VOLUME 36, ISSUE 1
B. Scott Christensen, M.D.
CA-2 Resident
Baylor Scott & White
Temple, TX
AnnaRose Dement, M.D.
CA-2 Resident
Baylor Scott & White
Temple, TX
Craig J. Lilie, M.D.
TSA Newsletter Academics Editor
Assistant Professor of Anesthesiology
Baylor College of Medicine-Temple
Residency Program Director
Baylor Scott & White-Temple
Temple, TX
Russell K. McAllister, M.D., FASA
TSA Newsletter Editor in Chief
Professor and Chair of Anesthesiology
Baylor College of Medicine-Temple
Chair-Baylor Scott & White Health-Central Texas
Temple, TX
Anesthesiology Residency Match – An Update on the Impact of Changes in the Application Process
The Match Background
In 1952, the first residency match was run by the National Interassociation Committee (now the National Residency Matching Program, or NRMP).1 Prior to the match, obtaining a residency program position lacked uniformity. Medical students would receive offers as early as the beginning of their third year of medical school and would face a tough choice of accepting an offer without having fully explored their options. Similarly, residency programs had to extend offers with little knowledge of the academic performance of medical students or run the risk of not filling their positions. The match was meant to be a solution to this problem and what started as a central clearing house of applications has evolved into the matching process used today. The application process is now managed through the Electronic Residency Application System (ERAS) which has created a universal application process through which applicants can apply to any or all programs through a single application with a fee structure that escalates as the number of programs applied to increases. The ERAS and NRMP have been designed to address past problems with the residency application system and to optimize results for both applicants and programs.1
Current Anesthesiology Application Climate
Anesthesiology has become more competitive with an increasing pool of applicants applying for a comparatively small number of spots. For example, in 2023 there were 2959 applicants for only 1609 positions. In 2023, 11.9% of allopathic (M.D.) and 29.3% of osteopathic (DO) candidates who applied to anesthesia went unmatched,2 mirroring trends also seen in other specialties as the number of American medical school graduates rises at a rate much faster than the number of residency positions available. Due to the specialty’s increasingly competitive nature, medical students have been applying to more programs to optimize their chances of matching. In 2019, applicants applied to an average of 38 anesthesiology programs. In 2023, that number has increased to 67. This rise in the number of applications per applicant has created problems for both applicants and residency programs. As an applicant, the financial burdens of applying to 60+ programs are considerable. Within the current financial structure of ERAS (costs per application increase significantly above a baseline threshold number of applications), it costs over $1400 in application fees to achieve the 60+ application number. This is an additional financial burden for the average medical student who has already accumulated significant educational debt. For residency programs, the average number of applications received has steadily increased from 985 in 2019 to 1,486 in 2023.2 It can be difficult for programs to thoroughly review each of these applications for their limited positions available within the compressed timeline of interview season. The program’s ability to gauge an applicant’s true interest in their program was also difficult with the traditional process.
The Signal Process
In response, ERAS has adopted the use of “signals” sent by applicants to indicate incremental interest in the residency program.3,4 Each specialty’s academic leaders were given freedom to design their signaling system in a way that was felt to be best for their processes.4 In the 2022-2023 application cycle, anesthesiology candidates were given 5 signals to send to programs to indicate increased interest for those programs that were signaled. In the 2023-2024 cycle, that system was modified to allow candidates to send 5 “gold” signals and 10 “silver” signals.4 As these changes were implemented, some degree of uncertainty and unpredictability for both applicants and programs followed. With these changes, it is important to examine how this system is being utilized by residency programs and medical students and what applicant strategies optimize their chances of matching into our specialty.
