Proceed with Caution Before Assigning "Red Flags" in Residency Applications.

To the Editor:

We read with interest the paper by Bohrer-Clancy et al.1 regarding variables in applications to emergency medicine residency that correlate with “adverse outcomes” in training programs. We have some concerns regarding the methods of this paper, and therefore the validity and generalizability of its results.

Inclusion of “extension of residency” as an isolated “adverse outcome” is problematic. These residents were not placed on formal remediation, nor did they fail to complete the residency. Is the extension of residency training for non-academic reasons an “adverse outcome” that should be avoided, or should residency programs and institutions provide a supportive environment such that residents who need additional time due to personal, medical, or family reasons can receive the support they need in order to finish successfully and go on to productive careers? This is the central tenet behind the ACGME’s (Accreditation Council for Graduate Medical Education) Next Accreditation System, which places clinical competency and educational outcomes before program length. In addition, it is unclear with which domains or competencies residents with adverse outcomes had difficulties. Ability to predict issues with medical knowledge, communication, or professionalism may be an important distinction to make depending on the resources of the program to address these issues.

Another concern is the inclusion of a leave of absence (LOA) for any reason as an indicator of potential difficulty. While some reasons for LOA may portend future challenges in medical training, all LOAs are not created equal. It is the responsibility of student advisors to make recommendations regarding LOAs during medical school, and to attach a stigma to any LOA may pressure students to make decisions that are not in their best interest for fear that it will impact their chances of successfully matching.

Although some of these limitations are addressed in the paper, program directors may not have the time or inclination to dive into the details of the study and may take the results at face value, thereby unfairly disadvantaging students who may have taken a LOA for a variety of legitimate reasons during medical school. As educators with a responsibility for providing support, guidance and accountability in medical education, we must not claim that we want students and physicians to achieve educational milestones and also cultivate their own wellness, and then penalize them and future applicants for taking steps to do so.

With respect,

Shellie Asher, MD, MS

Kimberly A. Kilby, MD, MPH

To the Editor:

We would like to thank the Editor for the opportunity to respond to the thoughtful comments from Drs. Asher and Kilby.

Residents who have delayed graduation from residency for non-academic reasons such as the birth of a child, bereavement, and medical reasons were not included in this cohort since while their graduation date might shift, there was no modification of the curriculum on their behalf. We considered an extension of residency to be a situation in which the curriculum was modified with additional clinical time to address one or more deficits in the Accreditation Council for Graduate Medical Education (ACGME) Core Competencies. While the respondents point out that ACGME has introduced the notion of variable progression through residency curriculum with the Next Accreditation System, it is clear that stakeholders in the medical community do not yet accept the concept of a fluid duration of training as a routine matter given the significant amount of additional documentation and justification required from medical licensing boards and hospital credentialing committees. Any substantial change in the residency curriculum or duration of training most certainly involves the disciplinary process of the program and the residency’s Graduate Medical Education Committee. These actions, even when accepted by trainees without the potential for multiple layers of appeals or legal action, are highly time-consuming and stressful for residency faculty and staff. As such the authors reiterate that an extension of residency training represents a negative outcome for a resident.

We recognize that there are many reasons for students to take a leave of absence, all of which we assume to be necessary and appropriate. As in the application of the conclusions of a clinical trial to the care of a specific patient, we expect program faculty to seek the “big picture” in assessment of a specific applicant, not to substitute the findings of our study for good judgment about the likelihood of success for an applicant. In formulating this study the authors did not seek to assign a value judgment or to stigmatize any of the factors examined in this study; rather we were seeking to identify any potential patterns in the overwhelming sea of data available to program faculty in the residency application process.

Most sincerely,

Jesse Bohrer-Clancy, MD

Shawn London, MD