Rejecting Reforms, Yet Calling for Change: A Qualitative Analysis of Proposed Reforms to the Residency Application Process

Purpose Annual increases in the number of residency applications burden students and challenge programs. Several reforms to the application process have been proposed; however, stakeholder input is often overlooked. The authors examined key stakeholders' opinions about several proposed reforms to the residency application process and identified important factors to guide future reforms. Method Using semistructured interviews, the authors asked educational administrators and trainees to consider 5 commonly proposed reforms to the residency application process: Match to obtain residency interviews, preference signaling, application limits, geographic preference disclosure, and abolishing the Match. The authors conducted a modified content analysis of interview transcripts using qualitative and quantitative analytic techniques. Frequency analysis regarding the acceptability of the 5 proposed reforms and thematic analysis of important factors to guide reform were performed. Fifteen-minute interviews were conducted between July and October 2019, with data analysis completed during a 6-month period in 2020 and 2021. Results Participants included 30 stakeholders from 9 medical specialties and 15 institutions. Most participants wanted to keep the Match process intact; however, they noted several important flaws in the system that disadvantage students and warrant change. Participants did not broadly support any of the 5 proposed reforms. Two themes were identified: principles to guide reform (fairness, transparency, equity, reducing costs to students, reducing total applications, reducing work for program directors, and avoiding unintended consequences) and unpopular reform proposals (concern that application limits threaten less competitive students and signaling adds bias to the system). Conclusions Key stakeholders in the residency application process believe the system has important flaws that demand reform. Despite this, the most commonly proposed reforms are unacceptable to these stakeholders because they threaten fairness to students and program workload. These findings call for a larger investigation of proposed reforms with a more nationally representative stakeholder cohort.