A Solution Worth Trying: Providing Program Preference in Residency Applications.

I n this issue of the Journal of Graduate Medical Education, Whipple and colleagues examine a theoretical model for a possible modification to the current residency application process: allowing medical students to provide their program preferences early in the application process. They argue that the prevailing system results in an abundance of applications, which prevents programs from comprehensively reviewing all candidates. The authors suggest that their modification could provide an additional criterion to screen and reduce the pool of interested applicants. Whipple and colleagues provide preliminary theoretical evidence that their intervention may conserve resources with little impact on the highestperforming students while potentially benefiting programs and all other students. From the perspective of a program director in a competitive specialty (L.M.Y.), this article’s conceptual framework hits home. Our emergency medicine residency program received applications from more than 1300 students this year for 11 positions, and we were able to interview approximately 10% of applicants. The assumptions made by the authors based on their experience in otolaryngology (detailed in the article’s online supplemental material) approximate my experience: a program can holistically review a maximum of 40 applications per residency slot, can interview a maximum of 10 applicants per residency slot, and a student can interview at a maximum of 20 residency programs during the interview season. In the article’s discussion section the authors describe their model’s prediction of ‘‘a counterintuitive situation where a competitive specialty could have both unmatched and unfilled programs. ’’ While this situation may be counterintuitive, in my experience, it represents the current reality. The most desirable programs are likely to have a common pool of top applicants. Because the metrics best suited to screening, such as United States Medical Licensing Examination (USMLE) scores, medical school status, and student ranking, are not subject to program interpretation, we find ourselves with a common pool of applicants invited to interview as well. However, as the season progresses, the combination of interview trail fatigue and positive feedback regarding their competitiveness can result in applicants withdrawing from interview appointments at programs lower on their preference list. This practice can be good for students and good for the program, as long as they match and the program fills. However, as a program director, I have had last-minute interview day openings (or even ‘‘no shows’’) that I have been unable to fill, and as an advisor, I have seen students with strong, but not top, applications struggle to secure interviews and even go unmatched. Thus, this article is timely and the conversations it will spark are necessary. It is in the best interest of trainees and programs to modify a system that currently encourages indiscriminate, if inadvertent, saturation of programs’ abilities to holistically review applications and determine interview day selections. The current system does not provide each applicant the same opportunity to match at a program that may be an excellent mutual fit. The authors begin their study by substantiating a previously peer-reviewed analysis as well as an analysis by the Association of American Medical Colleges. These studies found that when students apply to many programs, they receive a slightly higher number of interview invitations; thus, the practice of applying to as many programs as possible is advantageous, yet only marginally. Whipple and colleagues then examine—using theoretical models and simulation—the effect of their suggested intervention (offering students the option to reveal program preferences) on the number of subsequent interviews offered. While the authors should be commended for their candid discussion of the limitations of this analysis, there are significant issues with the generalizability and validity of their approach. It is important to restate the authors’ acknowledgement that their analysis is based on assumptions and simplifications, as is required in simulation analyses. This simplification is multifaceted: it analyzes only one method for implementing statements of preference, relies on a potentially inaccurate random DOI: http://dx.doi. org/10.4300/JGME-D-18-01092.1