Poor match rates of osteopathic applicants into ACGME dermatology and other competitive specialties

Methods

The online public databases Electronic Residency Application Service (ERAS), National Resident Matching Program (NRMP), Association of American Medical Colleges (AAMC), National Match Service, Inc. (NMS), and the Accreditation Council for Graduate Medical Education (ACGME) were used to gather statistics that evaluated USMLE and COMLEX scores, total applications, and unmatched applicants. Dermatology, otolaryngology, neurosurgery, plastic surgery (integrated), and orthopedic surgery were identified as some of the most competitive specialties [5], [6]. The NRMP also referred to these specialties as “traditionally competitive specialties” in 2019 [5].

The public databases were also used to compile annual match statistics from 2012 to 2019 for DO and MD candidates to the selected specialties. For dermatology, advanced (program year 2 [PGY-2]), categorical (PGY-1), and physician positions were included. All other included competitive specialties only match categorical (PGY-1) positions.

Data on DO and MD match placement that were not included in the above sources were gathered through residency program websites, medical school websites, and residency program communication. From 2017 to 2019, total available ACGME residency positions include both former AOA (newly ACGME-accredited) and historical ACGME programs (those previously accredited through the ACGME).

Results

Match statistics for the studied specialties from 2012 to 2019 are shown in Table 1A. Prior to implementation of single GME accreditation (2012–2016), herein referred to as “preunification,” DOs comprised only 0.5% of matches (47 of 8695) into competitive specialties (Table 1B). Newly ACGME-accredited (former AOA) programs first participated in the NRMP in 2017. After GME unification (2017–2019), herein referred to as “postunification,” DOs appeared to comprise 2% of these specialties (11 of 5785). However, when former AOA programs were excluded from the calculation of total postunification DO match rates into these specialties, the true DO match rates into traditionally ACGME positions was 0.6% (34 of 5658). At the time of this study, the total number of DO matches for 2020 was known for all competitive specialties; however, data about whether the matches were into former AOA or traditional ACGME positions was not yet known.

Given our specialty, we paid particular attention to dermatology match data. In 2017, 2018, and 2019, there was an apparent increase in DOs who matched into ACGME dermatology programs. Preunification, DOs matched to 0.9% (19 of 2051) of the total ACGME dermatology positions. Postunification, DOs matched to 4.4% (64 of 1439) of the total ACGME dermatology positions. However, in 2017, 6 of the 8 (75%) DO dermatology matches were into former AOA positions. In 2018, 15 of the 16 (93.8%) DO dermatology matches were into former AOA positions; only 1 (0.2%) DO matched into a traditional ACGME position, the lowest DO-to-ACGME dermatology match rate observed over the previous seven years. In 2019, 38 of the 40 (95%) DO dermatology matches were into former AOA positions. Therefore, the true postunification DO match rate to traditionally ACGME dermatology programs was 0.4% (5 of 1,350). Approximately two fewer DOs matched per year to traditionally ACGME programs compared to preunification. From 2017 to 2019, only five DOs matched into 1,350 available traditional ACGME dermatology positions (0.4%).

DOs matching into other traditional ACGME competitive specialty positions have also experienced low match rates. When averaging DO match rates to ACGME positions from 2012 to 2019 (Table 1), DOs represented less than 1.0% (81 of 14,353) of all matches in otolaryngology, orthopedic surgery, neurosurgery, and plastic surgery.

With the unification of GME, MD applicants are matching into former AOA positions that now have ACGME accreditation. Since unification, 27.6% (35/127) of former AOA positions in these competitive specialties have been filled by MDs (Table 1B). By specialty, MDs filled 24.7% (22 of 89) of dermatology, 0% (0 of 11) of otolaryngology, 47.6% (10 of 21) of orthopedic surgery, and 50% (3 of 6) of neurosurgery positions which were formerly AOA accredited. Integrated plastic surgery had no matches to formerly AOA accredited positions. Conversely, DOs only filled 0.6% (29 of 5159) of traditionally ACGME positions in these competitive specialties.

Discussion

Without careful interpretation of match data, it can appear that osteopathic match rates to ACGME competitive specialties are increasing. This increase is misleading and is due to the transition of former AOA programs into ACGME accreditation status and participation in the NRMP. When former AOA positions are excluded from the calculation of postunification DO match rates, the true DO match rates into traditionally ACGME positions remain alarmingly low.

