Document from the collections of the AAMC Not to be reproduced without permission ASSMATION OF 2450 N STREET NW AMERICAN IATASHNGTON BE 20037-1126 MEDICAL COLLEGES TELEPHONE (202) 828-0400 October 28, 1991 MEMORANDUM TO: Participants in the Fifth Annual Forum on the Transition from Medical School to Residency Members, National Resident Matching Program Board of Directors FR: August G. Swanson, M. RE: Forum Agenda R- AJ Enclosed is a copy of the agenda for the Forum to be held on Friday, November 8, at the Washington Hilton, 1919 Connecticut Avenue, N.W., Washington, D.C. Included as an agenda item and also enclosed is the April 1991 NRMP Data book. Societies that intend to be represented at the Forum and have not yet informed us should contact Lynn Milas, 202-828-0475, as soon as possible. cc: Presidents of societies not yet registered enclosures
Transcript
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ASSMATION OF 2450 N STREET NWAMERICAN IATASHNGTON BE 20037-1126MEDICAL COLLEGES TELEPHONE (202) 828-0400
October 28, 1991
MEMORANDUM
TO: Participants in the Fifth Annual Forum on the Transition from Medical School to ResidencyMembers, National Resident Matching Program Board of Directors
FR: August G. Swanson, M.
RE: Forum Agenda
R-AJ
Enclosed is a copy of the agenda for the Forum to be held on Friday, November 8, at the WashingtonHilton, 1919 Connecticut Avenue, N.W., Washington, D.C. Included as an agenda item and alsoenclosed is the April 1991 NRMP Data book.
Societies that intend to be represented at the Forum and have not yet informed us should contact LynnMilas, 202-828-0475, as soon as possible.
cc: Presidents of societies not yet registeredenclosures
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MC ASKEIATION OFAMERICANMEDICAL COLLEGES
AGENDA
FOR THE
FIFTH ANNUAL
FORUM ON THE TRANSITION FROM
MEDICAL SCHOOL TO RESIDENCY
FRIDAY, NOVEMBER 8, 19911:30 PM - 4:30 PMJEFFERSON ROOM
Washington Hilton Hotel1919 Connecticut Avenue, N.W.
Washington, D.C.
0
,00
FORUM ON THE TRANSITION FROM MEDICAL SCHOOL TO RESIDENCY
Friday, November 8, 19911:30 p.m.-4:30 p.m.
Jefferson RoomWashington Hilton Hotel
1919 Connecticut Avenue, N.W., Washington, D.C.
1. Participants 1
2. Experiences of 1991 Graduates in Obtaining a Residency
Compared to those of 1987 and 1990 /
3-14
3. The Residency Interview 15-17
• Report of 1990 and 1991 Graduates on Inappropriate Inquiries
During Residency Interviews
4. Improving Evaluation Qualities of Deans' Letter (presentations)
• Comparing Assessments of Medical Students' Potential as Residents
0 Made by Residency Directors and Deans at No Schools
D. Daniel Hunt, M.D.0
Associate Dean for Academic Affairs, University of Washington School of Medicine
• Gass Ranking Models for Deans' Letters and Their Psychometric Evaluation
Robert S. Blacklow, M.D.
Senior Associate Dean, Jefferson Medical College
5. Disability Insurance Programs for Medical Students, Residents, and Fellows 18-19
8
6. AMA-FREIDA Report (presentation)
7. NRMP Report
• 1991 FAX Gridlock 20
• Residency Assignments Outside of the NRMP Match 22
• Reported Matched Applicants Who Did Not Honor Their Commitments 23
• 1991 National Resident Matching Program Data (booklet enclosed separately)
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FORUM ON THE TRANSITION FROM MEDICAL SCHOOL TO RESIDENCY
Friday, November 8, 1991
PARTICIPANTS
PresidingL. Thompson Bowles, M.D., Ph.D.
