Keywords
plastic surgery - residency match - diversity
Introduction
In the United States, plastic surgery (PS) is highly competitive, with a total of
419 applicants and 194 positions in 2022.[1]
[2] Furthermore, the number of total positions only increased by four between 2021 and
2022, growing the discrepancy between the number of applicants and positions.[3] Competition will likely continue to grow, impacting both students pursuing PS and
program directors evaluating applicants.
Due to the growing number of applicants who fail to match into PS, there has been
increased interest in identifying factors that influence success as well as barriers
that may disadvantage applicants.[4]
[5] Past research shows that several factors such as test scores, research productivity,
letters of recommendation (LOR), and performance on away rotations are highly important
when evaluating candidates as well as if a candidate has previously failed to match.[6]
[7]
[8] A recent study also found that graduates from allopathic medical schools without
an affiliated integrated residency program comprised 24.4% of successfully matched
applicants, while those with affiliated programs comprised 72.2%. Additionally, at
the top quartile residency programs, applicants without a home residency program (HRP)
comprised only 17.4% of residents.[9]
[10]
A study aimed at measuring the concerns of students without an HRP found that almost
half consider themselves to be underrepresented and that their initial exposure to
PS came through shadowing. Only 10% reported being exposed to PS through their school's
curriculum and more than half mentioned they did not have any professional exposure
to PS. Most students reported an inability to identify a mentor, and all reported
difficulties securing subinternships. Importantly, more than half of students reported
being extremely concerned about matching.[11]
[12]
[13]
[14]
Additionally, with the implementation of a P/F United State Medical Licensing Examination
(USMLE) Step 1 score, students without an HRP might be at an even greater disadvantage
in the Match process.[15]
[16]
[17] The USMLE Step 1 test has been historically used as an objective measure to distinguish
students. With fewer objective measures moving forward, school names, professional
networking, and LOR will likely hold greater value.[18] Furthermore, programs might also have trouble evaluating applicants successfully,
which may be compounded by an increase in students applying to competitive surgical
specialties.[18] Ultimately, these changes could generate potential challenges, associated with an
emphasis on more subjective measures. Additionally, the coronavirus disease 2019 pandemic
led to restrictions on away rotations, and students without an HRP had fewer opportunities
to gain experience and mentorship.[19]
[20]
[21] While restrictions have eased, it is unclear whether opportunities for away rotations
will return to the prepandemic years.
There is paucity in the literature examining the direct impact of medical students
without an HRP. The goal of the present study is to investigate whether having an
HRP confers an advantage to applicants. Additionally, the authors hope to identify
challenges that applicants without HRPs face and propose solutions that aim to address
disparities in the Match.
Methods
Two separate surveys were designed for integrated PS applicants from the 2022 match
and residents who attended a medical school without an HRP. The surveys were distributed
via Qualtrics and were emailed three times over the course of 3 weeks to encourage
response. In the applicant survey, question 1 addressed their ethnicity. Questions
2 to 5 characterized their home institution, including the presence of plastic surgeons
and a PS division. Questions 9 and 10 characterized their match process, which included
whether they matched successfully to PS, the location of their residency on their
rank list, involvement in a subinternship, and the number of programs to which they
applied. Questions 11 to 20 addressed the applicant's perception of how their home
institution impacted variables such as exposure to and the decision to pursue PS,
research opportunities, mentorship, and resources used. When addressing resources
used, we defined cold calling/emailing as phone or email contact without a prior relationship.
Question 21 addressed the impact of COVID-19 on their application. The resident survey
matched the applicant survey; however, there were additional questions that addressed
any changes in their home institution since they graduated.
Applicant surveys were distributed via email to medical students who applied to our
institution's integrated PS residency program in 2022 who did not have HRPs. In addition,
we utilized a community-sourced Google document that contains a public list of matched
2022 applicants and included all additional medical students from schools with no
HRP.
Resident surveys were distributed via email to post-graduate year 1-5s (PGY1-5s).
