Commentary: Trends in the National Resident Matching Program (NRMP) Data for Graduating US Medical Students Matching in Neurosurgery

Commentary: Trends in the National Resident Matching Program (NRMP) Data for Graduating US... ABBREVIATIONS ABBREVIATIONS ACGME American Council of Graduate Medical Education AOA American Osteopathic Association GME graduate medical education IMG international medical graduate NIH National Institutes of Health NRMP National Residency Matching Program USMLE United States Medical Licensing Examination Since 1952, the National Residency Matching Program (NRMP) has provided matching services to medical students applying to American Council of Graduate Medical Education (ACGME) accredited residency programs. The NRMP employs a mathematical algorithm to “match” rank-ordered preferences of applicants to those of residency program directors.1 In 2009, US neurosurgery residency programs transitioned from the San Francisco Match program to the NRMP.1 The NRMP publishes a comprehensive summary of match data for all specialties in 2 reports entitled Results and Data and Charting Outcomes of the Match.1-13 Several specialties, such as plastic surgery, emergency medicine, and orthopedic surgery, have utilized NRMP-published reports to analyze trends in their own residency match data and to identify characteristics of matched applicants to their specialties.14-16 However, similar analyses of neurosurgery match data and applicant characteristics are lacking in neurosurgery peer-reviewed literature. Analyzing trends in neurosurgery match data is important for many reasons. First, since 2009, the number of neurosurgery residency programs has increased from 97 to 107, leading to an increase in the number of residency positions from 191 to 218.1-9 It is unknown whether increase in the number of programs and positions has resulted in a decrease in neurosurgery match competitiveness. Second, by 2020, all American Osteopathic Association (AOA) accredited and ACGME-accredited residency programs will transition to a single accreditation system under the supervision of the ACGME.17 In the current system, osteopathic students are eligible to apply to both AOA-accredited and ACGME-accredited neurosurgery programs, but only 10 osteopathic medical students have matched in ACGME-accredited programs since 2009.1-9 For the academic year starting in 2020, all osteopathic and allopathic medical students will be entering a single NRMP match for ACGME-accredited neurosurgery programs.17 Therefore, there is value in performing a baseline evaluation of neurosurgery residency match data before 2020, when the influx of osteopathic medical students will undoubtedly alter the dynamics of the neurosurgery match. Third, since 2009, a total of 388 graduating US medical students who ranked neurosurgery as their preferred (first) choice have failed to match in neurosurgery.1-9 A survey of first-year neurosurgery residents showed that the mean cost of the application process is $10 255.18 The tremendous loss of productivity and expense resulting from failure to match places a responsibility upon those making match decisions to candidly advise medical students about their prospects of matching in neurosurgery. Therefore, a report on neurosurgery match data and applicant characteristics will be invaluable to medical student advisors and to prospective students entering the NRMP neurosurgery match. For each of the above reasons, the objective of this article is to analyze trends in the neurosurgery match and to document characteristics of matched graduating US medical students since neurosurgery joined the NRMP in 2009. METHODS A retrospective observational analysis of neurosurgery match data was performed using NRMP-published reports since 2009. Institutional Review Board approval was not required because patient information was not analyzed in this study. Data Collection To examine trends in the neurosurgery match, data were obtained from NRMP, Results and Data: Main Residency Match for the years 2009 to 2017.1-9 Data collection included number of programs, positions offered, positions unfilled, graduating US medical student applicants, graduating US medical student matched applicants, and all other matched applicants by category (international medical graduates [IMGs], osteopathic graduates, Canadian medical graduates, and US graduates who previously failed to match). Applicant to position ratio, defined as the ratio of number of graduating US medical students to number of neurosurgery positions, and match rate, defined as the percentage of matched graduating US medical students, were used as measures of neurosurgery match competitiveness. To examine trends in applicant characteristics, data were obtained from NRMP, Charting Outcomes in the Match for U.S. Allopathic Seniors, which was published only in 2009, 2011, 2014, and 2016.10-13 Data collection included number of contiguous ranked programs (continuous rank list of neurosurgery programs as preferred [first choice] specialty without intervening rank of other specialties), United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, number of abstracts, presentations and publications, percentage of Alpha Omega Alpha (AOA) honor society students, percentage of students from top 40 National Institutes of Health (NIH) funded medical schools, and percentage of students with combined MD/PhD degrees. Unlike the Main Residency Match reports, the Charting Outcomes reports required applicants to consent for their information to be used in match research. The Charting Outcomes reports, although requiring applicants to opt in, are remarkably comprehensive. For example, in 2016, 244 out of 264 (92%) neurosurgery applicants opted in their information to be included in Charting Outcomes. Rationale for Selecting