Evaluating Residency Applicants: Stable Values in a Changing Market

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1 252 April 1999 Family Medicine Evaluating Residency Applicants: Stable Values in a Changing Market Charles Travis, MD; Christine A. Taylor, PhD; Harry E. Mayhew, MD Background and Objectives: A 1994 study found significant differences in the way family practice and OB-GYN residency directors ranked the importance of components of the residency application package. Family practice residency directors favored qualitative measures (dean s letter, personal statement), and OB-GYN residency directors favored quantitative measures (transcripts, National Board of Medical Examiners score). The authors of the 1994 study hypothesized that the differences could be attributed to specialty competitiveness and philosophy. Our study reexamined family practice rankings of these same application components to determine if the programs, with increased competition for residency positions, had changed their values. Methods: We surveyed all Accreditation Council for Graduate Medical Education-approved residency directors, using the core questions from the 1994 study, plus 2 additional questions. Results: The component rankings in 1997 were virtually identical to the rankings in The new variables, computed to identify competitiveness, failed to elicit any meaningful or consistent differences. Conclusions: Program directors have remained relatively stable in favoring the qualitative aspects of the application package, ranking the dean s letter and personal statement consistently in the top 3 positions. This stability is found across time and independent of success in the National Resident Matching Program and number of US graduate applicants. Residency directors have not increased their reliance on quantitative measures. (Fam Med 1999;31(4):252-6.) Motivated by predictions of inadequate numbers of primary care physicians, federal and state agencies, as well as private foundations, planned initiatives to promote medical student career choice in family practice, general internal medicine, and general pediatrics. Due in part to these efforts, family practice has experienced an increase in popularity as a specialty. The National Resident Matching Program (NRMP) Match rates for family practice residencies have increased from 67.5% in 1992 to 89.1% in 1997, despite an increase in the number of residency programs. 1,2 In a study published in 1994 (reporting on 1993 Match data), Taylor et al 3 investigated the value that residency directors from family practice and OB-GYN programs placed on components of the application package for making decisions about granting students an interview. Taylor s study identified those elements From the Department of Family Medicine, Medical College of Ohio, Toledo. as the dean s letter, the chair s letter, a personal statement, transcripts, application form information, and National Board of Medical Examiners (NBME) scores. Family practice residency directors ranked the dean s letter highest, followed by the personal statement and transcripts, whereas transcripts ranked highest among OB-GYN residency directors, followed by the dean s letter and NBME scores. OB-GYN residency directors ranked the student s personal statement last in importance. Taylor et al offered 2 hypotheses to explain the differences between the specialties. The first is related to the differences in competitiveness of the residency application process. In 1992, OB-GYN programs filled 96.6% of their first-year positions through the NRMP, as opposed to family practice programs, which filled 67.5% of available positions. Wagoner et al 4,5 in 1978 and again in 1984 predicted that greater weight would be placed on academic credentials (eg, transcripts, NBME scores) as competition for residency positions increased. The second, more-philosophical hypothesis focused on the markedly different ranking of the

2 Educational Research and Methods Vol. 31, No personal statement. The authors hypothesized that the disparity in the ranking of the personal statement illustrated that family practice has a more psychosocial orientation in contrast to the more technically oriented specialty of OB-GYN. In light of the current pro-primary care environment, we surveyed family practice residency directors again to test the 2 hypotheses outlined above. If the first hypothesis is true, one would expect that the 1997 cohort would rank the quantitative components (transcripts and US Medical Licensing Exam scores [USMLE]) higher than they had in 1993 because family practice residencies are now more competitive. If the second hypothesis is true, one would expect that the importance of the personal statement would remain as highly ranked as it had been in In addition to the longitudinal comparison between studies, we added an additional comparison based on programs success in the NRMP and the number of US graduates applying to a program. We added these variables because both could influence the decision-making process. Specifically, this study sought to answer the following 2 questions. First, will family practice residency directors, in the current pro-primary care climate, prioritize the usefulness of either the quantitative application components (transcripts and USMLE scores) or the personal statement differently than they did 4 years ago? Second, will family practice residency programs identified as highly successful and with a high number of applicants, as described below, rank the qualitative and quantitative components of the application differently than those programs identified as either less successful or low number? Methods Subjects We obtained a list of family practice residency programs from the 1997 Directory of Family Practice Residency Programs. 