Letters COMMENT & RESPONSE
Gift Horse To the Editor As a program director, I enjoyed the viewpoints shared by Christophel and Levine1 regarding the deluge of applicants received by otolaryngology residencies. Don’t get me wrong: I wish there were a process that allowed me to spend less time reviewing applications and arrive at a match perfect for our program. However, I wonder whether the downsides proposed in their Viewpoint are evident. First, the authors state that the sheer number of applicants causes a loss of fidelity in the selection process. If this were true, one consequence of this would be matching applicants who were not suited for the specialty, for that institution, or for that program. This might be manifested in an increased attrition rate. According to data compiled by the Accreditation Council for Graduate Medical Education, the attrition rate seems to be stable (Table 1), although this may be a lagging indicator. Second, the authors are concerned that the hoarding of interviews—and subsequent last-minute cancellations—by applicants is problematic in that it leads to unfilled interview spots and fewer interviews to unmatched applicants. The latter issue actually seems desirable in that fewer interviews are being “wasted” on less likely candidates. Regarding the former issue, the consequence of unfilled interview spots could be manifested in a decreased program match rate. However, Table 2 shows the match rate to be stable. The authors suggest that one solution would be for programs to publish typical criteria for matched residents, citing examples such as mean board score, AΩA Honor Medical
Society membership status, and publications. However, programs using such easily quantifiable criteria can already utilize tools in the National Resident Matching Program software to quickly screen for such applications, if they find such a strategy desirable. Yet there have been publications that show that such criteria are poor predictors of resident success.7,8 Perpetuating the use of such criteria to dissuade would be applicants may not be the best strategy in selecting for the best future otolaryngologists. I am grateful that otolaryngology is in a position where we get bright candidates and have a high program match rate and a low attrition rate. Is the residency selection process arduous? Sure. Every year I try to second-guess applications, and I wrestle over whom to grant interviews. It is good to proactively troubleshoot problems in the system before they occur, taking care not to be too reactive. Right now, I’ll accept this gift horse, although I still try to look in its mouth. C. W. David Chang, MD Author Affiliation: University of Missouri, Department of Otolaryngology–Head and Neck Surgery, Columbia. Corresponding Author: C. W. David Chang, MD, University of Missouri, Department of Otolaryngology–Head and Neck Surgery, 1 Hospital Dr, MA314, Columbia, MO 65212 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Christophel JJ, Levine PA. Too much of a good thing. JAMA Otolaryngol Head Neck Surg. 2014;140(4):291-292. 2. Accreditation Council for Graduate Medical Education Data Resource Book. Academic Year 2012-2013. Chicago, IL: Accreditation Council for Graduate Medical Education. https://www.acgme.org/acgmeweb/Portals/0/PFAssets
Table 1. Residency Attrition Dataa No.
Residents Not Graduating From a Program, %
Deceased
Dismissed
Transferred
Unsuccessful Completion
2012-2013
0.9
0
4
3
0
6
2011-2012
1.5
0
2
6
0
14
2010-2011
0.8
0
0
2
0
9
2009-2010
1.1
0
0
8
1
7
2008-2009
1.4
0
2
6
NA
12
Year
Withdrew
Abbreviation: NA, not applicable. a
Accreditation Council for Graduate Medical Education Data Resource Books.2-5
Table 2. Match Dataa Year
Match Spots Offered, No.
Unfilled Spots, No.