Immediate Past Chair, AAMC Council of Deans
Organizations(in specialty alphabetical order)
AAMC Group on Educational AffairsReed G. Williams, Ph.D., Chair-elect
AAMC Group on Student AffairsBernice Sigman, M.D., Chair-elect
AAMC Group on Student AffairsJ. Robert Suriano, Ph.D., Chair
AAMC Group on Educational Affairs
Section for Resident EducationStanley M. Kirson, M.D., Chair, Organizing
Committee
AAMC Organization of StudentRepresentativesLawrence Tsen, M.D., Chair
Association of Anesthesiology Program
DirectorsJames E. Cottrell, M.D.
Association of Professors of Dermatology*
Society for Academic Emergency Medicine
Louis Binder, M.D.
Council of Emergency Medicine Residency
DirectorsDavid Sklar, M.D., President
Association of Departments of Family
Medicine*
*Invited
1
Association of Family Practice ResidencyDirectorsJohn W. Saultz, M.D.
Association of Program Directors in Internal
MedicineHerbert S. Waxman, M.D.
National Resident Matching Program
Richard S. Wilbur, M.D., President
Association of University Professors of
Neurology*
American Association of Neurological
SurgeonsDon M. Long, M.D., Ph.D.
Association of Professors of Gynecology and
ObstetricsSharon T. Phelan, M.D.
Association of University Professors of
OphthalmologyRobert E. Kalina, M.D.
Academic Orthopaedic Society*
Association of Academic Departments of
Otolaryngology - Head and Neck Surgery*
Association of Pathology Chairmen, Inc.
William A. Gardner, Jr., M.D.
Association of Pediatric Program Directors*
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PARTICIPANTS(continued)
Association of Academic Physiatrists*
Association of Academic Chairmen of PlasticSurgery*
Association of Teachers of PreventiveMedicine*
American Association of Directors ofPsychiatric Residency TrainingStefan Stein, M.D.Sidney H. Weissman, M.D.
Society of Chairmen of Academic RadiologyDepartments*
Society of Surgical Chairmen*
*Invited
2
Association of Program Directors in SurgeryRobert E. Berry, M.D.
Council of Transitional Year ResidencyProgram DirectorsRichard A. Olafson, M.D., Chairman
Society of University Urologists*
USA Graduate Medical Education OfficeEarl Fauver, MC
USAF Graduate Medical Education OfficeBryant D. Mauk, MCLee Toon, MC
USN Graduate Medical Education OfficeHarriet P. Gordon
it
MOI
EXPERIENCES OF 1991 GRADUATES IN OBTAINING A RESIDENCY
COMPARED TO THOSE OF 1990 AND 1987
Discussions about improving the transition from medical school to residency began with a plenary session at the 1986 AAMC Annual Meeting
in New Orleans. Subsequent to that meeting the experiences of students in obtaining a residency have been monitored for each Annual Forum
through the AAMC's Graduation Questionnaire. The report of the class of 1987 was not different than that of the 1986 graduates. This was
not unexpected because actions tO set November first as the release date for deans' letter, to move the NRMP deadline for submission of rankorder lists to later in the year and to initiate discussions about audition electives and the use of National Board scores for resident selection did
not occur soon enough to affect the experiences of 1987 graduates. Since 1987, there have been definite shifts in students' experiences, generally
in the direction of improving the transition.
This year, 1991 graduates report experiences similar to 1990 graduates. As usual, experiences differ depending upon the type of specialty
program being pursued. The comments below point out the outlier specialties.
Table 1 The percentage of respondents who made a specialty decision before entering medical school increased by 1.6 percentage points
compared to 1987. Orthopedic surgery has had the greatest increase, from 25% in 1987 to 31.4% in 1991. The percent of
students making their decisions in their senior year is greater than in 1987 for all specialties.
Table 2 Thirty-nine percent or more of the respondents report that there are programs in neurosurgery, ophthalmology, orthopedic
surgery, otolaryngology and urology that continue to require completed applications before the November first dean's letter release
date.