Graduating US Medical Students who Ranked Neurosurgery as Preferred Choice The NRMP classifies applicants to the match into 2 broad categories: graduating US medical student and Independent. US allopathic medical schools sponsor graduating US medical students to apply for the match. Independent applicants are those in all categories other than graduating US students, including graduates from foreign medical schools, osteopathic medical schools, and previous US allopathic graduates. Since the NRMP often presents data on Independent applicants as 1 group, it is not possible to determine values for variables, such as USMLE Step scores and number of publications, for a subgroup within Independent applicants. Therefore, due to the heterogeneity of the Independent applicant data, we only analyzed data on graduating US medical students who ranked neurosurgery as preferred (first choice) specialty. Statistical Analysis Normality of variables was assessed using the Kolmogorov–Smirnov test. Means and percentages were calculated where appropriate. Two-tailed t-test was used to compare 2 normally distributed variables, whereas analysis of variance was used to compare 3 or more normally distributed variables. Data that were not normally distributed were analyzed using nonparametric tests (Wilcoxon rank-sum test for comparing 2 variables and Kruskal–Wallis test for comparing more than 2 variables). For categorical variables, percentages were calculated as appropriate, and statistical comparison was performed with Fisher exact test or chi-square test. Correlation between continuous variables was assessed using Pearson's test and reported as correlation coefficient (r). Statistical significance was defined as P < .05. Statistical analysis was performed using SPSS 21.0 (IBM Corp, Armonk, New York). RESULTS Trends in Number of Neurosurgery Programs, Positions, and Applicants From 2009 to 2017, the number of neurosurgery residency programs increased from 97 to 107 (r = 0.95, P < .001), and the number of residency positions increased from 191 to 218 (r = 0.98, P < .001; Table 1). However, there was no statistically significant trend in the total number of applicants (r = 0.54, P = .13), particularly graduating US medical students who ranked neurosurgery as their preferred (first choice) specialty (r = 0.56, P = .12). The total number of applicants varied from year to year, with 354 being the highest number in 2015 and 2016. Similarly, the total number of graduating US medical students who ranked neurosurgery as their preferred choice varied from year to year, with the highest number being 250 and 264 for 2015 and 2016, respectively. Of note, there were fewer graduating US medical student applicants in 2017 (210) than in 2009 (215). Graduating US medical students comprise the overwhelming majority of matched applicants, filling at least 87% of all positions since 2009, except in 2017 (84%). In 2017, the decrease in percentage of matched US graduating medical students was offset by an increase in that of US graduates (7%), a group consisting of US allopathic medical school graduates who previously failed to match. The number of unfilled positions has remained low since 2009, with the highest number of unfilled positions at 3 in 2010 and 2011 (Table 1). TABLE 1. Summary of Match Data From 2009 to 2017     2009  2010  2011  2012  2013  2014  2015  2016  2017  r  P value    Number of programs  97  97  98  98  99  102  102  105  107  0.95  <.001    Number of positions  191  191  195  196  204  206  210  216  218  0.98  <.001    Unfilled positions  0  3  3  2  1  0  2  2  0  −0.26  .50    Total number of applicants  317  309  283  318  314  335  354  354  311  0.54  .13    Graduating US Seniors who ranked neurosurgery as preferred specialty (% of all applicants)  215 (67.8%)  208 (67.3%)  202 (71.3%)  200 (62.8%)  238 (75.8%)  238 (71.0%)  250 (70.6%)  264 (74.6%)  210 (67.5%)  0.56  .12    Matched graduating US Seniors who ranked neurosurgery as preferred specialty  171  173  174  170  190  188  188  200  183  0.76  .02    Match rate for US Seniors who ranked neurosurgery as preferred specialty  79.5%  83.2%  86.1%  85%  79.8%  79.0%  75.2%  75.8%  87.1%  −0.20  .61    Applicant to position ratio for US Seniors who ranked neurosurgery as preferred specialty  1.12  1.09  1.03  1.02  1.17  1.16  1.19  1.22  0.96  0.11  .78    Matches by applicant type                           Graduating US Senior (% of positions filled)  172 (90%)  173 (92%)  175 (90%)  170 (87%)  190 (93%)  189 (92%)  188 (90%)  200 (93%)  183 (84%)         US Graduate (%)  3 (1.6%)  7 (3.7%)  6 (3%)  5 (3%)  3 (1%)  7 (3%)  4 (2%)  3 (1%)  15 (7%)         Osteopathic graduate (%)  1 (0.5%)  1 (0.5%)  0  1 (0.5%)  2 (1%)  3 (1%)  0  0  2 (0.9%)         Canadian graduate (%)  0  0  0  0  0  0  1 (0.5%)  0  0         US IMG (%)  3 (1.6%)  3 (1.6%)  4 (2%)  5 (3%)  2 (1%)  1 (0.5%)  1 (0.5%)  3 (1%)  4 (2%)         Non-US IMG (%)  12 (6.3%)  4 (2.1%)  7 (4%)  13 (6.6%)  6 (3%)  6 (3%)  14 (7%)  8 (4%)  14 (6%)          2009  2010  2011  2012  2013  2014  2015  2016  2017  r  P value    Number of programs  97  97  98  98  99  102  102  105  107  0.95  <.001    Number of positions  191  191  195  196  204  206  210  216  218  0.98  <.001    Unfilled positions  0  3  3  2  1  0  2  2  0  −0.26  .50    Total number of applicants  317  309  283  318  314  335  354  354  311  0.54  .13    Graduating US Seniors who ranked neurosurgery as preferred specialty (% of all applicants)  215 (67.8%)  208 (67.3%)  202 (71.3%)  200 (62.8%)  238 (75.8%)  238 (71.0%)  250 (70.6%)  264 (74.6%)  210 (67.5%)  0.56  .12    Matched graduating US Seniors who ranked neurosurgery as preferred specialty  171  173  174  170  190  188  188  200  183  0.76  .02    Match rate for US Seniors who ranked neurosurgery as preferred