Did More Otolaryngology Residency Applicants Match at Their Home Institutions in 2021? Investigating the Impact of the COVID-19 Pandemic

Introduction

The COVID-19 pandemic posed many challenges for medical students; particularly those who were applying for otolaryngology residency positions in the 2021 Electronic Residency Application Service (ERAS) cycle. Otolaryngology is one of the most competitive specialties to match into. ¹ According to the National Resident Matching Program (NRMP) data from 2020, there were 493 applicants for 350 positions, for an overall match rate of ~71%. ² Rising United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, combined with increasing research productivity and publications per applicant continue to contribute to an already competitive match process. ³

Traditionally, away rotations allow medical students to “audition” for the residency position they are applying for and obtain letters of recommendation from otolaryngologists outside of their home institution. As such, they are thought to have significant impact on residency interview invitations and subsequent match outcomes. ⁴ However, due to national COVID-19 restrictions and a combined statement released by the Society of University Otolaryngologists (SUO) / Association of Academic Departments of Otolaryngology (AADO)/Otolaryngology Program Directors Organization (OPDO) in April 2020 that discouraged away rotations, many students were unable to participate in away rotations during the 2021 application cycle. ⁵

Students without home otolaryngology programs are at a relative disadvantage when it comes to applying for residency. ⁶ On average, such students typically participate in a greater number of away rotations and are less likely to match at their top choice institution. ⁶ For these students, away rotations are of particular significance and offer a chance to put a face and personality behind the name on their application. In addition, these rotations offer an expanded clinical experience and exposure to clinical scenarios and surgical procedures these students may otherwise not see. ⁷ A recent 2019 study demonstrated that students without home programs participate in more away rotations than their counterparts. These applicants are also less likely to match at their top choice institution. ⁶ While these students were not altogether prohibited from participating in away rotations for the 2020-2021 cycle, imposed restrictions limited their choices compared to years prior. For instance, our institution mandated that only students within a 100-mile radius without a home program would be considered for an away rotation. A survey of otolaryngology program directors in October 2020 indicated that over half of otolaryngology program directors surveyed believed that a lack of away rotations would hinder their ability to “evaluate prospective resident[s].” ⁸

While away rotations alone are not enough to ensure a successful match for an applicant, multiple studies have shown that students who match into otolaryngology typically have a geographical tie to the region in which they match (family presence, medical school attendance, away rotation).^9,10 Therefore, away rotations are often used as a tool to “open up” a geographical location of the country that a student otherwise does not have a tie to. Given the severely limited nature of away rotations in 2020 due to the COVID-19 pandemic, we hypothesized that a greater proportion of applicants would match to their home otolaryngology program compared to years prior (2016-2021).

Materials and Methods

Results

We identified otolaryngology residency programs within the United States based on match data published by the NRMP between 2016 and 2021. Traditionally osteopathic programs (n = 9), military programs (n = 6) and “young” programs, defined as programs that did not have a full resident complement (PGY1-5) beginning in 2016 (n = 7) were all excluded from analysis. We also excluded residents classified as PGY>5 (n = 5) as they did not participate in the 2016 match, and residents where medical school information was unavailable (n = 2) (Figure 1). Ultimately, 39 residents were excluded from our analysis.

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Figure 1.

Criteria for inclusion and exclusion of the study. Twenty-three programs were excluded from the study for one of the following reasons: osteopathic programs, military programs, “young” programs, and programs with incomplete data. These 23 excluded programs ultimately resulted in exclusion of 39 residents from the study.

A total of 1885 residents (including PGY0s) from 101 otolaryngology residency programs were included in our statistical analysis (Figure 1). We identified 308 residents from the 2016 Match (PGY5s), 307 from the 2017 Match (PGY4s), 306 from the 2018 Match (PGY3s), 319 from the 2019 Match (PGY2s), 326 from the 2020 Match (PGY1s), and 319 from the 2021 Match (PGY0s) (Table 1).

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Table 1.

Homematch Distribution of PGY 0, 1, 2, 3, 4, and 5.

