The proportion of fourth year medical students applying to ophthalmology has increased
dramatically, rising 18% from 2020 (635 applicants) to 2023 (742 applicants).[1] Yet, the number of available spots in the Match has only increased by 3%.[1] As a result, the ophthalmology match has become dramatically more competitive, with
match rates dropping from 78% in 2020 to 69% in 2023.[1] Furthermore, the match rate for applicants that failed to match the first time is
dramatically lower, suggesting that failure to match can be career-ending for burgeoning
ophthalmologists. Given the consequences of failing to match in an increasingly competitive
specialty, students are casting wider nets in order to maximize their chances of matching
anywhere.[2]
[3] The number of applications submitted by students has increased from 48 in 2008 to
88 in 2023, representing a 87% increase or an extra $1,400 spent per student.[1]
[4] Thus, it is not surprising that a study by Venincasa et al determined that the greatest
driver of the increased number of applications is “fear of failure to match.”[4]
The increased number of applications per student has created considerable additional
burden for both students and residency program directors. Students are expected to
take on more financial burden to apply to more programs, while program directors are
expected to review and screen a greater number of applications for a relatively stagnant
number of positions. Interestingly, the number of interview invitations received by
students does not meaningfully increase proportional to the number of programs to
which they applied.[1]
[5] The average number of interviews offered was 9.3 for all students submitting > 40
applications, with a range of 5 to 15.[6] Per SFMatch, historical data demonstrates that applicants with ≥ 10 interviews have
a 90% success rate of matching.[6] This suggests that there is a marginal return to applying to a greater number of
programs.[5] Furthermore, this suggests that there is room for applicants to cut down on the
number of applications by screening out programs where they are not expected to be
a strong fit.
Given the match process is inefficient, stakeholders have proposed or implemented
several potential solutions to improve efficiency and reduce burden on students and
faculty. Commonly proposed improvements across all specialties include implementation
of an application cap, creation of a standardized program database, utilization of
standardized letters of evaluation, and preinterview screening.[7] Within the ophthalmology match, SFMatch has made recent strides by graduating application
costs, setting a limit on the number of accepted interviews, and implementing virtual
interviews for all programs, all of which exert an effect by theoretically altering
applicant behavior. Despite proposed and attempted improvements, the current match
process still leaves considerable gaps for students who lack ophthalmology connections.
It is an unfortunate paradox that medical students, who have undergone years of rigorous
training focused on practicing evidence-based medicine, must make arguably one of
the most important choices of their career based on incomplete or potentially biased
information and without the benefit of objective data.[8]
[9]
[10] In an effort to improve transparency, SFMatch started to publish data on participating
ophthalmology residency programs in 2020.[11] The intent of such a site is to consolidate relevant information for applicants,
which may allow applicants to tailor where they apply to based on objective program
characteristics that they would deem a strong fit for their interests. To date, there
has been limited analysis on the approach SFMatch has taken and its success. Thus,
the purpose of this study was to characterize and identify gaps in the information
available to residents in the 2022to 2023 match on the SFMatch site.
Methods
Explanation of the SFMatch Tool
The SFMatch hosts a Web site that is updated yearly to provide medical students with
access to a list of participating programs in that year's residency match, as well
as select pieces of data provided by each residency program.[11] Data provided by SFMatch includes the type of residency program (i.e., integrated
vs. joint), the number and specialty of teaching staff, surgical volume caseload,
and proportion of residents participating in certain postgraduate career paths (i.e.,
fellowship vs. direct-to-practice).