Table 3 The percent of respondents who reported that one or more programs required NBME scores increased again. In 1990 76.6%
reported Part I scores were required, in 1991 80.6%. Over 90% reported that programs in neurosurgery, obstetrics, orthopedic
surgery, otolaryngology and surgery required Part I scores.
Table 4 The percent of respondents who reported that one or more programs advised taking an audition elective did not change much for
most specialties. However, reports about neurosurgery at 85.1% and orthopedic surgery at 84.6% were considerably increased
as compared to 1990 when only 64.3% reported such advice from neurosurgery programs and 78.9%, from orthopedic surgery
programs.
Table 5 The percent of respondents who take two or more electives in the specialty in which they plan certification has remained
essentially unchanged since 1987. Orthopedic surgery with 35.6% of respondents reporting two or more electives at other
institutions continues to be the most frequently reported. In 1990, 31.2% of orthopedic surgery candidates reported taking two
or more electives at other institutions.
Table 6 Only 8.9% of respondents reported that one or more programs asked them to make a commitment before the match, down from
11.4% in 1990. Candidates for orthopedic surgery, pathology and physical medicine and rehabilitation continue to report the
highest rates. The percentage of anesthesiology candidates who reported being asked to make a commitment fell from 17.8%
in 1990 to 11.3% in 1991.
Table 7 The average number of days spent away the medical school applying and interviewing for a residency is the same as in 1987 and
increased from 16 days in 1990, to 18 days in 1991. Candidates for neurosurgery programs averaged 30 days and candidates
for urology programs averaged 25 days. Family practice candidates, on average, reported only 14 days away.
Table 8 The number of dollars spent applying and interviewing for a residency increased by 18%, from $1,254 in 1990, to $1,515 in
1991. There has been 30% increase since 1987. Candidates for neurosurgery programs continue to report the highest
expenditures. The $3,553 reported for 1991 is 24% greater than reported in 1990, and 44% greater than in 1987.
Table 9 Pursuit of a residency continues to have a major influence on students' choice of electives and organization of their clinical
education. There has been essentially no change since 1987.
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TABLE 1Percentage of Respondents Applying to Each Specialty Who Reported on When They Decided
on the Specialty or Subspecialty They Desire to Practice'
Since 1989, the Graduation Questionnaire has asked senior medical students whether they experiencedinappropriate or offensive questions in the course of their interviews when applying for residencies. Theresponses to the questionnaire in 1990 and 1991 are shown on the following pages. The number andpercent of respondents who reported inappropriate and/or offensive questioning about several topicsincreased considerably in 1991. The increase may be due to a modification of the wording of thequestion.
In 1991, there was one topic in the Background category and three topics in the Social Support categoryabout which 15% to 27% of the respondents reported they had experienced such questioning by one ormore interviewers.
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Residency Interviews
1990
46a. During your interviews, some of the following topics may have come up. They may have been brought up in anappropriate manner within the context of the conversation (non-threatening, complementary, neutral, or youbrought up); in a manner that you felt was inappropriate for the conversation; or in a manner that waspersonally offensive (threatening, judgmental). Please answer this question by indicating whether a topic wasbrought up in an inappropriate or offensive manner form any of your interviews. (Check all that apply.)
