Orphan Applicants in Plastic Surgery: Where Do Medical Students Without an Affiliated Residency Program Match?

  Each year, medical students across the nation meet with advisors from various specialties and ask the same question: What are my chances of matching if I apply to this specialty? This question is particularly difficult to answer when looking at highly competitive programs, such as integrated plastic surgery residency. This is compounded for those who are graduates of medical schools without affiliated residency programs with less academic mentorship, fewer clinical exposures, and reduced opportunities to obtain relevant letters of recommendation.

Although many applicant qualities are universally desired, there is no definitive method for choosing the perfect candidate. Applicant evaluation and rankings by programs are often highly subjective. The same is true for the evaluation of plastic surgery residency programs; however, outside resources have attempted to provide ranking systems that better account for research output, faculty research productivity, institution name recognition, and what fellowships accepted applicants pursue to ranked programs after training completion. This study uses The US News and World Report, Daneshgaran et al, and the Doximity ranking systems to categorize programs and their successfully matched applicants by rank.^1-3

The purpose of this study was to determine where applicants have successfully matched when they do not have a residency program associated with their medical school. The aforementioned ranking systems were used to look at prestige, medical school type (allopathic, osteopathic, and international), and medical school and residency program region. This information was analyzed to determine whether these factors impacted where successful applicants without an affiliated residency program match in plastic surgery from 2016-2021.

The Accreditation Council for Graduate Medical Education website was used to identify programs and the number of resident positions per year that were accredited from 2016-2021.^4,5 Data were obtained and tabulated from individual integrated plastic surgery program websites, social media accounts, and by contacting current residents and program coordinators. The data for each resident included the program to which they matched, medical schools attended, year matched, sex, and medical degree.     

Integrated plastic surgery programs and medical schools were ranked using 3 systems based on rankings by Daneshgaran et al,¹ Doximity,² and research productivity by The US News Report.³ Residency programs within the top quartile were identified using the earlier ranking systems provided by Daneshgaran et al¹ and Doximity,² whereas medical schools were identified as being within the top quartile of programs via the US News Report ranking.³ Allopathic medical schools were categorized as having an associated integrated residency program, not having an affiliated integrated residency program but having an associated independent residency program, or having no residency program associated with their medical school. Osteopathic medical schools and international medical schools were also analyzed, although none of these schools were included in the ranking system by The US News Report.³ US medical schools and residency regions were categorized as Northeast, South, West, and Midwest based on the US Census designation.  

Match data were collected from a total of 1024 applicants from years 2016-2021, accounting for 99.7% of matched applicants during the study period. Residency-related variables included residency region and residency prestige as determined by ranking. Medical school–related variables analyzed included matched applicants’ medical school prestige, medical school region, medical education, and residency program affiliation. Sex of applicants was also tabulated. Statistical analysis was performed using chi-square analysis to determine whether any significant trends existed within the National Resident Matching Program from 2016-2021 with a P value of less than 0.05 considered statistically significant.

Home Institute Selection  

A statistically significant trend was identified (P = 0.04) in the number of internally selected applicants over the study period (Table 1). Programs that selected an applicant from their affiliated medical school within the last 6 years represented 77.5% (62 of 80) of the sample, and 66.3% (53 of 80) of programs had multiple residency positions per year. When only 1 residency position per year was offered, programs were less likely to fill their residency spot with an internal applicant (15.2%) versus when a program had more than 1 position available (38.9%). 

Allopathic Schools Without an Affiliated Integrated Program and Without Any Program   

Between 2016-2021, all but 5 residency programs matched applicants from medical schools without an affiliated integrated program, and all but 12 programs matched applicants that had no integrated or independent program affiliated with their school. Graduates from a medical school associated with an independent residency program represented 7.3% of successful applicants, whereas 15.9% of successful applicants came from programs with no affiliated program. No statistically significant change was found in the number of successfully matched applicants from these types of programs between 2016-2021 (Table 2).

When looking at the top quartile residency programs (Table 3), there is a disproportionate representation of successful applicants from integrated plastic surgery programs. In these programs, approximately 78% of successful matches matriculate from medical schools with associated integrated plastic surgery programs (P < 0.001, Daneshgaran et al; P = 0.005, Doximity). Conversely, approximately 11% of successful applicants who matched in top quartile institutions came from medical schools without an affiliated plastic surgery residency (P < 0.001, Daneshgaran et al and Doximity). There was no statistically significant difference in matching from a program with only an associated independent program (6.5%, P = 0.4, Daneshgaran et al ; 7.2%, P = 0.9, Doximity).

Osteopathic/IMGs

At least 1 graduate from an osteopathic medical school successfully matched every year during the time span analyzed (Table 4), with the greatest number being 3 students in 2019. Of all the residency programs, 25 (29.8%) included IMGs. The lowest number of successfully matched IMGs occurred in 2019 (3), and the year with the most matched residents from IMGs was in 2016 (9).  

Internal Candidates 

As demonstrated in Figure 1, residency programs often selected applicants from within their own affiliated medical school. This study determined that 18.2% of residents matched at the same institution that they attended medical school between 2016-2021 (Table 1). This is consistent with the results previously reported for internal matching in competitive surgical specialties such as plastic surgery (19.6%)⁶ as well as for the otolaryngology match (20%).⁷ Internal matches comprised 20.2 and 21.6% of residents at top-quartile plastic surgery residency programs as ranked by Daneshgaran et al and Doximity, respectively. The residency program found to have the largest number of internal residents was Duke University Hospital with 8 residents. All programs listed in Table 5 were found to match at least 1 internal resident in 5 of the 6 years in this study period. Interestingly, if a program had more than 1 residency position, they were more likely to accept an applicant from their home institution to fill one of those spots (38.9 vs 15.2% for programs with only 1 position).

