Implementation of a Holistic Review Process of US Allopathic Medical Students Eliminates Non-Comparable Metrics and Bias in General Surgery Residency Interview Invitations

Association of Residency Applicant Sociodemographic Characteristics With Specialty Choice and Interview Outcomes

OBJECTIVE

To evaluate associations of residency applicant sociodemographic characteristics with specialty choice, academic metrics, and application outcomes. Academic metrics included clerkship honors, honor society membership, United States Medical Licensing Exam (USMLE) scores, degree type (allopathic or osteopathic), second degrees or research year, required remediation, couples match, research output, and volunteer or leadership positions.

DESIGN

Retrospective, cross-sectional analysis of applicants who responded to the Texas Seeking Transparency in Application to Residency (STAR) survey.

SETTING

National survey of medical students in the United States.

PARTICIPANTS

Medical students in the United States participating in the 2021 to 2022 and 2022 to 2023 residency application cycles.

RESULTS

Among 10,856 applicants during the 2022 and 2023 match years, 1,687 (15.5%) identified as Underrepresented in Medicine (URiM), 1642 (15.1%) were the first generation to attend college, 931 (8.6%) reported a history of food or housing insecurity, and 6104 (56.2%) identified as female. All of these groups were significantly less likely to apply to surgical subspecialties (OR 0.76, p < 0.001; OR 0.81, p = 0.009; OR 0.81, p = 0.041; OR 0.41, p < 0.001, respectively). When adjusting for academic metrics, this association persisted for female applicants (OR 0.58, p < 0.001), and it was the inverse for URiM applicants (OR 1.28, p = 0.016). Applicants with a history of food or housing insecurity had a lower match rate (73.3% vs. 83.4%; p = 0.008) than those without. Interview and match outcomes were noninferior among the other sociodemographic groups historically underrepresented in surgery.

CONCLUSION

Underrepresentation, already pervasive in medicine, is amplified in surgical subspecialties, underscoring the need for applying an equity lens across the continuum of medical education.

Developing a Holistic Rubric for Surgery Residency Interview Evaluations: A Pilot Study for Interview Use

OBJECTIVE

This pilot study evaluated the impact of a revised interview scoring form, incorporating holistic elements, on the assessment of surgical residency applicants.

DESIGN

The study was deemed IRB-exempt. The study team revised the institution's surgery residency interview scoring form to incorporate best practice factors for a more holistic applicant review. ANOVA analysis (p < 0.05) was conducted to compare scores between the old and new forms.

SETTING

Academic surgical residency program.

PARTICIPANTS

Fifteen total blinded applicants' files from match years 2019 to 2021 were reviewed using the new holistic interview scoring form.

RESULTS

Statistical analysis revealed only minor score differences for 4 applicants, with no notable directional bias. The incorporation of holistic elements did not significantly alter overall scoring outcomes.

CONCLUSIONS

The introduction of a holistic interview scoring form aligns with efforts to promote inclusivity in residency selection. Adding nontraditional assessment criteria, such as life experiences, growth mindset, and teamwork, the overall scoring outcomes remained consistent with the previous form. This suggests that traditional and holistic assessment factors can coexist without compromising the fairness of the interview process. Evaluation and revision of interview scoring forms is feasible for any program specialty and is recommended to ensure ongoing inclusion in resident selection practices.

Perceived Barriers to Conducting Holistic Review in Dermatology Resident Selection

This survey study examines potential barriers to the integration of holistic review into dermatology resident selection.

General Surgery Versus Integrated Surgical Sub-specialties: Predictors for Residency Match and Interview Invites Among Surgical Candidates

OBJECTIVE

The goal of this study was to assess predictive factors for receiving interviews and matching in general surgery (GS), cardiothoracic surgery (TS), vascular surgery (VS), and plastic surgery (PS).

DESIGN

The Texas Seeking Transparency in Applications to Residency (STAR) survey was analyzed for match years 2018-2023. Chi-Square Tests of Independence were used to assess differences among participants who received ≥16 vs <16 interviews and, separately, participants who matched vs went unmatched. Odds ratios (OR) for matching were adjusted for board scores, home region, publications, and honors in applicant specialty.

SETTING

All US medical schools participating in the Texas STAR survey from 2018-2023.

PARTICIPANTS

All fourth-year students who completed the survey during the study period.