Data Acquisition and Analysis
A total of 121 U.S. ophthalmology residency programs were identified using the 2022
SFMatch Ophthalmology Program Profile Information page.[11] The Web site was accessed on two separate dates (August 15, 2022 and October 15,
2022) to catalogue general availability of residency program information before and
after residency applications were released to programs on September 01, 2022. Program
SFMatch profiles from participating residency programs were evaluated on October 15,
2022 to evaluate availability and consistency of data on location, accreditation status,
intern year type, association with medical school, class size, fellowship availability,
research faculty, and surgical volume. Surgical volume of participating SFMatch programs
were catalogued based on verbatim descriptions of surgery type (e.g., “Laser Surgery”
and “Panretinal Laser Photocoagulation” were considered different types of surgery
despite using similar technologies). Finally, the home webpages of participating residency
programs were reviewed to identify other characteristics that were not provided on
the SFMatch site that applicants may deem useful in determining where to apply. All
collected data was catalogued in a Microsoft Excel spreadsheet. Analysis of data was
conducted using IBM SPSS.
Results
Of the 121 programs included on SFMatch, 98 (81%) provided data by August 15, 2022
(15 days prior to application submission deadline) and 112 (93%) had provided residency
program data by October 15, 2022 ([Table 1]). Of the 112 providing data, 108 (96.4%) reported an association with a medical
school. All included programs had transitioned to a joint or integrated postgraduate
year 1. Average class size was 4.6, while average number of research faculty was 6.0.
Table 1
Characterization of residency programs on SFMatch
|
Residency characteristics
(N = 121)
|
|
Provided any data (N, %)
|
|
|
Providing data on August 15, 2022
|
98 (81.0)
|
|
Providing data on October 15, 2022
|
112 (92.6)
|
|
Location (N, %)
|
|
|
Northeast
|
33 (27.2)
|
|
Midwest
|
29 (24.0)
|
|
South
|
43 (35.5)
|
|
West
|
15 (12.4)
|
|
Outside continental U.S.
|
1 (0.8)
|
|
Accreditation status (N, %)
|
|
|
Continued
|
106 (87.6)
|
|
Initial
|
2 (1.7)
|
|
Continued with outcomes
|
1 (0.8)
|
|
Continued with warning
|
1 (0.8)
|
|
Continued without outcomes
|
1 (0.8)
|
|
Probation
|
1 (0.8)
|
|
Intern year type (N, %)
|
|
|
Joint
|
63 (52.1)
|
|
Integrated
|
49 (40.5)
|
|
Have access to VA (N, %)
|
86 (71.1)
|
|
Associated with medical school (N, %)
|
108 (89.3)
|
|
Class size (mean ± SD)
|
4.6 ± 2.7
|
|
Fellow-slot availability (N, %)
|
|
|
Slots available
|
80 (66.1)
|
|
Slots not available
|
32 (26.4)
|
|
Full-time research faculty (mean ± SD)
|
6.0 ± 7.8
|
Abbreviations: SD, standard deviation; VA, Veterans Affairs.
Each program was required to provide cataract surgical volume, and had the option
to provide up to three additional surgical volumes ([Table 2]). The 112 participating programs provided surgical volumes for 23 different surgeries,
which included a range of surgical classifications (e.g., laser surgery) as well as
specific procedures (e.g., chalazia excision). A total of 111 (92%) programs provided
any data on cataract volume. Notably, two programs indicated that they did not have
any cataract surgical volume by entering “0” for the number of average annual surgeries
performed with the resident as primary surgeon. The most reported surgeries other
than cataracts were oculoplastics (67/121, 55%), glaucoma (55/121, 45%), and strabismus
(52/121, 43%).
