have increased. With recent changes in the step 1 grading system, PDs and APDs will rely more heavily on step 2 scores and the content of recommendation letters.

Plastic and reconstructive surgery (PRS) is widely recognized as a highly competitive specialty. There are currently 2 PRS residency training models available in the United States—the integrated and independent pathways. Both pathways are highly competitive processes, and significant literature has been devoted to the efficacy of each training approach. Recent trends from National Resident Matching Program data demonstrate an increasing number of integrated program applicants and decreasing match rate of doctor of medicine seniors over each of the last 5 years. The limited availability of residency spots, increasing cost of applying, and the evolving landscape of medical education necessitate ongoing research to gain insight into current selection criteria, which may help applicants prepare effectively for the match and provide administrators with relevant information to refine their selection processes.

An early evaluation of PRS resident selection criteria through a survey of integrated pathway program directors (PDs) was conducted in 2007. This study highlighted the various components of the review process that contribute to PRS' status as a highly competitive specialty. Academic criteria that ranked highly in importance included the content and writers of an applicant's recommendation letters, an applicant's membership in Alpha Omega Alpha (AOA), an applicant's United States Medical Licensing Examination (USMLE) step 1 score, and an applicant's grades on clinical rotations. The top nonacademic criteria were subinternship performance and interview performance, as well as perceived personality, maturity, and leadership potential. Similar findings were demonstrated by other studies assessing successful applicant qualities.

Over the last decade, PRS residency programs have adopted more holistic review processes to ensure a diverse pipeline of trainees and to make the specialty more accessible to those who have traditionally been underrepresented. Increasing diversity and inclusion within PRS is essential for providing health care that is more accommodating to minority patients, increasing research focusing on minority health concerns, and promoting additional mentorship. Various studies have assessed trends on diversity status within PRS and have highlighted the need for continued efforts to increase the recruitment of trainees from diverse backgrounds. These priorities are reflected in the declining emphasis on previously important selection criteria, such as AOA membership. In addition, the transition to a pass/fail grading system for the USMLE step 1 examination has prompted a reevaluation of the criteria used to assess applicants. This study was devised to determine the impact of these holistic changes in selection criteria on how applications are considered by PDs and associate program directors (APDs).

METHODS

An anonymous, 12-item, electronic survey was generated and distributed using Alchemer (Alchemer, Louisville, CO). Emails were sent to 171 PDs and APDs of PRS residency programs. Program directors and APDs of integrated and independent PRS residency programs were identified using the Fellowship and Residency Electronic Interactive Database and individual residency program websites. This study was assessed by the institutional review board at University of California, Irvine, and deemed exempt from institutional review board approval.

The initial email with a survey link was sent in October 2022. Participation was voluntary, and the survey was actively accepting responses for 2 months, with email reminders sent every 2 weeks. Survey questions were developed to collect data regarding respondent demographics and their desired criteria when assessing residency applicants. The survey consisted of multiple-choice and ranking questions, as presented in Figure 1. Complete responses were collected and analyzed. Responses were compared quantitatively and qualitatively using Alchemer and further analyzed with summary statistics and multivariate logistic regression using RStudio (version 1.3.109).

RESULTS

Response Rate and Demographics

Of the 171 PDs and APDs, 44 completed the survey, yielding a 25.7% response rate. Thirty-four (77.3%) of the respondents were affiliated with programs from urban areas, 6 (13.6%) were from suburban areas, and 4 (9.1%) were from rural areas. Among respondents, there was a relatively equal distribution for the number of years served as PRS faculty; namely, 7 respondents (15.9%) indicated serving a total of less than 5 years, 10 (22.7%) indicated serving 5 to 8 years, 11 (25%) indicated serving 10 to 14 years, 6 (13.6%) indicated serving 15 to 19 years, and 10 (22.7%) indicated serving 20+ years. Thirty (68.2%) of the respondents were PDs, whereas 14 (31.8%) were APDs. Most respondents (n = 27 [61.4%]) served in their respective roles for less than 5 years, followed by 11 respondents (25%) who served 5 to 9 years. Twenty-six (59.1%) of the respondents were directors of an integrated program, 5 (11.4%) were directors of an independent program, and 13 (29.5%) were directors of both an integrated and independent program at their affiliated institutions.

Selection Criteria

Sixteen of the 44 respondents (36.4%) specified using a minimum acceptable USMLE cutoff score when selecting applicants to interview. Seven (43.8%) reported a range of 230 to 239, and 6 (37.5%) reported a range of 240 to 249.

Most respondents (48.8%) expressed that they thought step 2 scores would supplant step 1 as an assessment criterion in light of the latter's change to a pass/fail examination, as demonstrated in Table 1. In addition, respondents were given the option to state their opinion as a free response. One responder indicated their perspective that independent programs are more likely to consider in-service training examination performance over USMLE scores. Another respondent mentioned that step 1 transitioning to a pass/fail grading system will likely pose a barrier for competitive applicants from smaller schools, suggesting an increased role for medical school reputation, as the respondent speculates that step 1 is a more sensitive measure of academic performance than step 2.

TABLE 1

Opinion on How USMLE Step 1 Transitioning to a Pass-or-Fail Grading System (as of the 2022–2023 Cycle) Changes Its Importance in Assessing Potential Residency Candidates

Respondents were also asked to choose three criteria that now hold greater weight in their selection process owing to the transition of step 1 to a pass/fail grading system. The content of recommendation letters was the criteria selected by most respondents (66.7%), as depicted in Table 2. In addition, 12 respondents (27.3%) mentioned that they require a step 2 score at the time of interview.

