Effect of COVID-19 Restrictions on 2021 Integrated Plastic Surgery Match Outcomes.

OBJECTIVE: Due to the Coronavirus Disease 2019 Pandemic (COVID-19), guidelines regarding both elimination of visiting subinternships and substitution of virtual interviews for the 2021 match were adopted. We hypothesize that these changes will result in an increase in home institution match rates compared to previous years.
DESIGN: Program match data was obtained using information posted to residency program Instagram pages and the hashtag #PRSMatch2021. Chi square was used to assess differences between groups.
SETTING: Medical school regions were categorized as West, Midwest, South, and Northeast and compared to match program region. PARTICIPANTS: Matched candidates to integrated plastic surgery residencies
RESULTS: A total of 181/187 (96.8%) integrated plastic surgery matched candidates were identified. Compared to historical controls, there was a statistically significant increase in the home match rate (24.3%, p = 0.004) and statistically significant decrease in match rate for students without a home plastic surgery program (21.0%, p = 0.004). Similar to prior years, applicants were more likely to match in their own region for all regions (p < 0.001); however, there was a statistical increase in students staying in the South region for residency compared to previous years (p = 0.007).
CONCLUSIONS: The 2021 match cycle resulted in an increase in home program match rates, while decreasing match rates among students without a home plastic surgery program. COVID-19 polices may have resulted in disadvantages to students from diverse institutional backgrounds. Influences of virtual subinternships and virtual interviews should be further evaluated.

INTRODUCTION

Integrated plastic surgery residency positions have continued to rank annually among the most competitive in the match. According to 2020 National Residency Matching Program (NRMP) statistics, the integrated plastic surgery match rate was 61.9%. Due to the competitive nature of the integrated plastic surgery match, in-person contact through visiting subinternships has historically played a vital role. Integrated program directors nearly universally agree that exposure to medical students through subinternships plays a major role in applicant evaluation. A survey of 42 program directors reported that subinternship performance was the most important factor when considering resident selection.

Nearly half of integrated plastic surgery applicants who successfully match will do so at a program with which they have had direct exposure. Over the past ten years, the proportion of applicants matching at home institutions and visiting subinternship institutions has been consistent, despite increasing numbers of integrated plastic surgery programs. Home institution matches represent about 15% of successful matches and visiting subinternship matches represent a higher proportion at 27% to 30%.3, 4, 5, 6, 7

Due to the Coronavirus Disease 2019 Pandemic (COVID-19), guidelines regarding both visiting subinternships and interviews for the 2021 match were adapted by the American Council of Academic Plastic Surgeons (ACAPS), under the recommendations of the Coalition for Physician Accountability. In an effort to eliminate disparities with travel and health restrictions, visiting subinternship opportunities were eliminated. Exceptions were made only for fourth year medical students who did not have a home plastic surgery program. Likewise, in-person interviews were universally replaced with virtual interviews and visits.

Although many integrated programs replaced visiting subinternships with virtual Meet-and-Greet or virtual subinternship experiences, we hypothesize that the changes to the 2020 to 2021 match year will have an impact on match rates. Due to decreased in-person interactions through the decreased availability of subinternships, we anticipate that home institution match rates in 2021 will be increased compared to previous years.

MATERIAL AND METHODS

A list of 2021 accredited integrated plastic surgery programs was obtained from the Association of American Medical Colleges (AAMC) website. Program match data was obtained from posts and stories created by accounts from integrated plastic surgery residencies on the social media platform Instagram following release of 2021 match results on March 19, 2021. Applicant data was confirmed through applicant posts using #PRSMatch2021 shared to the ACAPS Instagram platform. Applicant medical schools were recorded when available from posts and verified through publicly available medical school match reports. Medical schools were classified as either home program or non-home program match. Using regional classification previously cited in the literature, medical school regions were categorized as West, Midwest, South, and Northeast and compared to match program region. Applicants who successfully matched from a medical school with an associated plastic surgery residency program or from a 2021 Top 40 US News and World Report Medical School Rankings for Research and National Institute of Health funding were recorded.