specialty  79.5%  83.2%  86.1%  85%  79.8%  79.0%  75.2%  75.8%  87.1%  −0.20  .61    Applicant to position ratio for US Seniors who ranked neurosurgery as preferred specialty  1.12  1.09  1.03  1.02  1.17  1.16  1.19  1.22  0.96  0.11  .78    Matches by applicant type                           Graduating US Senior (% of positions filled)  172 (90%)  173 (92%)  175 (90%)  170 (87%)  190 (93%)  189 (92%)  188 (90%)  200 (93%)  183 (84%)         US Graduate (%)  3 (1.6%)  7 (3.7%)  6 (3%)  5 (3%)  3 (1%)  7 (3%)  4 (2%)  3 (1%)  15 (7%)         Osteopathic graduate (%)  1 (0.5%)  1 (0.5%)  0  1 (0.5%)  2 (1%)  3 (1%)  0  0  2 (0.9%)         Canadian graduate (%)  0  0  0  0  0  0  1 (0.5%)  0  0         US IMG (%)  3 (1.6%)  3 (1.6%)  4 (2%)  5 (3%)  2 (1%)  1 (0.5%)  1 (0.5%)  3 (1%)  4 (2%)         Non-US IMG (%)  12 (6.3%)  4 (2.1%)  7 (4%)  13 (6.6%)  6 (3%)  6 (3%)  14 (7%)  8 (4%)  14 (6%)      IMG, international medical graduate Preferred refers to first-choice specialty. View Large TABLE 1. Summary of Match Data From 2009 to 2017     2009  2010  2011  2012  2013  2014  2015  2016  2017  r  P value    Number of programs  97  97  98  98  99  102  102  105  107  0.95  <.001    Number of positions  191  191  195  196  204  206  210  216  218  0.98  <.001    Unfilled positions  0  3  3  2  1  0  2  2  0  −0.26  .50    Total number of applicants  317  309  283  318  314  335  354  354  311  0.54  .13    Graduating US Seniors who ranked neurosurgery as preferred specialty (% of all applicants)  215 (67.8%)  208 (67.3%)  202 (71.3%)  200 (62.8%)  238 (75.8%)  238 (71.0%)  250 (70.6%)  264 (74.6%)  210 (67.5%)  0.56  .12    Matched graduating US Seniors who ranked neurosurgery as preferred specialty  171  173  174  170  190  188  188  200  183  0.76  .02    Match rate for US Seniors who ranked neurosurgery as preferred specialty  79.5%  83.2%  86.1%  85%  79.8%  79.0%  75.2%  75.8%  87.1%  −0.20  .61    Applicant to position ratio for US Seniors who ranked neurosurgery as preferred specialty  1.12  1.09  1.03  1.02  1.17  1.16  1.19  1.22  0.96  0.11  .78    Matches by applicant type                           Graduating US Senior (% of positions filled)  172 (90%)  173 (92%)  175 (90%)  170 (87%)  190 (93%)  189 (92%)  188 (90%)  200 (93%)  183 (84%)         US Graduate (%)  3 (1.6%)  7 (3.7%)  6 (3%)  5 (3%)  3 (1%)  7 (3%)  4 (2%)  3 (1%)  15 (7%)         Osteopathic graduate (%)  1 (0.5%)  1 (0.5%)  0  1 (0.5%)  2 (1%)  3 (1%)  0  0  2 (0.9%)         Canadian graduate (%)  0  0  0  0  0  0  1 (0.5%)  0  0         US IMG (%)  3 (1.6%)  3 (1.6%)  4 (2%)  5 (3%)  2 (1%)  1 (0.5%)  1 (0.5%)  3 (1%)  4 (2%)         Non-US IMG (%)  12 (6.3%)  4 (2.1%)  7 (4%)  13 (6.6%)  6 (3%)  6 (3%)  14 (7%)  8 (4%)  14 (6%)          2009  2010  2011  2012  2013  2014  2015  2016  2017  r  P value    Number of programs  97  97  98  98  99  102  102  105  107  0.95  <.001    Number of positions  191  191  195  196  204  206  210  216  218  0.98  <.001    Unfilled positions  0  3  3  2  1  0  2  2  0  −0.26  .50    Total number of applicants  317  309  283  318  314  335  354  354  311  0.54  .13    Graduating US Seniors who ranked neurosurgery as preferred specialty (% of all applicants)  215 (67.8%)  208 (67.3%)  202 (71.3%)  200 (62.8%)  238 (75.8%)  238 (71.0%)  250 (70.6%)  264 (74.6%)  210 (67.5%)  0.56  .12    Matched graduating US Seniors who ranked neurosurgery as preferred specialty  171  173  174  170  190  188  188  200  183  0.76  .02    Match rate for US Seniors who ranked neurosurgery as preferred specialty  79.5%  83.2%  86.1%  85%  79.8%  79.0%  75.2%  75.8%  87.1%  −0.20  .61    Applicant to position ratio for US Seniors who ranked neurosurgery as preferred specialty  1.12  1.09  1.03  1.02  1.17  1.16  1.19  1.22  0.96  0.11  .78    Matches by applicant type                           Graduating US Senior (% of positions filled)  172 (90%)  173 (92%)  175 (90%)  170 (87%)  190 (93%)  189 (92%)  188 (90%)  200 (93%)  183 (84%)         US Graduate (%)  3 (1.6%)  7 (3.7%)  6 (3%)  5 (3%)  3 (1%)  7 (3%)  4 (2%)  3 (1%)  15 (7%)         Osteopathic graduate (%)  1 (0.5%)  1 (0.5%)  0  1 (0.5%)  2 (1%)  3 (1%)  0  0  2 (0.9%)         Canadian graduate (%)  0  0  0  0  0  0  1 (0.5%)  0  0         US IMG (%)  3 (1.6%)  3 (1.6%)  4 (2%)  5 (3%)  2 (1%)  1 (0.5%)  1 (0.5%)  3 (1%)  4 (2%)         Non-US IMG (%)  12 (6.3%)  4 (2.1%)  7 (4%)  13 (6.6%)  6 (3%)  6 (3%)  14 (7%)  8 (4%)  14 (6%)      IMG, international medical graduate Preferred refers to first-choice specialty. View Large Trends in Neurosurgery Match Competitiveness There was no statistically significant change in the applicant to position ratio for graduating US medical students who ranked neurosurgery as their preferred choice (r = 0.11, P = .78), although the ratio was lowest in 2017. Similarly, there was no significant change in the match rate for graduating US medical students who ranked neurosurgery as their preferred (first) choice (r = –0.20, P = .61). The match rate varied from year to year with the lowest at 75.2% and 75.8% in 2015 and 2016, respectively, and the highest at 87.1% in 2017 (Table 1). Matched Neurosurgery Applicants vs Overall Matched Applicants A comparison of the qualifications of matched graduating US medical students who ranked neurosurgery as their preferred choice to those of matched graduating US medical students across all specialties showed that matched neurosurgery applicants were more competitive (Table 2). Matched neurosurgery applicants on average ranked more programs (P = .001), had higher average USMLE Step 1 scores (P = .003), and had higher average number of abstracts, publications, and presentations (P = .006). In addition, matched neurosurgery applicants had a higher percentage of AOA students (P < .001), higher percentage of students