Table 2
Surgical volumes of participating SFMatch programs
|
Surgery type
|
Institutions providing data
|
(%)
|
Mean
|
Min
|
Max
|
Standard deviation
|
|
Cataract
|
111
|
92
|
195.2
|
0
|
365
|
62.8
|
|
Oculoplastic
|
67
|
55
|
67.5
|
15
|
146
|
27.2
|
|
Glaucoma
|
55
|
45
|
16
|
8
|
29
|
5.1
|
|
Strabismus
|
52
|
43
|
29
|
12
|
62
|
11
|
|
Globe trauma
|
28
|
23
|
13.1
|
7
|
33
|
5.2
|
|
Intravitreal injection
|
26
|
21
|
148.2
|
13
|
500
|
126.5
|
|
Retina/Vitreous
|
20
|
17
|
25.3
|
5.25
|
57
|
15.5
|
|
Pterygium/conjunctival and other cornea
|
17
|
14
|
16.1
|
4
|
26
|
5.9
|
|
Laser surgery
|
14
|
12
|
87.1
|
20.8
|
176
|
45.1
|
|
Blepharoplasty
|
12
|
10
|
24.5
|
10
|
85
|
20.3
|
|
Panretinal laser photocoagulation
|
8
|
7
|
92.6
|
17
|
294
|
89
|
|
Refractive
|
4
|
3
|
18.2
|
11
|
27
|
6.6
|
|
Entropion/Ectropion repair
|
3
|
2
|
10.8
|
6
|
20
|
7.9
|
|
Laser surgery-YAG capsulotomy
|
3
|
2
|
17.3
|
13.75
|
20
|
3.2
|
|
Eyelid laceration/Canalicular repair
|
3
|
2
|
20.5
|
9
|
31
|
11
|
|
Penetrating keratoplasty
|
2
|
2
|
11
|
10
|
12
|
1.4
|
|
LASIK/PRK
|
2
|
2
|
26.5
|
19
|
34
|
10.6
|
|
Vitrectomy
|
2
|
2
|
35.5
|
15
|
56
|
29
|
|
Muscle surgery
|
1
|
1
|
55
|
N/A
|
N/A
|
N/A
|
|
Peripheral laser iridotomy
|
1
|
1
|
21
|
N/A
|
N/A
|
N/A
|
|
Pediatrics
|
1
|
1
|
18
|
N/A
|
N/A
|
N/A
|
|
Chalazia excision
|
1
|
1
|
5
|
N/A
|
N/A
|
N/A
|
|
SLT
|
1
|
1
|
59
|
N/A
|
N/A
|
N/A
|
|
Orbit (non-chalazion, non-eyelid)
|
1
|
1
|
40
|
N/A
|
N/A
|
N/A
|
Abbreviations: LASIK, laser-assisted in situ keratomileusis; N/A, not available; PRK,
photorefractive keratectomy; SLT, selective laser trabeculoplasty.
Program home Web sites were reviewed, and additional residency considerations not
provided in SFMatch were characterized ([Table 3]). Of the 122 program Web sites evaluated, a small minority of programs provided
applicable datapoints regarding applicant considerations, with the majority of those
programs stating that they enlisted a holistic application review process to determine
applicants to interview. No program provided a discrete STEP 1 or 2 cutoff, though
two programs implied a favorable outcome for applicants in the 75th percentile or
greater. An additional 12 programs specifically indicated that there was no United
States Medical Licensing Examination (USMLE) score cutoff for consideration. The most
frequently cited program characteristics were the location and timing of rotations
during residency (82.0%) as well as gender balance (80.3%). Notably, only 21.3% of
programs provided any data on resident surgical volume. Approximately two-thirds of
programs shared program benefits, though notably a large proportion of these programs
shared the benefits on the hospital system Web site rather than the specific residency
program Web site. Interestingly, unionized programs were more likely to have provided
a comprehensive list of benefits available to residents versus nonunionized programs.