In addition to the applicant cohort, which represents the incoming PGY-1s, our survey
participants cover the current 2022 to 2023 entire resident cohort (PGY1–6). We utilized
publicly available information on current residents without HRPs' addresses as well
as phone numbers. For residents without publicly available contact info, we sent direct
a message through available channels such as LinkedIn, Instagram, or Twitter.
We compiled a list of all integrated and independent PS programs through Accreditation
Council for Graduate Medical Education (ACGME) and cross-referenced this to all the
residents and medical students who received the survey. We excluded DO and internationally
trained medical students/residents as well as all PGY6 residents. DO and international
medical graduate (IMG) applicants were excluded as they do not have home institutions
domestically and traditionally match at different rates than graduates from U.S. MD
programs. PGY-6 residents were excluded out of concern for low response rate.
Statistical analysis was performed using Microsoft Excel. Categorical variables were
analyzed using chi-square analysis. Independent Student's t-test was utilized for analyzing the difference between means of continuous variables.
The threshold for statistical significance was set at p < 0.05. The study received Institutional Review Board (IRB) exemption from our institution's
review board.
Results
Of the 82 applicants and 100 residents surveyed, 74 (39%) responded (33 residents,
41 applicants), resulting in a response rate of 33% for residents and 50% for applicants.
Among applicants, 76% (n = 31) strongly agreed that they were at a disadvantage when matching in PS ([Fig. 1]). Sixty-one percent of residents (n = 20) strongly agree that they were at a disadvantage when matching in PS ([Fig. 1]). Collectively, roughly two-thirds of all respondents reported feeling disadvantaged
in the Match due to the lack of an HRP.
Fig. 1 Total responses from applicants and residents (PGY1–5s) to the following question:
“Do you feel that as a medical student without a home plastic surgery department that
you were at a significant disadvantage matching in a plastic surgery program?”
The two most utilized resources by applicants were outside attendings (84%) and senior
students at their institution (54%). Similarly, 85% of residents utilized outside
attendings, and 62% relied on senior students. The least utilized resource among applicants
was medical school advisors (19%, n = 7). Among residents, the least utilized resource was participation in professional
societies (22%, n = 7).
Among surveyed applicants without HRPs, the overall match rate was 76% in 2022. Of
these, 48% strongly felt required to take an additional year to pursue research opportunities
or additional clinical experiences, compared with 10% of unmatched students. We also
found that students who identified a mentor were more likely to match with 97% of
matched students identifying a PS mentor compared with 40% of unmatched participants
(p < 0.05; [Fig. 2A]). The most utilized strategies to identify mentors by matched students were conducting
research (29%) and cold calling/emailing (25%; [Fig. 2B]). Furthermore, there were differences in usage of the following resources by matched
versus unmatched students: senior students (74 vs. 10%, p < 0.05) and social media (52 vs. 10%, p < 0.05; [Fig. 2C]).
Fig. 2 (A) (Upper left) Percent of matched (97%) versus unmatched (40%) applicants showing
if they had obtained a plastic surgery mentor (p < 0.05). (B) (Bottom) Percent responses of resources used by matched applicants to identify a
plastic surgery mentor. (C) (Upper right) Percent responses from matched versus unmatched applicants showing
resources used while applying to residency. * indicates p < 0.05.
Among surveyed applicants, 17% (n = 7) had a PS division at their home institution, while 83% (n = 24) did not. Of note, a PS division was designated to be distinct from having a
residency program. We noted no differences in match rate (71 vs. 76%). However, we
found that medical students without an HRP who also lacked a PS division perceived
that they were further disadvantaged. This included feeling delayed in their decision
(28 vs. 73%, p < 0.05), not having opportunities to explore the field (28 vs. 76%, p = 0.013), and difficulty in finding research opportunities (29 vs. 82%, p = 0.003; [Fig. 3]).
Fig. 3 Percent responses from applicants with and without plastic surgery divisions, demonstrating
their feeling delayed in their decision (28 vs. 73%, p = 0.022), not having opportunities to explore the field (28 vs. 76%, p = 0.013), and difficulty in finding research opportunities (29 vs. 82%, p = 0.003). * indicates p < 0.05.
