EXPERT ANALYSIS FROM AAD 18

SAN DIEGO – Whether the glut of applications contending for the roughly 420 dermatology residency positions in recent years may be corrupting the process was the topic of discussion at a session on dermatoethics at the annual meeting of the American Academy of Dermatology.

“I think it is unethical and we need to address it,” Jane M. Grant-Kels, MD , said during the session. “What we are doing through the process of physicians getting into dermatology residency programs is telling them to lie to us and to do well on a single examination,” the United States Medical Licensing Examination.

“That’s not a message I want to give,” added Dr. Grant-Kels, professor of dermatology, pathology, and pediatrics at the University of Connecticut, Farmington.

Lionel G. Bercovitch, MD , is among the dermatologists who acknowledge the unarguable fact that application rates are high but don’t see it as a crisis of credibility.

“I don’t believe that dermatology match is broken, unethical, or unfair. The match is not perfect, but it’s fair,” contended Dr. Bercovitch, professor of dermatology at Brown University, Providence, R.I. “The problem [of an application glut] is real, but it’s not an ethical issue.”

Dr. Grant-Kels sees it in ethical terms because, in her view, “everyone is gaming the system. It makes applicants liars” when they profess interest in moving to a remote location or planning to practice a certain type of dermatology.

She traces the dilemma to the large number of applications submitted by each candidate as they tried to contend with long odds: Each candidate was vying against about 651 U.S. and foreign physicians for 423 residency slots offered by 121 U.S. dermatology programs in 2017, according to statistics compiled by the National Resident Matching Program. This produced an applications glut: 2017-2018 data from the Association of American Medical Colleges showed an average of about 53 applications from every dermatology residency applicant overall and an average of 69 applications submitted by applicants with U.S. medical degrees.

The “extremely competitive” process leads a majority of applicants to “shot gun” their filings to many programs such that dermatology residency programs are “deluged” with applications, Dr. Grant-Kels said. Data from the Association of American Medical Colleges for 2017 showed an average of just over 500 applications received by each U.S. dermatology residency program.

As a result, residency programs feel forced to apply blind filters that generally cull out more than a third of the applications received. Dr. Grant-Kels decried the need for programs to impose arbitrary barriers to entering dermatology based on a score from a single examination or other criteria like membership in Alpha Omega Alpha or current location.

“Blanket screening methods run the risk of excluding genuinely interested and qualified candidates who do not fall above a threshold. This violates the principal of nonmaleficence,” she said. “Screens are unfair.”

Dr. Grant-Kels proposed a pair of potential remedies: putting a cap on the number of applications someone can make and – a more realistic approach – mentors’ giving guidance to prospective applicants.

“It’s a problem that kids are applying to dermatology programs who have no business applying, who really don’t have a chance,” she said.

Dr. Bercovitch noted that most dermatology residency programs are too small and that, while the number of residency slots has been rising, it has not kept pace with increasing demand from physicians seeking residency slots. He saw no ethical reason for physicians to feel they should rein in the number of applications they file, and he said the only obligations for residency programs are to strictly adhere to the Match rules and both federal and state civil rights and labor laws and to be nondiscriminatory and avoid nepotism and conflicts of interest. Because programs cannot seriously consider nor interview several hundred applicants each year, some type of filtering is needed, and no filter is fair or perfect, he conceded.

“Filters are inherently unfair” to certain applicants, “but how else to effectively screen” hundreds of applications, Dr. Bercovitch asked.

“We need to talk about this. It’s not a good system. If we don’t talk about it, it will never change,” Dr. Grant-Kels said.

Dr. Grant-Kels and Dr. Bercovitch had no disclosures.

mzoler@frontlinemedcom.com

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