Table 3
Key datapoints missing in SFMatch database
|
Missing datapoints provided on the residency program Web sites
|
Programs providing datapoint, N (%)
|
|
Applicant considerations
|
|
|
Enlist a “Holistic” application review process
|
22 (18.0)
|
|
Average STEP 1 score for current residents
|
4 (3.3)
|
|
STEP 1 score cutoff
|
13 (10.7)
|
|
No cutoff
|
11 (9.0)
|
|
Score > 75th percentile viewed favorably
|
2 (1.6)
|
|
Average STEP 2 score for current residents
|
2 (1.6)
|
|
STEP 2 score cutoff
|
14 (11.5)
|
|
No cutoff
|
12 (9.8)
|
|
Score > 75th percentile viewed favorably
|
2 (1.6)
|
|
3rd and 4th year grade cutoff
|
0 (0)
|
|
Typical matched programs[a]
|
1 (0.8)
|
|
Letters of recommendation requirements[b]
|
7 (5.7)
|
|
Additional application requirements[c]
|
6 (4.9)
|
|
Program characteristics
|
|
|
Average STEP 3 score
|
0 (0)
|
|
Gender balance
|
98 (80.3)
|
|
Explicit percentage provided
|
2 (1.6)
|
|
Provided via resident profiles
|
96 (78.7)
|
|
Research/Publication volume
|
12 (9.8)
|
|
International rotations
|
30 (24.6)
|
|
Patient population size
|
32 (26.2)
|
|
Resident surgical volume
|
26 (21.3)
|
|
Cataract volume only
|
7 (5.7)
|
|
Multiple surgical volumes
|
19 (15.6)
|
|
Area cost of living
|
14 (11.5)
|
|
Rotation locations
|
100 (82.0)
|
|
Rotation time allocation
|
100 (82.0)
|
|
Call structure
|
51 (41.8)
|
|
Research requirements
|
67 (54.9)
|
|
Required but no specifics provided
|
35 (28.7)
|
|
Participation in scholarly research project
|
16 (13.1)
|
|
Publication of paper or case report
|
11 (9.0)
|
|
Poster presentation
|
8 (6.6)
|
|
Quality improvement project
|
3 (2.5)
|
|
Program benefits[d]
|
|
|
Salary information
|
74 (60.7)
|
|
Medical/Dental benefits
|
73 (59.8)
|
|
Vacation/PTO
|
78 (63.9)
|
|
Parental leave
|
39 (32.0)
|
|
Retirement programs
|
40 (32.8)
|
|
Travel funds
|
50 (41.0)
|
|
Research funds
|
55 (45.1)
|
|
Other benefits[e]
|
58 (47.5)
|
Abbreviation: PTO, paid time off.
a Though no program provided data regarding “target” medical schools, one program provided
percentages on regions where matched applicants resided.
b Seven programs provided specific requirements or preferences for letters of recommendations;
typically 3 letters of recommendation (of which at least 2 were from ophthalmologists)
were required. Three programs also required a Dean's letter.
c Most common additional application requirement was a program-specific statement of
interest, which was to be sent by the applicant directly to the program director.
d Of note, unionized residency programs were more likely to have a comprehensive list
of benefits publicly available.
e A list of additional benefits mentioned by programs include: adoption assistance,
addiction services, blood donor club, business cards, campus currency, care coordination,
cell phone discounts, childcare services, commuter services discounts, discount entertainment
tickets, financial counseling, genetic testing, guaranteed resident housing, housing
stipends, in-house gym, life/disability insurance, MBA program, meal stipends, mentorship
programs, moving allowances, professional organization memberships, protected research
time, scrubs, smartphone stipends, tax-sheltered annuities, tuition reduction, unionization,
work hour limitations, and white coats
Discussion
Calls for reform within the ophthalmology match have grown in response to greater
competitiveness and increasing application volume, which have increased burden on
both students and residency program directors.[7] Though a number of changes have been proposed, implemented reform measures (e.g.,
interview caps, virtual interviews, and graduated application costs) have focused
on influencing applicant behavior by increasing the cost burden of superfluous applications
and improving applicant cost equity.[6] However, these do not address the core drivers of applicant behavior, including
the fear of not matching, lack of transparent data, or inequity in the residency selection
process.[12] Thus, further reform is necessary and should seek to target aspects of the match
process that continue to drive inefficiencies in applicant behavior and/or review.
