Results of the 2001 Match: A Shot Across the Bow?

Joseph B. Cofer, MD, FACSProfessor of Surgery

Program Director

University of Tennessee College of MedicineChattanooga Unit Department of Surgery

Chattanooga, Tennessee

• Applications to the nation’s medical schools fell 3.7% in 2000 in the fourth straight year of decline

• The decline was 6% in 1999

• The applicant / acceptance ratio has dropped from 2.7 in 1995 to 2.1 in 2000

Barzansky, JAMA, 286:9,2001

Women constituted 43% of U.S. graduates in 2001 (up from 42.6% in 2000) and 46% of total first year enrollment (up from 45.8% in 2000)

Barzansky, JAMA, 286:9, 2001

Nursing Vacancy Rate

University of Cincinnati Hospital > 20%

Erlanger Hospital, Chattanooga, TN 8.6%

Estimated National Rate 11-20%

Fischer, Bulletin, ACOS, 86:8, 2001

Personal Communication

The average age of a registered nurse in the U.S. in March 2000 was 45.6 years.

Associated Press, Sept. 9, 2001

“If current trends continue, the nation will face a shortage of half a million nurses by 2020. The nursing shortage in our country is increasing, and it places our system of medical care at risk.”

Secretary Tommy Thompson, Health and Human Services, Sept. 28 , 2001

• Decreasing medical school applications• Changing demography of applicants• Nursing shortage• Shortage of ancillary personnel• Early retirement of physicians• Surgeons refusing to take call• Diverse societal issues

Fischer, Bulletin, ACOS, 86:2001

“There is a freight train headed down the track and it’s pointed directly at the fragments of what previously was a good to excellent medical system”

Fischer, Bulletin, ACOS, 86:2001

Conclusions

The environment has changed!

– Worsening nursing shortage

– Decreasing medical school applicant pool

– Increasing relative numbers of female medical students

– Societal issues

U.S. Seniors Matched to PGY-1 General Surgery

891

928915

890 883

853840

874

820

760780800820840860880900920940

1993 1994 1995 1996 1997 1998 1999 2000 2001

PGY-1 General Surgery

57

4539

31 35

55 55

73

92

0102030405060708090

100

1993 1994 1995 1996 1997 1998 1999 2000 2001

PGY-1 General Surgery

Foreign Trained Physicians Matched to PGY-1 General Surgery

Number of Programs Ranked by U.S. Senior Students to Obtain a Categorical PGY-1 Position in the Match (Total Applicants Including FMG’s)

1996 1997 1998 1999 2000 2001

11.2 10.9 9.6 9.6 9.1 8.2

(13.8) (13.5) (11.7) (11.7) (11.0) (9.9)

Match Results for U.S. Seniors Who Choose One Type of Specialty (General Surgery)

Students Matched

Students Unmatched

Ttl Students -GenSurgery Only

% BySpecialty

% Unmatched

2001 1063 50 1113 9.0 4.5

2000 1125 89 1214 9.7 7.3

1999 1120 97 1217 9.4 8.0

1998 1109 88 1197 9.3 7.4

1997 1156 202 1358 10.5 14.9

1996 1185 272 1457 11.2 18.7

1995 1209 258 1467 10.3 21.3

Ratio of U.S. Applicants Choosing a Specialty with the Number of Categorical Positions Available in that Specialty – 2001 Match

0.1Radiology – Diagnostic1.8Family Practice

Psychiatry

Internal Medicine

General Surgery

Preventive Med /Public Health

Neurology

Pathology

1.5

1.5

1.5

1.7

2.0

2.0

0.8Orthopaedic Surgery

0.6Physical Medicine

0.5Anesthesiology

0.5Plastic Surgery

0.1Radiation – Oncology

0.1Dermatology

Positions Ranked and Filled in 2001 by U.S. Senior Students

No. Ranks /Position

No. Ranks / Position

8.2

10.4

10.6

11.2

11.8

13.3

Internal Medicine

Anesthesia

Psychiatry

Family Practice

Pathology

Neurosurgery

4.7General Surgery

4.6Plastic Surgery

3.8Orthopaedic Surgery

3.2Radiation – Oncology

2.2Dermatology

0.8Radiology – Diagnostic

Old vs. New Study• Original study (1996 – 1999)

– 90 programs (1,312 residents)Am J Surg

181(44);2001

• New study (1996 – 2001)– 49 programs (of original 90)– 17 programs (new additions)

66 total programs (1,556 residents)

Total Residents in Study(% of Residents Matched That Year)

1996 1997 1998 1999 2000 2001

Old Study

305

(30.4)

323

(32.0)

337

(32.9)

347

(34.3)— —

New Study

251

(25.0)

252

(25.0)

253

(24.7)

262

(26.0)

266

(26.0)

272

(28.0)

230

YEAR

1999199819971996

Mea

n P

art

1 sc

ore

225

220

215

210

205

200

PROGSIZE

4 or fewer residents

5 or more residents

Programs In Original Sample Providing 6 Years of Data

Programs From Original SampleNot Providing 6 Years of Data

YEAR1999199819971996

Mea

n P

art

1 sc

ore

230

225

220

215

210

205

200

PROGSIZE

4 or fewer residents

5 or more residents

Programs Providing Data After the Original Study Was Published

YEAR

200120001999199819971996

Mea

n P

art

1 sc

ore

230

225

220

215

210

205

200

PROGSIZE

4 or fewer residents

5 or more residents

Conclusions• Small programs that were exhibiting a

downward trend in Part I scores, and contributed data to the first study, did not contribute to the second study

• Small programs that were exhibiting an upward trend in Part I scores and who had not contributed data to the first study, added their 6 years of data to the second study

• Was this a Hiesenberg effect?

