Residency Application and Selection Is Complex Adaptive System That Requires a Multipronged Strategy

CLINICAL QUESTION

What is the “shadow economy of effort” in undergraduate medical education, how does the complex adaptive system (CAS) of residence application and selection affect the system’s outcomes, and what can be done to address the system’s inherent challenges?

BOTTOM LINE

The medical residence application and selection system must be optimized for cooperative outcomes and design incentives to ensure that the outputs of medical schools align with student, institutional, patient, and societal goals.

BACKGROUND: The shift to pass/fail grading in undergraduate medical education has yielded a “shadow economy of effort,” wherein students move away from traditional learning and toward activities to enhance their residency applications. Residency application and selection have become a CAS, which self-organizes without centralized control, resulting in unpredictable outcomes.

STUDY DESIGN: Commentary

SETTING: Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio

SYNOPSIS: Authors discuss the repercussions of the current pass/fail era in undergraduate medical education. Although the shift to pass/fail is intended to reduce student stress, foster collaboration, enhance mental well-being, and provide more holistic, personalized learning, it has also incentivized students to escalate their efforts to stand out as residency applicants via non-clinical activities in the form of research, volunteer, and advocacy experiences. Authors dub this a “shadow economy of effort,” in which medical schools, which do not require all these extracurricular efforts, do not have an accurate accounting of what students are doing. The overall result is the devaluing of clinical excellence and burned-out students, potentially producing superficial or even inauthentic academic and community work. Authors frame the current state of residency application and selection as a CAS, wherein environments are characterized by volatility, randomness, and uncertainty. A CAS, they emphasize, relies on feedback loops to self-regulate and adapt. They suggest steps to facilitate continuous feedback and adjustment, incentivize desired activities and outcomes, address information flow and aggregation within the system, and continuously monitor and evaluate the system.

CITATION: Warm E, et al. The shadow economy of effort: unintended consequences of pass/fail grading on medical students’ clinical education and patient care skills. Acad Med. 2025. doi:10.1097/ACM.0000000000005973.