6 We surveyed all directors from the Accreditation Council for Graduate Medical Educationapproved residency programs in family practice. Each residency director received a short survey accompanied by a cover letter describing the purpose of the survey. Follow-up letters were used to increase the number of respondents. Procedure The survey consisted of the core questions on the 1994 survey, 2 additional questions pertaining to the residency programs history of attracting applicants, and a short section on program characteristics. Residency directors were asked to share their NRMP fill rates for and to complete the following questions: 1) Do you currently request applicants USMLE scores? 2) Which information would be more meaningful to you, actual scores or pass/fail? 3) Approximately how many applications did you receive from graduates of US medical schools? and 4) Did you grant interviews to all US graduate applicants? Residency directors were asked to rate the usefulness of the individual components of the application package for making decisions about inviting a student for an interview. The application package components included dean s letter, chair s letter, personal statement, transcripts, application form, USMLE scores, and letters of reference. (Letters of reference were not included in the initial study.) The ratings of these application components were used to develop a ranking in which those items rated as highly useful were considered to be the highest-ranked items, those rated as mildly useful were the lowest-ranked items, and those rated as moderately useful were ranked in between. The survey instrument was pilot tested by the faculty of the Department of Family Medicine at the Medical College of Ohio. Faculty suggestions for the clarification of survey items were incorporated in the final draft. Data Analyses We used descriptive statistics to summarize the responses of the participating residency directors. We used a t test that compared mean ranks to examine the 1997 data and used 2 different indicators of recruitment success as the categorical variables. A P value of.01 was set for both analyses. For the 1994 and 1997 comparisons, we collapsed the ranked components into 3 priority categories from an original scale of 1 7. Those categories were highly useful (ranked 1, 2), moderately useful (ranked 3, 4), and mildly useful (ranked 5, 6, 7). These ratings were used to differentiate the highest rankings (highly useful) and the lowest rankings (mildly useful) with the remaining rankings that composed the mid-level (moderately useful). Overall relative rank by cohort (1994 versus 1997) was determined by the percentage of respondents in each cohort who ranked the component in the highly useful category. Although a somewhat arbitrary strategy, it was used in the original published study and will be used to describe differences between the 1994 and 1997 cohorts to remain consistent with the earlier methodology. We used a chi-square goodness-of-fit analysis to compare the responses to the 1994 survey with those from the programs responding again in To examine whether highly successful programs within the 1997 cohort (all 339 programs responding to the 1997 survey) differed in any significant way from less-successful programs in their ranking of application components, the success variable was computed. The success variable was computed by summing the differences between the number of positions offered in

3 254 April 1999 Family Medicine the Match and those reported as filled through the Match for 1994, 1995, and For example, a success score of 3 would indicate that between 1994 and 1996, 3 positions had been unfilled through the Match. For this analysis, the criterion for missed filled positions was set at zero for the highly successful programs. To be included in this category, programs would have had to fill all available positions through the Match in The criterion for less-successful programs was set at 4; that is, programs would have averaged 4 or more missed fill positions over the last 3 years. To address the question of whether the number of applicants per available position would influence the ranking of application components, an additional variable, number, was computed to examine the ratio of US graduate applicants to positions available in the 1996 Match. The number variable was computed by dividing the number of US graduates applying for positions at each program by the number of positions available at that program. For example, if a program reported 350 applicants and 6 first-year positions, one would compute a 350/6 ratio or approximately 58 applicants for every position open. A number score of 58 indicated that a program reported approximately 58 applicants for every 1 first-year position