graduating from top 40 NIH-funded medical schools (P = .001), and higher percentage of students with combined MD/PhD degrees (P < .001; Table 2). TABLE 2. Comparison of Qualifications of Graduating US Medical Students Matching in Neurosurgery to Those Matching Across all Specialties   2009  2011  2014  2016  P value  Number of contiguous ranked programs (mean)          .001   Neurosurgery  13.5  15.2  14.9  15.7     All  9.5  10.4  11.5  11.8    USMLE Step 1 score (mean)          .003   Neurosurgery  239  239  244  249     All  225  226  230  233    USMLE Step 2 score (mean)          .27   Neurosurgery  237  241  247  251     All  231  235  243  245    Number of abstracts, presentations and publications (mean)          .006   Neurosurgery  7.8  7.4  11.7  13.4     All  2.8  3.2  4.2  4.7    Percentage of AOA students          < .001   Neurosurgery  28.1  25.3  28.3  32.8     All  15.3  15  16  17.3    Percentage of students from top 40 NIH-funded medical schools          .001   Neurosurgery  50.3  44.8  41  47     All  35  34.4  32.7  32.1    Percentage of MD/PhD students          < .001   Neurosurgery  11.7  10.3  12.8  9.5     All  4.1  3.9  4.4  4.2      2009  2011  2014  2016  P value  Number of contiguous ranked programs (mean)          .001   Neurosurgery  13.5  15.2  14.9  15.7     All  9.5  10.4  11.5  11.8    USMLE Step 1 score (mean)          .003   Neurosurgery  239  239  244  249     All  225  226  230  233    USMLE Step 2 score (mean)          .27   Neurosurgery  237  241  247  251     All  231  235  243  245    Number of abstracts, presentations and publications (mean)          .006   Neurosurgery  7.8  7.4  11.7  13.4     All  2.8  3.2  4.2  4.7    Percentage of AOA students          < .001   Neurosurgery  28.1  25.3  28.3  32.8     All  15.3  15  16  17.3    Percentage of students from top 40 NIH-funded medical schools          .001   Neurosurgery  50.3  44.8  41  47     All  35  34.4  32.7  32.1    Percentage of MD/PhD students          < .001   Neurosurgery  11.7  10.3  12.8  9.5     All  4.1  3.9  4.4  4.2    AOA, Alpha Omega Alpha; NIH, National Institutes of Health; USMLE, United States Medical Licensing Examination View Large TABLE 2. Comparison of Qualifications of Graduating US Medical Students Matching in Neurosurgery to Those Matching Across all Specialties   2009  2011  2014  2016  P value  Number of contiguous ranked programs (mean)          .001   Neurosurgery  13.5  15.2  14.9  15.7     All  9.5  10.4  11.5  11.8    USMLE Step 1 score (mean)          .003   Neurosurgery  239  239  244  249     All  225  226  230  233    USMLE Step 2 score (mean)          .27   Neurosurgery  237  241  247  251     All  231  235  243  245    Number of abstracts, presentations and publications (mean)          .006   Neurosurgery  7.8  7.4  11.7  13.4     All  2.8  3.2  4.2  4.7    Percentage of AOA students          < .001   Neurosurgery  28.1  25.3  28.3  32.8     All  15.3  15  16  17.3    Percentage of students from top 40 NIH-funded medical schools          .001   Neurosurgery  50.3  44.8  41  47     All  35  34.4  32.7  32.1    Percentage of MD/PhD students          < .001   Neurosurgery  11.7  10.3  12.8  9.5     All  4.1  3.9  4.4  4.2      2009  2011  2014  2016  P value  Number of contiguous ranked programs (mean)          .001   Neurosurgery  13.5  15.2  14.9  15.7     All  9.5  10.4  11.5  11.8    USMLE Step 1 score (mean)          .003   Neurosurgery  239  239  244  249     All  225  226  230  233    USMLE Step 2 score (mean)          .27   Neurosurgery  237  241  247  251     All  231  235  243  245    Number of abstracts, presentations and publications (mean)          .006   Neurosurgery  7.8  7.4  11.7  13.4     All  2.8  3.2  4.2  4.7    Percentage of AOA students          < .001   Neurosurgery  28.1  25.3  28.3  32.8     All  15.3  15  16  17.3    Percentage of students from top 40 NIH-funded medical schools          .001   Neurosurgery  50.3  44.8  41  47     All  35  34.4  32.7  32.1    Percentage of MD/PhD students          < .001   Neurosurgery  11.7  10.3  12.8  9.5     All  4.1  3.9  4.4  4.2    AOA, Alpha Omega Alpha; NIH, National Institutes of Health; USMLE, United States Medical Licensing Examination View Large Averages and percentages for various applicant characteristics of matched graduating US medical students, including USMLE Step 1 and Step 2 scores, contiguous ranked programs, abstracts, presentations, and publications, AOA membership, graduation from top 40 NIH-funded medical school, and combined MD/PhD degree, for the years 2009, 2011, 2014, and 2016 are listed in Table 2. Although the average USMLE Step 1 score for matched neurosurgery applicants increased from 239 (2009) to 249 (2016), there was a parallel increase in the average score for matched applicants across all specialties from 225 (2009) to 233 (2016). Similar parallel increases were noted in average number of ranked positions, average USMLE Step 2 score, average percentage of students with AOA status, and average number of abstracts, presentations and publications. There was a parallel downward trend in the percentage of students graduating from top 40 NIH-funded schools. Predictors of Matching in Neurosurgery A comparison of the qualifications of matched vs unmatched graduating US medical students who ranked neurosurgery as their preferred specialty showed that higher number of ranked programs (P = .02), higher USMLE Step 1 score (P = .02), AOA membership (P = .02), and graduation from a Top 40 NIH-funded medical school (P = .02) are independent and statistically significant predictors of matching in neurosurgery. Of note, combined MD/PhD degree (P = .25) and number of abstracts, publications and presentations (P = .25) were not found to be predictors of matching in neurosurgery (Table 3). TABLE 3. Predictors for Matching