Dermatology specialty data were extensively evaluated. Dermatology match procedures had historically differed between the NMS and NRMP. For DOs, dermatology was an “option 3” residency in the NMS, meaning applicants could only apply and match into dermatology as interns or after a research fellowship (PGY-1). For MDs, applicants classically applied and matched as fourth year medical students for categorical or advanced dermatology positions with few matching into physician positions (those reserved for physician applicants that did not match in PGY-4 and/or chose to complete a research fellowship or other residency). With GME unification, former AOA programs that have transitioned to ACGME accreditation must now adopt NRMP procedures in which they match fourth year medical students instead of interns. While evaluating the data, it became apparent that each former AOA program must now undergo a unique NRMP match year where they match both fourth year medical students and interns, essentially recruiting two class years simultaneously. This causes the match data and the number of DOs matching into ACGME dermatology to appear further inflated. This skew will be present in annual match data until all former AOA programs exclusively match 1 class year in the NRMP. It is also important to recognize that since unification, MD applicants now have the opportunity to match into former AOA (newly ACGME-accredited) positions that previously were available only to DO applicants.

While the unification of graduate medical education has many benefits, it also has contributed to AOA program closures. Of the specialties included in this study, 15 out of 91 former AOA programs have either not participated in the NRMP, have not yet achieved ACGME accreditation, or have voluntarily withdrawn (presumed closing) [7]. The decreasing DO match rates, coupled with the closing of AOA programs and MDs matching into former AOA positions, threatens the future of osteopathic physicians in competitive specialties. If the trends evidenced above continue, it will effectively decrease opportunities for osteopathic applicants to pursue competitive specialties and dramatically reduce the representation of osteopathic physicians practicing in those specialties. Losing this diversity within healthcare, especially losing osteopathic qualities that are known to benefit healthcare teams and patient experience [8], is something the medical community as a whole should adamantly try to prevent.

Healthcare is shifting to become more patient-centered and team-based, which is already aligned with existing osteopathic values [8]. The osteopathic philosophy, also known as osteopathic principles and practice (OPP), encompasses core principles that are taught from day one of medical training. Specifically, these principles stem from the osteopathic tenets: the body is a unit, the person is a unit of body, mind, and spirit; the body is capable of self-regulation, self-healing, and health maintenance; structure and function are reciprocally interrelated; and rational treatment is based on an understanding of these principles [8]. The osteopathic community has been utilizing this holistic approach to patient care since its inception and osteopathic physicians are an indispensable asset in the changing tides of medical care.

Maintaining residency positions designed to support and develop the osteopathic philosophical mindset and/or osteopathically-trained physicians is essential to the ongoing evolution of our healthcare system across all specialties. A recent study [9] suggested that osteopathic medical students experience a less significant decrease in empathy throughout their four years of medical school compared to their allopathic counterparts. Differences have also been found between osteopathic and allopathic physicians in communication with patients [8]; osteopathic physicians were shown to communicate in a more personal manner compared to their allopathic counterparts. Osteopathic physicians undergo extensive training in osteopathic manipulative treatment (OMT), which requires a thorough understanding of the fundamental relationship between structure and function. This ultimately leads to a deep understanding of anatomy and the development of refined palpatory skills, both of which are valuable in nearly every medical specialty, especially dermatology, orthopedic surgery, and other surgical specialties. This reinforces the importance of accepting osteopathic physicians into all specialties and supports the benefits to patient care.

Osteopathic recognition (OR) has the potential to preserve the osteopathic philosophy and culture in the single accreditation era. Programs may apply for OR once ACGME accreditation is obtained; this designation demonstrates a program’s commitment to teaching and instilling OPP at the GME level [10]. For this reason, more programs should consider pursuing OR. Of the specialties reviewed, which included over 600 programs, only nine have pursued OR as of September 2020 (four are dermatology; four are orthopedic surgery; one is otolaryngology) [11].

Case Western Reserve University/University Hospitals Cleveland Medical Center (UH-CMC) dermatology program in Cleveland, Ohio is a large residency program accepting six residents per year; it was ranked as the 10th best dermatology program based on academic achievement in 2018 [12]. UH-CMC has consistently accepted two DO candidates and four MDs every year since 2003. In our internal review of a 14-year period at this institution, there was no statistical difference between the MD and DO dermatology residents’ scoring on the In-Training Exam (Figure 1) [13]. While this data is representative of only one program, it should encourage traditional ACGME programs to consider and match DOs just as formerly AOA programs have been considering and matching MDs.

Figure 1:

In-training exam percent (%) correct score average comparison of osteopathic (DO) and allopathic (MD) graduates, 2005–2018.

Conclusions

DOs are highly underrepresented in competitive medical specialties. DO match rates into dermatology and other competitive specialties were poor prior to GME unification and continue to remain low. DOs – with a holistic approach to patient care, high levels of empathy, enhanced palpatory skills, and anatomical knowledge – are indispensable assets in the healthcare system and should be represented in competitive specialties. OR is a means to help potentially preserve the osteopathic philosophy and may assist in alleviating the DO representation disparity in the single accreditation system era. While continued data collection is warranted, ACGME programs of all specialties should not be hesitant to consider osteopathic applicants.