Statistical analysis was performed using Microsoft® Excel version 16.46 (© 2021 Microsoft, All Rights Reserved) with Measuring Usability LLC plugin software. Differences between groups were assessed using Chi square test for categorical variables. P-values of less than 0.05 were considered statistically significant.

RESULTS

A total of 181 applicants (96.8%) were identified of 187 filled integrated plastic surgery residency positions from the 2021 match. The majority of successfully matched candidates came from medical schools with an affiliated integrated plastic surgery program (135/181, 76.7%), with 5 medical students matching from medical schools with only an affiliated independent plastic surgery program (2.8%), while 38 students matched from programs without an affiliated plastic surgery program (21.0%). Medical students matched at the integrated residency program affiliated with their home medical school in 44 instances (24.3%).

Northeast and South reg5ions each accounted for 24 of 84 programs (28.6%), with 21 programs in the Midwest (25.0%) and 15 in the West regions (18.5%). Matched medical student representation per region was similarly distributed to program representation, with 27.6% of students from the Northeast (50/181), 26.5% from the South, 24.8% from Midwest, and 19.3% from West region. Four international students were identified (2.2%). In all regions, medical students were more likely to match at a program within their own region compared to matching elsewhere (p < 0.001). Medical students from the South region were most likely to stay within their region (64.6%), followed closely by the Northeast region (62.0%). See Table 1 for match rates by region.

Table 1

Integrated Plastic Surgery Applicant Match Data for Each Region.

	MW program	NE program	S program	W program
	n (%)	n (%)	n (%)	n (%)
MW applicant	24 (53.3)	7 (14.0)	8 (16.7)	5 (14.3)	p < 0.001*
NE applicant	8 (17.8)	31 (62.0)	6 (12.5)	9 (25.7)
S applicant	10 (22.2)	10 (20.0)	31 (64.6)	5 (14.3)
W applicant	3 (6.7)	2 (4.0)	3 (6.2)	16 (45.7)

MW, Midwest; NE, Northeast; S, South; W, West.

denotes statistical significanc

Integrated programs affiliated with US News and World Report Top 40 medical schools accounted for 42.9% of programs (36/84). Number of medical students matching from Top 40 medical schools were comparable (43.6%, 79/181). Medical students who matriculated through a Top 40 medical school were statistically more likely to match at a Top 40 affiliated program (p < 0.001). The majority of applicants from Top 40 medical schools matched at Top 40 programs (62%, 62/100), compared to 21% of applicants graduating from other medical schools or international programs matching at Top 40 programs (17/81).

When compared to historical data, 2021 applicants were statistically more likely to match at their home program (p = 0.004). The number of applicants matching from programs that did not have an affiliated plastic surgery program was also statistically lower than previously published data (p = 0.004). Trends seen in regional match rates were similar to historical data; however, there was a statistically significant increase in the number of South regional applicants staying in the South (p = 0.007). There was no change in the statistical significance of applicants from Top 40 programs matching at higher ranked research programs; however, the representation of medical students from Top 40 medical schools successfully matching overall was statistically increased (p = 0.002). Comparisons to historical controls are outlined in Table 2 .

Table 2

2021 Match Results Compared to Historical Controls.

	2021 Match Data	Historical Control
	n (%)	n (%)
Home program match rate	44 (24.3)	94 (15.1)†	p = 0.004*
Affiliated plastic surgery program	135 (76.7)	80 (69.5)‡	p = 0.004*
Top 40 medical school	79 (43.6)	374 (40.9)§	p = 0.002*
Midwest regional match rate	24 (53.3)	94 (54.0)†	p = 0.93
Northeast regional match rate	31 (62.0)	98 (56.7)†	p = 0.50
South regional match rate	31 (64.6)	61 (42.3)†	p = 0.007*
West regional match rate	16 (45.7)	64 (55.0)†	p = 0.33

denotes statistical significance

Silvestre J, Lin IC, Serletti JM, Chang B. Geographic Trends in the Plastic Surgery Match. J Surg Educ. Mar-Apr 2016;73(2):270-4. doi:10.1016/j.jsurg.2015.10.015