RESULTS

Of the 2,687 individuals included, 78.15% applied in GS, 13.58% in PS, 4.43% in VS, and 3.82% in TS. Participants had higher odds of receiving ≥16 interviews when having >240 step 1 score vs ≤239 (OR 1.76 (95% CI 1.46-2.12); p < 0.001), >250 step 2 score vs ≤249 (2.42 (2.00-2.91); p < 0.001), honors in their specialty (1.48 (1.21-1.80); p < 0.001), and >5 publications vs ≤4 (1.46 (1.16-1.83); p = 0.001). Odds of matching were lower among PS (0.50 (0.36-0.69); p < 0.001) and TS (0.2 (0.13-0.31); <0.001) compared to GS applicants. Participants had higher odds of matching when having >240 step 1 score vs ≤239 (1.33 (1.04-1.70); p = 0.026), >250 step 2 score vs ≤249 (1.52 (1.20-1.92); p < 0.001), and were more likely to match at a program where they indicated a geographic preference (5.49 (2.58-11.66); p < 0.0001) or program signal (3.87 (1.85-8.11); p < 0.001).

CONCLUSIONS

The novel geographic preferencing and program signal functions were associated with increased match success. More studies are needed to assess the generalizability of these findings.

Public Board Score Reporting Undermines Holistic Review for Residency Selection

Holistic review has become the gold standard for residency selection. As a result, many programs are de-emphasizing standardized exam scores and other normative metrics. However, if standardized exam scores predict passing of an initial certifying exam, this may lead to an increase in board failure rates within specific residency training programs who do not emphasize test scores on entry. Currently, the board pass rates of residency programs from many of the American Board of Medical Subspecialities (ABMS) are publicly reported as a rolling average. In theory, this should create accountability but may also create pressure and distort the way residency program selects applicants. The risk to programs of having a lower board pass rate publicly reported incentivizes programs to focus increasingly on standardized test scores, threatening holistic review. All programs do not recruit students entering residency with an identical chance of passing boards. Therefore, we believe the ABMS member boards should stop publicly reporting raw certifying exam rates above a certain threshold for normative comparison. We strongly encourage the use of learning analytics to create a residency "expected board pass rate" that would be a better metric for program evaluation and accreditation.

Abdominal Transplant Surgeons: The Lack of Female Surgeons and People From Underrepresented Racial and Ethnic Minority Groups in Academic and Clinical Leadership

OBJECTIVES

The demographic disparities among surgeons in academic leadership positions is well documented. We aimed to characterize the present demographic details of abdominal transplant surgeons who have achieved academic and clinical leadership positions.

MATERIALS AND METHODS

We reviewed the 2022-2023 American Society of Transplant Surgeons membership registry to identify 1007 active abdominal transplant surgeons. Demographic details (academic and clinical titles) were collected and analyzed using the chi-square test, the Fisher exact test, and t tests. Multinomial logistic regressions were conducted.

RESULTS

Female surgeons (P < .001) and surgeons from racial-ethnic minorities (P = .027) were more likely to be assistants or associates rather than full professors. White male surgeons were more likely to be full professors than were White female (P < .001), Asian female (P = .008), and Asian male surgeons (P = .005). There were no Black female surgeons who were full professors. The frequency of full professorship increased with surgeon age (P < .001). Male surgeons were more likely to hold no academic titles (P < .001). Female surgeons were less likely to be chief of transplant(P = .025), chief of livertransplant (P = .001), chief of pancreas transplant (P = .037), or chair of surgery (P = .087, significance at 10%). Chief of kidney transplant was the most common clinical position held by a surgeon from a racial or ethnic minority group. Female surgeons were more likely to hold no clinical titles (P = .001).

CONCLUSIONS

The underrepresentation of women and people from racial and ethnic minority groups in academic and clinical leadership positions in the field of abdominal transplant surgery remains evident. White male physicians are more likely to obtain full professorship, and they comprise most of the clinical leadership positions overall. A continued push for representative leadership is needed.

A Practical Guide to Implementing Holistic Review during Surgery Resident Selection

Provider workforce diversity is a key component of improving healthcare quality and addressing healthcare disparities. Furthermore, the traditional approach of "score-centered" application metrics do not consistently correlate with meeting milestones in surgery, nor do they adequately predict a surgical resident's clinical strength and operative abilities. We present here an adaptable process by which surgical residency programs can identify their values and incorporate holistic review into their resident selection process to improve resident selection and physician workforce diversity.