Keywords
ophthalmology - residency match - residency interviews - residency application - cost
- medical student
In 2017, 18,261 students graduated from U.S. medical schools[1] with a mean debt of US$190,694.[2] Both of these figures are continuing to rise year over year, and educational debt
remains a central concern in addressing physician workforce diversity in geographic
location and specialty.[3] Medical students have additionally raised concerns about the cost of the residency
interview process, indicating that the expenses are overly burdensome and that financial
considerations influence their decision to attend interviews.[4]
This past match cycle, 689 U.S. and international applicants competed for 475 ophthalmology
residency positions. Over the past decade, the number of positions offered has slightly
increased from 458 in 2009, whereas the number of applications has actually decreased
from 767. Despite this, the competitiveness of the match, as measured by percent matching,
has not changed. What has increased substantially, however, is the number of applications
per applicant: from 41 in 2004, to 50 in 2009, and up to 73 and 69 for the average
matched and unmatched applicants in 2018, respectively. Matched and unmatched applicants
also attended an average of 12 and 4 interviews, respectively.[5]
Data regarding the financial burden of the match process for applicants are limited
but suggest significant expense for this cost-conscious population.[3]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15] The goal of this study is to provide a reasonable estimate of the cost associated
with the ophthalmology residency match process for both applicants and programs using
available national and local data.
Materials and Methods
The numbers of registrants, participants, rank list submissions, and matched and unmatched
applicants for the 2017 to 2018 ophthalmology residency match cycle were obtained
from the publicly accessible Association of University Professors of Ophthalmology
(AUPO) and San Francisco (SF) Match Summary Report.[5] The mean number of applications and interviews for matched and unmatched applicants
were also obtained using the same dataset. Application fees for the SF Match Residency
Matching Services were used to determine the mean application cost for matched and
unmatched applicants.[16] Existing literature was used to estimate the applicant cost per interview[3]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]; the mean of these reports was used.
Program costs were calculated from interview costs for each of four half-day interview
sessions at the University of Kentucky during the 2017 to 2018 ophthalmology residency
match cycle. A total of 48 applicants were interviewed for four positions. Clinical
productivity was based on the fiscal year 2017 to 2018 mean half-day collections and
fixed overhead for the 12 faculties that participated in each of the interviews. Fixed
costs were based upon the same faculty and fiscal year and included the sum of the
Dean's overhead cost, faculty and personnel salaries and fringes covered by the department,
and other fixed expenses.
All costs were in 2017 U.S. dollars and converted when necessary using the consumer
price index data for urban consumers.
Results
There were a total of 735 registrants, 689 participants, and 625 rank lists submitted
for 475 available positions in the 2017 to 2018 ophthalmology residency match. The
mean number of applications was 73 for the 475 applicants that matched and 69 for
the 150 that went unmatched. The application cost for the mean applicant was US$1,665
and US$1,525 for matched and unmatched applicants, respectively, for a total estimated
application fee of US$1,082,125 for the 625 applicants that submitted rank lists ([Table 1]).
Table 1
Estimated 2017 to 2018 match costs for ophthalmology residency applicants
|
Mean matched applicant, N = 475
|
Mean unmatched applicant, N = 150
|
Total cost for all applicants, N = 625
|
|
Number of applications submitted
|
73
|
69
|
|
|
Total application fees
|
US$1,765
|
US$1,625
|
US$1,082,125
|
|
Number of interviews
|
12
|
4
|
|
|
Cost for interviews
|
US$4,848
|
US$1,616
|
US$3,564,825
|
|
Total match costs
|
US$6,613
|
US$3,241
|
US$4,646,950
|
Eleven surveys were conducted between 2006 and 2016, providing estimates of applicant
cost per residency interview, with a mean of US$404 (range: US$306–US$522) ([Table 2]). The mean number of interview invites was 12 and 4 for matched and unmatched ophthalmology
applicants during the 2017 to 2018 match, respectively. Presuming applicants attended
all invited interviews, the mean cost for interviews was US$4,848 and US$1,616, and
the total cost of applications and interviews was US$6,613 and US$3,241, respectively.
Based on these mean data, the total match cost for all 625 applicants was US$4,646,950
([Table 2]).