in Neurosurgery for Graduating US Medical Students who Ranked Neurosurgery as Preferred Specialty   Matched  Unmatched  P value  Number of contiguous ranks (mean)  14.8  9.3  .02  USMLE Step 1 score (mean)  242.7  228  .02  USMLE Step 2 score (mean)  244  228  .06  Number of abstracts, publications and presentations (mean)  10.1  6.6  .25  Percentage of AOA students  28.6%  7.8%  .02  Percentage of students from top 40 NIH-funded medical schools  45.8%  29.5%  .02  Percentage of students with combined MD/PhD  11.1%  9.2%  .25    Matched  Unmatched  P value  Number of contiguous ranks (mean)  14.8  9.3  .02  USMLE Step 1 score (mean)  242.7  228  .02  USMLE Step 2 score (mean)  244  228  .06  Number of abstracts, publications and presentations (mean)  10.1  6.6  .25  Percentage of AOA students  28.6%  7.8%  .02  Percentage of students from top 40 NIH-funded medical schools  45.8%  29.5%  .02  Percentage of students with combined MD/PhD  11.1%  9.2%  .25  AOA, Alpha Omega Alpha; NIH, National Institutes of Health; USMLE, United States Medical Licensing Examination Preferred refers to first-choice specialty. View Large TABLE 3. Predictors for Matching in Neurosurgery for Graduating US Medical Students who Ranked Neurosurgery as Preferred Specialty   Matched  Unmatched  P value  Number of contiguous ranks (mean)  14.8  9.3  .02  USMLE Step 1 score (mean)  242.7  228  .02  USMLE Step 2 score (mean)  244  228  .06  Number of abstracts, publications and presentations (mean)  10.1  6.6  .25  Percentage of AOA students  28.6%  7.8%  .02  Percentage of students from top 40 NIH-funded medical schools  45.8%  29.5%  .02  Percentage of students with combined MD/PhD  11.1%  9.2%  .25    Matched  Unmatched  P value  Number of contiguous ranks (mean)  14.8  9.3  .02  USMLE Step 1 score (mean)  242.7  228  .02  USMLE Step 2 score (mean)  244  228  .06  Number of abstracts, publications and presentations (mean)  10.1  6.6  .25  Percentage of AOA students  28.6%  7.8%  .02  Percentage of students from top 40 NIH-funded medical schools  45.8%  29.5%  .02  Percentage of students with combined MD/PhD  11.1%  9.2%  .25  AOA, Alpha Omega Alpha; NIH, National Institutes of Health; USMLE, United States Medical Licensing Examination Preferred refers to first-choice specialty. View Large DISCUSSION In 2018, over 300 applicants, including graduates from international medical schools and from US allopathic and osteopathic medical schools, will be entering the NRMP neurosurgery match. The successful neurosurgical candidate is more likely to graduate from a US allopathic medical school, rank a higher contiguous number of neurosurgery programs, achieve AOA membership and score higher on the USMLE Step 1 examination than prior matched neurosurgery candidates. Practicing neurosurgeons who screen applications for residency positions often mention how grateful they are that they applied when they did, a sentiment rooted in the realization that current matched applicants are scoring higher on USMLE Step 1 than those of prior years. The steady rise in matched applicants’ USMLE Step 1 scores has therefore led to a perception that the neurosurgery match has become increasingly competitive. This analysis of neurosurgery NRMP data, however, debunks this perception by demonstrating that despite increasing USMLE scores and the addition of 10 new ACGME-accredited programs with 27 additional residency positions, neurosurgery has maintained a stable level of competitiveness from 2009 to 2017. Characteristics of Matched Neurosurgery Applicants From 2009 to 2016, the mean USMLE score increased from 239 to 249 for Step 1 and from 237 to 251 for Step 2 (Table 2). However, rising USMLE scores are not a trend unique to neurosurgery. Studies on trends in applicant characteristics for plastic surgery and emergency medicine demonstrate similar increases in matched applicants’ USMLE Step 1 scores.14,15 As listed in Table 2, from 2009 to 2016, the mean USMLE Step 1 score for matched applicants across all specialties increased from 225 to 233. The findings that combined MD/PhD degree is not a predictor of match success and that the percentage of matched applicants with combined MD/PhD degrees has progressively declined since 2009 may reflect applicants’ lack of interest in pursuing a PhD degree in the face of a 7-yr residency, the longest of any specialty in medicine. The decreasing percentage of matched neurosurgery applicants from top 40 NIH-funded medical schools reflects an overall increase in the number of US allopathic medical schools. The lack of association between number of abstracts/publications and matching in neurosurgery perhaps indicates that applicant attributes other than research, such as interviewing skills and letters of recommendation, may ultimately play an important role in matching into neurosurgery. Neurosurgery Match Competitiveness Since 2009, there has been a net increase in 27 neurosurgery residency positions across the country. This increase in positions has resulted largely from ACGME accreditation of 10 new neurosurgery programs since 2009. This study demonstrates that neurosurgery match rates and applicant to position ratios do not demonstrate a trend towards increased competitiveness. The number of applicants varied from year to year, leading to inconsistent match rates. The year 2017 is an example of an anomalous year with the highest ever match rate (87.1%) due to a dramatic drop of 55 applications from graduating US medical students compared to the previous year. The year 2017 followed 2015 and 2016, the 2 most competitive years, with match rates of 73% and 75%, respectively. Due to the highly competitive 2015 and 2016 neurosurgery matches, it is possible that less competitive applicants may have been discouraged from entering the 2017 match, which may