LAUSR

Application to hematology-oncology fellowships is a competitive process. In the 2019 National Resident Matching Program (NRMP) match, there were over 800 applicants for just over 600 positions. Specific factors that hematology-oncology fellowship program directors (PDs) take into account when choosing applicants to invite for interviews, and ranking interviewees for the match have not been well-described in the literature. However, evidence from other specialties and personal discussion with several PDs suggests that “traditional” markers of success such as perceived quality of residency program, United States Medical Licensing Examination (USMLE) Step 1 and 2 board scores, academic productivity (measured by number of publications/ presentations), and letters of recommendation from Internal Medicine (IM) PDs and subspecialty faculty are common elements used to rank applicants. We believe that these “traditional” markers of success leave a gap in the assessment of applicants and, if used in isolation, are not the ideal ways to assess and rank hematology-oncology fellowship applicants. Defining a “high-quality” or “high-ranking” residency program is subjective, and the rank of a program does not necessarily indicate the quality of an individual resident. For example, the Doximity residency ranking system relies on subjective physician opinion of quality to produce a “reputation” value. A resident who attended a residency program perceived by some application committees as “lower quality” for financial or social reasons (need to be close to family, for example), and was one of the best residents in the program may not be offered an interview or ranked highly on the match list. Whereas, a resident who attended a “top-quality” residency program (possibly at least in part on the basis of attending a “top quality” medical school or having high USMLE board scores), but did not perform well in residency may be offered interviews at top fellowship programs, and even potentially ranked highly on the match list due in part to their residency program's perceived quality. The same constraints apply to use of USMLE board scores, where trainees with socioeconomic advantages may be able to pay for board review courses and/or tutoring, and trainees without these advantages may not score as highly. Additionally, as those from disadvantaged backgrounds may be the very candidates we hope to attract to our programs to increase diversity, equity, and inclusion we are doing these applicants a disservice by focusing entirely on traditional metrics of success. We would also like to acknowledge the disadvantages faced by International Medical Graduates (IMGs) who trained outside the United States and have little chance at being accepted to “top-quality” residency programs. These applicants often take the USMLE examinations much later on in their medical training than American trainees (eg, after completion of medical school and often a home-country internship). Therefore, the use of residency quality and USMLE scores to rank applicants puts IMGs at an inherent disadvantage, no matter their level of skill as physicians. Additionally, our prior research suggests that specifically for hematology-oncology fellowship programs, ranking of residency program and letters of recommendation indicating a “top” applicant (which are notoriously subjective), are not associated with hematology or oncology in-training examination scores, research productivity, or choice of an academic vs private practice career after fellowship. While higher USMLE step 1 and 2 scores were associated with higher in-training examination scores, neither were associated with research productivity or career choice (and, we would add, test scores may have little to do with other important milestones such as effective communication). The USMLE examination will become pass/fail as of January 2022, and future studies should examine the effect of this change on fellowship application outcomes. On the one hand the reduced reliance on numeric scores may prompt further consideration of other applicant qualities in a more holistic manner. But on the other hand it has been noted that high USMLE scores may be one of few advantages available to IMGs to set them apart from their competitors. In our research, we also found that IMGs had higher academic productivity, both pre-fellowship and during fellowship, and were more likely to choose academic careers. As such, we already have data that “traditional” markers of success (residency quality), and country of training are not associated with what we often consider important outcomes as hematology-oncology fellowship programs. One way that residency training programs have attempted to overcome these challenges is with the Holistic Review process. The Association of American Medical Colleges has defined core principles of the Holistic Review process as (i) emphasizing the importance of individualized consideration of every applicant, (ii) developing mission-driven, diversity-oriented processes, and (iii) encouraging the application of a balanced approach to address the experiences, attributes, competencies, and academic/scholarly metrics (E-A-C-M) of each candidate. The AAMC urges that all graduate medical education (GME) programs take into account elements of the Holistic Review process when screening and ranking applicants. Additionally, the Alliance for Academic Internal Medicine (AAIM) has developed guidelines for a standardized fellowship letter of recommendation (SLOR), as SLORs have been shown to demonstrate increased reliability as predictors of performance and greater inter-rater reliability, compared to non-standard letters of recommendation. The AAIM recommends that IM PDs should write Received: 30 June 2020 Accepted: 2 July 2020