		Matched elsewhere	Homematch	Total
PGY 0	N	223	96	319
	% within PGY	69.90%	30.10%	100.00%
	% within all homematches	14.90%	24.40%	16.90%
PGY 1	N	263	63	326
	% within PGY	80.70%	19.30%	100.00%
	% within all homematches	17.60%	16.00%	17.30%
PGY 2	N	246	73	319
	% within PGY	77.10%	22.90%	100.00%
	% within all homematches	16.50%	18.60%	16.90%
PGY 3	N	256	50	306
	% within PGY	83.70%	16.30%	100.00%
	% within all homematches	17.20%	12.70%	16.20%
PGY 4	N	248	59	307
	% within PGY	80.80%	19.20%	100.00%
	% within all homematches	16.60%	15.00%	16.30%
PGY 5	N	256	52	308
	% within PGY	83.10%	16.90%	100.00%
	% within all homematches	17.20%	13.20%	16.30%

Note. This table displays the rate of homematches to non-homematches within each PGY as well as the proportion of homematches within each PGY to the overall number of homematches from 2016 to 2021.

The HMP across all programs included in the study ranged from 0% to 100%. Of all the residents, PGY0s had the highest HMP at 30.1% (N = 96), followed by PGY2 (N = 73 [22.9%]) and PGY1 (63 [19.3%]) (Table 1). The average HMP for PGY1s through PGY5s (2016-2020) was 18.9%. Nationally, of all the residents who home matched within the study period, 24.4% came from the 2021 Match (PGY0s).

The distribution of PGY0s who home matched was statistically higher when separately compared to PGY1- 5s. (PGY0 vs PGY 1, 2, 3, 4, 5: 96 [30.1%] vs 63 [19.3%] P = .002, 73 [22.9%] P = .048, 50 [16.3%] P < .0005, 59 [19.2%] P = .002, 52 [16.9%] P < .0005) The home match rate of the PGY3 group was significantly less than that of the PGY2 group (50 [16.30%] vs 73 [22.90%] P = .044) (Figure 2). There was no statistical difference in any other binary combination within PGY1 through PGY5 (Table 2).

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Figure 2.

Trend in home match proportion from 2016 to 2021. This graph displays the percentage of residents from each year that matched at the same institution for residency that they graduated from for medical school.

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Table 2.

Differences in Rate of Homematching Among PGY Classes in P-values.

	PGY 0	PGY 1	PGY 2	PGY 3	PGY 4	PGY 5
PGY 0		.002*	.048*	<.0005*	.002*	<.0005*
PGY 1			.289	.351	1	.471
PGY 2				.044*	.282	.072
PGY 3					.398	.914
PGY 4						.465
PGY 5

Note. This table compares each PGY class to one another to determine statistical difference in homematch rates.

*

Statistical significance at <.05.

Discussion

Otolaryngology has consistently been shown to be among the most competitive specialties in the NRMP Match. Despite confusion created by reporting discrepancies, there has been an increase in pre-Supplemental Offer and Acceptance Program (pre-SOAP) applicants each year since 2017. ¹⁰ According to the NRMP data from 2020, there were 505 applicants for 350 positions, or 0.69 positions per applicant. ² For the 2021 Match, there were 559 applicants for the same number of positions, or 0.63 positions per applicant. ³

Not only are we seeing an increased trend in the number of applicants for a limited number of positions, but the applicants themselves are becoming more competitive. A study conducted by Lenze et al included a subanalysis of the characteristics of matched applicants in the 2021 cycle compared to those of matched applicants in the 2018 to 2020 cycles. A significant increase was shown in the number of abstracts, posters, publications, and peer-reviewed publications among applicants in the 2021 cycle compared to those in the prior years. However, no other applicant characteristics were significantly different. ¹¹ In the 2020 Match, the mean USMLE Step 1 score for matched applicants was 248 compared to 243 for unmatched applicants. Applicants achieved similarly high scores on the USMLE Step 2 (256 vs 249). Applicants also excelled in research, as matched applicants had an average of 13.7 abstracts, presentations, and publications versus 9.5 for unmatched applicants. ² Both matched and unmatched applicants in otolaryngology are among the highest achieving medical students. As a result of this competitiveness, away rotations have become an increasingly useful tool for applicants to make their application stand out in years past.

Due to the COVID-19 pandemic, away rotations were severely limited for the 2020-2021 application cycle. As a result of this, fewer applicants had the opportunity to participate in away rotations and therefore programs had to rely more heavily on other aspects of the applicant’s curriculum vitaes. Anecdotally, there is a predilection for trusting in a known commodity (home program medical student or away rotator) versus an unknown commodity. Our data demonstrated a statistically significant increase in the proportion of applicants who matched to their home institution in otolaryngology in 2021 compared to the previous 6 years. This year, nearly a third (30.1%) of all applicants matched to their home program compared to just 19.3% last year. Further, the average home match proportion from 2016 to 2020 was 18.9%, significantly lower than this year. Nationally, of all the residents who have home-matched over the last 6 years, nearly a quarter of them came from this year’s match. This data suggests that the COVID-19 pandemic may have had an influence on applicants’ program choices and similarly program directors’ evaluation applicants. We believe that the severely limited nature of away rotations during the 2020-2021 application cycle was a major contributing factor to this increased proportion of home matching. Students typically utilize away rotations as a way to network and gain exposure to new programs outside of their home institution. However, the inability to do that left students in the 2020-2021 application cycle with fewer connections to programs outside of their home programs.