% Filled
2013
292
2
99.3
2012
285
2
99.3
2011
283
3
98.9
2010
280
1
99.6
2009
275
2
99.3
a
jamaotolaryngology.com
See National Resident Matching Program, Results and Data.6
JAMA Otolaryngology–Head & Neck Surgery July 2014 Volume 140, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015
677
Letters
/PublicationsBooks/2012-2013_ACGME_DATABOOK_DOCUMENT_Final.pdf. Accessed May 6, 2014. 3. Accreditation Council for Graduate Medical Education Data Resource Book. Academic Year 2011-2012. Chicago, IL: Accreditation Council for Graduate Medical Education. http://www.acgme.org/acgmeweb/Portals/0/PFAssets /PublicationsBooks/2011-2012_ACGME_DATABOOK_DOCUMENT_Final.pdf. Accessed May 6, 2014. 4. Accreditation Council for Graduate Medical Education Data Resource Book. Academic Year 2010-2011. Chicago, IL: Accreditation Council for Graduate Medical Education. https://www.acgme.org/acgmeweb/Portals/0/PFAssets /PublicationsBooks/2010-2011_ACGME_DATA_RESOURCE_BOOK.pdf. Accessed May 6, 2014. 5. Accreditation Council for Graduate Medical Education Data Resource Book. Academic Year 2009-2010. Chicago, IL: Accreditation Council for Graduate Medical Education. http://www.acgme.org/acgmeweb/Portals/0/PFAssets /PublicationsBooks/2009-2010_ACGME_DATA_RESOURCE_BOOK.pdf. Accessed May 6, 2014. 6. National Resident Matching Program. Results and Data: 2013 Main Residency Match. Washington, DC: National Resident Matching Program; 2013. 7. Calhoun KH, Hokanson JA, Bailey BJ. Predictors of residency performance: a follow-up study. Otolaryngol Head Neck Surg. 1997;116(6, pt 1):647-651. 8. Chole RA, Ogden MA. Predictors of future success in otolaryngology residency applicants. Arch Otolaryngol Head Neck Surg. 2012;138(8):707-712.
In Reply We appreciate the comments by Dr Chang and are similarly grateful for the “problem” of excess applicants to our field. We did not mean to imply that the burden of excess applicants is burdensome to those reviewing applications; we will gladly look through more electronic applications if it means a better match for students and programs. Said in other words, the position of our Viewpoint is that excessive initial applications causes the selection process to rely more and more on the initial electronic application and less on the interview process, which we believe to be better in finding a “match.” Dr Chang’s point is true that there has not been a loss of fidelity yet. We attribute this to the still-strong applicant pool and the ceiling effect. With these conditions, the initial intake filter (selection for an interview) can be sloppy, and programs will still accrue high-quality residents, but this is not fair to applicants because we maintain that the shotgun approach puts the weight of applicant selection on the initial electronic application. Regarding the last-minute interview cancellations, Dr Chang is again correct in pointing out that there are not more unfilled spots. However, the same point applies; there remains such an influx of high-quality applicants that programs fill, but they fill with those who have a strong initial electronic application because fewer interviews are able to be offered to applicants who may be “diamonds in the rough.” If we are correct in noting that the current application process fosters a shotgun approach by medical students, the average initial application numbers should increase again this year when the National Resident Matching Program and Electronic Residency Application Service (ERAS) surveys are released. Medical students are not to be blamed for this behavior, because “survival of the fittest” mandates that they send out an excess number of applications to secure an interview and to secure a match. We are not alone in noting this trend. As stated in a recent New York Times article1 about college application numbers, there is “the opposite of a virtuous cycle at work. Kids see that the admit rates are brutal and drop678
ping, and it looks more like a crapshoot. So they send more apps, which forces the colleges to lower their admit rates, which spurs the kids next year to send even more apps.” We hope this conversation continues and results in an improvement in the application process with less financial burden on the medical students. While we do not claim to have the answer to fixing the system, in addition to the ideas discussed in our editorial, we offer the following food for thought. Instead of approaching this problem from an a priori “here’s how and why applying to residency should happen” let’s approach it from a top-down perspective. Should the application numbers continue to rise and every medical student send out an electronic application to every program, the function of ERAS would be defeated. This situation would be untenable, yet we are more than halfway there. J. Jared Christophel, MD, MPH Paul A. Levine, MD Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System, Charlottesville (Christophel, Levine). Corresponding Author: J. Jared Christophel, MD, MPH, University of Virginia, PO Box 800713, Charlottesville, VA 22908-0713 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Pérez-Peña R. Best, brightest, and rejected: elite colleges turn away up to 95%. The New York Times. April 8, 2014. http://www.nytimes.com/2014/04/09 /us/led-by-stanfords-5-top-colleges-acceptance-rates-hit-new-lows.html. Accessed May 7, 2014.