One key inefficiency that can be influenced directly by programs and residency directors
is the lack of transparency of program data. Programs use filters that can automatically
reject student applications if they do not meet certain “nonnegotiables” (e.g., a
minimum STEP 1 or STEP 2 score).[8]
[9] A student that does not meet this requirement would have wasted time and money on
an application that was guaranteed not to bear fruit. Furthermore, students with sufficient
board scores may still not be a good fit for a program, given programs may have soft
requirements or additional considerations for extending interviews (e.g., research,
geographic preference, third year rotation grades, Alpha Omega Alpha [AOA] status,
or program preference).[8]
[9] Conversely, applicants may be interested in weighing considerations such as program
size, geographic location, research focus, training sites, alumni placement, subspecialty
exposure, surgical case load, and cultural preferences into whether or not they would
apply to or accept an interview at a specific program.[4] However, information on program applicant considerations or characteristics is often
not readily available to most students, and thus students rely on word of mouth and
advising from administration to titrate their application decision-making.[2] Students with connections in the space or that attend a medical school with an associated
residency program immediately have an advantage, as program directors may be able
to guide students on both soft and hard requirements for application to certain residency
programs. Understandably, students with a home residency program are 40% more likely
to match than those without one.[9]
Improved transparency of data may include residency characteristics and benefits which
may reduce the number of applications by allowing applicants to filter programs based
on personal criteria, or absolute board score or rotation grade cutoffs which may
also reduce the number of applications by identifying programs where it would be futile
for select applicants to apply. SFMatch attempted to improve data transparency by
publicizing specific program characteristics in 2020. Given there has not been a formal
peer-reviewed evaluation of this effort, we sought to characterize the effectiveness
of these efforts and identify options that may provide the best path forward.
Our study demonstrated that there was significant variation in the type and usability
of data provided by ophthalmology residency programs to the SFMatch. Approximately
81% of programs had provided data prior to the application release date, suggesting
that a sizeable number of programs had not provided any information to help applicants
tailor their applications prior to the application release date on September 1. Of
the programs that provided information, there was significant variation in the way
that data was expressed, potentially forcing students to read between the lines.
Surgical volume, at face value, can be one of many objective measures to help determine
the focus of programs and opportunities available for training for residents. Programs
participating in the SFMatch were required to provide average volume of cataracts
where residents were the primary surgeon, as well as volume in up to three other procedures.
Per Accreditation Council for Graduate Medical Education (ACGME), residents are required
to demonstrate competence as the primary surgeon in a number of surgeries in order
to graduate, including cataract, cornea, glaucoma, globe trauma, oculoplastics/orbit,
retinal/vitreous, strabismus, and laser procedures (e.g., YAG capsulotomy, laser trabeculoplasty,
laser iridotomy, panretinal laser photocoagulation).[13] However, despite clear guidelines on achieving competence in specific surgeries,
the data provided on surgical volume was varied and occasionally did not meet the
definition of achieving competence. Interestingly, while an overwhelming majority
of programs were able to provide resident surgical volume on SFMatch, only 21% provided
any data on surgical volumes on their home Web site.
Furthermore, the type and quantity of procedures reported on SFMatch were varied and
difficult to compare. The four most commonly reported surgeries outside of cataracts
were oculoplastics (55%), glaucoma (45%), strabismus (43%), and globe trauma (23%),
all of which are included in the ACGME requirements. A greater proportion of programs
would specify one type of surgery within a given class, rather than the broader class
(e.g., vitrectomy rather than Retina/Vitreous). In total, 23 different surgeries or
classes of surgery were mentioned. This lack of consistency in reporting creates ambiguity
when cross-comparing residency programs, as a program that indicates an average of
70 oculoplastics cases is difficult to compare with a program that cites an average
of 20 eyelid laceration repairs. Thus, applicants must read between the lines to determine
what subspecialties a program might be “stronger” in or the expected surgical training
at a given program. Accurate and reliable data are essential to the validity and usefulness
of an online tool. Given there is a lack of consistency in data provided to SFMatch,
as well as a lack of reliability on specific measures, it is difficult to leverage
the SFMatch tool as it stands to compare programs on key metrics of importance to
applicants.
