OrthoMatch2024 — A letter to Applicants (2024)

While somehow summer is quickly turning to fall, it is beautiful here in Portland. The rains are still far away, my little garden is full of tomatoes and our backyard has pounds of fresh hops growing up the fence. I wanted to write this earlier, but things have been pretty packed:

• graduating our amazing class of 2023
• onboarding our interns, who are already dominating in the ED, OR, and everywhere else
• enjoying getting to know all our visiting medical students, including those that received a DEI Subinternship Scholarship
• writing all sorts of letters of recommendation, for medical students as well as fellowship-bound residents, among others
• a family trip to central Oregon, including hunting for fossils around John Day and seeing the Painted Hills

I also had the opportunity to be interviewed for an article in CORR — and in it managed to describe a lot of thoughts regarding the current orthopaedic surgery application landscape. While biased, I think it is worth a read. If anyone is having troubles getting access to that article (PMID 37678407), please reach out through ResearchGate.

The comments ranged somewhat, but we focused on the concept of ‘hoarding’ interviews due to a paper that OHSU PGY4 Dr. Kate Hutchison first-authored recently published. I think that full article is also worth a read, especially as it brings some real-world data (not survey responses) to a question that medical students and advisors wonder about. While we found that interviews are unsurprisingly distributed unevenly, modeling a modest redistribution of interviews (or having less applicants) would not meaningfully change that reality. The majority of applicants receive relatively few interviews. This speaks to the math of the match, and what happens when we continue to have about twice as many applicants as positions in orthopaedic surgery residency.

Here I hope to give a few updates and thoughts on the 2023–2024 application process. At this point ERAS Applications are going in, and quite soon all the programs will begin application review. I will focus on some practical matters, but feel free to reach out through our website or social media feeds if wanting to speak with a resident or if questions.

Last year I had to ponder how preference signals might influence the application process. While we still have only one season of experience, I do believe that preference signaling has been a positive for programs as well as applicants. Having thought about this quite a bit, and in talking to many people, I still struggle to find the applicant who is hurt by having the 30 preference signals.

Let me share some numbers from the OHSU Orthopaedic Surgery Residency Program. Last year we received 757 applications, which was itself a 15% reduction from the prior two years. I think this is itself a win, as it likely reflects less of a shotgun style approach to applications. More on the positives of this in a minute… First, though, we received 328 preference signals (43%). We still holistically reviewed each and every application. In the end, though, we only interview 60 applicants and even that is a lot, given that we have 5 residency positions and fill quite quickly on our rank list. Ultimately, we only offered an interview to applicants who gave us a preference signal. While some applicants who didn’t give us a preference signal were on our waitlist, we had zero movement from that waitlist last year.

I think this decision makes sense, especially for programs that receive a lot of preference signals. If we are super excited about an applicant, and they signaled us, then that means we are at least among the 30 programs they were interested in enough to signal. The next step then is to interview them, and decide together if our program seems the best place for them to train. If an applicant does not signal us, and we are less excited about their application, then the decision not to interview them makes sense. If we think an applicant is stellar, but we received no preference signal, then I suspect strongly that other programs will likewise see their high potential; in that scenario, we are at best that applicants 31st favorite program… given that most applicants who Match do so near the top of their list, it simply isn’t very likely that applicant will join us. I can be very happy knowing that great people are joining orthopaedic surgery, even if it isn’t at OHSU — and people have all kinds of reasonable reasons for where they prefer training.

It appears that we were far from alone in prioritizing applicants who had also prioritized our program. Some data presented at the AOA CORD meeting showed that an applicant who applied without a preference signal to a program had about a 1–2% chance of getting to an interview; that chance rose to ~25% for the programs where a preference signal was given. That is rather stark data.

Aside: this data unfortunately doesn’t tell us if some of those non-preference signaled interviewed happened at a home program or away rotation site that told medical students not to signal them. I think this is unfortunate, as it impacts the data for everyone as is against AAMC guidance. I strongly recommend applicants give preference signals to the 30 programs of greatest interest, and in consultation with a knowledgeable advisor. That includes home programs and places where away rotations occurred. This is one of the advantages of orthopaedic surgery having a relatively high number of signals!