Davies and Welch Draw Unfounded Conclusions About Thyroid Cancer From Epidemiological Data To the Editor In the article by Davies and Welch, “Current Thyroid Cancer Trends in the United States,”1 the authors draw some questionable conclusions and make potentially dangerous suggestions. Davies and Welch1 assert that the rise in thyroid cancer rates can be attributed to a rise in subclinical papillary thyroid cancer (PTC) tumors discovered incidentally, such as in “serendipitous detection.” They base this solely on statistical analyses of Surveillance, Epidemiology, and End Results (SEER) data. However, at least 2 studies2,3 find 12.4% or less of patients have nodules discovered during imaging for a different purpose. Significantly, the incidence of large tumors has not declined,4 and worldwide, World Health Organization rates indicate a rise in incidence in many countries that do not have easy access to imaging. As incidence has risen and mortality remained the same, Davies and Welch1 draw the conclusion of overdiagnosis and warn of the “harm” of the presumed phenomena. They reject the concept that early diagnosis can help avoid the development of aggressive and fatal cancers, and that surgical knowledge and techniques have greatly improved over the past 30 years and may account for the stable or improved mortality rate. It is illogical and unfounded to presume that increased awareness of patients’ thyroid nodules will pose harm. Rather, it is the lack of knowledge of these that is potentially dangerous. If anything, many patients are underdiagnosed as having preoperative indications of benign condition or singular indolent tumor, with postsurgical pathology confirming higher-
JAMA Otolaryngology–Head & Neck Surgery July 2014 Volume 140, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015
jamaotolaryngology.com
Gift Horse To the Editor As a program director, I enjoyed the viewpoints shared by Christophel and Levine1 regarding the deluge of applicants received by otolaryngology residencies. Don’t get me wrong: I wish there were a process that allowed me to spend less time reviewing applications and arrive at a match perfect for our program. However, I wonder whether the downsides proposed in their Viewpoint are evident. First, the authors state that the sheer number of applicants causes a loss of fidelity in the selection process. If this were true, one consequence of this would be matching applicants who were not suited for the specialty, for that institution, or for that program. This might be manifested in an increased attrition rate. According to data compiled by the Accreditation Council for Graduate Medical Education, the attrition rate seems to be stable (Table 1), although this may be a lagging indicator. Second, the authors are concerned that the hoarding of interviews—and subsequent last-minute cancellations—by applicants is problematic in that it leads to unfilled interview spots and fewer interviews to unmatched applicants. The latter issue actually seems desirable in that fewer interviews are being “wasted” on less likely candidates. Regarding the former issue, the consequence of unfilled interview spots could be manifested in a decreased program match rate. However, Table 2 shows the match rate to be stable. The authors suggest that one solution would be for programs to publish typical criteria for matched residents, citing examples such as mean board score, AΩA Honor Medical
Society membership status, and publications. However, programs using such easily quantifiable criteria can already utilize tools in the National Resident Matching Program software to quickly screen for such applications, if they find such a strategy desirable. Yet there have been publications that show that such criteria are poor predictors of resident success.7,8 Perpetuating the use of such criteria to dissuade would be applicants may not be the best strategy in selecting for the best future otolaryngologists. I am grateful that otolaryngology is in a position where we get bright candidates and have a high program match rate and a low attrition rate. Is the residency selection process arduous? Sure. Every year I try to second-guess applications, and I wrestle over whom to grant interviews. It is good to proactively troubleshoot problems in the system before they occur, taking care not to be too reactive. Right now, I’ll accept this gift horse, although I still try to look in its mouth. C. W. David Chang, MD Author Affiliation: University of Missouri, Department of Otolaryngology–Head and Neck Surgery, Columbia. Corresponding Author: C. W. David Chang, MD, University of Missouri, Department of Otolaryngology–Head and Neck Surgery, 1 Hospital Dr, MA314, Columbia, MO 65212 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Christophel JJ, Levine PA. Too much of a good thing. JAMA Otolaryngol Head Neck Surg. 2014;140(4):291-292. 2. Accreditation Council for Graduate Medical Education Data Resource Book. Academic Year 2012-2013. Chicago, IL: Accreditation Council for Graduate Medical Education. https://www.acgme.org/acgmeweb/Portals/0/PFAssets
Table 1. Residency Attrition Dataa No.