Virtual away rotations were a new offering for students in the 2020-2021 application cycle as an alternative to in-person away rotations. These virtual away rotations varied in terms of time commitments as some involved daily activities whereas others met on a weekly or biweekly basis. For example, The University of Pennsylvania implemented a virtual away rotation program that included engaging with surgeons and operating room staff, live streaming surgical procedures, as well as various responsibilities including telehealth, and virtual didactic sessions. Individuals at the University of Pennsylvania conclude that the virtual elective is a good supplement to medical education but should not be considered a replacement of gaining in-person exposure to the operating room and clinic. ¹²

Another opportunity for students to network without doing an in-person away rotation during the 2020 ERAS cycle was via the STAR OTO program initiated by Vanderbilt University Medical Center. STAR OTO is a program that assigned a faculty member from a participating institution to a fourth-year medical student applying to Otolaryngology which allowed students to meet with their assigned faculty member virtually. The students created short video talks and the faculty members provided feedback to them. These short video talks were on various subjects in Otolaryngology and provided students with the opportunity to learn about a certain topic in Otolaryngology while also networking with faculty members from around the country. Many students took advantage of both virtual away rotations and the STAR OTO platform in 2020; however, such rotations and virtual mentorship do not necessarily offer the breadth of experience and commodity that one gains from an in-person away rotation.

The severely limited nature of away rotations during the 2021 application cycle was not the only change to the 2020 ERAS cycle caused by the COVID-19 pandemic. Due to COVID-19 restrictions, virtual interviews were held in lieu of in-person interviews, which are thought to hinder an interviewer’s ability to interact with and evaluate applicants. ¹³ The combination of a lack of away rotations and interviews being held in a virtual format caused the applicants of the 2020 ERAS cycle to have minimal in person experiences. It is unclear if the observed increase in home-match rate was mostly due to the lack of away rotations or virtual interviews; however, both of these changes to the application cycle likely played a role. While away rotations have started to return to their pre-pandemic capacity, it is unclear what role virtual interviews will have in future residency application cycles.

In addition to these changes, the OPDO implemented a 5-token preference signaling system, whereby applicants were able to “signal” programs that they are most interested in an effort to convey an applicant’s interest in specific programs. ¹⁴ It is important to note that applicants were not permitted to “signal” their home program and therefore the preference signaling system should not have increased the home-match rate observed.

Our study is not without limitations. Perhaps the most glaring limitations are the inability to account for clinical research fellows and “defacto home programs.” Many applicants pursue clinical research fellowships at high-volume research institutions for 1 or 2 years before applying. While this is a way for applicants to bolster their research productivity and curriculum vitaes, it also serves as a pseudo-away rotation in that the research fellow works closely with faculty and gives them the opportunity to prove their work ethic and competency. While there is no “official” list of otolaryngology clinical research fellowships, we compiled a list of 18 such clinical research fellowships offering 35+ positions across the country. Anecdotally, applicants who have completed a clinical research fellowship at an institution may be more likely to match to that institution for residency, which is very similar to a home-match. Such applicants were not captured in our data. Furthermore, some medical schools have affiliations with otolaryngology programs that are not technically part of the same institution. Medical students rotate at these affiliated institutions as “home rotators.” Because we could not be confident of all such relationships that exist throughout the country, these “defacto home program” relationships were not included in our study. Future studies should account for these limitations. Additionally, the significant difference in home match rates between the PGY2 and PGY3 groups cannot be explained by the pandemic. Lastly, although we went to great lengths to ensure the accuracy of our data, there were still certain circumstances that we could not correct for. For example, residents who initially matched to a program and then transferred to their home program residency during training would pose an issue to our data. However, we felt that the number of residents that this scenario applied to was negligible.

Conclusion

In conclusion, we found that nearly a third (30.1%) of applicants matched to their home institution for otolaryngology during the 2021 application cycle, a statistically significant increase compared to an average of the previous 5 years (18.9%). While there are likely many reasons for this increase, we believe that the severely limited nature of away rotations due to the COVID-19 pandemic played a large role in this outcome. Further long-term prospective study is warranted to follow the trend during post-COVID period.