Sea Changes in Dermatology Residency Application Processes

The past 5 years have coincided with a sea change in the world of residency applications. The switch to pass/fail grading for US Medical Licensing Examination (USMLE) Step 1, the removal of the USMLE Step 2 Clinical Skills examination, adoption of virtual teaching and interviewing in the wake of the COVID-19 pandemic, and increasing societal awareness around diversity issues have all profoundly altered the relationships among medical students, their institutions, and residency programs. Students applying to dermatology are thrust into a landscape of ever-evolving norms, values, and selection criteria, while their mentors also struggle to keep up with these changes.

Finding Mentorship

It goes without saying that good mentorship is essential to matching in dermatology. Although some fortunate students may find good mentors at their home institutions, there are other methods for students, especially those without home programs, to find mentors. Students should cast a wide net when looking for mentors and if they are unable to find one within their institution, they should search through specialty societies of particular interest to them, and perhaps look for private practice dermatologists in their local area. Subspecialty societies, such as the American Academy of Dermatology (AAD), Skin of Color Society, Medical Dermatology Society, and numerous others, have formal mentorship programs where a student is paired with an attending, often with research or grant funding attached.

Mentorship programs are commonly bidirectional, benefiting both students and attendings. In fact, some of these grants and mentorship programs are even available to dermatologists in practice. For example, the American Contact Dermatitis Society (of which I am a proud member) issues mid-career grants for physicians who seek to learn the intricacies of patch testing, and who may not have been exposed to this training during residency.

Conferences

Presenting research at conferences can be a great way for students to learn about dermatology while also networking and finding additional mentorship. Although students may be excited to attend the biggest conferences such as the AAD annual meeting, they may benefit more from participating in smaller and more specialized meetings (see Financial Burden of Conference Attendance for Medical Students). Large conferences can be overwhelming, and it may be difficult to find specific people to make meaningful connections. In contrast, smaller meetings, such as the Society for Pediatric Dermatology or statewide dermatology society meetings, are often free for medical students and have a more intimate atmosphere conducive to impromptu meetings and close connections with others who share a similar academic interest.

Mentors should therefore advise students to choose a small number of higher-yield conferences to attend and make a clear agenda for each conference day. Students should identify a few key speakers who they would like to meet based on their connection to a specific residency program, or perhaps a shared research interest, and mentors may be able to facilitate these connections. It is human nature that we are more likely to form a connection with a potential mentee if an attending colleague vouches for them.

What Do We Mean by Diversity?

Dermatology remains one of the most competitive medical residencies. In 2024, dermatology residency programs across the country received a total of 939 applications for only 517 available spots. This translated to an average of more than 1.8 applicants vying for each position. The match rate for US MD graduates was approximately 78%, with even lower match rates for DO and international medical graduate (IMG) seniors. Aside from small year-to-year deviations, these rates remain similar to those over the past decade, according to an analysis of dermatology match data from 2007 to 2018.¹

Beyond the raw statistics, dermatology also contends with significant diversity challenges. Currently, dermatology ranks as the second-least diverse medical specialty, trailing only orthopedic surgery. Furthermore, many teaching resources, such as dermatology textbooks and residency program didactics, lack images of diverse skin colors, leading to suboptimal education and worse outcomes for patients of certain ethnic backgrounds.²

Unfortunately, terms such as diversity and equity have become somewhat controversial in recent years. Most dermatologists likely agree with the following statements: 1) our specialty benefits from incorporating a wide array of viewpoints and 2) no person’s entire identity can be summarized by checking boxes on an application. In this era of holistic review of applications, programs generally take an expansive view of diversity, which includes demographic factors, as well as factors specific to the applicant, such as their hobbies, interests, past experiences, and aspirations for the future.

Mentors should advise students that they are ultimately applying for a position where their main goal will be to care for patients and become a strong clinician. Applicants may choose to incorporate aspects of their identity, but all mention of these factors should be tied to their future practice as a clinician. For example, if an applicant speaks fluent Spanish, it would be beneficial for them to highlight this skill when applying to programs that serve a large Spanish-speaking population. In addition, a frequent applicant mistake is focusing too much on interests outside of dermatology, which can be perceived as lack of commitment to medicine. Although an applicant may have a brilliant Shark Tank pitch that could make them a multimillionaire, they will need to demonstrate to a program director they can dedicate themselves to patient care and studying for board exams for the next 3 years to be ranked to match.

