The Changing Landscape of Dermatology Residency Selection

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Dermatology residency programs recruit and train our future workforce. Understanding the changing landscape of residency admission processes, especially from the lens of equity and inclusivity, is imperative.¹ With an increasingly diverse patient population, recruiting underrepresented in medicine (UIM) physicians who may anticipate and understand their patients’ needs and sustain a diverse and equitable workforce should remain a priority.^2-5

Recently, many residency programs have re-evaluated their recruitment and selection strategies, and more changes in the application landscape are imminent. These changes include the shift to pass/fail scoring for clinical rotations and United States Medical Licensing Examination (USMLE) Step 1; use of virtual rotations and interviews, limits on the number of activities that can be described in the application, and mission-based alignment questions; and program signaling and geographic signaling. The current and upcoming residency application changes have the potential for both positive and negative impacts on diversity and equity in our workforce.

Pass/Fail Grading

Traditionally, residency selection processes have relied heavily on “objective” scoring, such as standardized testing and clerkship grading, yet these are imperfect tools for assessment.⁵ The USMLE Step 1 was implemented in 1992 with the intention of state licensure, and was never intended to be used by program directors as a tool for residency selection/screening.¹ However, USMLE Step 1 has been used for residency selection/screening by not only program directors, but also applicants during their program selection process. Yet studies have demonstrated that there is only a moderate correlation between USMLE Step 1 scores and the In-Training Examination, no correlation between USMLE Step 1 scores and overall residency performance, and no data correlating with core/applied exams or certifying board exam success.^5-7 As of January 26, 2022, USMLE Step 1 has transitioned to pass/fail scoring.⁶

This transition in USMLE Step 1 occurs as clerkship gradingis also increasingly becoming pass/fail. In a curriculumreport of more than 150 medical schools in 2021 to 2022, 20 used pass/fail grading for required clinical clerkships, 26 used honors/pass/fail, 82 used honors/high pass/pass/fail, 3 used a numerical grade, 19 used a letter grade, and 9 were using other measures.⁸ UIM medical students have lower third year clerkship grades compared to White students after adjusting for confounding variables, suggesting that implicit bias may play a role in grading.⁹ Research suggests that USMLE Step 1 scores and clerkship grades impact diversity in dermatology.⁹ As we acknowledge they are imperfect tools of assessment, the transition to pass/fail has a positive potential to make our field more approachable for students.

Virtual Rotations and Interview

Adoption of virtual rotations and interviews has had a large financial impact on students.^10,11 A retrospective cohort study of data from the nationwide Texas Seeking Transparency in Application to Residency survey found an average savings of $5000 (P < .0001) for dermatology applicants who attended virtual vs in-person interviews.¹⁰ This change to virtual rotations and interviews benefits those with financial limitations and will likely expand access to dermatology as a specialty choice for UIM medical students. Furthermore, limiting the number of away rotations for dermatology applicants also supports making the process more holistic and equitable.

Historically disadvantaged students or those of lower socioeconomic status may not be afforded the opportunities to pursue a research year or an away rotation, which often incur financial costs to the student.⁶ The advent of limits on the number of activities that can be described in the meaningful activities section of the residency application may level the playing field for dermatology applicants.¹² This will hopefully shift the focus to quality of activities rather than quantity. Furthermore, the incorporation of the supplemental application will allow applicants to highlight qualities that define excellence, including resilience and distance traveled.^5,6,12The application includes a past experiences section and a question regarding “other impactful life experiences.”^5,12 Previous work aimed at reducing health care disparities should also be considered.^4-6 One study proposed a system for defining merit when rating fellowship applicants.⁵ The ranking consisted of evidence of clinical excellence; leadership potential; collegiality; academic curiosity; and diversity competency, or potential for advocating for health equity in the field.⁵

Program and Geographic Signaling

With an increase in the number of competitive applications to dermatology, applicants may feel obligated to spend more time and money on mentorship, research, and away rotations, although post-interview communication and letters of intent are now prohibited.¹² To further alleviate financial burden, program signaling and geographic signaling, in which applicants can indicate their interest in specific programs or geographic locations, were introduced.¹² However, only a weakly positive correlation has been made betweensignaling and receiving an interview invitation, with an overwhelmingmajority of matched dermatology applicants having at least onepersonal connection to programs where they matched.¹³

