Reliance on Exam Scores in Residency Applicant Selection Restricts Diversity in Otolaryngology

Does strict use of United States Medical Licensing Examination (USMLE) otolaryngology scores in residency applicant selection lead to a restriction in diversity?

BOTTOM LINE

Strict adherence to USMLE scores may lead to disproportionally low recruitment of applicants who are female, >30 years of age, underrepresented minorities, and from institutions without an otolaryngology residency program.

COMMENT: Despite its intended purpose, the Step 1 component has taken on an alternate role. Residency programs have increasingly used this score during the screening stage to reduce the number of applications undergoing more in-depth review. Beginning on January 26, 2022, examinees who take Step 1 will receive only a notification of Pass or Fail rather than the standard threedigit score. The otolaryngology community has expressed apprehension about the scoring change and the likely substitution of Step 2 as a screening metric. Many of the currently underrepresented groups in otolaryngology would continue to be at a disadvantage if overemphasis on Step 2 were to develop. This presents an opportunity to prepare for this change, including a reassessment of screening metrics, and hasten the transition to holistic review. —Sarah N. Bowe, MD

BACKGROUND: Many residency selection committees among competitive specialties use the USMLE Step 1 score to filter applicant pools vying for limited residency positions. This may effectively reduce diversity based on gender, age, and distribution of underrepresented minorities (URMs). Otolaryngology lags behind other medical specialties in URM and female representation.

STUDY DESIGN: Cross-sectional study.

SETTING: Department of Otolaryngology–Head and Neck Surgery, University of California, Davis, Sacramento, Calif.

SYNOPSIS: Researchers analyzed 381 2019-2020 otolaryngology residency applicants to a single institution. Among applicants, 37% were women; 9% were >30 years of age; 12% were URMs; 71% to 81% had above-average socioeconomic surrogate markers; 22% were from a top-ranked institution; 81% were from an institution with an otolaryngology residency program; and 92% were U.S. allopathic medical school graduates. Most self-identified as Caucasian (50.5%), followed by Asian (29.6%), Hispanic/Latino (6.3%), African American/ Black (5.8%), and Native Hawaiian/ Pacific Islander (0.5%). Authors note the disparity between the U.S. population percentages of URMs and medical school graduates identified as such. The proportion of female otolaryngology applicants was low despite the increased numbers of women matriculating into medical school. Older and URM applicants had lower USMLE Step 1 and 2 scores than their counterparts; women’s Step 1 scores were slightly lower than men’s. However, noting the lack of an established link between USMLE Step 1 score and resident performance, authors suggest that as Step 1 moves to pass/fail, otolaryngology residency selection committees take preventative measures to avert an unwarranted overemphasis of Step 2 scores. Study limitations included reliance on self-reported variables among subjects.