Fewer Objective Metrics Pose a Challenge

Here we discuss one of the biggest controversies in dermatology residency selection: How can program directors balance the need to select the best medical students in a hypercompetitive landscape, while also ensuring diverse representation that reflects the patient population of our diverse nation? Historically, program directors cited high board scores, high clinical grades, strong letters of recommendation, and, to a lesser extent, research output as key factors in resident selection. However, due to concerns that the USMLE Step 1 put too much pressure on students at an early stage in their medical education, this exam was transitioned to a pass/ fail format in 2022. Additionally, many medical schools switched to pass/fail grading for clinical rotations after the preponderance of virtual clinical rotations and concerns that clinical grades were overly subjective. Although these changes were aimed at leveling the playing field for a diverse array of applicants, some of them may have the opposite effect.

Step 2 Clinical Knowledge (CK), typically taken at the conclusion of clinical rotations in a student’s third or fourth year of medical school, has replaced Step 1 as the main objective metric for stratifying applicants. Students will not know whether they are competitive for a field like dermatology until late in their medical education, which may prompt low-scoring students to switch to other specialties at the last minute. Students who perform poorly on Step 2 CK will have no further opportunity to show growth or improvement, and much of the knowledge tested on this exam is irrelevant to the future practice of dermatology. Furthermore, the lack of clinical grades makes it more challenging for residency programs to stratify applicants by their performance in arguably the most important aspect of medical school—clinical rotations.

The combination of these changes may inadvertently compound the advantages enjoyed by students at top-ranked institutions. Due to the lack of objective criteria, program directors may, consciously or unconsciously, place further emphasis on strong letters of recommendation and quantifiable research output, 2 areas in which students from top-ranked universities have more access. Indeed, the lack of a scored Step 1 likely harms IMG’s the most, as they have lost one of their main ways to distinguish themselves from US applicants, and IMGs may not be able to find high-quality clinical rotations or letters of recommendation from US programs.

One may also argue that given the relative difficulty in dermatology board examinations, especially given the shift to a new model of BASIC, CORE, and APPLIED examinations, we should be selecting residents with a demonstrated track record of performing well on standardized tests. Although tests have their own inherent biases, scoring highly on an examination can also indirectly hint at other valuable skills, such as self-discipline, time management, and knowledge retention.

One possible solution to this conundrum would be to gradually re-introduce additional quantitative measures to the application. Dermatology could institute a shelf examination, which would consist of questions appropriate for a fourth-year medical student. Many other specialties, such as emergency medicine and internal medicine, often use shelf examinations to stratify applicants, and this method has the advantage of encouraging students to obtain knowledge that will be directly useful in their future residency. Many fourth-year dermatology rotations already administer some form of end-of-rotation quiz; a shelf examination would standardize these questions and allow more consistent comparisons across a wide variety of medical schools. Designing such an exam would not be difficult for our specialty; questions from the BASIC exam administered to PGY-2 dermatology residents could be used as a template and simplified.

Application Overload

Due to the competitiveness of dermatology, applicants feel pressure to apply to more programs than they would conceivably be able to interview at. Application overload harms both applicants and programs. Program directors are so overwhelmed with applications that they are unable to read all of them in-depth for holistic review purposes, and they may not be able to identify applicants who are the best fit for their institutions. This results in suboptimal interview allocation; in other words, more interviews are doled out to students who may not truly be interested in a particular program at the expense of other individuals who would be much more interested. In the process, applicants may also spend more money on applications than they would prefer. Why does application overload still occur despite its harm to all parties?

The answer can be explained via game theory: While it is in the best interest of all students and all programs for there to be fewer applications, if any individual student applies to a high number of programs, they have a competitive advantage over their peers. Therefore, it is in the best interest of each individual student to apply to as many programs as possible, even if this results in a worse aggregate outcome for all parties. Formal restrictions on the number of applications have been proposed; however, these are impractical because it is difficult to determine the optimal number of applications in any given year, and the Association of American Medical Colleges benefits financially from students sending more applications.