In addition to concerns regarding the reliability of data presented on SFMatch, there
also remain key gaps in the data provided. Data provided by SFMatch is largely focused
on topics related to clinical experience and subspecialty exposure. This can be useful
to help applicants determine whether they are interested in a program, especially
if they have a specific subspecialty in mind. Indeed, a study by Venincasa et al demonstrated
that surgical caseload and prior fellowship match results were key drivers of choice
to apply to a specific program.[4] However, the database lacks information on academic, social, and economic considerations,
which were found to be at least a moderate influence on students' interest in a specific
program.[4] A majority (54.9%) of programs provided information on their individual program
research requirements, which were sometimes above and beyond the ACGME requirement
(e.g., publication of a first-author manuscript or annual poster presentations). Furthermore,
residency program Web sites often provided data on benefits that could be directly
compared between programs, with 60.7% providing data on salaries/stipends, 59.8% on
medical and dental benefits, and 63.9% on vacation policies. Fewer programs provided
data on parental leave (32.0%) or retirement programs (32.8%). Such data would be
relatively straightforward to provide on the SFMatch Program Profiles, and an objective
method to compare programs within the same geographic region with similar cost-of-living.
Ultimately, the SFMatch Program Profiles fail to solve some of the core inefficiencies
in the match process. Without data on cutoffs or “requirements” to be a candidate
for an interview, students still are unable to determine whether they would be a candidate
for a specific program, and thus may send in an application that will likely be rejected.
Specifically, data on STEP 1 and STEP 2 averages and/or other potential sources of
hard cutoffs were lacking. Notably, only a few programs were willing to provide this
data on their Web sites, with 3.3% providing current resident averages on USMLE exams,
9.8% specifically stating there was no cutoff for consideration, and two stating that
USMLE scores > 75th percentile would be “viewed favorably.” Given applicants are largely
driven by the ranking and reputation of programs, knowledge of cutoffs are a necessity
to inform feasibility of application to specific programs.[4]
Consolidation of residency data is a critical and necessary step toward ensuring transparency
in the residency match process. Key datapoints are spread across several platforms
with variable accessibility and accuracy. For example, the Texas STAR is a student-reported
application database that provides insight into average characteristics (e.g., STEP
scores, AOA percentage, research experience, number of honored clerkships) of students
who interviewed and matched at participating programs.[14] The generalizability of the data provided in the platform is questionable, as not
every medical school participates and student participation has ranged from 38 to
47% between 2018 and 2022.[14] Individual program Web sites may provide data on research stipends, benefits, housing,
and other residency characteristics, but are highly variable in what they publicly
share.
The scattered nature of data critical to applicant decision-making may enforce similar
inequities in the application process as medical schools that do not have an associated
residency program. Medical schools that are willing to pay for access to or participate
in databases will have more broad access to these data, whereas students at medical
schools that do not participate may be forced to pay out-of-pocket for database access
or forgo the data and make less-informed choices. Thus, these students are still required
to rely on word of mouth, or do individualized research on hundreds of programs to
determine which might be a good fit and worth applying to.
The SFMatch Web site is uniquely positioned to shape and reform the ophthalmology
match process, given it is the only program used for the match and all applicants
presumably have access to it. Thus, it is the best candidate to collect and provide
consolidated information on residency programs. However, the onus is largely on program
directors to share accurate and complete information, and likely requires a cultural
shift to achieve the desired level of transparency. Residency programs may be hesitant
to share such data given there will be data that are less flattering for certain programs
and thus may be politically untenable at an institutional level.[10] As such, it may be necessary for the SFMatch to implement requirements on data disclosure
that would improve transparency in order for programs to participate in the SFMatch.
This shift to a more transparent match process may have additional benefits as well—sharing
of characteristics such as resident benefits may accelerate adoption of benefits that
applicants find important (e.g., access to childcare, educational stipends) but may
not be universal across programs.
As with any study, there are limitations. This study only evaluated the SFMatch program
Web site, though other studies have explored separate databases in greater detail.[2] Additionally, this study only evaluated the presence of specific data points (e.g.,
applicant considerations, program characteristics and benefits) on the program Web
site. Thus, the study risks misrepresentation of the total number of programs that
may offer a benefit. Indeed, programs may not have provided data on a specific topic
(e.g., parental leave, international rotations) but still offer that particular benefit.
