The Residency Selection Arms Race, Part 3: The Research Arms Race

In 2005, medical students who wanted to match in orthopedic surgery had their work cut out for them.

Back then – just as it is now – orthopedics was one of the most sought after specialties in the Match. Successful applicants had median USMLE Step 1 scores that were higher than those for every other specialty except for plastic surgery and dermatology, and around a third of applicants were members of AOA.

But that’s not all.

Most applicants in orthopedic surgery had done some research as well, with 11% listing >5 research publications (including posters and abstracts) on their ERAS application.

Graphic from the NRMP’s *Charting Outcomes in the Match* report, 2006.

Pretty impressive, huh?

It is… until you compare it to the profile of the average orthopedic surgery applicant in 2022, when 79% of applicants listed >5 research presentations, abstracts, and publications on their residency applications.

Graphic from the NRMP’s *Charting Outcomes in the Match: Senior Students of U.S. MD Medical Schools* report, 2022.

Even more impressive is the shift in the distribution of research output among applicants.

Back in 2005, 35% of applicants matched in orthopedics despite listing zero research products on their application. By 2022, only 3 applicants – 0.6% of all matched applicants – managed to pull that off, while the average future orthopedic surgeon listed 16.5 research items on their application.

And this phenomenon is not limited to orthopedics. In fact, the typical orthopedics applicant has fewer publications than their future colleagues in otolaryngology (17.2), dermatology (20.9), neurosurgery (25.5), and plastic surgery (28.4). Across the board, almost all specialties have seen a 3-fold increase in the number of abstracts, presentations, and publications reported by successful applicants from 2009 to 2022.

Note the growth in research output by residency applicants from 2009 to 2022. (Data from the NRMP.)

Nowadays, the average unmatched applicant in anesthesiology or OB-GYN has 4-5 research items… which is more than twice the number reported by successful applicants in 2009.

How do applicants manage to produce so much more research than their predecessors did just a decade or so ago? After all, medical school is still just 4 years, right?

Right?

Well, for a growing number of applicants who want to match in the most competitive specialties, it’s not.

Around 16% of otolaryngology applicants and nearly a quarter of dermatology applicants take a research ‘gap year’ to lengthen their research CV and enhance their prospects of matching. Meanwhile, official ‘research fellowships’ targeting students or unmatched applicants interested in orthopedics have grown exponentially as shown in the graphic below.

Graphic from Bram JT, et al. *J Surg Educ* 2020. PubMed

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“Yeah, but…”

If you’re about to e-mail me to point out that:

Medical research is generally a good thing for society, so more is better
You personally have a rewarding career in research after starting out doing research just to enhance your CV
There are more venues to publish research now than there were a decade ago
Many medical students have research from their pre-med years
The rise could just reflect more authors per paper
Faculty are under more pressure to produce more research, too, so maybe there’s more interest in research

…let me just save you some time. I get all of that – and my retort to you will be not to lose sight of the big picture.

There is really no explanation for a tripling of research output among residency applicants over the past 15-20 years that is charitable or should lead a reasonable person to think that medical education or medicine as a whole is being made better off. It’s an arms race, pure and simple.

A Soviet intercontinential ballistic missile (ICBM) soars into the sky. During the Cold War, how many nuclear warheads you had was less important than having more than your opponent.

We need to think seriously about where we are – and where we’re headed.

Does doing more research in medical school really lead to better doctors?

Or does it simply encourage quantity over quality; erect barriers to entry for URiM and low SES applicants; calcify prestige hierarchies; prolong already lengthy training pathways; commoditize the ‘least publishable unit’’; incentivize guest authorship and paper mills; and create research pollution and even outright data fabrication?

(Sounds like a good research question to me.)

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