We caution to avoid reliance on personal connections, word of mouth or prior knowledge of an applicant, school name/reputation, letters of recommendation, and research or scholarly productivity because this will likely disenfranchise UIM medical students, including those without home dermatology programs and students with financial limitations.^4,13 As we restructure our selection processes, we must attempt to eliminate cognitive biases (Table).⁵ For example, the affinity bias is an unconscious bias that causes people to gravitate toward others who appear to be similar to them.^3,5 Affinity bias has been noted in multiple studies as a factor in residency selection and is considered a barrier to diversity.⁵ Similarly, language used in letters of recommendation has been shown to differ between students from historically marginalized racial and ethnic groups relative to White students. 

Conclusion

It is imperative that medical educators rise to the challenge of maintaining diversity and equity in order to find the best possible residents. With the goal of equitable and effective dermatologic care in mind, medical educators should use these changes to our dermatology residency selection review process to re-evaluate which qualities predict physician excellence and attempt to structure selection processes that are inclusive and limit bias.

Delve even deeper into this topic in our accompanying roundtable video, "Bringing Diversity to Dermatology Residency Selection Processes"

Reference

1. Howe A. Supreme Court strikes down affirmative action programs in college admissions. SCOTUSblog. June 23, 2023. Accessed October 26, 2003. https://www.scotusblog.com/2023/06/supreme-court-strikes-down-affi rmative-actionprograms-in-college-admissions

2. Bae G, Qiu M, Reese E, Nambudiri V, Huang S. Changes in sex and ethnic diversity in dermatology residents over multiple decades. JAMA Dermatol. 2016;152(1):92-94. doi:10.1001/jamadermatol.2015.4441

3. Hamilton RH, Rose S, DeLisser HM. Defending racial and ethnic diversity in undergraduate and medical school admission policies. JAMA. 2023;329(2):119-120. doi:10.1001/jama.2022.23124

4. Pritchett EN, Park AJ, Vasquez R. Contextualizing the landscape of diversity, equity, and inclusion in dermatology. JAMA Dermatol. 2023;159(1):19-21. doi:10.1001/jamadermatol.2022.4974

5. Capers Q. Diversifying the physician workforce—from rhetoric to positive action. New Engl J Med. 2023;388(10):865-867. doi:10.1056/NEJMp2211874

6. Isaq NA, Bowers S, Chen ST. Taking a “step” toward diversity in dermatology: de-emphasizing USMLE Step 1 scores in residency applications. Int J Women Dermatol. 2020;6(3):209-210. doi:10.1016/j.ijwd.2020.02.008

7. Fening K, Vander Horst A, Zirwas M. Correlation of USMLE Step 1 scores with performance on dermatology in-training examinations. J Am Acad Dermatol. 2011;64(1):102-106. doi:10.1016/j.jaad.2009.12.051

8. Association of American Medical Colleges. Curriculum reports. Accessed October 26, 2023. https://www.aamc.org/data-reports/curriculum-reports/report/curriculum-reports

9. Costello CM, Harvey JA, Besch-Stokes JG, et al. The role of race and ethnicity in the dermatology applicant match process. J Natl Med Assoc. 2022;113(6):666-670. doi:10.1016/j.jnma.2021.07.005

10. Williams GE, Zimmerman JM, Wiggins CJ, Seervai RNH, Mihalic AP, Ahmed AM. The indelible marks on dermatology: impacts of COVID-19 on dermatology residency Match using the Texas STAR database. Clin Dermatol. 2023;41(1):215-218. doi:10.1016/j.clindermatol.2022.12.001

11. Gorgy M, Shah S, Arbuiso S, Cline A, Russo M. Comparison of cost changes due to the COVID-19 pandemic for dermatology residency applications in the USA. Clin Exp Dermatol. 2022;47(3):600-602. doi:10.1111/ced.15001

12. Bardhi R, Musa A, Daveluy S, Potts G. Sophomore signaling: the second year of the ERAS supplemental application for dermatology residency. J Clin Aesthet Dermatol. 2023;16(4):26-27.

13. Luu Y, Gao W, Han J, Mihalic A, Vandergriff T. Personal connections and preference signaling: a cross-sectional analysis of the dermatology residency match during COVID-19. J Am Acad Dermatol. 2023;88(6):1381-1383. doi:10.1016/j.jaad.2023.01.032