Residents Not Graduating From a Program, %
Deceased
Dismissed
Transferred
Unsuccessful Completion
2012-2013
0.9
0
4
3
0
6
2011-2012
1.5
0
2
6
0
14
2010-2011
0.8
0
0
2
0
9
2009-2010
1.1
0
0
8
1
7
2008-2009
1.4
0
2
6
NA
12
Year
Withdrew
Abbreviation: NA, not applicable. a
Accreditation Council for Graduate Medical Education Data Resource Books.2-5
Table 2. Match Dataa Year
Match Spots Offered, No.
Unfilled Spots, No.
% Filled
2013
292
2
99.3
2012
285
2
99.3
2011
283
3
98.9
2010
280
1
99.6
2009
275
2
99.3
a
jamaotolaryngology.com
See National Resident Matching Program, Results and Data.6
JAMA Otolaryngology–Head & Neck Surgery July 2014 Volume 140, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015
677
Letters
/PublicationsBooks/2012-2013_ACGME_DATABOOK_DOCUMENT_Final.pdf. Accessed May 6, 2014. 3. Accreditation Council for Graduate Medical Education Data Resource Book. Academic Year 2011-2012. Chicago, IL: Accreditation Council for Graduate Medical Education. http://www.acgme.org/acgmeweb/Portals/0/PFAssets /PublicationsBooks/2011-2012_ACGME_DATABOOK_DOCUMENT_Final.pdf. Accessed May 6, 2014. 4. Accreditation Council for Graduate Medical Education Data Resource Book. Academic Year 2010-2011. Chicago, IL: Accreditation Council for Graduate Medical Education. https://www.acgme.org/acgmeweb/Portals/0/PFAssets /PublicationsBooks/2010-2011_ACGME_DATA_RESOURCE_BOOK.pdf. Accessed May 6, 2014. 5. Accreditation Council for Graduate Medical Education Data Resource Book. Academic Year 2009-2010. Chicago, IL: Accreditation Council for Graduate Medical Education. http://www.acgme.org/acgmeweb/Portals/0/PFAssets /PublicationsBooks/2009-2010_ACGME_DATA_RESOURCE_BOOK.pdf. Accessed May 6, 2014. 6. National Resident Matching Program. Results and Data: 2013 Main Residency Match. Washington, DC: National Resident Matching Program; 2013. 7. Calhoun KH, Hokanson JA, Bailey BJ. Predictors of residency performance: a follow-up study. Otolaryngol Head Neck Surg. 1997;116(6, pt 1):647-651. 8. Chole RA, Ogden MA. Predictors of future success in otolaryngology residency applicants. Arch Otolaryngol Head Neck Surg. 2012;138(8):707-712.
