Thread by @jbcarmody

It’s no secret that the number of residency applications per candidate has been rising.

In 2007, the average U.S. senior applied to 32 residency programs; the average IMG, 79.

By 2018, that was up to 60 and 136.

Why? Who benefits from “Application Fever?”

(thread)

You might think that candidates are forced to apply to more programs because it’s harder to match now than in the past.

Not true. Overall match rates have not changed for U.S. medical students, and have actually improved slightly for IMGs.

Another way to look at it is to consider the number of residency positions available per applicant.

In 2007, there were 0.78 residency positions for every applicant (1.44 per U.S. graduate).

In 2018, there were 0.81 positions/applicant (1.61 for every U.S. graduate).

Hmmm...

Yet as programs get overwhelmed with applications, a smaller percentage of candidates get interviewed - which contributes to students’ perception that they need to apply to more and more programs.

For example:

A total rockstar who applies to a not-so-competitive program may not be offered an interview.

From the program’s standpoint: “She’s not gonna come here - why waste our time?”

From the student’s: “This process is so random! I need to apply to more programs!”

Or a solid candidate who applies to 20 similar programs may only get interviews offered at half - even though the programs are all similarly competitive.

The more applications students submit, the more capricious the process seems - and in response, the more applications students submit.

Repeat this process iteratively over a decade and you get a graph like the one above.

Applicants are stuck in a Prisoner’s Dilemma, as highlighted nicely in this analysis:

ncbi.nlm.nih.gov/pubmed/27413430

In this Prisoner’s Dilemma, each applicant does best by overapplying. There is no incentive for an individual student to apply to an ‘ideal’ number of programs.

But if you consider outcomes beyond an individual’s Match rate, it’s clear that application fever hurts us. It fuels #Step1Mania, advantages candidates who pay more, increases student stress/debt, burdens PDs, and does absolutely nothing to benefit patients or society at large.

So should we expect ERAS or the NRMP to intervene to help us get to an ideal outcome for all applicants? One that might benefit society as a whole?

Well, applying to residency programs ain’t cheap. Here’s the current ERAS fee schedule:

students-residents.aamc.org/applying-resid…

Note that all of their examples are for students applying to a number of programs well below the national average.

So let’s do the math for an “average” U.S. student applying to 60 programs:

$99
+(10x$14)
+(10x$18)
+(30x$26)
___________
$1199

When you consider that there were 37,103 Match applicants in 2018... that’s a lot of money.

Where does all that money go? To the AAMC, sponsor of ERAS.

The financial fortunes of the AAMC have risen alongside application fever. Note that revenue from ERAS has more than doubled over the past decade, dramatically outpacing growth in the AAMC’s other programs.

And remember, the AAMC’s top executives are handsomely compensated.

AAMC President Darrell Kirch received reportable compensation of $1,986,987 in 2016.

So no, we should not expect the AAMC to prescribe the antipyretic we need for “application fever.”

If we want a solution, we’re gonna have to do it ourselves.

#ApplicationFever

(For anyone who needs a more durable link to these data, I posted them on my site.)

thesheriffofsodium.com/2019/03/02/the…