Social SupportPresent/future marital status 9,455 88.1 1,283 11.9Single status 10,037 93.5 701 6.1Stability or interpersonal relationships 10,295 95.9 443 4.1Balancing personal life with residency 9,861 91.8 877 8.2Peer/Family support system 10,520 98.0 218 2.0Couples-matching 10,552 98.3 186 1.7Spousal satisfaction/agreement with:
Spousal employment 10,398 96.8 340 3.2Spousal health status 10,706 99.7 32 0.3
Family PlanningYour/spouse's current pregnancy 10,617 98.9 121 1.1Pregnancy during residency 10,107 94.1 631 5.9Intention to have children 9,956 92.7 782 7.3Children/Managing parenthood 10,342 963 396 3.7
PersonalLevel of commitment to medicine 10,199 95.0 539 5.0Form of contraception 10,703 99.7 35 0.3Sexual preference 10,668 993 70 0.7Physical handicap 10,672 99.4 66 0.6Substance abuse 10,654 99.2 84 0.8Mental illness 10,667 99.3 71 0.7Venereal DiseasP 10,717 99.8 21 02
Other 10,237 953 501 4.7
Non Applicable 747
Total 11,485
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Residency Interviews1991
43. During your interviews, some of the following topics may have come up in a manner that you consider
to be inappropriate or offensive. In the first column, below, please indicate the number of programs
in which you interviewed where each of these topics (if any) was raised by an interviewer in an
Family PlanningYour/spouse's current pregnancy 10,403 97.6 261 2.4
Pregnancy during residency 9,846 92.3 818 7.7
Intention to have children 9,643 90.4 1,021 9.6
Children/Managing parenthood 10,094 94.7 570 5.3
PersonalLevel of commitment to medicine 9,676 90.7 988 9.3
Form of contraception 10,609 99.5 55 0.5
Sexual preference 10,582 99.2 82 0.8
Physical handicap 10,455 98.0 209 2.0
Substance abuse 10,425 97.8 239 2.2
Mental illness 10,472 98.2 192 1.8
Venereal Disease 10,646 99.8 18 0.2
Other 10,381 97.3 283 4.7
Non Applicable 782
Total 11,664
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DISABILITY INSURANCE PROGRAMSFOR MEDICAL STUDENTS, RESIDENTS, AND FELLOWS
The heightened interest in indemnifying medical students, residents, and fellows from the risks associatedwith human immunodeficiency virus (HIV) infection and other hazards has prompted the Association ofAmerican Medical Colleges (AAMC) to explore insurance programs to meet the special needs of itsmembers. A survey of student affairs deans confirmed that the most pressing need was for an adequateand affordable program of disability insurance for medical students, and as a result, the AAMC'sattention has been focused in that area. In May, 1991, the Association announced the availability of twoprograms that offer specially designed disability insurance products for AAMC members. Insurancecoverage for residents and fellows are available, in addition to coverage for medical students. Theprograms require as the sole condition of the offering 100 percent participation of the group eligible forparticipation, as defined by the institution. Thus, an institution may decide to insure only residents, onlythird and fourth year students, or any other predetermined grouping, as long as 100 percent of the definedgroup is enrolled. In June and July, 1991, the AAMC sponsored special information sessions on aregional basis at which representatives from member institutions could learn about the programs.
Key Features of the Insurance Programs
Key features that the Association sought in the development of these programs included the following:
• Guaranteed Issue - coverage for all within the defined group without medical tests orquestions. Both programs also contain exclusions for pre-existing conditions that are quiteliberal by industry standards.
• Broad-based Coverage - not limited to disabilities arising from HIV infection but from anysource. The programs as presented do include provisions for limitation of payout ondisabilities arising from mental/nervous or drug/alcohol-related problems.
• "Own Occupation" Coverage - For residents and physicians (in continuation of coverage),benefits are triggered by an inability to perform the material duties of one's specificoccupation, that is, practice specialty.
• Portability - Medical students and residents, upon completion of the specific trainingprogram, are given the option of picking up the premiums and continuing coverage.
• Future Purchase Guarantees - Medical students and residents, upon completion of coverageand at later dates, are given the option of purchasing increased amounts of insurance inaccord with their increased income, without medical tests or questions.
• Affordability - premium rates that would make it feasible for institutions to purchase suchinsurance for medical students and residents.
Both companies were able to meet these fundamental criteria by designing plans that combined group and
individual disability insurance coverage. Group insurance primarily is used to provide coverage fordisabilities that arise during medical training. Monthly income benefits of between $500 and $2000 aregenerally available. Individual insurance coverage, initially targeted at a low monthly benefit level, is
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in addition and provides a mechanism for guaranteeing to the insured the ability to continue coverage and
obtain additional coverage upon completion of training, without any medical tests or questions.
Premium Costs
The total annual cost for institutions interested in implementing these programs generally ranges from
$50-$100 per medical student and $150-$200 per resident, depending upon the specifics of theinstitutionally-tailored plan.
