A uniform third-year application and offer date for pediatric fellow applicants: Pro and con
Article Outline
Abbreviations: AAP, American Academy of Pediatrics, ABP, American Board of Pediatrics, ARP, Accelerated research pathway, FOPO, Federation of Pediatric Organizations, NRMP, National Residency Matching Program, SAP, Special alternative pathway
In 2005, the Resident Section of the American Academy of Pediatrics (AAP) recommended to the Federation of Pediatric Organizations (FOPO) that uniform application date (July) and offer date (November) be established for all pediatric fellow applicants in the third year of pediatric residency training. A discussion by the members of the Association of Medical School Pediatric Department Chairs led to a consensus of support for a third-year offer date, with some Chairs expressing reservations. Currently FOPO recommends this policy, but general acceptance by the pediatric subspecialty community has not yet occurred; the following opinions express pros and cons:
Pro: F. Bruder Stapleton, MD
In 1952, the National Residency Matching Program (NRMP) was created to improve the residency application process for both students and programs. Before the NRMP, students were faced with the decision of accepting time-limited offers from highly competitive programs before they had visited the menu of residencies they wished to consider. Residency programs competed for students early during medical school, before the students developed a clinical track record. The NRMP appears to meet the needs of students and residency programs.
The “uniform fellowship application and offer dates” proposal attempts to create a similar opportunity for fellow applicants. Currently, residents may apply for fellowship positions anytime during residency. Some pediatric subspecialties have successful national fellowship matches—usually during the second year of residency. Written applications are accepted on a rolling basis for most programs. Some programs use the web-based electronic residency application service (ERAS) system.
For specialties without a national match program, residents are sometimes under pressure to accept an offer before visiting all of their potential programs of interest. The request from pediatric residents indicates that our current system is not working for them. Similarly a 2001 survey of 8932 internal medicine residents planning subspecialty careers found that 70% supported a uniform match, and 71% favored fellowship appointments in October or December of post-graduate year 3.1
A major impetus for the residents’request is the limitation of elective experiences during the early year(s) of pediatric residency. This problem has been accentuated by the 80-hour work-week restrictions. Currently, some residents, while trying to decide on a potential career choice, must apply for fellowships before having elective experiences in their desired subspecialty area.
The extant fellowship application system also has disadvantages for fellowship directors. Recommendations for some applicants may be based on performance as interns, without opportunity to observe an applicant in the position of a supervising resident, which demonstrates a different set of skills.
Many concerns about adopting uniform offer and match dates in the third year have been centered on the perceived best interests of residents. Because fellow applicants are usually older than resident applicants, it is possible that they may have purchased homes, are married, balance 2 careers, and are parents. Some believe that an early decision on a fellowship program offers residents more time and opportunity to plan. This argument would be more compelling if residents, themselves, were not asking for a later offer date.
Legitimate questions are raised about a later offer date by program directors, who must fill their programs and plan for positions in training grants. Providing fellowship positions to highly qualified international applicants also will be a challenge. Considerable time and expense is required for international applicants to obtain visas. Concerns have been raised about how a uniform offer date might be monitored; a national fellowship match has been advanced as one means. This would be complicated to implement and would require consensus among multiple subspecialties, characterized by heterogeneity in number of applicants.
Another proposal is the recommendation of a uniform application date. This could be controlled (monitored) by the release of applications to fellowship programs by ERAS. Such a program has been implemented for fellowship applicants in Internal Medicine.
A number of resident pathways exist for future physician scientists, for example, the special alternative pathway (SAP) and the accelerated research pathway (ARP). Flexibility in a standard application and offer date would be necessary to accommodate the multiple training pathways. Only 6 residents nationally entered the SAP in 2003, 10 in 2004, and 5 in 2005; 4 residents pursued the ARP in either 2003 or 2004 (American Board of Pediatrics, 2006, written communication).
In summary, I favor a uniform application and offer date in the third year of residency, as well as a match for all pediatric subspecialties. This is what the residents, the consumers of our fellowship programs, are asking from us. The best time for an offer date/match remains to be determined. A date earlier in the fall may be more functional; however, any change in the current appointment system should focus on the best educational and personal interests of the residents.
