Costs of the Residency Match for Fourth-Year Medical Students

Costs of the Residency Match for Fourth-Year Medical Students

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The Journal — June 2014

Tex Med. 2014;110(6):e1.

By Jacqueline Guidry, MD; Stephen Greenberg, MD; and Lloyd Michael, PhD

From Baylor College of Medicine, Houston, Texas. Send correspondence to Jacqueline Guidry, MD, 602 Heights Blvd #8, Houston, TX 77007; email: jaguidry@bcm.edu.

Abstract

A vital step in the career of a physician is applying and interviewing for a position in a residency program. Unfortunately, the costs associated with this process are often not anticipated by fourth-year medical students. The authors collected data on these costs from fourth-year medical students in Texas (N=274) during 2012-2013. Results suggested that the average cost of this process was significant (M=$4783). The costs varied greatly, depending on the medical specialty for which the fourth-year medical student applied, with a range exceeding $12,000. Most students (60%) paid for these costs with personal savings. The authors suggest that documentation of the average cost of applying and interviewing for residency would allow future fourth-year medical students to make more accurate financial plans, provide evidence for increased financial need during the final year of medical school, and initiate an evaluation of the current residency match process for cost-saving strategies to decrease the financial burden on students.

Introduction

The education and training of a physician is a costly process, involving not only many years but also a significant financial investment by students and the institutions where they train. Youngclaus et al in 2013 found that 86% of graduating medical students had debt averaging $161,290.1 Undergraduate medical education is expensive: tuition, books, student fees, to name a few costs. However, other hidden costs are not factored into financial aid packages, and students often require additional funding. One of the largest unanticipated financial commitments, which is not traditionally included in medical education costs, is the match process (applying and interviewing for a residency position). 

Review of the literature produced only one reference evaluating the costs associated with this necessary step in medical training.2 These costs have rarely been published. In 1978, Gardner & Herbstman surveyed the graduating class from the University of Chicago and found students were spending an average of $713 (range, $60-$1935) on the application and interview process. They did not note any significant difference among medical specialties, and 24% of students used student loan money to finance their applications and interviews.2

One of us (JG) completed the match process during the 2012-2013 application cycle. Based on this experience and the experiences of peers, it was apparent that significant expenses were related to the match process. Hence, a study was launched to survey fourth-year medical students in Texas to determine associated expenditures. The primary objective of this study was to document by survey the average cost of the match process for fourth-year medical students graduating in 2013. 

Methods

Participants
Our plan was to include all graduating fourth-year medical students who participated in the match process from allopathic medical schools in the state: Baylor College of Medicine, The Texas A&M University Health Science Center, Texas Tech University Health Sciences Center, The University of Texas Medical School at Houston, The University of Texas Medical Branch at Galveston, The University of Texas Medical School at San Antonio, and The University of Texas Southwestern Medical Center. 

We used data about the incoming class published on the schools’ websites to estimate the total number of graduating medical students. First-year enrollment at all 7 allopathic medical schools in Texas was 1415 students. We assumed an attrition rate of 10 students per school (70 total) who would not graduate or participate in the match process because of incomplete graduation requirements, academic probation, delay or deferment of graduation, or discontinuation of medical school. Therefore, we calculated that the survey instrument would be sent to approximately 1345 students. The Institutional Review Board at Baylor College of Medicine approved this study.

Any fourth-year allopathic medical student in Texas who participated in the match process was eligible for participation. Therefore, the exclusion criteria included not being a current fourth-year medical student in the state or not participating in the match. 

Survey
To reach fourth-year medical students, we contacted the Dean of Admissions and/or Student Affairs at each of the 7 allopathic medical schools in Texas. We asked those deans to forward an email with a hyperlink to our electronic survey to the listserve for their fourth-year students. Our survey included 9 questions about consent to participate, medical school attended, number and types of residency programs applied to, and sources of financial support for the match process. The full survey is shown below. We did not have direct contact with the participants, and no personal demographic information was collected.   