open. The criterion for high numbers was set at 15 applications for each first-year position. The criterion for low number was set at 5; that is, programs would have reported 5 or fewer applicants for each first-year position. For low numbers (less than 5 applicants per position), the upper limit of 15 was chosen because 90 applicants (15 times 6 positions) was considered to be a large enough number that a residency program would consider screening rather than interviewing all reasonable qualified applicants. Five applicants per position (5 times 6 positions) or 30 applicants, on the other hand, were considered to be a realistic number of applicants to interview. These cut-off numbers were chosen after discussions with local residency directors and were set to emphasize polar differences. Results Overall, representatives of 339 residency programs responded to the survey (78%). The responding programs represented a variety of institutional structures, locations, and geographic regions. No significant differences were seen between respondents and nonrespondents based on these characteristics. Of those individuals completing the survey, 91% were residency directors, 8% were associate directors, and 1% held other titles or positions. Respondents averaged 8.19 years (±5.7) at their current residency program and 4.96 years (±4.5) in their current position. When asked the number of US graduates applying to their programs, the respondents reported an average of 140 (range 0 1,000); 10% of the programs reported 24 or fewer applications, and 10% reported 300 or more applications received for the 1996 Match. The median number of applicants was 91. Approximately 50% of responding residency directors reported that they interviewed all of the US graduates who applied. Responding directors approached consensus on the issue of receiving USMLE scores; 91% reported that actual scores would be considered more useful than a pass/fail grade. At the time of the study, 77% of the programs were requesting USMLE Step-One scores, and 69% were requesting Step-Two scores as part of their application process Versus 1997 Comparisons Of the 339 programs that responded to the 1997 study, 260 had also responded to the 1994 study. While we recognize that the residency directors who responded to the current study may not be the same individuals as those who responded in 1994, the following analyses are based on the 260 programs that responded to both studies. In the 1994 study, family practice residency directors ranked the dean s letter highest, the personal statement second, and transcripts third. In 1997, the dean s letter and personal statement again ranked first and second, and the application form replaced transcripts in the third-place position. A chi- square analysis within category found a significant difference between ratings for the USMLE category, even though the relative ranking of fifth was the same for both cohorts. Indicators of Success in Filling Through the Match A total of 156 programs (46%) met the criterion of being highly successful (ie, all available positions filled). Sixty-nine programs (20%) met the criteria for being less successful (4 or more unfilled positions per year). The remaining 114 programs fell in between these 2 criteria and were not included in our analysis. For the highly successful programs, the mean rank for the dean s letter was 3.33, personal statement was 3.60, and transcript was For the less-successful programs, the mean rank for the dean s letter was 3.44, personal statement was 4.14, and transcripts was A t test revealed no significant differences among variables. Table 1 summarizes the comparisons based on the success variable. Indicators of High Numbers of Applications A total of 125 programs (37%) met the criterion for high number (15 applicants per position). Forty-eight programs (14%) met the criterion for low number (less than 5 applicants per position). For the programs identified as high number, the mean rank for the dean s letter was 3.80, the personal statement was 4.08, and letters of reference was For the low-number programs the dean s letter was 3.34,

4 Educational Research and Methods Vol. 31, No Table 1 Mean Ranks Comparisons Between Family Practice Programs, Based on Success in the NRMP High Success* Low Success* Component Mean Rank Mean Rank Dean s letter Personal statement Transcripts Letters of reference USMLE scores Application form Chair s letter Ratings scale 1 7 * To be defined as highly successful, programs would have filled all available positions through the NRMP in The criterion for less-successful programs was set at 4. See the Methods section for a complete description. NRMP National Resident Matching Program USMLE US Medical Licensing Examination personal statement was 3.51 and letters of reference was Again, the t test analysis revealed no significant differences when comparing mean ranks based on number of applications per available position. Table 2 summarizes the comparisons based on the numbers variable. Discussion We hypothesized that the increased competitiveness enjoyed by family practice residency programs in 1997 might lead residency directors to place a greater emphasis on the quantitative aspects of the application package (ie, transcripts and USMLE scores) than they