Table 2
Mean estimated applicant cost per resident interview in the current literature
|
Study population
|
Response rate (%)
|
Mean cost[a] (in U.S. dollars)
|
|
All 468 urology applicants in 2006[6]
|
61
|
401[b]
|
|
All 367 plastic surgery residency applicants in 2006[7]
|
38
|
522
|
|
All 194 applicants to a single plastic surgery residency program in 2012[8]
|
65
|
463
|
|
All 202 first year neurosurgery residents in 2015 (2014 match cycle)[9]
|
64
|
485
|
|
An estimated 525 applicants to 18 urology residency programs in 2014[10]
|
33
|
517
|
|
1,091 applicants to 4 orthopaedic residency programs in 2015[11]
|
37
|
335
|
|
All 1,425 applicants to emergency medicine that were members of the emergency medicine
resident association in 2016[3]
|
13
|
344
|
|
All 81 residency applicants to a single emergency medicine program in 2016[12]
|
81
|
331
|
|
All 195 applicants from the University of Kansas School of Medicine in 2016[13]
|
84
|
306
|
|
All 61 applicants from the University of South Dakota School of Medicine in 2016[14]
|
68
|
404
|
|
All 370 otolaryngology residency applicants in 2016[15]
|
49
|
340[b]
|
|
Overall mean cost
|
|
404
|
a Adjusted for inflation and presented in 2017 U.S. dollars.
b Median cost reported.
Program costs are presented in [Table 3]. The estimated cost for each of the four interview dates was US$44,832, with a total
cost of US$179,327 for the match cycle, and an average of US$3,736 spent on each of
48 applicants interviewed.
Table 3
Total estimated University of Kentucky Ophthalmology program costs for 2017 to 2018
residency interviews
|
Category[a]
|
Cost (in U.S. dollars)
|
|
Meals[b]
|
4,655
|
|
Supplies
|
528
|
|
Losses in faculty clinical productivity[c]
|
89,952
|
|
Losses in clinic fixed costs[d]
|
84,192
|
|
Total program costs per interview
|
44,832
|
|
Total program costs per match cycle
|
179,327
|
|
Cost per applicant Interviewed
|
3,736
|
a Interviews were conducted over four separate half-day weekday sessions. A total of
12 faculties participated in each interview session and 48 applicants were interviewed.
b Include applicant reception with current residents, breakfast and lunch on the interview
day, and a rank list dinner for faculty following the final interview.
c Mean individual faculty collections per half-day session multiplied by 12 faculties
and 4 interview dates.
d Mean faculty fixed costs per half-day session multiplied by 12 faculties and 4 interview
dates. Fixed costs include the sum of the Dean's overhead, faculty and personnel salaries
and fringes covered by the practice, and other fixed expenses.
Discussion
The medical residency match is based upon a market algorithm designed by Alvin Roth,
leading to a Nobel Prize in Economics in 2012 shared jointly with Lloyd Shapley for
the “theory of stable allocations and the practice of market design.”[17] Despite the accolade, the medical matching process is the only professional training
organization currently using this system.[18] Because of the competitive nature of the match, applicants are applying to an increasing
number of programs. The costs associated with this process have the propensity to
be detrimental to the most financially strained, with one pointed comment in an applicant
survey stating: “This is the glass ceiling. It is set up to make economic minorities
fail.”[4] Furthermore, applicants from rural programs may have to travel longer distances
and incur even greater costs.[10] A survey of 2006 Urology resident applicants found that those attending northeastern
medical schools had significantly lower interview costs than other regions of the
country.[6] This, in part, may be why ophthalmology applicants are significantly more likely
to match in the same geographic region as their medical school.[19] These findings raise concerns about not only the match process for the applicants
but also the programs that seek to select the most desirable candidates from a diverse
geographic pool.
This study and calculations provide further validation of the costs. The mean matched
ophthalmology applicant spent an estimated US$6,613 on the match, whereas the mean
unmatched applicant spent roughly half that amount. Although it may initially be reassuring
that unmatched applicants spent less, one reason that applicants are willing to spend,
increasingly, so much on the match is the tremendous opportunity cost of going unmatched.