Con: Samuel E. Lux, MD
There are 2 questions: (1) Should there be uniform application and offer dates, and (2) Should these be in July and November; my answer to both is no. I favor subspecialty matches, or alternatively a specific offer date. In subspecialties without a match or offer date, residents are often pressured into a premature decision. Dates of such decisions tend to creep backward because of pressure to sign fellows before the competition. A match or specific offer date abolishes these abuses. I favor a match over a common offer date because a match optimizes decisions for both candidates and programs. A common offer date still creates considerable pressure on candidates who have offers but are waiting for an offer from their top choice. Similar uncertainties exist for programs. A common offer date is also more difficult for couples than a subspecialty couples match.
Having all subspecialties offer positions on a common date would be popular and effective. However, one major logistical problem is freeing residents for interviews. In some pediatric residencies, 50% to 85% of the residents pursue subspecialty training. With a common offer/match date, interviews will be held in the 2 to 3 months before the date. If the average resident applies to 6 programs and needs 1 day off for interviews and another for travel, each resident will need 2 weeks off during this interval. For programs with many subspecialty-bound residents, a substantial fraction of their residents would be gone every day during the interview period. Having the interviews occur during the summer, when many faculty are on vacation, will further complicate the process.
It is critical that any common match/offer process include all fast-tracking candidates; they are among the most sought-after applicants. There will be too many opportunities for gamesmanship and covert deals if they are exempted. There are now several fast-tracking options, but as long as the American Board of Pediatrics (ABP) maintains the current SAP, it will be impossible for residents in that pathway to participate in a match or common offer date that occurs after early June, since they must apply to the ABP and take the board examination during July and August. Under the proposed rules, SAP candidates would need a special early acceptance process and would have a large advantage because at the time they were accepted, programs would have no idea about the composition of the standard offer/match pool. Fall candidates would not yet have applied. Fast-trackers are not rare in some programs; 32% of our fellows over the years have been fast trackers, and, even with the new pathways, many continue to do the SAP.
A November match will penalize programs that depend on foreign (noncitizen) fellows, who must have a visa to obtain a license and begin work. Being ineligible for training grant (T32) funding, foreign applicants often have to organize funding for their research years. This takes a lot of time and usually cannot start until they are accepted into a program. Programs need 6 to 12 months notice if a fellow does not get funded to find funds within their own system. Cutting 6 months off the total process would be problematic.
Spouses need time to find jobs; many are not in medicine. Many fellows are married with children, requiring larger houses and strong spousal jobs to support higher living costs. Decisions about jobs and housing need to be made by April, which would be less than 5 months from a November offer or match day.
Fellows need as much time as possible to find a laboratory or a clinical research mentor. Beginning the search during the PL3 year is very advantageous. Nearly all PL3 programs include large blocks of elective time, some of which can profitably be used for career exploration. Approximately half of our fellows decide on their research before the start of their fellowship. The choice of research experience during fellowship is the most important decision in an academic physician’s life, even more important than the choice of specialty, in my opinion. Few physicians ever deviate from the research path they embark on in fellowship. Fellows need time to make this choice judiciously.
Most fellows can make up their minds before the mid-May hematology/oncology match. Less than 5% of our applicants spend an extra year after residency because they could not decide in time. Of course, most residents will say they want to delay the choice of fellowship as long as possible, because the decision is such a large one. Given a reasonable deadline, residents will choose, and I am willing to bet that few finishing fellows would have chosen differently if given 6 more months to consider their options. A match/offer date late in the PL2 year allows residents sufficient time to sample subspecialties that interest them, especially if programs offer appropriate elective time in the PL1 and PL2 years.
In summary, I favor a common offer or match day in late spring of the PL2 year for all pediatric subspecialties if the logistical problems of allowing large numbers of residents time off to interview can be solved. However, the proposed date in the fall of the PL3 year is a bad idea.
If, however, a single subspecialty offer/match day is logistically unacceptable to programs that train large numbers of subspecialty-bound pediatricians, I still favor having all pediatric subspecialties participate in a match/common offer date to protect residents and optimize their chances of obtaining the best fellowship. In that event, match/offer dates for different subspecialties would need to be spread throughout the PL2-PL3 year, with the more research-intensive specialties—those favored by fast-tracking candidates—scheduled earlier.
The fellowship selection process needs to balance the needs of the majority of residents who know what fellowships they want and need to begin planning their fellowship research, with the needs of the few who are uncertain. A match or uniform offer date late in the PL2 year best balances these competing needs. The date in the fall of the PL-3 year proposed will create more problems than it will solve.
Reference available at www.jpeds.com
Reference
PII: S0022-3476(06)00814-6
doi:10.1016/j.jpeds.2006.08.041
© 2006 Mosby, Inc. All rights reserved.