had when the original study was completed. This hypothesis was only partially verified by our findings. The 1997 cohort did rank USMLE scores as more useful (19% of the directors rated USMLE scores as highly useful as opposed to only 12% of the 1994 cohort). However, the 1994 cohort ranked transcripts as more useful than their 1997 counterparts. As a result, it would be difficult to verify that family practice residency programs in 1997 were more apt to value these quantitative measures. Both the 1994 and 1997 cohorts, however, included programs that were highly successful and those that were consistently less successful, even in the morepositive 1997 market. In response to this limitation, the 1997 data were analyzed in such a way that we could compare and contrast the highly successful programs with those who had a more-varied history of recruiting through the Match. By looking at these comparisons, we might be better able to determine if the more competitive programs were more likely to use USMLE scores and transcripts as screening tools for applicants. The t test analyses produced no significant differences based on either the success variable or the number variable. Based on these analyses, we have concluded that the directors of family practice residency programs have remained relatively stable in their evaluation of quantitative measures, rating them consistently in the third to fourth relative position, based on both analyses. This stability is found across time and independent of success in the Match and number of US graduate applicants. The second hypothesis, stability of the value placed on the personal statement, was also supported by this study. Family practice residency directors continued to place great weight on the applicant s personal statement. The personal statement was ranked as either 1 or 2 by all groups. Even in the more-competitive climate enjoyed by family practice residency programs in 1997, residency directors continued to rely on this component of the application package when choosing students to interview. Limitations Although requesting a priority ranking of application components is a reasonable and even usual approach to measuring the value placed on these components, this methodology does not lend itself to sophisticated analyses and results in a limitation for this study. To remain consistent with the earlier published analysis used in the 1994 study, the 1994 and 1997 comparisons were done using the ranks and chi-square analysis. Since the dependent measure was a 7-point scale, however, it could be treated as a continuous variable. Therefore, we chose a mean ranks analysis for the new Table 2 Mean Ranks Comparisons of Family Practice Programs, Based on Number of US Applicants Per Position Offered Through the NRMP Component High Number* Low Number* Dean Personal statement Letters of reference Transcripts USMLE scores Form Chair Ratings scale 1 7 * To be defined as high number, the number of applications was set at 15 applications for every 1 first-year position. The criterion for low-number programs was set at 5. See the Methods section for a complete description. NRMP National Resident Matching Program USMLE US Medical Licensing Examination

5 256 April 1999 Family Medicine computed variables. A second limitation of the study is that the we only elicited the opinions of residency directors. The choice of a resident is a complex matter, usually involving other residency faculty and sometimes current residents. This study does not address these other decision makers opinions. Conclusions Although all residency programs are interested in recruiting bright, academically gifted students, it is clear the family practice residency directors place greater emphasis on students stated attitudes and aptitude for family practice. These findings should encourage students to devote time and effort into thinking through their personal beliefs about the practice of medicine and writing an articulate and sincere personal statement. Residency directors in family practice should also take note of these findings and maintain their emphasis on recruiting academically gifted individuals who express a philosophy of medicine consistent with the principles of family practice. Correspondence: Address correspondence to Dr Taylor, Medical College of Ohio, Mulford Library Building, 3045 Arlington Ave, Toledo, OH Fax: ctaylor@mco.edu. REFERENCES 1. Association of American Medical Colleges. AAMC data report: results of the National Resident Matching Program for Acad Med 1992; 67: Association of American Medical Colleges. AAMC data report: results of the National Resident Matching Program for Acad Med 1997; 72: Taylor CA, Mayhew HE, Weinstein L. Residency directors responses to the concept of a proposed electronic residency application service (ERAS). Acad Med 1994;69(2): Wagoner NE, Gray GT. Report on a survey of program directors regarding selection factors in graduate medical education. J Med Educ 1979;54: Wagoner NE, Suriano JR, Stoner JA. Factors used by program directors to select residents. J Med Educ 1986;61: American Academy of Family Physicians. Directory of family practice residency programs. Kansas City, Mo: American Academy of Family Physicians, 1997.

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