Letter: Home-Turf Advantage? The Neurosurgery Residency Match During the COVID-19 Pandemic.

Abstract

To the Editor: To say that the coronavirus-19 (COVID-19) pandemic has changed and challenged the field of neurosurgery would be an understatement. Less than 2 mo after the first confirmed case in Seattle, Washington, the American College of Surgeons recommended that all elective surgical cases be delayed until further notice.1 Especially in the early stages of the pandemic, neurosurgical academic programs nationwide saw their caseloads drop drastically as changes were put into place.1 All the while, hospitals scrambled to create COVID intensive care unit (ICUs) efficiently, allocate limited resources appropriately, and keep healthcare workers safe amid an unprecedented situation. Neurosurgical departments were all privy to this chaos, affecting residency training at all institutions and altering the face of what was once typical—cutting-edge elective cases were quickly replaced by emergent cases and networking at conferences and grand rounds became messages across various video-conferencing platforms. Medical students, rather than flying to subinternships and residency interviews across the country, sat in front of their computers for these virtual events and, if they were fortunate enough, rotated in their home institution's department. Nevertheless, the neurosurgery community persevered and adapted to this new situation. There is now hope of some return to normalcy, or as close to it as possible, when one walks down the hospital hallways or sees the busy operating room schedule. However, given the drastic changes in interviews and subinternships, the question remains of if and how the 2021 neurosurgical residency match was affected by this unusual year. Specifically, if applicants were not able to travel and truly experience different programs for themselves instead of doing so virtually, could this influence their ranking and match decisions? It is conceivable that, when considering the inherent uncertainty of this pandemic, applicants may choose to stay somewhere where they are more comfortable: their home institutions. Thus, we approached this question by reviewing publicly available match data from accreditation council for graduate medical education-accredited US neurosurgical residency programs from 2017 to 2021. Using information sourced from residency program web domains and social media outlets, we determined the residents’ medical school affiliations or the most recent US-based affiliation for international medical graduates (total, n = 772). We also collected neurological surgery residency rankings available on the website Doximity. Surprisingly, we did not find a statistically significant difference (one-tailed t-test,) in the average percentage of home matches in 2021 (24.0%) when compared to the previous 4 aggregated match years, 2017 to 2020 (21.9%) (P = .2885) (Figure). Based on an adjusted multivariate odd model, including year, program ranking, and program size, programs in 2021 also were not more likely to match at least one home applicant to their home program when compared to the 2017 to 2020 match years (odds ratio [OR]: 1.24, 95% CI: 0.77-2.00, P = .3813) (Table). Interestingly, however, both Doximity-based residency quartile ranking and the number of residency positions available played a statistically significant effect on if there was a home match in 2021 when compared to the 2017 to 2020 aggregate match years (Table). The former makes sense—specifically, programs with 1 position were significantly less likely to match at least 1 home applicant than those with 2 positions, the median program size across all years. As for reputation, programs ranked between 51 and 75 and 100+/unranked were significantly less likely to match at least 1 home applicant, with a similar effect observed for programs ranked between 76 and 100 with near significance. This could potentially be due to higher-ranked, research-heavy programs matching students with whom they have worked closely with or who come from institutions with a similar research culture and emphasis.FIGURE.: Average percentage of home matches for the aggregate data from 2017 to 2020 when compared to the 2021 neurosurgical residency match. TABLE. - Adjusted Multivariate Odds Models, Including Match Year, Program Ranking Based on Doximity Reports, and Positions at Each Program, Comparing the 2017 to 2020 Aggregate Match Data to the 2021 Match Data Variable OR (95% CI) P Year 2017-2020 Ref 2021 1.24 (0.77, 2.00) .3813 Number of positions 1 0.40 (0.24, 0.68) .0007* 2 Ref 3 0.96 (0.57, 1.63) .8853 4 1.05 (0.45, 2.43) .9083 5 N/A Ranking 1-25 Ref 26-50 0.90 (0.52, 1.56) .7117 51-75 0.36 (0.18, 0.71 .0033 76-100 0.49 (0.23, 1.01) .0543 100+/unranked 0.42 (0.20, 0.90) .0265* Ref: reference group used to determine odds ratio.*statistically significant result (P<.05). Given the substantial changes that happened during the 2021 neurosurgical residency application, these results are surprising. Anecdotally, from conversations with other medical students during this match process, many have voiced concerns with matching at institutions that they did not visit or experience for themselves. Over recent years, there has been much speculation regarding this match process and possible ways of making it more equitable for all individuals.2,3 For example, the residency application process is notoriously expensive, especially for neurosurgery: individuals pay on average $10 225 per interview cycle, one of the highest costs out of all specialties.4 Presumably, these costs will only continue rising as residency applications become more and more competitive and as applicants apply to more programs as a result of this. A recent paper estimated that individuals may save upwards of $10 000 if virtual interviews and a lack of away rotations were to continue.5 Nevertheless, while there may be a financial incentive for a hybrid system of interviewing, this could prevent interviewees from experiencing the culture of a program and building connections with future colleagues and mentors in the field. A final question, then, is whether this 2020 to 2021 application year may have provided enough impetus to change the landscape of the neurosurgery residency process. This remains unanswered for now, but we encourage more studies to be done regarding how neurosurgery applicants created their rank list, the experience of virtual interviews and subinternships, and how program directors adapted their selection process during these atypical times. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.