Last week the Coalition for Physician Accountability released a report recommending comprehensive reforms to improve the transition between medical school and residency. The Coalition’s Undergraduate-Graduate Medical Education Review Committee (UGRC) included 34 recommendations spanning nine themes. The report’s authors strongly encourage related stakeholders to work together to implement the recommendations in full, as together they will “create better organizational alignment, likely decrease student costs, reduce work, enhance wellness, address inequities, better prepare new physicians, and enhance patient care.”
The Charge
The UGRC’s initial charge was to address the following documented problems occurring in the transition between medical school and residency, as well as to uncover other existing issues. The report noted that the impact of these problems has grown over time resulting in significant stress to the system.
Disproportionate attention towards finding and filling residency positions rather than on assuring learner competence and readiness for residency training
Unacceptable levels of stress on learners and program directors throughout the entire process
Inattention to optimizing congruence between the goals of the applicants and the mission of the programs to ensure the highest quality health care for patients and communities
Mistrust between medical school officials and residency program personnel
Over reliance on licensure examination scores in the absence of valid, trustworthy measures of students’ competence and clinical abilities
Lack of transparency to students on how residency selection actually occurs
Increasing financial costs to students as well as opportunity costs to programs associated with skyrocketing application numbers
The presence of individual and systemic bias throughout the transition; and
Inequities related to specific types of applicants such as international medical graduates
A Common Framework to Assess Students’ Clinical Skills
At its core, the report calls for changes that promote standardized ways to evaluate and assess medical students in a meaningful and equitable way. More specifically, the report suggests that less weight should be placed on the USMLE numerical scores and the emphasis should shift to a standardized and comparable assessment of students’ performance in a clinical setting. The report recommends that medical schools and residency programs work together to define a framework and set of competencies with which to measure students as they make the transition from medical school to residency.
The report’s recommendations also seek to increase efficiency in matching students with residency programs. The number of applications submitted per student continues to rise, as medical students fear that they will not find a placement so expand their reach. A recent AAMC article noted that the average number of residency applications per student in 2016 was 87.7 and in 2020 was 95. Among international medical student graduates, who often face a tougher time finding a spot, the average is 136. The process is a huge generator of stress for medical students, their advisors, as well as residency program directors. “This year, we received 5,800 applications for 24 positions. It’s just not possible to thoroughly review most of them,” explains Richard Alweis, MD, a UGRC committee member and associate chief medical officer for medical education at Rochester Regional Health in New York. Not surprisingly, the 2020 National Resident Matching Program Director Survey reported that just under half (49 percent) of applications receive an in-depth review.
The UGRC’s recommendations seek to provide stakeholders involved in the application, selection, and placement processes with better information and support in an effort to reduce the number of submitted applications. Students, they contend, need access to better information to appropriately gauge their likelihood of acceptance while residency programs need better ways to cull their applicants by updating and improving technology to provide effective and equitable filters for applications. Additionally, the UGRC encourages the entire eco-system to innovate and implement pilot programs to reduce the friction associated with matching medical students to residency placements.
Next Steps
While there is great optimism around the release of UGRC’s report, because of the comprehensive nature of the recommendations and the number of critical players involved, there is still considerable work to be done. Each of the 13 member organizations making up the Coalition is independently run; each organization will determine what recommendations they will enact and the timeline. And despite its support, the AAMC’s statement reacting to the final report emphasized a need to move with caution and carefully consider what, if any, unintended consequences may occur as a result of enacting recommendation(s). However, while the timing for change is unclear and the speed may be slow, there is unprecedented agreement within the member organizations around the need for change and improvement for students, residents, medical advisors, and resident program directors. “For the past 10 years or more, we've been stuck in the same place… The recommendations are a monumental step in breaking through that,” said Grant Lin, MD, PhD, a pediatric resident at Stanford Health Care in California and a member of the UGRC committee.