Kling RE, Kling RR, Agi C, Toirac A, Manders EK. A Closer Look at the 2013 to 2014 Integrated Plastic Surgery Match. Plast Reconstr Surg. Mar 2016;137(3):624e-629e. doi:10.1097/01.prs.0000475824.09531.21

Davis GL, Dean RA, Reid CM, Gosman AA. The Influence of Academic Pedigree on Integrated Plastic Surgery Resident Training Location. J Surg Educ. May 5 2021;doi:10.1016/j.jsurg.2021.03.021

CONCLUSIONS

The 2021 integrated plastic surgery match cycle presented unique challenges due to the ongoing public health crisis. With changes to interview structures and eliminating away subinternships for those with access to a home plastic surgery program, rates of medical students matching at home institutions were significantly higher. Additionally, although some medical students from schools without plastic surgery programs may have had the opportunity to complete an away subinternship, a significant decrease in the match rate for students from schools without a plastic surgery program was seen. Medical students continued to be more likely to stay in their own region for residency, although the rate of students staying in the South increased compared to previous years.

There were likely significant cost savings to applicants of the 2020 to 2021 match cycle. A 2016 editorial in the New England Journal of Medicine recommended eliminating away subinternships due in part to the substantial cost sustained by students. Drolet and colleagues estimated that the average cost of away subinternships is $3951. An additional cost of $2500 to upwards of $10,000 may be accrued related to interviews. However, the value of in-person interactions sustained through these instruments should not be overlooked. The majority of applicants report feeling that an away subinternship makes them more competitive at the program which they are rotating. Additionally, applicants have rated interactions with faculty and residents as the most important aspect in evaluating a program interview, and this may be diminished in the virtual setting. Although full impacts are not yet known, increasing diversity in trainee backgrounds through outside and away student matches may allow for shared experiences to benefit both residency programs and trainee education and should be further evaluated.

Although this study provides a comprehensive optic of the 2021 match cycle outcomes, it is not without limitations. Data was obtained through program-reported matches using a social media platform and is subject to accuracy of reporting. A number of factors were affected in the match cycle. The individual effects of decreased visiting subinternships and substitution of virtual interviews is unknown and should be further evaluated. Additionally, a minority of applicants may have still completed an away subinternship if they did not have access to a home plastic surgery program, and the outcomes of these subinternships was not evaluated in this study. Many programs did offer virtual subinternships, which may have allowed students to gain exposure to outside institutions and should be further researched. Finally, the comparison to historical controls is limited by the evolution and availability of integrated plastic surgery programs. As the number of integrated plastic surgery programs increases, home institution match rates may evolve. Future research is needed to evaluate the performance and experiences of residents matching during this unique match cycle to further define the impacts of COVID-19 constraints.

Trends in the 2021 data showed decreasing match rates for medical students who did not come from a medical school affiliated with a plastic surgery program or from a Top 40 United States News and World Report medical school. These trends are concerning for further decreases in representation of medical students in plastic surgery with diverse institutional backgrounds. In an increasingly competitive field, the 2022 elimination of an objective measure of the Step 1 exam numeric value will likely place even greater importance on interpersonal interactions and pedigree for medical students applying to plastic surgery and may further disadvantage these students. Although short-term costs may be substantial to medical students, long-term benefits of resuming away subinternships, and increasing diversity in plastic surgery trainees likely warrants safe resumption of in-person interactions when safely allowed.

FINANCIAL DISCLOSURE STATEMENT

The authors have nothing to disclose. No funding was received for this study.