What do I wish?
I wish that information on how many preference signals each and every program received were made public. I think this would really help applicants — which ought to be a very high priority — and I think it would help programs as well. Reasonable applicants might well look at programs who received less preference signals, and see if perhaps that is a good place for them to train that wasn’t previously on their radar. There are so many great residency programs. While ORIN is a fantastic site I strongly recommend, I think a simple list of all programs and how many signals they received would be beneficial each year. (For what it is worth, the number of preference signals we received was exactly in the middle of what I remember the Google Sheet estimating).

What might be different this year?
I think programs and applicants have a bit more knowledge going into this year. I suspect shotgun applications will go down further, though not completely, as applicants react to the data above. While I very much understand that not matching is the far more costly outcome, applying to 50–60 programs without a preference signal will, on average, yield an estimated 0–1 additional interviews. While we will continue to holistically review every application, and we haven’t made a decision in advance about whether to interview any non-signaling applicants, I think similar application numbers will likely lead to a similar outcome. For other programs, I hope at least that holistic review will become more possible for those applicants who give a preference signal. The AAMC provides some good information on holistic review for those who are interested.

Another hope for this year is that program directors take the advance from Dr. Bryan Carmody, who spoke at our recent AOA-CORD meeting. The Sheriff of Sodium told us that rather than feeling forced into looking at things like research deliverables or Step 2 scores, that we have the great ability to think deeply about what exactly we are looking for in the next generation of orthopaedic surgeons. Ideally, if we are able to articulate those desired attributes, then we will only benefit from telling prospective applicants this information in a clear manner. At OHSU we expect our residents to be hard-working, team-oriented, others-focused, and trainable/teachable. Beyond that, a question that really drives me throughout the application process is, “What will this applicant add to our residency program?” For as much as we train our residents, in the five years of training I expect our residents to also improve us and the program.

This application season we will continue to have virtual interviews. This format has worked well for us, and are several years in matching fantastic residents in this manner. I don’t think people should have to buy a plane ticket and fly here to “prove interest” in the program. We also don’t schedule all our interview days on the busiest Fridays (or any weekends) in order to force applicants to decide where to and not to interview. Our sense is that the great majority of applicants either have been to Portland or the Pacific Northwest before, or don’t need to visit in order to make their rank list. However, for those who do, we have offered an optional in-person event for applicants now for several years. Importantly, this event happens after our rank list is completed and unchangeable. I love this system, because no one feels pressured to come merely to “show interest”. It cannot make any difference to our rank list — it is only to help applicants. Also… only a few people come, and that is wonderful! Less than 10% of our interviewed candidates come — useful for them, and unnecessary for everyone else… sounds like efficiency.

Clearly there is interest in this method, as the NRMP was receiving public comment on making this method easier for all programs. I still hope that this could become standard in the future: virtual interviews, and then a travel period after program rank lists are due, so that applicants can see a few places before submitting their own rank lists. This is how OHSU orthopaedic surgery will continue to do things.

• Definitely go on a trip or vacation or otherwise do something (or many things) you are keen to do prior to residency starting. The post-Match, pre-Graduation period is a relatively free time, especially compared to the first several years of orthopaedic residency. That said, be careful about scheduling travel in June! In the least, wait until after the Match and find out exactly when orientation starts. It is not uncommon for orientation for residency to start in the second week of June.
• With Step 2 scores remaining as a numerical score, and the results coming relatively late in the process, I would really encourage medical students to talk with knowledgeable advisors before massively changing application plans based on the result. I ended up talking to one applicant who thought their rather respectable score precluded their application to orthopaedic surgery… and this was in the middle of an away rotation that they were rocking! There was no reason to worry. Rather, I am concerned that students are getting advice from fellow students or the internet-ethers, instead of from people who are experience with the decision process. If you are early in the medical school process, a reminder — make connections! Find advisors and mentors! They become so critical through the application process and in the rest of life.

That is all I have for this year. I aim to keep track of questions asked and various themes, and address them at least once a year. If there is something missing from this or prior posts, please reach out. While email is not our friend, I do hope to provide applicants with worthwhile information as you all work through this challenging process.

Good Hunting,

Kenny Gundle

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Kenneth R. Gundle, MD

OHSU Orthopaedic Surgery Residency Program Director
Orthopaedic Surgical Oncologist
Associate Professor of Orthopaedic Surgery
OHSU | Department of Orthopaedics & Rehabilitation
Portland VA Medical Center | Operative Care Division
Fellow of the American Academy of Orthopaedic Surgeons
Fellow of the American Orthopaedic Association