How the Quadruple Aim Widens the Lens on the Transition to Residency

The current transition places significant financial burdens on debt-laden applicants and overstretched residency program staff. Graduates from Liaison Committee on Medical Education–accredited schools have median educational debt from $200,000 to $215,000.⁴  Electronic Residency Application Service fees are substantial based on average numbers of applications submitted. Registration for the National Resident Matching Program and costs for interviewing and away rotations add to expenses. Applicants commit time reviewing suboptimal advising resources, preparing applications, and interviewing, all of which detracts time from their final year of medical school. Yet the stakes of not matching far outweigh monetary and opportunity costs, and applicant behavior has reflected this with year-over-year increases in applications submitted and programs ranked.⁵  In parallel, residency programs are overwhelmed by the volume of applications. The cost of recruitment and selection, measured in faculty time as well as financial expenditures, pulls resources from education and patient care.

The UGRC recommendations address these problems. Recommendations for continued virtual interviews during the COVID-19 pandemic, and for ongoing studies on the benefits and disadvantages of in-person interviews and away rotations, are directed at controlling costs. Recommendations centered on providing low-cost, trustworthy program information in an easily accessible database will allow applicants to create a feasible application plan. If pilot programs that are aimed at helping students identify goals and reducing application numbers continue to gain support, costs may further be reduced for applicants and residency programs.

Data suggest that physician racial and gender concordance is associated with better patient outcomes.^6,7  Unfortunately, many aspects of the current UME-GME transition perpetuate inequities among applicants and disadvantage underrepresented in medicine (UIM) applicants applying for residency positions. UGRC recommendations aimed at decreasing the overemphasis on grades or examination scores can help mitigate the influence of minimal differences in group performance on residency selection.⁸  Recommendations focused on equity are aimed at mitigating structural biases toward UIM applicants as well as international and osteopathic applicants, many of whom struggle with belonging.⁹ 

The UGRC recommendations also call for faculty development in anti-racism, avoiding bias, and ensuring equity.

Residents serve critical roles in the delivery of care, and their ability to do so is affected by their clinical readiness and personal well-being.¹⁰  Ensuring applicant-program compatibility is critical to optimizing training. Many of the UGRC recommendations aimed at matching applicants and programs with corresponding mutual interests have the capacity to improve the experience of all members of the care team. In addition, UGRC recommendations focused on the availability of inclusive and trustworthy advising materials can help applicants find programs that fit their goals and needs. Recommendations aimed at improving resident onboarding and coaching can optimize both trainee well-being and, by extension, patients' experiences of care. For residency program faculty and newly matched learners, improved transparency of assessments, including a post-match summary assessment, can help foster the development of incoming residents' self-directed learning, which has the potential to improve patient care.

Optimal patient experiences depend on more than the medical knowledge of a health care professional. Recommendations focused on creating consensus assessment frameworks have the capacity to create competency standards that more directly relate to improved patient experiences. Students and residents afforded clinical learning environments that support growth mindsets and positive identity formation may have the skills necessary for lifelong learning and should therefore be able to deliver optimal care. Recommendations focused on specialty-specific preparation and orientation to local learning environments can translate to residents who are more aware of expectations and are better able to provide high-quality patient care.¹¹ 

Nundy et al recently proposed the Quintuple Aim to emphasize the importance of achieving health equity.¹²  This newly proposed aim also aligns with the UGRC recommendations, specifically those related to diversity, equity, and inclusion; holistic review of applicants; and training and competency expectations in all areas of medicine, including health equity and anti-racism.

The UME-GME transition is viewed as a transactional process that occurs over a limited time frame. In reality it is a complex system that, if not reformed, will be driven by self-interest over the public good. Throughout the work of the UGRC, clarity developed on the interconnectedness of the transition, the broader health care system, and our goals for health care improvement. The UGRC recommendations are not mandates but are suggestions for broad improvements to a decentralized process. As a result, the UGRC's recommendations may suffer from a condition of everyone being accountable; therefore, no one being accountable. Leaders in medical education should be compelled to implement the recommendations through individual and local action, organizational and professional societal initiatives, as well as advocacy for systems-wide changes. Adopting the UGRC's recommendations not only has the capacity to improve experiences and outcomes for applicants and residency program faculty and staff, but also holds the promise of contributing to positive patient outcomes.