A Transitional Year Residency Program Provides Innovative Solutions for Unmatched Medical Students

The transition to residency is an increasingly competitive and expensive endeavor,^1–3  with more medical school graduates seeking residency positions than the total number of positions offered in the National Resident Matching Program (NRMP).^4–6  On average, over the past 5 years, about 20% of active applicants have not secured a position in the NRMP Main Residency Match.⁷  In 2021, the absolute number of unmatched applicants in the main Match, reflecting more than 9000 medical school graduates, is the highest on record in recent years.⁷  This number exceeds the number of positions placed in the Supplemental Offer and Acceptance Program (SOAP), which has remained at just under 1900 positions in the past couple years.^6,8 

Although many systemic factors may contribute to a medical student failing to secure a position in the Match, more commonly reported reasons include student factors such as academic deficiencies or lack of a fit between applicants and their first-choice specialty.^3,9,10  Less commonly, some research has focused on improving institutional strategies in the advising process to better prepare students for the Match,¹¹  but overall, there is not abundant literature on the topic of unmatched or partially unmatched students,^10,12  or how they progress through the SOAP and into their careers.

One of our institutional solutions to the unmatched applicant challenge was to develop and implement a transitional year (TY) residency program. Our program was designed in large part to meet the needs of our initially unmatched medical students who had no preliminary or postgraduate year (PGY) 1 position on the Monday of Match week. Our development of the program coincided with the expansion of undergraduate medical student enrollment in the United States at a time of heightened concern with increasing numbers of unmatched students.^13,14  Interestingly, from 2015 to 2020, TY programs have shown remarkable growth in the United States, increasing by 74% from 101 to 176 programs, with a concomitant 71% increase in the number of positions from 842 to 1436.^6,15  However, only a handful of articles address various TY program topics,^16–24  and none have addressed the needs of unmatched medical students as a program mission. There is also little research on the career trajectories of TY graduates or how many residents complete a TY program as a precursor to an advanced position intentionally versus other reasons. This article aims to address this gap and describes our TY program and initial results in evaluating the success of meeting its mission to date from the vantage point of residents' reflections and stakeholders' perceptions about the program's value.

The impetus for our TY residency program originated from the University of Arkansas for Medical Sciences (UAMS) College of Medicine leaders who were concerned with the increasing rate of medical students who did not initially secure a position in the main residency Match. In 2014–2016, before implementing the TY program, 10%–11% of our senior medical students did not match into a PGY-1 position in the NRMP Main Residency Match, and thus participated in the SOAP. The Dean's office prioritized the development of this TY program as a type of safety net option for such medical students to continue their careers. With this charge, the graduate medical education (GME) team at our institution designed a program to meet the diverse needs of these potential applicants. The designated institutional official at the time selected the assistant dean for GME to implement and administer the program, and she collaborated with our emergency medicine and internal medicine residency programs to gain faculty buy-in and to secure their roles as sponsoring programs.

The TY program follows Accreditation Council for Graduate Medical Education (ACGME) guiding principles and requirements to provide a well-balanced curriculum of competency-based educational and clinical experiences in multiple disciplines. This approach facilitates meeting PGY-1 residents' needs as they prepare to enter a specific medical or surgical specialty. Because the institution is over the cap, the positions are funded by the College of Medicine's Dean's office. This support has survived several transitions in leadership, and the Dean's office continues to offer strong financial and philosophical support for the program.

The TY program is funded for 5 positions. All 5 positions are listed in the main Match in accordance with the NRMP All In Policy. The program does not submit a rank order list or interview anyone but remains in active status with SOAP participation selected. This allows us to begin interviewing candidates who apply to the program in Round 1 of SOAP and have all 5 positions available to fill with any local candidates who were not matched. We make this process and information about our interview process available to any interested candidates via our profile in FREIDA (American Medical Association residency database), on our residency website, and any time we speak with an interested applicant.

A summary of the program and curricular highlights are provided in the Table. Key elements related to institutional support, capacity, curriculum, and costs are described. To assist residents in professional development and career choices, the TY program director (PD) mentors and meets directly with each TY resident. The schedule is designed to meet requirements for the TY program and to expose residents to increased opportunities for securing career goals and progressing to advanced programs (eg, anesthesiology, radiology, dermatology, ophthalmology, physical medicine and rehabilitation, neurology).

For institutions considering implementing a TY program, costs other than resident salary and benefits that may be helpful include recurring budget items such as education/book funds, supplies, didactic support, coaching, mentoring, and professional development resources. In addition, there are expenses such as the ACGME new program application fee as well as salary costs for PD time (0.25 FTE) and program coordinator time (0.5 FTE). There are also soft costs that aren't easily captured. For example, there is no additional salary support for faculty members of other programs and departments that teach and mentor rotating TY residents.

