Match Day can be a tense time for medical students waiting to know where they’ll spend the next two years of their lives. But over the last few years, the match has caused anxiety for otolaryngology as well, as the number of applicants versus the number of residency slots has swung pendulum-style between having too many applicants to having too few.
After a peak in 2014, the number of applicants to otolaryngology remained fairly stable until 2016, when it dropped precipitously, according to the National Resident Matching Program. Even so, only two residency spots that year went unfilled prior to the Supplemental Offer and Acceptance Program (SOAP). In 2017, the number of ranked U.S. seniors who applied to the specialty (303) fell below the actual number of available positions (305), and 14 spots went unfilled after the initial match. In the 2018 match, the numbers weren’t much better: The number of ranked U.S. seniors (284) again fell below the actual number of available positions (315).
This changed in 2019 when a total of 398 U.S. seniors applied for 328 otolaryngology positions. Indications from the 2020 match show that the pendulum has swung up again, with the number of applications per applicant climbing steeply. Otolaryngology applicants put in an average of 72 applications each, according to David Chang, MD, residency program director for the department of otolaryngology–head and neck surgery at the University of Missouri in Columbia, who has examined the otolaryngology match numbers in depth over the last five years.
“For a couple of years, we came dangerously close to the number of applicants being near to the number of slots,” said Michael G. Stewart, MD, professor and chairman of otolaryngology–head and neck surgery at Weill Cornell Medical College/NewYork–Presbyterian Hospital. “But the numbers have gone back up, and by a lot. For our four slots, two years ago my program received 275 applications. This year we received 405.”
Many believe the reason behind this year’s influx is perceived competition to garner enough interviews to ensure a match. “Match 2020 is very competitive. We received 454 applications this season for four positions,” said Cristina Cabrera-Muffly, MD, associate residency program director and associate professor of otolaryngology at the University of Colorado in Aurora. “If a student is going to spend money on medical school, then spending a bit more to apply to more programs during the match really isn’t a disincentive.”
Mona M. Abaza, MD, MS, professor of otolaryngology at the University of Colorado in Aurora, said she believes an additional factor in the higher application numbers is the completion of the single accreditation process with the Accreditation Council for Graduate Medical Education (ACGME). “Last year was the first year that all of the osteopathic residency programs in the country, in every specialty, were accredited under the ACGME and in a single match rather than in their own separate match,” she explained. “There are some osteopathic programs that have been rolled into the otolaryngology total, but I’m certain that the single match has increased the numbers of applicants.”
Although there have been up-and-down swings, the underlying interest in otolaryngology has always been there. —Michael G. Stewart, MD
The challenge this can create for residency programs, however, is a difficulty in finding applicants who actually want to be at their program. “From this side of the desk, it’s difficult to know who’s really interested,” added Dr. Cabrera-Muffly. “Unless someone has clearly given a reason they want to be here, I don’t know which applicants are truly interested in our program.”
Cause and Effect
To understand why numbers are rising, it’s important to examine the factors that caused them to dip in the first place. But there are differing opinions on these factors, and how—or whether—they affected the match process at all.
Caution in recommending otolaryngology. For many years, otolaryngology was considered difficult to match in, Dr. Abaza said. She added that this has been a factor in anxiety among medical school applicants to the match, fueling the high number of applications per applicant. Even those who shouldn’t worry about matching, she said, are concerned.
“I’ve heard from students interested in otolaryngology who were counseled by their advisors outside otolaryngology that the specialty was so competitive that if they didn’t take a year for research, have a PhD, or have a certain board score, they couldn’t match,” added Dr. Stewart. “I do think we as a specialty bear some co-blame in sending a message to our own applicants that it’s pretty hard to get into otolaryngology, but in the last two years, we’ve been more proactive about reaching out and letting them know what a wonderful specialty it is.”
Dr. Chang noted that many students who did not match previously have been entering the match again. “Many have decided to do a year of research before reapplying, to make themselves more competitive.”
Taking steps to enhance a CV, like adding a year of research, may not help in a competitive match year, however. “We have a person currently doing a research year to make her application better,” said Dr. Cabrera-Muffly. “She’s a fabulous applicant, but I told her I can’t guarantee that she’s going to get a spot. This year, even the best applicants may slip through the cracks. There are so many variables, including how well they interview and whether they applied to the right programs.”
Personal statement paragraph. In 2016, the program-specific personal statement paragraph became a mandatory requirement for each otolaryngology application, and many feared that it would be an obstacle. By the 2018 match, the paragraph was no longer considered mandatory.