In Reply We appreciate the comments by Dr Chang and are similarly grateful for the “problem” of excess applicants to our field. We did not mean to imply that the burden of excess applicants is burdensome to those reviewing applications; we will gladly look through more electronic applications if it means a better match for students and programs. Said in other words, the position of our Viewpoint is that excessive initial applications causes the selection process to rely more and more on the initial electronic application and less on the interview process, which we believe to be better in finding a “match.” Dr Chang’s point is true that there has not been a loss of fidelity yet. We attribute this to the still-strong applicant pool and the ceiling effect. With these conditions, the initial intake filter (selection for an interview) can be sloppy, and programs will still accrue high-quality residents, but this is not fair to applicants because we maintain that the shotgun approach puts the weight of applicant selection on the initial electronic application. Regarding the last-minute interview cancellations, Dr Chang is again correct in pointing out that there are not more unfilled spots. However, the same point applies; there remains such an influx of high-quality applicants that programs fill, but they fill with those who have a strong initial electronic application because fewer interviews are able to be offered to applicants who may be “diamonds in the rough.” If we are correct in noting that the current application process fosters a shotgun approach by medical students, the average initial application numbers should increase again this year when the National Resident Matching Program and Electronic Residency Application Service (ERAS) surveys are released. Medical students are not to be blamed for this behavior, because “survival of the fittest” mandates that they send out an excess number of applications to secure an interview and to secure a match. We are not alone in noting this trend. As stated in a recent New York Times article1 about college application numbers, there is “the opposite of a virtuous cycle at work. Kids see that the admit rates are brutal and drop678
ping, and it looks more like a crapshoot. So they send more apps, which forces the colleges to lower their admit rates, which spurs the kids next year to send even more apps.” We hope this conversation continues and results in an improvement in the application process with less financial burden on the medical students. While we do not claim to have the answer to fixing the system, in addition to the ideas discussed in our editorial, we offer the following food for thought. Instead of approaching this problem from an a priori “here’s how and why applying to residency should happen” let’s approach it from a top-down perspective. Should the application numbers continue to rise and every medical student send out an electronic application to every program, the function of ERAS would be defeated. This situation would be untenable, yet we are more than halfway there. J. Jared Christophel, MD, MPH Paul A. Levine, MD Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System, Charlottesville (Christophel, Levine). Corresponding Author: J. Jared Christophel, MD, MPH, University of Virginia, PO Box 800713, Charlottesville, VA 22908-0713 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Pérez-Peña R. Best, brightest, and rejected: elite colleges turn away up to 95%. The New York Times. April 8, 2014. http://www.nytimes.com/2014/04/09 /us/led-by-stanfords-5-top-colleges-acceptance-rates-hit-new-lows.html. Accessed May 7, 2014.
Davies and Welch Draw Unfounded Conclusions About Thyroid Cancer From Epidemiological Data To the Editor In the article by Davies and Welch, “Current Thyroid Cancer Trends in the United States,”1 the authors draw some questionable conclusions and make potentially dangerous suggestions. Davies and Welch1 assert that the rise in thyroid cancer rates can be attributed to a rise in subclinical papillary thyroid cancer (PTC) tumors discovered incidentally, such as in “serendipitous detection.” They base this solely on statistical analyses of Surveillance, Epidemiology, and End Results (SEER) data. However, at least 2 studies2,3 find 12.4% or less of patients have nodules discovered during imaging for a different purpose. Significantly, the incidence of large tumors has not declined,4 and worldwide, World Health Organization rates indicate a rise in incidence in many countries that do not have easy access to imaging. As incidence has risen and mortality remained the same, Davies and Welch1 draw the conclusion of overdiagnosis and warn of the “harm” of the presumed phenomena. They reject the concept that early diagnosis can help avoid the development of aggressive and fatal cancers, and that surgical knowledge and techniques have greatly improved over the past 30 years and may account for the stable or improved mortality rate. It is illogical and unfounded to presume that increased awareness of patients’ thyroid nodules will pose harm. Rather, it is the lack of knowledge of these that is potentially dangerous. If anything, many patients are underdiagnosed as having preoperative indications of benign condition or singular indolent tumor, with postsurgical pathology confirming higher-
JAMA Otolaryngology–Head & Neck Surgery July 2014 Volume 140, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015
jamaotolaryngology.com