The estimated total cost of US$4,646,950 for all applicants that submitted rank lists
are similar to prior studies of US$3,228,556 for urology,[10] US$3,358,584 for otolaryngology,[20] US$3,557,410 for neurosurgery,[9] and US$20,177,666 for emergency medicine[3] applicants per match cycle. Similarly, we found that resident interviews produced
a substantial cost to our department: US$179,327 in total or US$3,736 per applicant
interviewed. A comparable estimation of program costs for resident interviews of a
single plastic surgery residency that interviewed 53 applicants found the total cost
was US$151,277 and the cost per applicant was US$2,854.[21] A survey of 82 emergency medicine program directors estimated that the cost was
US$214,845 per program per year and US$47,910,292 for all emergency medicine programs
in an interview season.[3]
What changes could be made to potentially improve this process? Video conference interviews
for ophthalmology resident applications have been trialed at the University of Arizona,[22] although there are some potential trade-offs with this approach.[23] Particularly in large urban areas, programs can coordinate the scheduling of interview
dates, as was done in Chicago for emergency medicine applicants with significant cost
savings and a favorable applicant review.[24] Specialty societies and other national organizations could negotiate special interview
rates with national airlines and hotel chains, and grassroots efforts by medical schools
and residency programs may provide more affordable housing and travel options for
applicants.[3] A recent publication regarding the surgical fellowship match suggested using a variation
on the deferred acceptance matching algorithm currently used to have an “interview
match” that precedes the standard fellowship match. After applications have been submitted
and reviewed, both applicants and programs would create rank lists to fill a more
limited number of interview spots. Therefore, both parties theoretically interview
preferentially with fewer required interviews.[25]
Another option that would benefit both applicants and programs is to limit the number
of applications an individual can submit. Applying the game theory model of prisoner's
dilemma to the urology match, Weissbart et al[26] determined that not only is allowing unlimited applications inefficient, but it
is also financially burdensome for both applicants and programs. In their estimation,
applicants could collectively save up to US$613,000 and program directors individually
1,639 minutes per match cycle with an application limit of 30. Using similar logic,
an application limit could be set for the ophthalmology residency match. Based on
match data from the past 2 years, the number of interview invites does not increase
significantly for applicants beyond 40 applications,[5]
[27] and such a cap would result in an estimated savings of US$825,875 for the 625 applicants
that submitted rank lists this past match cycle. Using the previous estimate of 5
minutes spent reviewing each application,[26] the mean of 114 program directors participating in the match would have reviewed
176 fewer applications and saved 878 minutes or 14.6 hours of time with this limit.
However, these potential savings for applicants would have to come at the expense
of the sponsoring organization and beneficiaries. As an example, using the Electronic
Residency Application Services (ERAS) fee formula, 2015 fees for all student ERAS
applications was US$72 million, representing approximately 40% of the Association
of American Medical Colleges operating revenue for that year.[3] Using the tiered distribution fee schedule from SF Match,[16] an application limit of 40 would cost each applicant US$410, for a total of US$256,250
for all 625 applicants in 2017 to 2018. With an estimated US$1,082,125 in application
fees, this limit would reduce revenue by approximately 80%. It should be emphasized
this is an estimate based on mean application data, and while exact financial analysis
is not possible, the loss to SF Match and other beneficiaries would be substantial
if compensatory changes were not made in the fee structure.
A restriction to the number of applications per applicant poses several reasonable
potential objections. For instance, applicants may potentially be applying to an increasing
number of programs not to improve the probability of matching but due to interest
in a larger and broader range of programs. Other concerns include the possibility
that applying to an unlimited number of programs improves applicants' happiness and
sense of control or that an application limit would decrease competition. Weissbart
et al[26] presents a thorough analysis and refutation of these and other objections. Regardless
of where an application limit is set, applicants would need sufficient information
to make educated decisions on where to selectively apply. Accordingly, programs would
need to provide information about screening criteria and additional standards when
reviewing applications to allow applicants the opportunity to strategically apply
to a restricted number of programs.
There are several important limitations to this study. The match dataset presents
mean statistics; therefore, precise measurements are not possible. The surveys used
to estimate interview costs have multiple inherent biases and are not specific to
ophthalmology. While we plan to obtain this information in the future, it is unlikely
to alter the underlying conclusion of this and other similar studies: the interview
process is expensive. In fact, this analysis likely underestimates to true cost of
matching for two reasons. First, the cost of away rotations is not included. There
is one limited survey including ophthalmology that found applicants completed a mean
of 1.9 away rotations at a cost of US$990 per rotation.[28] Another study estimated a mean cost of US$1,100 for emergency medicine applicants.[12] Second, these figures do not account for the separate cost to apply and interview
for preliminary year positions. There are no existing data to estimate these costs,
although the independent matching process may soon be changing.[29] This analysis presumed that applicants attended all invited interviews. While this
is not likely the case, the mean of 12 interview invites is similar to the overall
average of 10.91 ranked programs for all 27,424 successfully matched applicants in
the 2018 National Resident Matching Program.[30] Lastly, the program costs are specific to our institution and the interview year.
The number of interview dates offered, faculty involvement, and weekday versus weekend
dates, among other factors, vary widely. Collectively, these data compel a broader
examination of the costs associated with the match process.
The AUPO and SF Match should be commended for providing match statistics to the public
for evaluation; these data continue to be beneficial for applicants and programs alike.
The trends in recent years, however, coupled with cost analyses demonstrate the need
for change. It is time to reconsider the ophthalmology residency application and interview
process, primarily to aid not only our applicants and future colleagues but also the
programs themselves.
