https://orcid.org/0000-0001-8688-3024
Graduate medical education success depends on program excellence and recruiting appropriate trainees. However, identifying the qualities, strengths, and weaknesses of applicants has become increasingly difficult due to third-party revisions of their applications. While applicants send personal statements and other documents through the Electronic Residency Application Service (ERAS), many are purchasing the services of support businesses, or hired contractors, to review and revise their submissions. These contractors can distort applicant information, increase student debt, and create potential ethical problems. The application process should be transparent and accurate and emphasize applicant input.
For an applicant, entry into a residency program begins with an application that the program director decides warrants an interview. Last year, program directors received a mean of 1013 applications and offered interviews to 249 applicants.1 This low rate for interviews has led some applicants to hire contractors to improve their submissions, which may disadvantage other applicants who cannot afford their services or who view paying businesses to revise their applications as unethical.
Large and Expensive Services
Applicants pay ERAS approximately $2,500 in fees depending on how many applications they submit. They also pay fees for licensing examinations, transcripts, and participation in the National Resident Matching Program, as well as sundry interview expenses, such as buying new clothes. These expenses add to student debts, the median of which for indebted medical school graduates in 2019 was $200,000, with 73% of graduates reporting education debts.2
In addition to paying required fees, many applicants buy various help services because they worry others are using them and gaining a competitive advantage. Costs for these services can exceed $10,000, ranging from approximately $100 for editing of a personal statement to $15,000 for practice interview sessions. For additional fees, some contractors will write applicant personal statements after a phone conversation. These contractors advertise their speed, quality, and acceptance rates. Sample advertisements from an internet search for “residency application services” include, “We can be your secret weapon in positioning you for a successful medical career,” “When you purchase the Complete Application Package…we will do everything short of submitting your application for you,” and “Match… with your dream residency program.” Exactly how many applicants buy these services is unknown, but businesses advertise having served thousands of applicants, and the industry has $1 billion in annual revenues.3 In 2021, 50 830 applicants filed an average of 101 applications each through the ERAS system.4
Emphasis on Personal Statements and Recommendation Letters
The United States Medical Licensing Examination and the Comprehensive Osteopathic Medical Licensing Examination recently changed reporting Step 1 test results to pass/fail. However, in a 2021 survey of all program directors participating in the Main Residency Match (23% response rate), they ranked the Step 1 test score as their most considered academic credential in deciding which applicants to interview.1 The absence of this score to differentiate applicants places a greater reliance on personal statements. In that same survey, program directors rated personal statements and recommendation letters as the 2 most considered personal characteristics for deciding whom to interview.1 Residency programs primarily interview applicants virtually now,5,6 which can be a difficult way to assess interpersonal skills. Contractor editing of personal statements further increases the difficulty for program directors to understand the qualities and potential for success of their applicants.
We have observed a change in applicant personal statements over the past decade as the application support industry has grown. Some personal statements now describe lives dedicated to helping others while overcoming obstacles, with compelling experiences in a particular medical specialty, flawlessly written, even for applicants for whom English is their second language. These personal statements can create feelings of unease and suspicion among residency program directors. Programs also receive recommendation letters from prominent people. One searchable support business advertises, “Letter of Recommendation Service…We ensure that you are portrayed in the best light possible. Turnaround time: 24 or 48 hrs. Prices start at: $109.” Whether applicants have used support businesses to revise their personal statements or solicit recommendation letters is unknown to the program directors receiving the applications.
In 2013, we measured a plagiarism rate of 14% for international medical students and 4% for US students in their personal statements.7 We and others warned applicants against plagiarism, and the current rate appears to be under 2%.8 This decrease may relate to warnings against plagiarism as well as a shift by some applicants to paying contractors to write or edit original statements.
Dishonesty in higher education is increasing, with an estimated 16% of students now paying third parties for help with coursework.9 Most observers view some proofreading and editing of personal statements as acceptable, but ghostwriting is deceitful and an ethical erosion of a profession that the public expects to be truthful, trustworthy, and authentic. Ghostwriting of applications, hidden from program directors, reminds some of the widely publicized 2019 college admissions scandals.10 Aside from ethical concerns, the more information that comes from applicants and the less from contracted third parties, the better program directors will understand their applicants and choose trainees who will succeed in a specific specialty and residency program.
Recommendations
We recommend 4 improvements for residency program applications:
Define what application help is allowed and require applicants to disclose the assistance they have received. Lack of clear guidelines leaves the choice of whether and how to use third-party services to the most vulnerable and least experienced person in the application process.
Leaders of every specialty society should advise applicants not to pay for editing of their applications and personal statements. Help from unpaid medical school and professional society mentors and advisers is available and acceptable. One of us (M.Z.) works in a national society program that helps, at no cost, underrepresented minorities enter medical school and residency training.
Study replacing the personal statement with a few questions pertinent to the backgrounds and interests of applicants. Some short-answer questions might include explaining any gaps in education, listing 3 nonmedical interests, and envisioning their lives in 5 years. Some investigators and the Association of American Medical Colleges (AAMC) collect information from program directors on what they find most useful for evaluating applicants.11,12 ERAS could modify the application based on these results.
Require applicants to describe their relationship with anyone writing a recommendation letter.
A committee of interested and knowledgeable participants, organized by the AAMC or the Coalition for Physician Accountability, could consider these and other recommendations to improve residency program applications and forward them to ERAS. Committee members might include program directors, academic medical center leaders, recent applicants, and representatives of the Accreditation Council for Graduate Medical Education and Liaison Committee on Medical Education. A goal would be to identify which elements of the application process best identify characteristics of successful residents.
