The strange and stressful path to residency.

The path that any orthopaedic (or other) resident applicant travels--from completed Electronic Residency Application Service (ERAS) application, to program interview, to rank number, to selection by the residency match--is a complicated, expensive, stressful, and chancy trip. A paucity of signs, billboards, and consensus standards exist to clarify that path.

In their article "What Attributes are Necessary to be Selected for an Orthopaedic Surgery Residency Position: Perceptions of Faculty and Residents," (1) Bajaj and Carmichael add legitimate fuel for thought with their targeted and triaged questions to orthopaedic resident "wannabes" and selected teaching faculty. The nonstatistically compared responses are interesting, if not telling. Their findings emerge from a setting in which expense and applicant dollar value are significant. Total direct and indirect costs are approximately $150,000 per resident per year.

For any specialty, there are generic commonalities and unique differences related to the application process, the interview process, and the match itself. Roughly one third of the issues for the applicant and the program are clear-cut and objective. One third are subjective. One third have subjective and objective components. These issues include: (a) the size of the program sought and the type of individual sought; (b) what is being sought, ie, the "personality" of the program and of the individual; (c) the commitment to and enthusiasm for the process on the part of faculty, residents (and fellows if involved), as well as the applicant's perception of that commitment and enthusiasm; (d) medical school class rank; (e) United States Medical Licensing Examination (USMLE) scores; (f) externship aggregate performance; and (g) dean's letter, recommendation letters, and so forth.

It is possible for even the subjective factors to be roughly quantified, therefore enabling tangible comparisons for granting interviews, and so forth. Orthopaedic recommendation letters, for instance, are very subjective and their value dependent on the "eye of the beholder," as it were. Many are easy to interpret. Many are obtuse. Other credentials include scholarly efforts, the dean's letter, personal statements, legacy status, and extramedical activities. These carry less weight in generic resident "recruiting," but more weight when competition is keen and positions are at a premium--as in orthopaedics. Sex, race, and background have minimal to no part in decision making. Most would agree with this. The authors and I certainly do. The heightened importance early on of the quantification/interpretation of these criteria for interview establish bias toward a population that will affect rank order. Most orthopaedic residency programs are intensely selective and competitive, given the specialty's popularity. Most of these applicants are the "best and brightest." With this intense interview and match competition comes a parallel evolution of ceiling and/or floor criteria for many of these credentials.

This "ceiling or floor" concept targets absolute credentials that can usually be quantified. Certain credentials become hurtful if absent but unhelpful in excess. For instance, three completed scholarly efforts (peer-reviewed articles, posters, or poster exhibits) may be important minimum criteria, but nine scholarly efforts do not triple that importance. USLME part 1 and part 2 minimum scores of 220 may be thought necessary, but a score of 250, though laudable and having some meaning, does not add much to the applicant's credentials.

Furthermore, a biography that includes substantial mission work (more than lip service), true Eagle Scout status, documented multilingual abilities, important undergraduate leadership positions, elite athletic accomplishments, or meaningful athletic awards become important in orthopaedics as a "next-level credential." Also, when 60 programs are applied to by the applicant and 30 interviews granted, questions such as "Are there ties to the area?" become important. In that case, you have to wonder if the effort is just part of a "shotgun multiapplication."

Characterizing an applicant's work ethic remains a necessary, potent, real, and powerful judgment call during the process. This is particularly true in a specialty such as orthopaedics, which is severely affected by the recently accepted and implemented 80-hour limit to the resident's work week. These new rules notwithstanding, the intangible work ethic remains the hidden diamond sought in formal and informal queries to the applicant for orthopaedic residency. This quality, so important in actual practice after training in orthopaedics (or other specialty), is equally important during the residency. An important corollary to this judgment is whether an applicant is in possession of time-efficient work habits and an ability to multitask.

Other issues that roll into larger categories but have unique importance are an ability to be articulate on one's feet, family stability, peer opinion, and subculture abilities, that is, getting along and networking with the non-MD medical workforce. A tendency toward veneer interpretation rather than in-depth penetrating analysis is another important factor, but tough to judge and/or quantify with limited personal exposure. A medical student or "subintern" rotation, of course, provides more in-depth information.

The gaining of information by modes of communication and through programs that are not in the written guidelines and formal structure of the residency match system occur. There are numerous undocumented or unrecorded communication paths that Drs. Bajaj and Carmichael do not attempt to address (which is admittedly not their purpose). These include (1) oral communication including phone calls; (2) Email, faxes, and letter-written communication to faculty and others at the medical school of origin; (3) contacts, oral or written, at earlier applicant job sites or "back home" references; and (4) personal visits related to the above, often at meetings or when other reasons for contact arise.

Factors often considered by residency programs, and possibly the dominant issue, are the recruitment and input of current program residents. As with a college basketball program, smaller residency programs can go up and down in quality very quickly. The older residents need and want to recruit the best of the younger residents. These recruited young men and women will make their senior residents' lives easier. Externships and peer-age "vibes" then again become very important.

The residency match process is clearly evolving and is substantially more user-friendly for all parties now than a generation ago. But do the "best fits" as currently determined produce better physicians and better orthopaedists and in an optimum environment? I'm not sure. More objectivity is needed. Efforts toward this end are ongoing, but with variable consistency and mixed results. The residency process cannot approach the NFL draft model, where every performance factor is weighed and compared and where "poor fits" and "best fits" can be traded. But there is a similarity between these two systems in their mutual need for the most objective evaluations possible. The following are some of the possibilities for continued improvement of the resident selection process, although individual variation will still occur: (a) Rank and assign numbers to recommendation letters using (in general) the older faculty, who know the letter-writers and understand the verbiage. Use other similar formulas to better quantify and increase objectivity. (This is already done in many places.) (b) Assign quantitative numbers to extracurricular activity or a lack thereof. (c) Designate specialty-wide interview mechanics that (1) limit applicant expenses, (2) reduce applicant stress, (3) utilize video interview (or reinterview), live, taped, or electronic, and (d) continue Accreditation Council for Graduate Medical Education (ACGME) initiatives to monitor clinical and educational experiences that have to do with the phasing in of general and core competencies. This is helping to better define an objective difference between a successful and an unsuccessful applicant. This has to do with outcome and we need outcome studies.

In summary, there are several concepts that will continue to be dealt with as the system improves for both the applicant and the program. (a) I agree with the authors that "each program is unique." This is the one given that will not change in our current graduate training world. (b) Subjective, out-of-system evaluation by the many nonformal communication techniques will persist and will be perpetual. It is difficult enough to be objective within the system, but we must also inject more science into the informal part of the process that occurs outside of the system. (c) Analyzing the quality of the graduates in postresidency practice and developing a statistical relation to early selection processes remains a goal. Achieving that goal remains a quantum leap. (d) Overall ethical considerations as well as an understanding of the art and science of orthopaedics (or for that matter, any specialty or any physician-to-be) must continue to be our overriding concern in triaging and recruiting for the residency match.

Accepted June 15, 2004.

Please see "What Attributes are Necessary to Be Selected for an Orthopaedic Residency Position: Perceptions of Faculty and Residents" on page 1179 of this issue.

Reference

1. Bajaj G, Carmichael KD. What attributes are necessary to be selected for an orthopaedic surgery residency position: perceptions of faculty and residents. South Med J 2004; 97:1179-1185.

Angus McBryde, MD

From the Department of Orthopaedic Surgery, University of South Carolina School of Medicine, Columbia, SC.

Reprint requests to Dr. Angus McBryde, Two Medical Park, Suite 104, Columbia, SC 29203. E-mail: [e-mail]