The design of this study is an evaluation of the first 3 years of the TY residency program in terms of how well the core mission of the program was met. We used participatory action research methods that fit well for the task of formative evaluation of a new residency program, lending opportunities for rapid program improvement cycles. Participatory action research as applied in higher education settings, and in this study specifically, typically involves active engagement of researchers, stakeholders, and participants in the community of practice as co-creators systematically working together in continuously iterative cycles to evaluate and improve real world programs or processes.^25,26 

To obtain residents' perceptions of the value of the TY program, the evaluator who is a certified appreciative inquiry (AI) facilitator, used an AI approach²⁷  to engage TY residents annually in the program evaluation and improvement process. Each year from 2017 to 2020, TY residents received AI question prompts prior to participating in a 2- to 3-hour AI “mini-summit.” During the mini-summit, residents discussed their responses and were led through a discussion of the discovery, dream, and a combined design/destiny phases of AI.²⁷  The AI questions analyzed for this report were as follows: (1) Describe an experience in the TY program when you felt you were at your best; and (2) As you've gone through this year, you've likely had thoughts about what the ideal TY program could be like. What do you think about the structure of the program and what are your proposed innovations?

Each year, the program evaluator aggregated resident feedback and compiled responses and discussion points to reflect commonalities and information for program planning and improvements. For this study, a TY resident who served on the TY program evaluation committee and as a co-author of this article confirmed the accuracy and integrity of the themes. Additional resident perceptions of program value were elicited at year end by the TY program director via an email request and are presented here as direct quotes.

Perceptions of the effectiveness and value of the TY program were also elicited from our institutional stakeholders including 4 residency PDs and 2 medical school leaders. The PDs were purposively selected based on having accepted at least 1 or more TY graduate in the past 3 years, and the medical school leaders were selected based on their key roles in leading undergraduate medical education programs at our school. All stakeholders were asked to respond to an open-ended question: How would you rate the value of the UAMS TY program? (eg, How prepared are the UAMS TY residents you have accepted? What is the quality of residents you have accepted? What are the outcomes of residents you have accepted?).

The Institutional Review Board for the University of Arkansas for Medical Sciences deemed this project as not human subjects research.

In 2017–2018, the inaugural year for the TY program, we matched the full cohort of residents (n = 5) from the SOAP. In subsequent years to date, 88% (n = 14) of residents have matched to the TY program through the SOAP, and 12% (n = 2) were offered a position after the SOAP. All positions were filled by medical students from our own institution, although students from other medical schools would have been considered for acceptance to the program if positions had remained unfilled.

Over the first 3 years, 6 of the 21 incoming residents were partially matched (ie, had a PGY-2 spot) and continued into their initially desired specialties upon graduation from the TY program (2 hospital-based, 2 medical-other, 2 surgical). Another 6 residents successfully matched into a program consistent with their initially desired specialty choices (5 medical-primary care, 1 surgical), while 8 residents successfully matched into a different specialty than they had first pursued in the primary Match (1 hospital-based, 7 medical-primary care). One resident, who initially wanted to go into a surgical specialty, chose not to pursue further residency training following completion of the TY program. For the 8 residents who changed career paths, one TY resident initially was interested in a hospital-based specialty but chose TY clinical elective experiences in a community-based ambulatory care setting, which provided exposure to a broad number of patient cases and relevant mentoring. This ultimately led them to pursue a medical-primary care specialty. In another example, one resident who was competitive for a surgical specialty took advantage of the TY flexible curriculum. This allowed them to meet the PGY-1 requirements for a successful NRMP Match into a PGY-2 in that surgical specialty.

The AI mini-summit discussions regarding when residents felt they were at their best in the program revealed 3 themes across all 3 years of data: confidence, clinical proficiency, and professional enculturation.

TY participants expressed an overall increase in confidence and clinical abilities as first-year physicians in training. For example, one resident said, “Anytime I was able to perform procedures I felt like I was at my best.” Another resident shared, “The ICU allowed me to combine experiences up to that point and made me shine especially on procedures.” In a third example, the resident said, “Helping run the internal medicine ward team as an off-service intern, I felt efficient and equipped to handle a majority of the situations.”

The clinical proficiency theme was evident from resident comments such as “I enjoyed working with multiple cases,” “I got to perform many procedures that physicians were required to know,” and “I was exposed to more procedures than traditional PGY-1s.” The confidence and clinical proficiency themes appear related. We understand that clinical proficiency can lead to confidence and vice versa. We chose to separate the themes to add texture to the interpretation.

A third theme, professional enculturation, emerged indicating that residents in the TY program experienced the same first-year experience as categorical first-year residents. Residents' comments indicated that they felt they were fulfilling a defined role in medicine, felt “connected to the continuity of training,” and “learned the culture of medicine.” These phrases indicate that TY residents felt integrated into the clinical learning environment quite well.

