For the past couple of days, my timeline has been full of headlines about how medical students are avoiding states with more restrictive abortion laws.
The headlines are tantalizing… but are they true?
I’m skeptical.
(🧵)
If you’ve somehow missed all of this, here’s a typical article (which happens to be the one I screenshotted above).
…and here’s the analysis by the @AAMCtoday, which used Electronic Residency Application Service data to find a decrease in U.S. MD graduates applying to residency programs in states with more restrictions on reproductive health.
Then, they looked at how many ERAS applications were sent to residency programs in those state groups.
Last year, applications from U.S. MD applicants were down across the board.
But applications ⬇️ most in states with abortion bans; a little less in states with gestational age restrictions; and the least in states where abortion remained legal.
The effect was largest in OBGYN.
There are several things about the AAMC’s numbers that don’t make sense to me, but for now, I’m gonna set all that aside and take their figures as fact - because even then, there are some strange things.
Only *two* states saw an increase in applicants: Montana (30.3%) and Delaware (3.7%). Both of these are states where abortion remains legal.
But then again, so is the state that saw the biggest drop in applicants: New Mexico (-19.3%).
Some red states saw big decreases - e.g., Texas dropped by 11.7%.
But Washington (blue) had an even bigger drop - in both relative (13.7%) and absolute terms (-1521 vs. -1499).
Similarly, abortion-banned Indiana (-9.1%) saw a smaller drop in applicants than abortion-legal California (-9.2%).
Oregon (-13.7%) had a bigger drop than Tennessee (-12.7%).
Colorado (-10.6%) had a bigger decrease than North Dakota (-9.8%).
Wait, what?
If the decline in applicants is driven by a desire to avoid abortion restrictions - or even with other political/social factors that are collinear with abortion restrictions - shouldn’t applicants be flocking to the bluest states?
Or is something else going on?
Beyond any state-by-state breakdown, the big story in the AAMC analysis is the decline in applications OVERALL.
So IMHO, we should also look at the state breakdown through the lens of what is driving this unprecedented decrease in applications:
And that’s preference signaling.
Dobbs wasn’t the only big thing that changed in residency application over the past couple of years.
Among other things, the AAMC also introduced geographic preference signaling, in which applicants can signal up to three regions of interest.
And when I look at the state-by-state results, they seem to conform better to the ERAS geographic signaling map than the KFF map.
If you’re unfamiliar with preference signaling, or the strategy behind effective preference signaling, I’d invite you to watch the guide for applicants I made last year:
The Applicant’s Guide to Strategic Preference Signaling
Briefly - because applications are expensive (and geographic preference signaling is free), it makes sense for many applicants to target most of their residency applications within regions for which they’ve indicated a geographic preference.
Thing is, you can only signal three geographic regions… and these regions aren’t created equally.
And yes, yes, yes - many applicants have strong desires to be in one geographic region or another. But ALL applicants have a strong desire to successfully match.
The ERAS regions that attract the *fewest* geographic preference signals from applicants are the “West North Central” (yellow), “East South Central” (pink), Mountain West (blue), and “West South Central” (dark red).
And these are the states with the greatest ⬇️ in applicants.
In contrast, the New England (purple), Middle Atlantic (orange), South Atlantic (light blue) and “East North Central” (green) have greater program density and attract more geographic signals - and applicants.
And these states were most protected against a decline in applicants.
I think this best explains why a state like Kentucky (-15.4%) did worse than West Virginia (-12.0). Both states are abortion-banned - but one is in a more favorable ERAS region.
Similarly, Minnesota (-12.5%) did much worse than neighboring Wisconsin (-6.3%) - but it’s stuck in the yellow region. Meanwhile, Indiana’s decrease (-9.1%) was similar to that in abortion legal states like Maine (-8.8%) and Connecticut (-9.3%).
None of this is to say that applicants aren’t motivated by the political climates in states where they apply. But that was true pre-Dobbs, too.
I’m certain some applicants are strongly motivated by this issue. I’m just skeptical it’s of the magnitude the AAMC suggests.
Totally forgot to say:
This probably also explains the AAMC’s otherwise-puzzling finding that the avoidance of abortion-limited states only applies to MD applicants, not DOs or IMGs.
Although the greatest density of prestigious programs within ERAS regions is in the East Coast/Great Lakes, the regions with the greatest density of DO- and IMG-friendly programs are in other regions (where states tend to have more abortion restrictions).
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Last week, a Nepali doctor filed a class action lawsuit against the National Board of Medical Examiners, alleging discrimination based upon national origin and requesting that invalidated USMLE scores be restored while examinees appeal.
The court will issue a ruling by February 21 - so the outcome of the suit remains uncertain.
Still, the NBME’s filing provides additional details on the scope of the scandal, how the cheaters were caught, and what’s likely to happen in the future.
First, the NBME confirmed the number of examinees involved.
According to their filing, 832 examinees have had at least one of their USMLE scores invalidated… so far.
This week, a Nepali doctor and Match applicant whose Step 1, Step 2 CK, and Step 3 scores were all invalidated has sued the NBME.
The NBME will respond by February 19, and the court will render a decision by February 21.
(🧵)
The suit alleges that the NBME did not follow its own policies by invalidating scores before the involved examinees had an opportunity to appeal.
The suit also alleges violations of the Civil Rights Act due to discrimination based on national origin and ethnicity, based on the USMLE’s initial statement that the scandal was “associated with Nepal.”
Big changes may be coming for internal medicine residency applicants in the 2024-2025 application cycle…
The @AAIMOnline is recommending:
-⬆️ preference signals from 7 to 15 (3 gold, 12 silver)
-capping interviews at 15
-no interviews before November 1
Increasing the number of signals will likely function as a soft application cap, as we’ve seen in other specialties.
Many IM programs will still evaluate/interview applicants who don’t signal - but many others will receive so many signaled applications that they’ll stop there.
This will shift the dominant application strategy from “Apply to as many programs as possible” to “How do I most effectively allocate my preference signals?”
Applicants who signal wisely will benefit… those who don’t will suffer.
If you want to become a pediatric subspecialist, you’ve gotta do a fellowship.
For most subspecialties, that fellowship lasts 3 years.
But most of that time isn’t spent learning clinical medicine. It’s spent doing research.
Ever wondered why these fellowships last so long?
🧵
The short answer is, “because the American Board of Pediatrics requires it.”
But why?
For instance, in many specialties, a resident can choose between a 2-year clinical or a 3-year academic fellowship. The ABIM accepts either… but the ABP only accepts the latter.
To find the answer, we’ve gotta go back to the early 1980s.
At that point, peds heme-onc was a 2-year fellowship. But PDs felt trainees needed more training time to attain clinical proficiency.
So they asked the ABP if they could increase ⬆️ their fellowship from 2 to 3 years.
For weeks, I’ve waited patiently for preliminary application data for the 2023-2024 residency application to be released by the AAMC.
And today they dropped.
So you know what that means.
Yup, that’s right.
It’s time to break it down, Winners & Losers style™️.
(🧵)
LOSER: Application Fever.
For years, the biggest theme in the ERAS opening data is some variation of “What incredibly large number of applications are being submitted now?”
Applicants are still submitting lots of applications… but many specialties are DOWN from last year.
When you look at the overall application numbers, you’ve got to remember that these figures consider all comers (MD, DO, IMG). But there are important differences between these groups.