explain the steep drop in the number of applicants. Graduating US medical students enjoy a distinct advantage among all applicants to the neurosurgery match. For example, in 2012, graduating US medical students made up 62.8% of all applicants but accounted for 87% of all filled positions. Similar trends are true across all years analyzed in this study, as demonstrated in Table 1. Reasons for this trend may include language and cultural barriers faced by IMGs, or the stigma of failure to match for former applicants (referred to as US Graduates in NRMP reports), or a sense of obligation felt by those making match decisions to offer graduating US medical students the first right of admission. The Future of the Neurosurgery Match In 2014, the AOA, the American Association of Colleges of Osteopathic Medicine, and the ACGME agreed to form a single accreditation system for graduate medical education (GME) by 2020. The single GME will be under the supervision of the ACGME; as a result, by June 30, 2020, all AOA-accredited residency programs are required to obtain ACGME accreditation, which will lead to an increase in ACGME-accredited neurosurgery programs. In the current system, osteopathic students are eligible to apply to both AOA-accredited and ACGME-accredited programs, but only 10 osteopathic students have matched in ACGME-accredited programs since 2009 (Table 1). However, for the academic year starting in 2020, all osteopathic and allopathic medical students will be entering a single NRMP match for ACGME-accredited neurosurgery programs. It remains to be seen how the influx of osteopathic medical students into the NRMP neurosurgery match will impact neurosurgery match competitiveness. A similar analysis to assess neurosurgery match competitiveness will be valuable in the years following the formation of a single accreditation system. Limitations Data collection was restricted to the information available in NRMP-published documents. Applicant demographical information is not available; therefore, we are unable to comment on applicant age, gender, and location. Data regarding graduating US medical student applicant characteristics, such as USMLE scores and AOA status, are released approximately every 2 yr. Since neurosurgery joined the NRMP in 2009, only 4 data points are available for various applicant characteristics, which limits the statistical analysis. All applicants other than graduating US medical students are categorized as Independent; therefore, we are unable to analyze match data for subgroups, such as foreign medical graduates, within the Independent category. The NRMP does not report on several factors that may contribute to applicant competitiveness, such as letters of recommendation, medical student performance evaluations, medical school grades, and faculty interviews. Future studies involving surveys of neurosurgical faculty are required to determine the impact of letters of recommendation and interview on applicant ranking. CONCLUSION Despite implementation of residency duty hour restrictions and increase in the number of ACGME-accredited programs and residency positions from 2009 to 2017, there has been no statistically discernable change in the level of competitiveness in the application process for neurosurgery. Analysis of characteristics of matched US medical graduates demonstrates an upward trend in USMLE Step 1 scores and number of contiguous ranked programs. The current analysis suggests that neurosurgery match competitiveness would be maintained even if the number of neurosurgery positions is further expanded. Medical student advisors and prospective applicants will benefit from these data as they prepare for future NRMP neurosurgery residency matches. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. National Resident Matching Program. Results and Data: 2009 Main Residency Match® . Washington, DC: National Resident Matching Program; 2009. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 2. National Resident Matching Program. Results and Data: 2010 Main Residency Match® . Washington, DC: National Resident Matching Program; 2010. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 3. National Resident Matching Program. Results and Data: 2011 Main Residency Match® . Washington, DC: National Resident Matching Program; 2011. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 4. National Resident Matching Program. Results and Data: 2012 Main Residency Match® . Washington, DC: National Resident Matching Program; 2012. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 5. National Resident Matching Program. Results and Data: 2013 Main Residency Match® . Washington, DC: National Resident Matching Program; 2013. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 6. National Resident Matching Program. Results and Data: 2014 Main Residency Match® . Washington, DC: National Resident Matching Program; 2014. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 7. National Resident Matching Program. Results and Data: 2015 Main Residency Match® . Washington, DC: National Resident Matching Program; 2015. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 8. National Resident Matching Program. Results and Data: 2016 Main Residency Match® . Washington, DC: National Resident Matching Program; 2016. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 9. National Resident Matching Program. Results and Data: 2017 Main Residency Match® . Washington, DC: National Resident Matching Program; 2017. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 10. National Resident Matching Program. Charting Outcomes in the Match for U.S. Allopathic Seniors, 2009 . Washington, DC: National Resident Matching Program; 2009. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 11. National Resident Matching Program. Charting Outcomes in the Match for U.S. Allopathic Seniors, 2011 . Washington, DC: National Resident Matching Program; 2011. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 12. National Resident Matching Program. Charting Outcomes in the Match for U.S. Allopathic Seniors, 2014 . Washington, DC: National Resident Matching Program; 2014. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 13. National Resident Matching Program. Charting Outcomes in the Match for U.S. Allopathic Seniors, 2016 . Washington, DC: National Resident Matching Program; 2016. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 14. Abraham JT, Nguyen AV, Weber RA. Integrated plastic surgery residency applicant trends and comparison with other surgical specialties. Ann Plast Surg . 2017. doi: 10.1097/SAP.0000000000001199 (published online ahead of print). 15. Manthey DE, Hartman ND, Newmyer A et al.   Trends in NRMP data from 2007-2014 for U.S. seniors matching into emergency medicine. WestJEM . 2017; 18( 1): 105- 109. doi:10.5811/westjem.2016.10.31237 Google Scholar CrossRef Search ADS PubMed  16. Schrock JB, Kraeutler MJ, Dayton MR, McCarty EC. A comparison of matched and unmatched orthopaedic surgery residency applicants from 2006 to 2014. J Bone Joint Surg . 2017; 99( 1): e1. doi: 10.2106/JBJS.16.00293 Google Scholar CrossRef Search ADS PubMed  17. Henry T. Single accreditation system for graduate medical education: What to know. AMA Wire. Available at: https://wire.ama-assn.org/education/single-accreditation-system-graduate-medical-education-what-know. Published April 5, 2016. Accessed November 20, 2017. 18. Agarwal N, Choi PA, Okonkwo DO, Barrow DL, Friedlander RM. Financial burden associated with the residency match in neurological surgery. J Neurosurg . 2017; 126( 1): 184- 190. Google Scholar CrossRef Search ADS PubMed  COMMENTS The authors have taken on an important task in examining NRMP trends for neurosurgery applicants going back to 2009 using publicly available data. They should be commended for applying sound statistical techniques to their analysis and providing a succinct summary of the available information. This commentary does have limitations which are largely due to the limited nature of the data provided, as discussed in the manuscript. The NRMP surveys were only administered during a limited number of years, and it was an opt-in process, meaning that they were not quite comprehensive. Future studies using independently collected data over consecutive years from the students together with companion surveys administered to senior faculty would add value to this investigation. Nonetheless, this report as it is currently constituted presents an important baseline from which to proceed with studying the factors that are likely to make an applicant successful in the neurosurgical match process. Edjah Kweku-Ebura Nduom Bethesda, Maryland This is an important and very well executed analysis of the neurosurgery NRMP data since 2009. It is important to publish this data for the neurosurgery community and the general public to see. It is not surprising that US graduates who matched were from better medical schools, had higher board scores and were more likely to be selected for AOA. It would be interesting in the future to try and include an the influence of medical school grades or class standing. Whereas interviews are critical, this would be very difficult to quantify. Even though number of abstracts, presentations, and publications and MD/PhD status did not demonstrate an advantage in those matching, neurosurgery was nevertheless much higher in these categories than all other specialties. It appears that we are still attracting the “best and the brightest” and will need to attract even more in the future. William F. Chandler Ann Arbor, Michigan The authors conducted an important, well-designed, well-written, and timely manuscript aiming to highlight trends in the neurosurgery match and document characteristics of matched graduating students. They found that the level of competitiveness in the application process for neurosurgery residency has not statistically changed from 2009 to 2017 despite implementation of duty hour restrictions and increase in the number of ACGME-accredited programs and residency positions. They also found that higher USMLE Step 1 score, AOA membership, and graduation from a Top 40 NIH-funded medical school were independent predictors of matching in neurosurgery. Surprisingly, MD/PhD degree and number of publications and presentations were not found to be predictors of matching in neurosurgery. Although the goals of the manuscript was only to examine global trends in NRMP match data for graduating US medical students, future studies including demographic data and additional information provided by the ‘Annual Survey Report’, are necessary to identify other potential predictors of matching in neurosurgery. This will enable future medical graduates to be better prepared for a successful application. Finally, this study raises important questions: How the number of neurosurgery residency positions may be effectively increased in a way that will not lead to the production of poorly trained neurosurgeons? Should this increase be regulated by the AANS or may the free market play a role in this process, especially in those counties with no neurosurgeons? These questions remain to be answered. Francisco Vaz-Guimaraes Alfonso Fuentes Houston, Texas Copyright © 2018 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

Commentary: Trends in the National Resident Matching Program (NRMP) Data for Graduating US Medical Students Matching in Neurosurgery

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Congress of Neurological Surgeons
Copyright
Copyright © 2018 by the Congress of Neurological Surgeons
ISSN
0148-396X
eISSN
1524-4040
D.O.I.