Among residents, 16 (48%) had a formal PS division. Comparing survey responses between
residents with and without formal PS divisions, 36% with home divisions felt they
had opportunities to explore PS, compared with 12% of those without a division. Additionally,
residents without home divisions felt more disadvantaged in finding research (94 vs.
65%, p < 0.05), delay in deciding on PS (50 vs. 28%), and obtaining mentors (44 vs. 35%)
and LOR (31 vs. 24%). Otherwise, residents with home divisions felt more limited in
networking (29 vs. 19%) and obtaining subinternships (29 vs. 13%) than residents without
home divisions. Residents with home divisions employed the following strategies to
find PS-related research projects: contacting outside departments (35 vs. 38%), personal
mentors (35 vs. 12%), contacting community physicians (11 vs. 6%), and utilizing a
research year (6 vs. 6%).
Discussion
Within the applicant pool, those without an HRP account for the minority of PS residents
(26%) despite the majority of U.S. allopathic medical schools not having a PS HRP
(54%).[22] Additionally, applicants without an HRP represent a disproportionately small minority
at top-quartile PS residency programs.[9] However, our survey data show that those without an HRP seem to match at higher
rates than the national average (76 vs. 67%). Despite many studies, including our
own, demonstrating sentiments of being disadvantaged among unaffiliated applicants,
few studies to date directly compare match rates between these populations.[10] While additional studies are warranted to further characterize factors influencing
match rates for unaffiliated students, not having an HRP undeniably reduces an applicant's
exposure to PS, their ease of access to mentorship, and their ability to conduct PS
research. The PS community has already made improvements to become more inclusive,
and we propose the following solutions to build upon these efforts and combat barriers
unique to applicants without HRPs[23]
[24] ([Table 1]).
Table 1
Proposed solutions to better support applicants without home residency programs
|
Theme
|
Supporting findings
|
Recommendation
|
|
Mentorship is a critical component to Match success
|
Applicant without HRPs were more likely to match if they had identified mentors in
plastic surgery
|
Create formalized mentorship programs with already established ACAPS sister institutions,
based on proven strategies in other surgical subspecialties
|
|
Peers represent alternate sources of mentorship
|
Outside the attendings, applicants cited peer mentorship as their most utilized resource
when applying into plastic surgery
|
Investigate the current prevalence of plastic surgery interest groups and form additional
groups associated with national organizations
|
|
Applicants are turning toward social media to inform their Match process
|
Over half of matched applicants reporting using plastic surgery social media during
their Match process
|
Encourage the establishments of social media presence by all plastic surgery residency
programs
|
|
Applicants without access to a plastic surgery division are at an increased disadvantage
in the Match
|
Disparities found in applicants without HRPs were exacerbated in those who also did
not have access to a plastic surgery division
|
Establish national or regional grants targeted toward students without HRPs to bolster
their access to research opportunities
|
Abbreviations: ACAPS, American Council of Academic Plastic Surgeons; HRP, home residency
program.
