Residency applicants, especially today, come from diverse backgrounds, including various careers, SESs, gap years, and geographic location. Despite an increase in applicants from diverse backgrounds, the application process may still perpetuate inequities for students and presents operational challenges for reviewing committees. Many of these intrinsic challenges to the application process have been compounded by shifting incentives inspired by changes to the Step 1 exam switching to a pass/fail format.
In light of these and other issues, the AAMC has announced research-informed reforms to the ERAS process. Though these adjustments can potentially increase the efficiency, efficacy, and equitability of the application process, we would like to share medical student perspectives on the opportunities as well as potential obstacles to education equity.
One significant change to ERAS for the 2024 cycle is limiting applicants to ten experiences on their application. In previous cycles, students could list as many experiences as needed. This change potentially increases the equity of the application process through indirect mechanisms. A shorter average application length and the ability to draw attention to three “most meaningful” activities may allow program directors to review a greater number of applications in the same amount of time, thereby discouraging harsh filtering of applicants based on superficial characteristics such as perceived medical school status, which may improve equity in The Match for years to come. Additionally, some students in the previous system equated having more experiences with a better application, resulting in students including “filler experiences.” With the recent update, this phenomenon is inherently discouraged by the limitation to ten experiences.
Despite the potential benefits of this new system, numerous students will be disproportionately disadvantaged by this change. Below are four main situations and ways this can occur.
Situation 1: Due to the immense financial demands of medical school and residency applications, many students of varied SES pursue opportunities to support themselves in paying off ancillary costs. For example, a student may work jobs during medical school or in a gap year to afford residency application-related fees such as flying to interviews. Capping students at ten experiences may prevent them from including such work on their application, in favor of “more clearly relevant experiences” such as research, masking the immense diligence, creativity, and fortitude necessary to balance these competing priorities. Therefore, this change may signal a shift away from a holistic review that captures the breadth and nuance of individual applicants – a particular concern as test scores are increasingly deprioritized.
Situation 2: Many students also come from previous careers, such as serving in the army, which provide these students with immensely relevant backgrounds and unique perspectives that the field of medicine would benefit from inviting to the table. Again, limiting us to ten experiences may prevent such students from including these unique backgrounds in their applications. This issue can be partially mitigated through the inclusion of such topics in the personal statement, however, these students may not have enough space in the personal statement to do so.
Situation 3: Students may be forced to remove application components, even if these pieces mandated considerable time, effort, or investment. This is particularly true for projects, hobbies, or volunteer efforts which have no immediate public record, i.e., a publication, and therefore may limit the ability to highlight specific research skills, individual capacity for managing multiple projects simultaneously, or creative endeavors which reflect the spirit of the applicant and their ability to serve as humanistic, patient-centered providers. This may lead to shifting incentive schemes within medical training and an increasing emphasis on research output as the only metric of medical student success.
Situation 4: Additionally, given that this change discourages the inclusion of activities not concretely aligned with a specific program, it forces us to reckon with the purpose of medical training itself. To what degree do we expect students to enter medical training with a concrete roadmap for their future instead of providing them time, space, and resources to explore – particularly when such exploration may not be rewarded? Further, what are this implications for equity? Students from higher SES backgrounds are likely to have greater opportunities to explore areas of interest at earlier stages of their education relative to first-generation, low-income, or minoritized applicants?
In addition to reducing equity, capping the application at ten experiences will prevent program directors (PDs) from fully understanding their fit with students. The ten-experience max will force them to selectively list what they believe is most important to a PD, such as research or clinical volunteering. But in a sea of applications, this will prevent us from displaying what makes us unique and interesting colleagues for the long hours we will spend alongside our attendings. During our medical education research and advocacy work, we learned firsthand from PDs that they heavily value individual fit with students. One such example included sharing a deep passion for jazz music with some of their residents and even meeting to play guitar/bass together.
The new 2024 ERAS also changed how students describe their hometown, from a free-form text box to a series of standardized boxes such as “country, state, city, postal code, and setting … including hometown and addresses for experiences and education.” Standardizing the way students describe their lives moves directly against the notion of uniqueness and equity. Within even a zip code, some schools receive significant funding whereas others do not. Some regions experience significant violence and other safety issues, such as anti-gay discrimination, making their region unconducive to an upbringing that would allow a student to safely flourish. It is important to acknowledge how poorly counties are drawn, and now, how limited the standardized boxes on ERAS 2024 are. AAMC’s new ERAS moves to cram our geographic upbringings into standardized boxes will hide the unique challenges that students face, while simultaneously reducing our abilities to explain it on other parts of the application due to restrictions to the experience list, thus, further reducing equity.
ERAS is in significant need of change. We applaud the AAMC for conducting research to inform whether change is needed and which changes to bring about. However, we believe that the specific changes implemented for 2024 will create more issues that need to be addressed in the future. These effects may potentially be exacerbated by the recent change of Step 1 of the USMLE becoming a pass/fail exam, as we do not yet fully know how the residency application process has changed and how students can best be advised during medical school for the match. ERAS and the USMLE have changed simultaneously, making the process even more nebulous. Students with less access to advising are now even more susceptible to experiencing the inequitable effects of this series of changes.
Ank Agarwal, Aditya Narayan, Joshua Leaston, and Akshay Bhamidipati are medical students.