Survey Questions Sent to Fourth-Year Texas Medical Students:  

  1. Would you like to participate?
  2. Which Texas medical school do you attend?
  3. How many residency programs did you apply to?
  4. How many residency programs did you interview at?
  5. What specialty (specialties) did you apply to?
  6. What specialty did you match?
  7. How much did you spend applying to residency?
  8. How did you pay for these costs?
  9. Did any of the residency programs with which you interviewed provide support (cash, goods, etc), which offset some of the interviewing expenses? If yes, what did they provide? 

The electronic survey was sent and tabulated from March to June 2013. The survey used software from a third-party company, Survey Monkey (www.surveymonkey.com), which populated the data into a downloadable spreadsheet for data review and analysis. Statistical analyses were limited to calculating the mean and percentages for the number of programs applied to and interviewed for and to the amount of money spent on the match process.

Results

We received 274 responses. Based on our sample size of 1345, our response rate was 20.4%. Overall, students (n=272) applied to an average of 7.4 Texas programs and 30.9 out-of-state programs for a total average of 38.3. They interviewed at an average of 4.5 Texas programs and 8.6 out of state programs for a total average of 13.1. Table 1 shows the breakdown of the number of programs to which students applied and interviewed by specialty.

Students seeking to match into psychiatry applied to the fewest number of programs with an average of 16.5 programs and also interviewed at the fewest number of programs with an average of 9.8, followed by 22.5 average applications for family medicine and 10.8 interviews for pathology. Students seeking to match into dermatology applied to the highest number of programs with an average of 104.7 programs and also interviewed at the highest number of programs with an average of 23.3, followed by radiology with an average of 66.5 applications and 19.3 interviews. 

Students (n=268) reported spending between $127 and $20,000. The average amount spent on the match process for all students was $4783 (median, $4300). One hundred nine students (40.7%) reported spending $5000 or more on the match process. Only 45 (16.8%) students reported spending $2000 or less on the match process. We analyzed the mean cost of the match process among different specialties, which ranged from an average of $2176 (n=24, 9.0% of respondents) for Family Medicine to $14,333 (n=3, 1.1%) for Plastic Surgery as delineated in Table 2.

Most student costs were for travel (58.2%), followed by lodging (17.9%), application fees (15.7%), and miscellaneous costs (9.4%), which included but were not limited to interview attire, taxi fare, and meals during interviews. On average, the total spending amount entered by students was $61 less than they entered as individual cost constituents. For the purposes of this article, we calculated percentages based on the costs entered by students both for individual cost constituents and total cost, which varied by 1.3%.

Students were also asked to report the source of financing for the match process. Two hundred sixty-eight students responded. Sixty percent (n=159, 59.3%) of students reported using personal savings to finance at least part of the match process, 39.1% (n=105) reported using parental support, 37.7% (n=101) reported using private loans, 13.4% (n=36) reported using their medical student loans, and 4.1% (n=11) reported using credit cards.

Students could also report if and what type of support the residency programs provided them before or after the interview. This included no support, dinner the night before the interview, parking reimbursement, airport transfer, discounts on hotels, or complete cost of hotel for one night. Overall, these subsidies occurred infrequently and had high variability among programs. 

Discussion

National Resident Matching Program (NRMP) data reported that 17,487 US fourth-year medical students participated in the match in 2013.3 If we extrapolate that these 17,487 also spent an average of $4783, it would mean that US medical graduates are spending approximately $83.6 million on the match process.

Our data should serve as a baseline for future fourth-year medical students in estimating the average cost of the match process, so that they can make educated decisions about their financial planning during their fourth year of medical school and earlier. In addition, we hope that these findings will prompt a discussion among students, medical school deans, and residency program directors about any potential ways to decrease the costs associated with the match process. Currently, the cost of the match process is not factored into financial aid packages for fourth-year medical students.

