Letter: Pressure to Publish-A Precarious Precedent Among Medical Students.

Abstract

To the Editor: The National Resident Matching Program (NRMP) recently published its biennial report “Charting Outcomes in the Match” for the recent 2021 to 2022 application cycle.1 The goal of this report was to provide characteristics of both matched and unmatched applicants within each specialty. These data, which include measures such as average United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, average number of publications/presentations/abstracts, and average number of volunteer/research/work experiences, are often used by applicants and residency programs to compare an individual's characteristics with the average applicant profile. Neurosurgery is one of the most challenging specialties to match into, with the 2022 match rate being 61%.1 Given the relative scarcity of postgraduate year 1 (PGY-1) positions, several benchmarks have been established to assess applicant competitiveness, with research productivity being a primary measure.2,3 Although neurosurgery applicants have historically reported the highest number of publications, presentations, and abstracts, the NRMP's 2022 report revealed a departure from this trend. From 2020 to 2022, the average number of publications, presentations, and abstracts listed by matched U.S. MD plastic surgery applicants increased from 19.1 to 28.4 while the average number listed by matched U.S. MD neurosurgery applicants increased from 23.4 to 25.5.1,4 However, research productivity by unmatched U.S. MD neurosurgery applicants did not change dramatically between 2020 and 2022 while unmatched U.S. MD plastic surgery applicants saw a modest increase from 11.6 to 13.8.1,4 Not surprisingly, these data support an association between research productivity and likelihood of matching in each of these specialties.5,6 However, concerns over excessive research output by neurosurgery applicants have been raised previously.7 Now, it appears that the research “arms race” is beginning to involve other specialties. What has caused such an increase? As surgical residencies become increasingly competitive, applicants may opt to complete a dedicated research year to boost their research output. This is becoming more common in many surgical specialties, such as neurosurgery, orthopedic surgery, and plastic surgery.6,8 Although a research year is not necessary for every applicant, students may feel pressure to delay their graduation to achieve research output comparable with what is demonstrated in the 2022 Charting Outcomes data. This pressure is felt by US and international medical graduates alike.9 Indeed, research productivity is a valuable asset for academic residency programs, but there is evidence to suggest that the 2022 Charting Outcomes data may not necessarily represent an increase in high-quality publications. Rather, this rise in research output could be due to nonindexed publications, such as abstracts, book chapters, presentations, and “ghost” or “phantom” publications, which are unverifiable publications listed on residency applications.5,10,11 This presents a dilemma for applicants and residency programs alike. Peer-reviewed research is held to high standards, and medical student research is no exception to this. As applicants face more pressure to publish, they may gravitate away from performing high-quality research, which tends to be more difficult to complete in a timely manner. The value of quantity ought not to supersede that of quality, and a 49% increase in research output by successful plastic surgery applicants over the course of 2 years may threaten this principle. What can be done to address this trend? First, research mentors and residency program directors ought to emphasize the value of meaningful research projects, high-quality methodologies, and ethical principles of research.7 Second, the NRMP should consider reporting research output more granularly and specifically. Currently, publications, abstracts, and presentations are reported as a single number in the biennial Charting Outcomes report. However, these categories of research are not equivalent and should not be treated as such. Third, the Association of American Medical Colleges should consider changes to the formatting of research input in the Electronic Residency Application Service. For example, the American Council of Academic Plastic Surgeons has developed the Plastic Surgery Common Application, which is an alternative to Electronic Residency Application Service.12 Within the Plastic Surgery Common Application, applicants are required to list up to 3 publications to discuss during interviews and can list no more than 5 research, service, and leadership experiences. Although applicants are still able to list additional publications, this format draws attention to meaningful research endeavors.12 Although neurosurgery, and now plastic surgery, applicants lead all specialties in research output, there is an opportunity to set a new precedent. The value of medical student involvement in research should not be understated because it provides an opportunity to advance the field of medicine and collaborate with peers on a global scale. However, students must maintain a balanced educational experience with focus on patient care, academic excellence, and personal well-being. The 2022 Charting Outcomes data may be a signal that the academic medical community should reassess its current approach to applicant assessment.