The importance of trainee advocacy in residency education reform

The moment of truth looms nearby on the horizon for medical students across the US.^[] 

At the end of September, residency programs will begin sifting through mountains of applications, searching for the chosen few to fill their coveted slots. Aspiring doctors with the weight of years of hard work, grueling studies, and challenging rotations will find themselves at peak anticipation, wondering if they have made the cut. 

The stakes are higher than ever, the competition fierce, and the sense of anticipation is palpable. The road to residency can be perilous, however, and systemic inefficiencies and flawed policies can make it seem all but impossible for some qualified candidates.

The urgent need for UME-GME reform

Transitioning from undergraduate medical education to graduate medical education (UME-GME) is a defining moment in the journey of every physician, but the current system governing the US residency application and Match process is fraught with dysfunction and complexities. 

Despite a 35% increase in MD program enrollments from 2002 to 2020, national residency programs have not kept pace, leading to a growing number of medical school graduates facing job scarcity.^[] 

The escalating expenses of externships, application fees, and face-to-face interviews cause a heavy burden on some applicants, and can push them further into overwhelming debt. Heartbreaking stories of medical student suicides underscore the seriousness of the situation.^[] 

There is an urgent call for trainee advocacy and transformative change in the system. 

The UGRC recommendations

The Coalition for Physician Accountability formed the Undergraduate Medical Education-Graduate Medical Education Review Committee (UGRC) to address these calls and concerns.^[] 

With 30 members—including four trainee representatives— the UGRC laid out recommendations to make the residency application process transparent, equitable, diverse, and inclusive.

In an invited commentary published in Academic Medicine, these trainee representatives discussed the opportunities and concerns related to the UGRC recommendations.^[]

The power of trainee advocacy

The AMA stresses the importance of physicians advocating for political changes to improve people's well-being and reduce suffering. 

More medical schools now offer advocacy training, although some worry it takes time away from scientific and clinical lessons. However, advocates argue it improves communication skills and complements clinical coursework—important features, considering that trainees will be affected by flawed health policies.^[]

Trainees have a history of advocating successfully for essential reforms, note the authors of the Academic Medicine commentary. These include initiatives such as White Coats for Black Lives, #MedOuttheVote, changes in score reporting for USMLE Step 1, and the discontinuation of the USMLE Step 2 Clinical Skills exam.

The commentary describes medical students as “youthful critics who combine insider credibility with outsider idealism and values and act as catalysts for change in medical education.” 

Pilots for decreasing application numbers

The current application process overwhelms residency programs with an avalanche of applications, and longer rank-order lists congest the system. 

In 2022, medical school graduates submitted an average of 78.2 applications per person, marking a 29.6% increase since 2018.^[] 

To tackle this issue, the trainee representatives advocate for pilot programs to prioritize reducing application volumes and concentrating applicants and programs based on mutual interest.

The UGRC envisions creating a trustworthy database of applicant characteristics through innovative application processes for residency programs like virtual interviewing, which can remove financial barriers and promote equity.

Concerns raised by trainees

The commentary writers expressed fear that increased reliance on trainee fees due to the UGRC recommendations would exacerbate students' financial strain. They were also concerned that incomplete implementation of the UGRC recommendations may overly emphasize existing assessments, including the USMLE Step 2 CK and COMLEX-USA Level 2-CE.

Moreover, the UGRC hesitates to adopt changes immediately due to insufficient information and models for proposed improvements. However, waiting for more data contradicts the immediate need to implement these policies.

Trust gap

A notable conflict arises between medical schools and residency programs regarding how they assess and choose applicants. Medical schools tend to portray students positively to boost their matching statistics, whereas residency programs maintain secrecy about the criteria and process of selection.

The UGRC pushes for greater openness and clear information to offer improved guidance, yet applicants remain hesitant to trust solely based on assurances from medical school advisors and residency programs.

A call to action

The UGRC's vision can be realized, but it demands a collaborative effort from all parties involved—including the trainees themselves. The commentary urges the creation of a national committee to oversee changes in the UME-GME transition and safeguard against any harm to students’ careers while implementing the UGRC recommendations.