YEAR

200120001999199819971996

Mea

n

20

18

16

14

12

10

PROGSIZE

4 or fewer residents

5 or more residents

Means of Square Root of Total Number of Surgical Applicants From U.S. Medical Schools

YEAR

200120001999199819971996

Mea

n26

24

22

20

18

16

14

PROGSIZE

4 or fewer residents

5 or more residents

Means of Square Root of Total Number of Applicants to U.S. Surgery Programs

(U.S. + Foreign)

YEAR

200120001999199819971996

Mea

n

3.0

2.9

2.8

2.7

2.6

2.5

2.4

2.3

2.2

2.12.0

PROGSIZE

4 or fewer residents

5 or more residents

Analysis of Square Root of the Ratio of Applicants to Interviews Granted

YEAR

200120001999199819971996

Mea

n P

art

I Sc

ore

230

225

220

215

210

205

200

PROGSIZE

4 or fewer residents

5 or more residents

Mean Part I Scores of All Residents

YEAR

200120001999199819971996

Mea

n p

art

1 sc

ore

240

235

230

225

220

215

210

205

200

PROGSIZE

4 or fewer residents

5 or more residents

Mean of Part I Scores of First Resident Matched

YEAR

200120001999199819971996

Mea

n P

art

I Sc

ore

240

235

230

225

220

215

210

205

200

PROGSIZE

4 or fewer residents

5 or more residents

Means of Part I Scoresof Last Resident Matched

Private

282725

1,007

216222

0 – 4> 5

University

213212

2120 – 4

Hybrid

42263

223> 5

2212130 – 4

No. of Residents

Mean Part I Board Scores

No. of Categorical PGY-1 Spots

No. of Residents

131210987654321

Ad

just

ed M

ean

Par

t I

Scor

e240

230

220

210

200

Mean Part I Score vs. Program Size Adjusted for Differences Between Years

YEAR

200120001999199819971996

Per

cent

age

AO

A.5

.4

.3

.2

.1

0.0

Percentage of All Matched Categorical Residents Who Are AOA

YEAR

200120001999199819971996

Per

cent

age

AO

A

.5

.4

.3

.2

.1

0.0

PROGSIZE

4 or fewer residents

5 or more residents

Percentage of All Matched Categorical Residents Who Are AOA by Program Size

YEAR

200120001999199819971996

Per

cent

age

.5

.4

.3

.2

.1

0.0

Percentage of First Matched Residents Who Are AOA

YEAR

200120001999199819971996

Per

cent

age

.50

.40

.30

.20

.10

0.00

Percentage of Last Matched Residents Who Are AOA

YEAR

200120001999199819971996

Med

ian

ran

k20

15

10

5

0

Median Rank List Position of All Residents Matched (p= .000)

YEAR

200120001999199819971996

Med

ran

k li

st p

osit

ion

30

25

20

15

10

5

0

PROGSIZE

4 or fewer residents

5 or more residents

Median Rank List Position of Matched Residents by Program Size

YEAR

200120001999199819971996

Med

ian

ran

k5.0

4.0

3.0

2.0

1.0

0.0

Median Rank List Positionof First Resident Matched

YEAR

200120001999199819971996

Med

ian

ran

k

25

20

15

10

5

0

Median Rank List Position of Last Resident Matched

YEAR

200120001999199819971996

Med

ian

ran

k

40

30

20

10

0

PROGSIZE

4 or fewer residents

(p = .12)

5 or more residents

(p = .003)

Median Rank of Last Resident Matched by Program Size

The overall quality of medical students applying for a surgical residency has declined over the last six years.

Mean 2.7 – Disagree (P=.04)

The number of medical students wishing to go into general surgery has declined over the last six years.

Mean 3.4 – Agree (P=.01)

Activities of medical schools and medical school deans to encourage medical students to go into family practice or primary care has hurt recruitment for general surgery residents.

Mean 3.6 – Agree (P=.000)

Conclusions

• The USMLE Part I Scores are increasing over time

• The % of our PGY-1’s who are AOA is declining

• Big programs attract residents with higher board scores

Conclusions

• The applicant pool may be shrinking

• General surgery is not as competitive a residency to obtain as some other more lucrative and less rigorous careers in medicine

• Decreasing numbers of FMG’s applying, but more matching

• Going deeper into the rank list to fill

Conclusions

U.S. Surgical Residency Program Directors do not think that the quality of their categorical PGY-1 residents has declined, but they do feel that the applicant pool is shrinking, and that Medical School Deans are contributing to this decline in the desire of medical students to become surgeons.

Conclusions

• The popularity of general surgery as a specialty is declining– Increase in unfilled categorical PGY-1 spots– Decreasing number of programs needed to

rank to obtain a spot• If you are a U.S. senior medical student, there

is a 95% chance you can be a surgeon if you want to