Principals
While the AAMC was instrumental in the design of these offerings and it negotiated several features thatare exclusive to AAMC members, the program is not formally sponsored by the Association. Nor doesthe Association receive any financial compensation from the companies. The AAMC's intended role hasbeen to be a catalyst in the development of improved insurance offerings for its members. The insurancebrokerages, carriers, and representatives involved in this offering are the following:
1) Medical Group Financial Services, Inc.!University Physicians Trust (contacts: James Andrew and Kenneth Arnold)One Devonshire PlaceSuite 3006Boston, MA 02109(800) 742-0300
Insurance Carriers: The United States Life and UNUM
2) CM Financial Group of Chicago (contact: John Nichols or Rick Cote)Suite 85010 South Riverside PlazaChicago, IL 60606(312) 984-1000
Or
Alexander & Alexander of the Carolinas, Inc. (contact: Steve Barone)
2000 Frontis Plaza Blvd.P.O. Box 2896Winston-Salem, NC 27102(800) 432-3734
Insurance Carriers: Connecticut Mutual and GroupAmerica
(For further information, contact Robert F. Jones, Ph.D., AAMC Assistant Vice President for
Institutional Studies, 202/828-0520.)
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NRMP REPORT
1991 FAX GRIDLOCK
This year, fax machines impeded the rapid process of matching "unmatched" medical students withresidencies.
In the past, the "unmatched" student was allowed to call programs during the 24 hours prior to thegeneral revelation of match results ("match day") in order to obtain a residency. In the three institutionswhere I have worked, the student was provided with a list of available residencies published by theNRMP, and faculty members were available for consultation on the students' options. Although thestudent would inititate the inquiry with a program, many faculty members served as advocates forstudents. As such, the faculty member would actively "present" the student to the chosen program. Theprogram would likely have no records, transcripts, or letters of recommendation on the student, so thatthe integrity of the faculty member presenting the student would be at stake to insure that no student wasbeing "oversold." Based on friendships, networking, reputations, and a spirit of honesty, a facultymember could effectively assist a student to obtain a reasonable residency after failing to match. Thisprocess of advising students was frenetic for one morning, but virtually all "unmatched" students wereplaced with a residency within two hours of the noon starting time.
In 1991, the system fell apart. The cause was a data gridlock due to dependency on facsimile machines.This year, the Albany program had six "unmatched" students who worked with four faculty members forplacement in surgical, radiology, and medical programs. The responses to our telephone inquiries weredisappointing: "Our program director is not available. Fax us some information, and call later thisafternoon." "Our program director will review the fax'ed information tonight and make a decision inthe next two days." "We will review the fax'ed applications and set up interview dates later this week."We found that the facsimile numbers were incessantly busy for several programs. Some programdirectors were unavailable during the period where inquiry was acceptable, and they failed to leave asurrogate with authority to deal with our students. Instead, the response was "Fax us the application."
This will continue to be an important problem, and it can be controlled by the ACGME and NRMP. Isuggest the following:
(1) Facsimile machines are not going to go away. Define a data base acceptable for evaluation bya recipient program. I suggest identification data from the NRMP application, a transcript,NBME scores, a personal statement, a CV if the student wishes, and a summary of the Dean'sletter and all other letters of recommendation. The summary should be prepared by a programdirector and should be brief enough to give an idea of the student's aptitude. The documents willtherefore comprise six or seven pages.
(2) The list of unmatched positions should be made available 48 hours before "match day." For 24hours, students can send information to any program with an open position, but commitmentscannot be made. A faculty member can call for a student to determine the name and telephonenumber of the person with authority to contract with a student under #3 below. Just as theNRMP booklet of unmatched positions gives the telephone number for the educational programoffice of a hospital, central facsimile numbers can be provided. It may be necessary for the
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(3)
NRMP finally to provide departmental telephone and facsimile numbers, rather than the generalinstitutional numbers currently provided.