In response to the AI prompt asking about program innovations, residents reported that the TY program was already innovative. Overall, their comments highlighted how the program promoted hard work, flexibility, resilience, and self-respect. However, one area for improvement that has emerged each year for TY residents is eliminating the stigma of “real resident” vs “not a real resident.” In one instance they reported being referred to as “fifth-year medical students” by residents in another program. Other suggestions for improvements included ideas to better integrate residents on some rotations where they felt peripheral. The TY program is aware of these issues and continues to make improvements to address them by working with the program evaluation committee on ways to promote and improve the educational and professional content and curriculum and by continued relationship building and positive promotion of the TY program internally with other program directors and faculty.

Additional insights into what residents valued about the TY program are displayed in Box 1, which shows examples of their end-of-year evaluation comments. Their comments mirror the findings from the AI mini-summits and illustrate an appreciation for flexibility in rotations and experiences, and for the freedom to explore a range of clinical specialties that were not available during their traditional clerkship rotations as students. Overall, TY residents revealed that gaining exposure to various clinical skills provided them with confidence and an advantage over their traditional first-year colleagues, and that the program improved their understanding of other specialties and their relationships with residents in other programs.

Box 2 presents direct quotes elicited from stakeholders, with only slight modifications in some cases to delete words that could serve as identifiers. The PD stakeholders indicated that the TY residents they received were exceptionally well-prepared clinically and had the right skillset and attitude to succeed in their programs. PDs also expressed appreciation for the TY program to help fill the physician shortage needs in our state and to provide a safe, supportive option for some students who benefited from additional time needed to reevaluate their goals and fully commit to new career decisions. Moreover, the PD comments indicate they believe the TY program will continue to serve as a conduit for candidates into their programs in the future and as a pipeline for retaining graduates to practice in the state.

Notably, 67% (14 of 21) of the TY program graduates to date have remained at our institution or affiliated regional programs to complete their residency training. The medical education leadership stakeholders both noted the increasingly challenging Match environment and the importance of having a modern TY program specifically designed to fill the range of various students' needs. They also expressed deep appreciation for how the TY program helps fill an institutional commitment that prioritizes meeting the educational and training needs for students to successfully transition to becoming physicians in their desired career paths.

The overall findings from this study indicate that the TY program provided a feasible and normative pathway into many desired categorical and advanced residency positions. The program worked well for those who had a consistent specialty goal, for those who were still somewhat undecided, as well as for those who altered their original specialty goal during the TY year. The flexible curriculum, variety of clinical experiences and individualized feedback, and mentoring and coaching helped some residents evaluate alternate career options and make more informed career choices not previously considered. Residents self-reported the TY program increased their exposure to primary care, surgical procedures, and boosted their confidence overall in their clinical and surgical skills. Also valued by TY residents were the opportunities for developing relationships that facilitated their integration in the culture of medicine. Stakeholders perceived the TY program as a valuable pipeline for our institution to retain good residents. PDs reported that their TY graduates were very well-prepared. Finally, the creation of the program also decreased the number of unmatched students for the medical school. As these graduates advance into their careers, many in primary care and specialty shortage areas, we hope the state of Arkansas will also benefit by retaining them as practicing physicians in our state.

We believe another benefit of our program is the requirement for residents to take the USMLE Step 3 examination, adding strength to their application for those who reentered the Match. The program also allows for the 1 year of postgraduate medical training required to obtain a medical license. This allows TY graduates to continue to practice medicine and generate income even if they do not complete a categorical program or become board eligible in an area.

The study findings are limited due to the single site nature of the design. Findings are based on a relatively small sample size, comprised of heterogenous learners and heterogeneous reasons they didn't match. Similarly, the varied mix of outcomes following completion of the TY program limit our ability to estimate the extent to which the findings are applicable to other programs and settings. Also, explanations for the eventual success of TY residents are too multifactorial to attribute solely to the TY experience.

Our findings advance the literature in terms of a TY program providing a valuable transition to residency, but also underscore the need for future research. Future studies are needed to assess the differences in program mission and structure as well as corresponding and longitudinal outcomes for TY graduates. It would be interesting to know whether program directors might view TY graduates more favorably for certain specialties than other preliminary training program or research year graduates. Studies using multicenter designs would allow for more transferability and generalizability of findings and could provide direction for a comprehensive TY program research agenda. More generally, research on the topic of unmatched student characteristics and relevant factors is also needed. To our knowledge, very little research has looked at the effectiveness of various career advising resources^28,29  and strategies¹¹  to prepare medical students for entering the Match or what students do during the SOAP at baseline. Although a couple of recent articles describe institutional solutions to provide fully unmatched applicants with structured research and skill-building experiences for those seeking a pathway into psychiatry,^30,31  overall additional research is warranted to better understand the options pursued by fully unmatched residency applicants.

Creating a TY residency program to meet the needs of unmatched medical students provided an institutionally valued solution to a concerning trend and was acceptable to learners for meeting their individual career direction needs and plans.

The authors would like to thank Jeff Pettit, PhD, for kindly reviewing an early version of this paper, as well as JGME reviewers and editors for constructive feedback.