While Dr. Chang doesn’t believe the paragraph diminished the number of applications per applicant, it may have partially factored in the dip in applicants. “The number of the applications per applicant when the paragraph was introduced was 61; in 2017 it was 58. In 2018, when the paragraph stopped being mandatory, the number was 60. That’s fairly steady, but since then it has risen. I think the real issue was that, for most programs, the paragraph provided little insight, and there was little in-depth information available for applicants to really differentiate the programs.”
Otolaryngology Resident Talent Assessment (ORTA). Completion of the ORTA, a phone-based pre-interview survey to assess personality traits, was required before the match when it was first introduced. Last year, students were invited to take the ORTA after matching.
“I think deciding to do the ORTA after the match, along with making the program-specific paragraph optional, really changed the number of applicants over the last two years,” said Dr. Cabrera-Muffly. “Last year was quite competitive, and this year is even more so.”
Dr. Abaza believes the problem was one of timing. “I think part of the struggle was when the ORTA was placed on the application—just weeks before they were due,” she said. “I think that made it a huge burden, particularly in the first couple of years.”
However, Dr. Stewart doesn’t believe that the ORTA by itself caused a dip in otolaryngology applications. “I don’t think that students who prepared for a specialty their entire medical school career found out they were expected to do a 45-minute phone interview and said, ‘Forget it—I’m doing something else.’ I do think ORTA can be a helpful tool in deciding who’s the best fit for our specialty. Personality assessments are a hiring standard in many industries, and the ORTA hopefully can give programs information about how applicants’ personality characteristics correlate with successful otolaryngologists.”
Predicting the Future
Predicting and preparing for the next swing in the otolaryngology match is a difficult exercise at best, said Dr. Chang. “It’s kind of like predicting the stock market, then tweaking one thing after another to try to see what really makes a difference.”
“If I had to guess, I think there will be some really low and some really high application spikes over the next five to 10 years as students talk to each other and to the next class down,” said Dr. Cabrera-Muffly. “When we tried to stabilize match numbers, it didn’t work very well, and there were some unintended, unpredictable consequences.”
One thing that could make the process easier for residency programs is the addition of more subjective measures on which to base a decision.
“We do look for excellent letters of recommendation, but I’ve seen only a handful of letters in my eight years of reviewing applications that were negative,” said Dr. Cabrera-Muffly. “Many medical schools are going to a pass/fail curriculum, and sometimes transcripts are difficult to parse out because they aren’t labeled ‘A, B, C, D, F’—they’re labeled ‘excellent’ or ‘outstanding.’”
Dr. Chang noted that while the United States Medical Licensing Examination (USMLE) score can provide an objective measure, giving it too much significance can be detrimental. “The USMLE score is one of the hard numbers you can get out of an application that’s easily comparable across the spectrum,” he explained. “But if every program uses it as their main ranking measure, they may end up chasing after the same group of applicants.”
One possibility is a system that encourages applicants to signal their actual preferences for programs. “I’ve read about a ‘star’ system where applicants have, say, 10 stars to allocate to their top program choices,” said Dr. Cabrera-Muffly. “I think that would make a difference for smaller programs. If you have someone who clearly wants to be at your program, that motivation translates into being a good resident.”
“I’ve heard several ideas discussed, including a tiered application process where residents can apply to a given number of programs initially; the programs respond to the first tier, and then, if applicants get all the interviews in their first tier, they don’t apply to a second set,” added Dr. Abaza. “It allows programs to know applicants’ first choices, and it may help curb getting applications from students who are padding their numbers but aren’t likely to choose the program.”
While cause-and-effect opinions on the match differ, one thing that most agree on is the need to be more transparent. “I think we need to find ways to let applicants be honest about their wants and needs—not just in otolaryngology but in all competitive specialties,” said Dr. Abaza. “And we have to be honest, with the applicants and with ourselves, about who will be successful rather than who we think we should take because of the prestige of their background.”
The ultimate goal of the match is for applicants to find a residency that fits their needs, and for residencies to find applicants that best match their goals and objectives, said Dr. Chang. “But much like a first date, you don’t always know each other’s hidden objectives because everyone’s trying to put a good face forward. In the end, I don’t think anyone will ever be completely transparent because everyone has an overwhelming interest in simply matching.”
“I think that, although there have been up-and-down swings, the underlying interest in otolaryngology has always been there,” added Dr. Stewart. “We’re now doing a better job of directing that interest, and that’s a very positive thing for our specialty overall.”
Amy E. Hamaker is a medical writer based in Canyon Country, Calif.