A more practical solution that has been recently implemented is preference signaling. Applicants are given 3 gold tokens that indicate a high degree of interest in a program, and 25 silver tokens indicating a significant but lower degree of interest. Applicants can also indicate geographic preferences. However, due to the novelty of these signaling mechanisms, guidelines are inconsistent as to how these tokens should be applied. For example, should students send a gold token to their home program, which statistically has their best chance of matching, and any programs where they conducted an away rotation? Or would these be wastes of precious gold tokens? Also, will applicants get screened out automatically if their geographic preference falls outside the range of a specific program?

Providing advice to students on these topics is challenging for mentors because they did not exist even 3 years ago when current senior residents applied for dermatology. Therefore, advice should be determined on a case-by-case basis, in careful consultation with an applicant’s home program if available. Over the next few years, programs may wish to develop a standardized guide for these metrics that can be distributed to all dermatology applicants to minimize confusion.

Away Rotations

Before the pandemic, the financial burden of away rotations on medical students likely exacerbated the lack of diversity in our specialty. Therefore, the past few years have provided opportunities for residency programs to re-evaluate the role of away rotations.

By rotating at multiple institutions, students gain insight into diverse training environments, patient populations, and teaching methodologies. Moreover, these rotations provide valuable networking opportunities, enabling students to establish connections with faculty and residents, which can lead to mentorship opportunities, letters of recommendation, and collaborative research endeavors. Away rotations serve as a powerful signaling mechanism for students interested in specific programs and certain regions of the country.

However, away rotations also come with challenges. They can impose a significant financial burden, particularly for students who need to cover expenses such as travel and housing. Additionally, the time and energy required to rotate at multiple institutions can be exhausting, and students miss out on valuable learning experiences in their final year of medical school.

As a compromise, the Association of Professors of Dermatology residency program directors recommended that students with a home dermatology program be limited to completing 2 away rotations, whereas those without a home program can participate in up to 3 rotations. This guideline appears reasonable, as it allows students to gain some benefits from away rotations while minimizing some of the downsides.

Mentors should advise applicants to choose away rotations using the following criteria:

• Interest in that specific program

• Interest in a particular region of the country (especially important for applicants interested in Texas or California but who may not have a clear connection to these states)

• Likelihood of obtaining a strong letter of recommendation

• Likelihood of securing an interview based on the program’s track record of interviewing away rotators

• Likelihood of an applicant standing out from the crowd

Mentors should help applicants understand their overall competitiveness among their dermatology applicant peers and select away rotations where the applicant is more likely to be compared favorably to other rotators. For example, a student who excels in pediatric dermatology should be advised to seek a rotation in which they have more opportunities to demonstrate their knowledge and skills.

Residency Selection: The Interview Stage

Many program directors argue that the ideal method to select residents should include some combination of holistic review, which incorporates some objective performance measures, as well as an applicant’s personal qualities and their overall fit for each institution. These goals are admirable, and proper implementation would significantly improve diversity within our specialty. The ongoing practical challenge with this approach is that applicants often struggle to identify what sets each program apart from others. Virtual interviews have only worsened this problem; although students report significant cost savings, and there is an ancillary benefit of reduced carbon footprint from less air travel, nothing replaces an in-person meeting.

Programs may wish to gradually re-introduce in-person interviews, and perhaps use them as an additional screening metric. For example, programs could conduct short screening interviews with their favored candidates virtually, and then only invite a select few to the in-person interview day. This approach would reserve interviews for only the applicants who would benefit most and likely result in both programs and applicants moving higher up on each other’s rank lists. An alternative option would be to follow the model of specialties such as orthopedic surgery and conduct regional interviews. For example, all the Washington, DC-area programs may wish to coordinate their interviews over a single weekend, thereby allowing students to make a single trip. Such an approach would require high levels of coordination among competing institutions, which may not always be practical. Nevertheless, this approach would also result in cost savings and carbon footprint reduction.