Observations
Based on a 2022-2023 anesthesia program director survey, 92% said signals were used as a screening tool prior to a more thorough review.5 Additionally, 95% said they used signals to determine who to interview and 85% said they used the signal tool as a tie breaker when deciding who to interview.5 However, only 39% said it was “important” or “very important” when creating their final rank order list. Furthermore, 66% of PDs surveyed assumed that lack of signal meant an applicant was less interested in their program.5 At the Baylor Scott and White Anesthesiology Residency in Temple, our application process aligns with this reported data. Signals are used to help filter the vast number of applications and find those applicants who have expressed additional interest in our program through the signaling process. Those applications are then more closely vetted, and an interview is extended after a holistic review of the application. With the modification in program signals this year, we expect to interview more people who have provided a gold signal, signifying a great interest in our program. Yet, excellent candidates who have provided a silver signal are still being selected for interviews. Once a candidate has been interviewed, we expect that program signal of gold versus silver (or no signal at all) will have insignificant impact on the final rank list creation.
Applicant Considerations
Given the competitiveness of anesthesiology residencies nationwide, many programs receive multiples more program signals than interview positions they plan to offer. It is less likely that candidates will receive an interview invitation if the program does not receive a signal. This is demonstrated by the data above and by applicant survey data within orthopedic surgery, which utilizes 30 signals.6 Last year, their applicants had a 3.8% chance of receiving an interview invitation to a non-signaled program, calling into question the utility of applying to many programs at significant financial cost.6 From the orthopedic surgery applicant perspective, 57% found the signaling system to be helpful in the residency matching process while 16% found it to be unhelpful.6 The effect of gold versus silver signal delineation in anesthesiology remains to be seen, though it seems likely that programs will be motivated to interview those who demonstrate more interest in their program. The viewpoints of applicants and programs may vary. For example, an applicant may view themselves as a good fit for a certain program and may falsely assume that they will get an interview at that program without utilizing one of their signals. However, the program may view that candidate and feel they are a suitable candidate for the program but judge the absence of a signal as a lack of interest in the program (a fair assessment by the program since each applicant gets a total of 15 signals). Therefore, they may choose to give the interview spot to a candidate that has expressed interest through signaling. The question of whether to send a gold or silver signal to an applicant’s home institution or away rotation should be discussed with the program director for that program. Due to the high stakes of the process and the complexities that will be encountered, medical students should utilize an experienced advisor or mentor to help them navigate the decisions of which programs should receive their signals to maximize the potential of each signal.
Conclusion
The changes in the preference signaling system seek to correct some of the deficiencies in the previous application systems, especially considering the abundance of applications sent and received by candidates and programs, respectively. Ideally, the signals help streamline the match process for candidates and programs and ensure each application receives its due evaluation. This system has the potential to reduce the stress and financial burden on medical students and allow programs to dedicate their attention to those applicants most interested in their program. As time passes and the application process changes, candidates and programs should carefully study the data from prior years to ensure both make their best effort toward a successful and meaningful match.
References:
- Roth AE. The Origins, History, and Design of the Resident Match. JAMA. 2003;289(7):909–912. doi:10.1001/jama.289.7.909
- https://www.aamc.org/data-reports/data/eras-statistics-data (last accessed 12/28/23)
- American Medical Association & American Medical Association. (2022, August 17). How to effectively use program signaling as a residency applicant. American Medical Association. https://www.ama-assn.org/medical-students/preparing-residency/how-effectively-use-program-signaling-residency-applicant (last accessed 12/28/23)
- The MyERAS® application and program Signaling for 2023-24 | Students & Residents. (n.d.). Students & Residents. https://students-residents.aamc.org/applying-residencies-eras/myeras-application-and-program-signaling-2023-24 (last accessed 12/28/23)
- Martin B. (2023, August 13). How to Match into Anesthesiology for Residency. Elite Medical Prep. https://elitemedicalprep.com/applying-into-anesthesia-acceptance-factors/ (last accessed 12/28/23
- Deckey DG, Lin E, Gerhart CRB, Brinkman JC, Patel KA, Bingham JS. Decoding the Signals: An Analysis of Preference Signaling in the 2023 Orthopaedic Surgery Residency Match. JBJS Open Access. 2023 Sep 1;8(3): e23.00052. doi: 10.2106/JBJS.OA.23.00052.
Additional reading:
National Resident Matching Program, Results and Data: 2023 Main Residency Match®. National Resident Matching Program, Washington, DC. 2023.