Gardner and Herbstman suggested two potential means to decrease the cost of interviewing for residency in their article in 1978.2 They suggested that residency programs only offer interviews to candidates who are under serious consideration and to offer interviews in different regions of the country.2 Using the current system of the NRMP, residency programs might consider inviting only candidates to interview who are being considered seriously for placement on their rank lists. An alternative recommendation might be to limit the number of programs to which an applicant might apply or limit the number of interviewees per residency program. These alternative suggestions would likely prove very complicated given the variation in competitiveness among different medical specialties and the differentiation among categorical, preliminary, and advanced residency programs. 

The second proposal to decrease the cost of interviewing for a residency position was to offer regional interviews.2 This option would present alternative challenges, such as defining who would travel to conduct the interviews, where the interviews would be held, and the duration of the interviewing window. For large programs that accept 50 or more residency positions each year, regional interviews would likely necessitate several months of effort interfering with other crucial faculty commitments. 

The relationship between number of interviews and amount of money spent does not appear to be a direct correlation. For example, the results demonstrated that students applying for dermatology interviewed at a higher number of residency programs than those applying for plastic surgery. Yet, the average amount spent on the match process for prospective dermatology residents was less than that for plastic surgery residents. This suggests that other associated costs outside of travel, lodging, and application fees might be contributing to the costs for some specialties and not others. 

Finally, though the match process is very expensive for fourth-year medical students, traveling to the location of their potential future residency program to get a firsthand view of the program might be worth the cost. These costs could be viewed as an investment in the students' medical careers and, thus, the amount of money spent is less relevant or amortized over a career.

Our documentation of the average cost of the match process for fourth-year medical students supports the need for additional financial support for this necessary step in pursuing a medical career. Most students paid for the match process with financial resources other than student loans. We recommend that the financial need for fourth-year medical students be reevaluated in light of these data to accommodate the match costs in the amount of student loans that fourth-year medical students can borrow or to spur the development of grants, scholarships, or other sources of funding that will help fourth-year medical students finance these costs. 

Limitations

We recognize several limitations to our study, most notably a response rate of 20%. However, this still represents the experience of 274 individual students. We do not believe that additional responses would alter the results of our study significantly. Nineteen different medical specialties were represented in our study, so we believe that we had a broad and representative sample.

Our survey was distributed to fourth-year medical students during the late spring following Match Day. At many institutions, medical students have highly flexible schedules during the months leading up to graduation. Most likely, the emails sent by the deans from each institution reached the fourth-year medical students at a time when various events might have prevented them from completing the survey. 

Furthermore, fourth-year medical students receive frequent requests to complete surveys. At our institution, many different types of surveys from different departments are sent to students near the end of the fourth year. Probably, several fourth-year medical students did not respond to our survey request because they were inundated with survey requests. Furthermore, students who did not reply to our survey may have been unsure of how much money they spent on the match process. 

We believe the information gained through our study regarding the average cost of the match process is beneficial to fourth-year medical students as they plan for applying and interviewing for residency positions. We hope these data will prompt a reevaluation of the current match process from a financial perspective. In the match year 2012-2013, fourth-year medical students spent an average of $4783 on the match process with wide variations among different medical specialties. Most students funded the match process using personal savings. 

Acknowledgments

The authors wish to thank the deans at each of the participating institutions for forwarding the survey request to their students and the students who participated. 

References  

  1. Youngclaus JA, Koehler PA, Kotlikoff LJ, Wiecha JM. Can medical students afford to choose primary care? An economic analysis of physician education debt repayment. Acad Med. 2013;88(1):16-25.
  2. Gardner P, Herbstman B. Rites of fall: the costs and utility of the internship interview. J Med Educ. 1978;53(11):929-931.
  3. National Resident Matching Program. Results and Data: 2013 Main Residency Match®. Washington, DC: National Resident Matching Program; 2013. 

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