Research Years

Students who receive very few interviews should begin planning for the possibility of going unmatched. In these situations, the main choices include pursuing a PGY-1 position or doing a research fellowship. Some research fellowships are targeted to students between their third and fourth years of medical school, whereas others are specifically designed for students who have graduated. Students considering a research fellowship must commence the application process as soon as possible because some positions start recruiting candidates as early as the January before their fellowship year, which typically begins in the summer. When selecting a research fellowship, students should select programs based on the following criteria:

• Institutions that have an associated residency

• Institutions that have a track record of either matching fellows from their own program or successfully helping their fellows match elsewhere

• Probability of producing high-impact publications and having opportunities to network with academic dermatologists and program directors

Vague promises of a guaranteed interview at the end of the research year are red flags, as these programs may extend courtesy interviews to research fellows but may not rank them at all. Students should also proceed with caution when selecting fellowships sponsored by pharmaceutical companies or those administered primarily through private practice offices; recommendations from these programs may not carry the same weight as those from academic programs.

Unmatched Applicants

Many medical students interested in dermatology will find themselves unmatched. This may be a huge psychological blow to students who have excelled throughout their career, and providing emotional support to students at this vulnerable time is crucial. After receiving the news about their match situation, students should have an honest conversation with their loved ones and mentors about their career goals. Do they wish to pursue an alternative specialty or is dermatology their only goal? For those pursuing an alternative specialty, they may be able to secure a position in the Supplemental Offer and Acceptance Program (SOAP) depending on their preferences. However, most applicants will want to reapply for dermatology in the future.

Given that over 99% of dermatology programs fill all their spots each year, it is extremely rare for students to match into dermatology during the SOAP period. Unmatched students should first decide whether they are pursuing a research year or participating in a PGY-1 intern year. If choosing the latter, they should prioritize programs that have an associated dermatology residency in the same institution. PGY-1 interns have many opportunities to rotate with dermatology and get to know the residents and faculty; these close connections may prove decisive when the student ultimately reapplies to residency. Some dermatology programs may even obtain funding for additional PGY-2 positions and prefer to fill these new positions with interested candidates from the PGY-1 preliminary internal medicine program at the same institution.

After the emotional shock of their situation has worn off, students should engage in tough conversations with their mentors and home institution as to what specific weaknesses prevented them from matching. Perhaps the student had weak letters of recommendation, mediocre scores or grades, or interviewed poorly. Receiving brutally honest feedback is critical at this stage because students will need to address any or all weaknesses before reapplying. Often, home institutions provide excuses, such as “it was a difficult application cycle” or “there were too many applicants from our school.” Both students and mentors should not accept these vague excuses; students have a right to receive specific feedback, even if it can be difficult for them to hear. Only by addressing the feedback can a student give themselves the best chance of success in a subsequent application cycle.

Conclusion

Dermatology remains one of the most competitive residencies, and the application process has only become more complicated over the past several years. The lack of objective metrics makes it more difficult for program directors to compare students across different medical schools, and increased emphasis on holistic review has led to varied and often conflicting advice. Students looking for mentorship outside of their home institution can find it through subspecialty societies, and dermatologists from all practice models may benefit from participating in mentorship programs. Additionally, the following policy changes to the application process may benefit both programs and students: introduction of additional objective metrics such as a dermatology shelf exam, clearer guidance for students on appropriate use of signaling tokens and geographic preferences, and hybrid interviews that incorporate the benefits of both virtual and in-person interviews.

Disclosure: The author reports no relevant financial relationships.

References

1. Jayakumar KL , Lipoff JB. Trends in the dermatology residency match from 2007 to 2018: Implications for the dermatology workforce. J Am Acad Dermatol. 2019;80(3):788-790. doi:10.1016/j.jaad.2018.06.071.

2. Kaundinya T, Kundu RV. Diversity of skin images in medical texts: recommendations for student advocacy in medical education. J Med Educ Curric Dev. 2021; 8:23821205211025855. doi:10.1177/23821205211025855

© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of The Dermatologist or HMP Global, their employees, and affiliates.