Improving Mentorship Pairing
Medical student mentorship has long been an area of interest, and the positive effects
of having a mentor have been clearly demonstrated.[25]
[26] This is no exception for students without HRPs as our data showed that students
from HRPs who identified a mentor in PS were more likely to match. Successful strategies
for establishing mentorship included cold-calling/emailing and performing research;
however, these methods seem to place a large amount of onus on the student to establish
a relationship. A study performed by Sasson et al demonstrated that nearly 60% of
students interested in PS reported difficulties establishing a mentor–mentee relationship
because they simply did not know where to find one.[11] The American Council of Academic Plastic Surgeons (ACAPS) has since developed a
database to pair institutions without HRPs with sister institutions with residency
programs.[27] This database consists of name and contact information of sister institutions' program
directors for 103 medical schools without HRPs.[11] Additionally, a formalized mentorship program between these sister institutions
has been trialed by ACAPS, with over 30 students receiving mentors. A similar program
has been shown to be successful in the field of urology, where 94% of participating
students successfully matched.[28]
Peer Mentorship
In addition to mentorship from attendings and residents, our study highlights the
importance of peer mentorship with 74% of matched students having reported utilizing
help from senior students. Within medical schools, student interest groups represent
an easily accessible and approachable way for students to develop peer mentorship,
gain exposure to the field, and discover career-building opportunities. In other specialties
such as orthopaedic surgery, it has been shown that a majority of U.S. allopathic
schools have a student interest group.[29] However, similar work is yet to be done within PS, especially examining the presence
of interest groups at institutions without HRPs.[29] Moving forward, we believe that it is important to characterize the prevalence of
PS interest groups. Additionally, we propose forming a partnership with national societies
such as ACAPS or the American Society of Plastic Surgeons to create official chapters
at medical schools without HRPs. A similar concept has been done with the American
Association of Neurological Surgeons with more active chapters being associated with
increased residency match success.[30]
Social Media as a Tool for Education
Social media has become a powerful tool for plastic surgeons and PS programs to brand
themselves and disseminate information. A study performed in 2020 revealed that over
85% of integrated PS residency programs had Instagram accounts with 44% of posts pertaining
to either education, promotion of PS, or resident life.[31] These resources are openly available to applicants without HRPs and massively expand
their ability to connect and learn, when previously their interest in PS would be
limited by institutional access and geographic base.[31] Our data show that applicants without HRPs are already taking advantage of these
resources with 52% of matched applicants using Twitter, Instagram, or Facebook as
a resource for PS. Since the COVID-19 pandemic, there has been an overall increase
in social media presence by U.S. residency programs. Social media has become a powerful
tool for plastic surgeons and PS programs to brand themselves and disseminate information.
A 2018 study performed by Chandawarkar et al demonstrated that only 21% of integrated
U.S. PS residency programs had active Instagram accounts.[32] While this statistic is outdated, the point stands that all PS residency programs
should strive to maintain some form of social media presence.[32] As this appears to be a lasting trend, we encourage applicants without HRPs to continue
to access residency program social media pages as a resource during their Match process.
The Value of Surgical Divisions
In their article titled “Building an Academic Colorectal Division,” Koltun et al describe
the efforts required to create a formal surgical division.[33] He lays out critical factors to the formation of a division, which includes culture,
commitment, collaboration, control, cost, and compensation.[33] Within these factors, Koltun et al also highlight the importance of developing a
system of mentorship and focused research. Similar studies have been performed within
PS, which address the eventual creation of departments from divisions.[34] Our data demonstrate that a significant barrier for PS applicants without an HRP
or home division is difficulty in identifying research opportunities. It is possible
that the organizational infrastructure associated with surgical divisions aids applicants
in obtaining research opportunities and may later improve their outcomes in the Match.
However, the creation of an academic surgical division is a timely process, requiring
manpower, time, and financial resources. As a substitute, we encourage the establishment
of national or regional grants targeted toward students without HRPs. A similar effort
has already been done for minority students.
In conclusion, the results of this study emphasize the importance of obtaining a PS
mentor for students without HRPs. This study also revealed that applicants who lack
both an HRP and home division face additional barriers to matching. We believe that
this population is further disadvantaged due to their lack of exposure to the field
and limited access to research opportunities and mentorship. When assessing a PS applicant,
program directors should be aware of the additional barriers that these candidates
face. These learning points can be applied to the upcoming application cycle to improve
the overall experience and results for programs and medical students alike.
There are several limitations to our study. Although there is a representation of
applicants and residents from various institutions, the overall response rate was
low. We were unable to capture all PS applicants, particularly those who participated
in the supplemental offer and acceptance program or who ultimately matched into general
surgery. Additionally, as a survey-based study, our results are subject to response
bias, possibly selecting applicants who were successful in their Match and impacting
our match rate data. Recall bias is also of concern for PGY5 resident responses as
they are commenting on their perceptions from over 5 years prior. In addition, there
is also subjectivity in the interpretation of some questions that may lead to variability
in survey responses.