Affiliated Plastic Surgery Residency Programs 

There are 154 allopathic medical schools in the nation. Currently, 84 allopathic medical schools have affiliated integrated plastic surgery residency programs, 13 have only an affiliated independent program, and 95 have no affiliated program. Overall, fewer applicants who graduated from a medical school without an affiliated plastic surgery residency program successfully matched compared with those who graduated from a school with affiliated programs (Figure 2). There are 163 current residents who graduated from allopathic medical schools with no affiliated programs, representing 15.9% of all matched applicants. Bhadkamkar et al hypothesized this could be due to a lack of strong recommendation letters from home institutions, lack of support provided by program directors from home institutions, or a general lack of exposure to the field of plastic surgery and subsequent disinterest in pursuing this residency.⁸ 

No significant change occurred during the study period in percent composition of residency programs regarding graduates of medical schools without an associated residency program (P = 0.69). When the data was further analyzed as shown in Table 3, however, it does appear that there is a statistically significant difference (P < 0.001) in the number of matched applicants at top quartile residency programs from medical schools without affiliated programs when compared with students with an affiliated home program. Interestingly, the residency program with the most residents from medical schools without an integrated program or without any program (Table 6) was the Cleveland Clinic, a top-ranked residency program.

Osteopathic Graduates 

The overall number of osteopathic medical school graduates has steadily increased; however, their representation in competitive specialties including otolaryngology, neurosurgery, orthopedic surgery, and plastic surgery have not increased comparatively. Osteopathic medical graduates have been shown to be at a disadvantage when it comes to matching into these competitive surgical subspecialties, representing less than 1% of all matches.⁹ This study is consistent with this data, as a total of 10 osteopathic students were found to have matched into integrated plastic surgery residencies between 2016-2021 (Table 4). As shown in Figure 3, this represented less than 1% (10 of 1024) of all matched applicants.

Six programs selected residents from osteopathic medical schools, with graduates being most likely to match at the Cleveland Clinic (3) and the University of South Florida Morsani (2). Other programs that matched with osteopathic applicants included University of Pennsylvania Health System, University of Washington, Indiana University School of Medicine, University of Tennessee College of Medicine, and University of Missouri in Columbia. Of these programs, 3 are in the top quartile.

IMGs

During the 2017 Match cycle, 80% of IMGs failed to match into an integrated plastic surgery residency, whereas 26% of US medical school seniors failed to match.¹⁰ Although this study did not investigate the overall match rate of IMGs, we did find that IMGs represent 3.6% of all successful matches, with 37 IMGs successfully matching between 2016-2021 (Table 4). At least one IMG was included in 25 programs (29.8%). The Mayo Clinic in Rochester was found to be the most likely to match an IMG with 6 total residents, followed by University of Pittsburgh Medical Center with 3 (Table 7).

Female Applicants

Though not a primary endpoint of this study, there was an increase in the number and percentage of successfully matched female applicants from 2016 to 2021 (Table 8). The overall number of successful male candidates has stayed the same, between 90 and 96 annually. However, the overall percentage of male candidates has decreased from 2016 to 2021. Although it was not statistically significant, there is a trend approaching significance (P = 0.06). In 2021, female candidates accounted for 56% of all successfully matched applicants (103), the highest percentage during this study period and the first time that more than 50% of successfully matched applicants were female.  When looking at programs that had at least 1 resident match every year, there were 11 programs with more than 75% male residents whereas there were 3 programs with more than 75% of residents being female. These female resident–predominant residency programs included the Mayo Clinic College of Medicine and Science in Arizona, University of Virginia Medical Center, and the University of Missouri in Columbia. 

Limitations of this study are largely due to the method of data collection. Data were compiled by program website review, social media posts, and conversation with residents and program coordinators, which are incomplete, anecdotal, and variable year to year. This study does not account for the total number of applicants, including unmatched applicants from institutions without a plastic surgery residency program. Although 18.2% of applicants matched at their home programs, conclusions cannot be drawn regarding the likelihood of matching from a school without a plastic surgery residency program. These are interesting areas to explore with further research.

Critically evaluating and reevaluating the match in plastic surgery, or the equivalent specialty-specific system under consideration by the American Council of Academic Plastic Surgeons, is essential for the future of plastic surgery trainees. The transition to pass/fail for the United States Medical Licensing Examination step 1 exam will affect the overall evaluation process. It is thought certain application factors will play a larger role, with research productivity cited to be increasingly important for applicant success, like what was seen in Canada after the transition to pass/fail for the Canadian board examination.^11,12 Evaluating these factors as they shift, especially in light of this major change and the prevalent gender gap within plastic surgery, is extremely valuable for both programs and applicants.  

There are many factors that go into residency selection process, and there is no perfect pathway outlined for students to successfully match into a plastic surgery residency. The data in this study shows that successfully matched medical students without a home integrated plastic surgery program represent a minority, especially in the top quartile of institutions. There continues to be only a few successfully matched allopathic graduates from schools without affiliated programs, osteopaths, and IMGs. Interestingly, specific programs within the top quartile appear to be the most likely place for these groups of applicants to match. Finally, there seems to be an increasing trend in female applicants matching in plastic surgery residency.

Affiliations: University of New Mexico, Albuqerque, NM

Correspondence:  Shawhin Rostam Kadivar Shahriari; shawhin7@gmail.com

Disclosures: The authors have no relevant financial or nonfinancial interests to disclose.