The Unmatched Integrated Plastic Surgery Applicant: A Focus on Improving the Application.

Integrated plastic surgery residency is regarded to be one of the most competitive specialties for prospective residents. Applicants routinely have some of the highest United States Medical Licensing Exam scores, proportion of students in Alpha Omega Alpha Honor Society, research experience, and more. Due to the hypercompetitive nature of the specialty, the resulting match rate is among the lowest tracked by the National Resident Matching Program. In fact, in 2022, 351 applicants applied for 194 spots—a dismal 55% match rate.[1] With such a high proportion of unmatched applicants, the question arises: how should the unmatched plastic surgery applicant proceed?

Historically, popular alternative pathways to plastic surgery include, but are not limited to, pursuing a 1-year preliminary surgical training program, completing a categorical general (or other) surgery residency before applying to the independent match, or completing a research fellowship. However, securing a spot in one of these positions is not always an easy feat, specifically categorical general surgery, which is also a competitive match (though it has more available positions nationwide than integrated plastic surgery).[2] To assess applicants’ willingness to pursue various opportunities, the 2019 National Resident Matching Program applicant survey asked US senior applicants their likelihood of pursuing different strategies if they did not match.[3] Results are shown in Table 1. Notably, participants would ideally pursue the Supplemental Offer and Acceptance Program (SOAP) in plastic surgery; however, unmatched positions rarely occur, essentially eliminating that option and altering the trajectory for the prospective resident. Members of our group have previously analyzed reapplicants to plastic surgery and found that reapplicants received roughly 2.5 less interviews during their respective reapplication cycle.[4] These data, in accordance with data seen in both the orthopedic[5] and otolaryngology[6] literature, suggest that applications from reapplicants are favored less than first-time applicants. However, it should also be noted that while program directors from these specialties more often recommend that applicants pursue preliminary surgical training over research fellowships,[5,6] in plastic surgery, there was no difference in match rate when completing a research fellowship compared with a preliminary year.[4]

Table 1.

Likelihood to Pursue a Strategy if Applicant Did Not Match (Answers from Unmatched Applicants)

Strategy	Likelihood
Participate in SOAP for a position in my preferred specialty	4.4
Participate in SOAP for a preliminary year position and reenter the Match next year	3.9
Pursue research and reenter the Match next year	3.9
Participate in SOAP for a position in a less competitive back-up specialty	3.9
Reenter the Match next year	2.6
Delay graduation and reenter the Match next year	2.1
Pursue nonclinical training	1.9
Pursue a graduate degree	1.6
Pursue graduate medical education training outside the United States	1.4

Data retrieved from National Resident Matching Program. Results of the 2019 NRMP Applicant Survey by Preferred Specialty and Applicant Type. 2019. Accessed May 9, 2022.[3]

To answer the question of how the unmatched applicant should proceed, a holistic review of one’s application will likely provide the most meaningful information to best guide the decision. Table 2 outlines potential deficiencies in an application and interventions to strengthen that area. Characteristics are broken down into academic and subjective factors. Likely, there may be multiple areas of an application needing improvement, and the applicant should carefully consider how all deficiencies can best be ameliorated.

Table 2.

Weakness in Application and Recommended Potential Interventions to Increase Competitiveness

Deficiency	Potential Intervention to Increase Competitiveness
Academic
Letters of  recommendation	Identify potential mentors for research fellowships or complete preliminary/categorical surgical training at an institution with an academic plastic surgery department with well-known faculty who can wrist strong personal letters. Strong letters do more than reiterate the CV, but rather speak superlatively about strengths and qualities the applicant possesses.
United States Medical  Licensing Exam scores	Demonstrate ability to improve performance on other standardized tests (eg, ABSITE if completing preliminary or categorical surgical training).
Clinical clerkship grades	Demonstrate ability to succeed clinically during preliminary or categorical surgical training, and especially in working well in teams while taking exemplary care of patients.
Research experience	Complete a research fellowship or perform research with mentors outside of a fellowship. Impact of articles is generally regarded as Published > Accepted > Submitted > In Draft.
AOA membership	N/A
Subjective
Personal statement	Seek feedback to improve personal statement; consider transparently discussing not matching and improvements in the application in the time from not matching.
Performance on away  rotation/subinternship	Seek feedback from institutions at which away/subinternships were completed, and integrate feedback into improving performance if completing preliminary or categorical surgical training.
Interview performance	Seek feedback from interviewing institutions and perform practice interviews before next cycle. Prepare to discuss not matching and actions taken to improve oneself.
Personality/maturity	Seek feedback from previous mentors and faculty evaluators with a specific focus on deficiencies in professionalism or perceptions of maturity.

ABSITE, American Board of Surgery Inservice Training Exam; AOA, alpha omega alpha; CV, curriculum vitae.

There is no “one size fits all” recipe for matching into plastic surgery. Additionally, many opportunities are associated with additional costs, which may introduce an inequity of opportunities before reapplying. Nonetheless, applicants should evaluate their initial applications with academic plastic surgery faculty and mentors to identify deficiencies and areas for improvement. This careful review will help guide the reapplicant as to which pathway—and at what institution—their application will best be improved. Furthermore, if able to identify potential deficiencies before applying, applicants may be able to take additional time off during medical school to address them, maximizing their chances of a successful match the first time applying.