TABLE 2

Criteria Which Now (Without a Score for Step 1) Have Increased Weight in the Respondent's Decision Making Process

Participants also ranked both academic and nonacademic criteria in order of importance. The top 3 academic criteria in order of decreasing importance were the content of recommendation letters, clinical grades, and letter writers, whereas the top 3 nonacademic criteria were subinternship performance, perceived maturity, and interview performance. Academic and nonacademic criteria rankings are displayed in Table 3. Statistical analysis comparing how respondents from different program types rank selection criteria determined that those of integrated programs were more likely to claim maturity as an important criterion for resident selection (odds ratio, 1.20; 95% confidence interval [1.2–1.7]; P = 0.046). Maturity was not a significant factor under consideration by independent programs (P = 0.39). In addition, no significant difference was found between the opinions of PDs and APDs.

TABLE 3

Academic and Nonacademic Criteria Rank Scores

DISCUSSION

The residency match process uses a meticulously designed algorithm that seeks to pair residency programs and medical students according to their preferences. Selecting PRS residents is a highly competitive process that demands continuous assessment pertaining to the evolving nature of medical education. Both integrated and independent pathways are highly selective and differ marginally in assessment criteria. Step 1 scores, which were factored significantly by integrated programs before its transition to pass/fail grading, are not considered as heavily by independent programs. Instead, high-quality letters of recommendation are considered as the most impactful criterion for evaluating independent pathway applicants. These findings are supported by this survey, the results of which report that the content of recommendation letters was ranked as the most important academic criterion, as well as the top criterion that now holds the greatest weight in their decision-making process because of the step 1 grading transition. In addition, 1 respondent stated that independent programs are more likely to consider in-service examination performance over USMLE scores, further supporting the aforementioned study. Furthermore, our results show that independent programs are less likely to claim maturity as an important criterion, possibly because of the notion that applicants have already had some surgical training and professional development.

According to data from 2022 released by the National Resident Matching Program, those who matched into integrated programs had a higher number of contiguous ranks, research experiences, USMLE scores, AOA membership and were more likely to have attended a medical school among the top 40 receiving the highest National Institutes of Health funding. Our survey results demonstrate similar criteria to be of importance when assessing applicants. Although AOA membership continues to be reflected among those who match into a PRS residency, its significance continues to decline as medical schools choose to no longer participate in selecting students, aiming to promote equity and wellness. This decision has also been scrutinized and deemed detrimental to the process of selecting residents, as it removes an objective assessment criterion.

Another recent study evaluating the impact of resident selection in light of the change in the step 1 grading system reported that PDs are more likely to primarily use subjective metrics, along with the score for step 2 as the only remaining objective metric. Subjective metrics include applicant familiarity, subinternship performance, and interview performance. Other current studies assessing qualities that make a successful PRS resident reported the importance of research fellowships, which allow applicants to effectively prepare for the match by enhancing publication and presentation experience. This finding was also supported by the present study, in which 14 respondents reported an increased importance of research experience as a criterion in their selection process, given the step 1 grading transition. Although PRS consistently ranks as the most competitive specialty, data regarding other surgical specialties such as otolaryngology and orthopedic surgery also demonstrate similar selection criteria and a challenging match process.

This study highlights the current state of applying to a PRS residency with respect to changes in selection criteria. Although step 1 is no longer scored, and applications are reviewed through a more holistic approach, PRS is likely to remain highly competitive and costly. One study surveying the perception of students on the step 1 grading transition determined that students interested in highly competitive specialties are more likely to oppose the policy, as they believe that it limits individual competitiveness. The recent introduction of the Plastic Surgery Common Application, which allows applicants to apply without needing to pay a fee, has addressed some concerns of the cost of applying. However, a more holistic review process entails greater costs for attending more subinternships to increase familiarity with programs, accelerated timelines for taking step 2, and time taken off for research. This financial burden may potentially limit access into PRS for students who are unable to bear the costs of applying. In addition, virtual interviews introduced during the pandemic may have resulted in a greater number of interview spots and a decreased cost of travel for interviews. Therefore, their potential for addressing barriers to PRS should be considered for upcoming interview cycles.

A limitation to this study lies in the combined analysis of integrated and independent programs when asked about USMLE scores and how they are evaluated. Independent programs are generally less likely to factor USMLE scores and rather focus on in-service training examinations. Their combined analysis may have artificially decreased the importance of USMLE scores, as respondents affiliated with independent programs would likely have indicated not requiring a USMLE cutoff score. In addition, it is possible that some respondents were affiliated with the same institution and therefore valued similar selection criteria.

CONCLUSIONS

In conclusion, PRS remains a highly competitive specialty for residency applicants. Our findings suggest that AOA membership remains diminished in importance, whereas USMLE cutoff scores have increased. With recent changes in the step 1 grading system, PDs and APDs will rely more heavily on step 2 scores and the content of recommendation letters. Future studies should focus on the assessment of major subjective criteria, such as the criteria used to assess research experience, including the number of publications, types of research, and length of experience.

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Keywords :

plastic surgery; residency; selection criteria; match; program director; survey

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