Commencing noon, 24 hours prior to "match day," a student can telephone to obtain a position.This corresponds to the current process.
(4) Programs are to be strongly discouraged from conducting interviews for open positions after"match day."
( ) For the 48 hour period before "match day," programs with unmatched positions should beencouraged to have a program director or coordinator available. It should be acceptable for anunmatched student to have a faculty member contact programs on his behalf during this period,in lieu of sending application material by facsimile. No deal can be struck, unless the studenthimself or herself calls a program at the 24 hour mark.
Should there be no allowance for the role of the facsimile machines in the process of matching students,there will be increased proliferation of the applications for residency. This will be fueled by fear offailure to match, particularly for those students applying in competitive areas, such as the surgicalspecialties. By applying to a greater number of programs, students will assume that upon failure to matchfor a categorical residency, they will have an application on file in that department for an unmatchedpreliminary position. From the standpoint of residency programs, this will result in an increase inpaperwork and expense.
Please address these issues in order to restore some sanity to the process of matching the "unmatched"student.
Jeffrey L. Kaufman, M.D.Associate Professor of SurgeryBaystate Medical CenterSpringfield, Massachusetts(formerly at The Albany Medical College)
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RESIDENCY ASSIGNMENTS OUTSIDE OF THE NRMP MATCH
Students Who Did Not Enroll or Withdrew* prior to the Match
1990 1991
ProgramsInvolved
# U.S.Seniors
ProgramsInvolved
# U.S.Seniors
Anesthesiology 4 7 3 3
Emergency Medicine 1 1 2 2
Family Practice 19 22 21 23
Internal Medicine & Pediatrics 2 2 2 2
Internal Medicine--Preliminary 8 8 18 18
Internal Medicine--Primary Care 2 2 2 4
Internal Medicine (General) 21 26 36 50
Obstetrics & Gynecology 5 5 5 5
Pathology 21 24 10 14
Pediatrics 13 14 14 16
Physical Medicine 0 0 1 1
Preventive Medicine 0 0 0 0
Psychiatry 8 11 12 14
Radiology, Diagnostic 8 9 2 2
Surgery, General 16 20 23 27
Surgery, Orthopedic 4 7 4 4
Surgery, Preliminary 28 34 25 36
Transitional 7 8 5 5
TOTALS 167 200 185 226
*"Withdrew" includes those who did not submit a Rank Order List
The policies of the NRMP state:
The sole purpose of the Matching Program is to allow both applicants and programs tomake selection decisions on a uniform schedule and without pressure. Both applicantsand programs may try to influence decisions in their favor but commitments prior to thesubmission of Rank Order Lists should not be expected or made. The final preference
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of program directors and applicants at the time of the submission of Rank Order Listswill determine the offering of positions and the placement of applicants.
By signing the NRMP agreement both program directors and applicants agree to abide by this policy.Nevertheless, each year the AAMC follow up survey of the medical schools after the match identifiessome U.S. graduate who withdrew from the match are reported to be in a residency program.
In 1991, general internal medicine programs had the largest number of cases, followed by preliminarysurgery, general surgery and family practice. The total number, 226, is 1.5% of the number of 1991graduates.
REPORTEDWHO DID
MATCHED APPLICANTSNOT HONOR THEIR COMMITMENTS
1990 1991
U.S. Seniors 40 32Released 23 24Not Released 14 5Requested 3 3
Other Matched Applicants 44 34Released 26 24Not Released 18 8Requested 0 2
Totals 84 66Released 49 48Not Released 32 13Requested 3 5
Source: National Resident Matching Program
Each year the NRMP receives a number of reports about matched applicants having failed to fulfill their
commitment to enter the program into which they have been matched. The numbers are not large. In
1990 only 40 U.S. seniors were reported and in 1991, the number fell to 32. The total numbers of 84
in 1990, and 66 in 1991 represent only 0.4% of those matched in 1990 and 0.5% of those matched in
1991.
Program directors who report these occurrences are justifiably upset, but over 50 percent release the