10.1093/neuros/nyy181
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Abstract

ABBREVIATIONS ABBREVIATIONS ACGME American Council of Graduate Medical Education AOA American Osteopathic Association GME graduate medical education IMG international medical graduate NIH National Institutes of Health NRMP National Residency Matching Program USMLE United States Medical Licensing Examination Since 1952, the National Residency Matching Program (NRMP) has provided matching services to medical students applying to American Council of Graduate Medical Education (ACGME) accredited residency programs. The NRMP employs a mathematical algorithm to “match” rank-ordered preferences of applicants to those of residency program directors.1 In 2009, US neurosurgery residency programs transitioned from the San Francisco Match program to the NRMP.1 The NRMP publishes a comprehensive summary of match data for all specialties in 2 reports entitled Results and Data and Charting Outcomes of the Match.1-13 Several specialties, such as plastic surgery, emergency medicine, and orthopedic surgery, have utilized NRMP-published reports to analyze trends in their own residency match data and to identify characteristics of matched applicants to their specialties.14-16 However, similar analyses of neurosurgery match data and applicant characteristics are lacking in neurosurgery peer-reviewed literature. Analyzing trends in neurosurgery match data is important for many reasons. First, since 2009, the number of neurosurgery residency programs has increased from 97 to 107, leading to an increase in the number of residency positions from 191 to 218.1-9 It is unknown whether increase in the number of programs and positions has resulted in a decrease in neurosurgery match competitiveness. Second, by 2020, all American Osteopathic Association (AOA) accredited and ACGME-accredited residency programs will transition to a single accreditation system under the supervision of the ACGME.17 In the current system, osteopathic students are eligible to apply to both AOA-accredited and ACGME-accredited neurosurgery programs, but only 10 osteopathic medical students have matched in ACGME-accredited programs since 2009.1-9 For the academic year starting in 2020, all osteopathic and allopathic medical students will be entering a single NRMP match for ACGME-accredited neurosurgery programs.17 Therefore, there is value in performing a baseline evaluation of neurosurgery residency match data before 2020, when the influx of osteopathic medical students will undoubtedly alter the dynamics of the neurosurgery match. Third, since 2009, a total of 388 graduating US medical students who ranked neurosurgery as their preferred (first) choice have failed to match in neurosurgery.1-9 A survey of first-year neurosurgery residents showed that the mean cost of the application process is $10 255.18 The tremendous loss of productivity and expense resulting from failure to match places a responsibility upon those making match decisions to candidly advise medical students about their prospects of matching in neurosurgery. Therefore, a report on neurosurgery match data and applicant characteristics will be invaluable to medical student advisors and to prospective students entering the NRMP neurosurgery match. For each of the above reasons, the objective of this article is to analyze trends in the neurosurgery match and to document characteristics of matched graduating US medical students since neurosurgery joined the NRMP in 2009. METHODS A retrospective observational analysis of neurosurgery match data was performed using NRMP-published reports since 2009. Institutional Review Board approval was not required because patient information was not analyzed in this study. Data Collection To examine trends in the neurosurgery match, data were obtained from NRMP, Results and Data: Main Residency Match for the years 2009 to 2017.1-9 Data collection included number of programs, positions offered, positions unfilled, graduating US medical student applicants, graduating US medical student matched applicants, and all other matched applicants by category (international medical graduates [IMGs], osteopathic graduates, Canadian medical graduates, and US graduates who previously failed to match). Applicant to position ratio, defined as the ratio of number of graduating US medical students to number of neurosurgery positions, and match rate, defined as the percentage of matched graduating US medical students, were used as measures of neurosurgery match competitiveness. To examine trends in applicant characteristics, data were obtained from NRMP, Charting Outcomes in the Match for U.S. Allopathic Seniors, which was published only in 2009, 2011, 2014, and 2016.10-13 Data collection included number of contiguous ranked programs (continuous rank list of neurosurgery programs as preferred [first choice] specialty without intervening rank of other specialties), United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, number of abstracts, presentations and publications, percentage of Alpha Omega Alpha (AOA) honor society students, percentage of students from top 40 National Institutes of Health (NIH) funded medical schools, and percentage of students with combined MD/PhD degrees. Unlike the Main Residency Match reports, the Charting Outcomes reports required applicants to consent for their information to be used in match research. The Charting Outcomes reports, although requiring applicants to opt in, are remarkably comprehensive. For example, in 2016, 244 out of 264 (92%) neurosurgery applicants opted in their information to be included in Charting Outcomes. Rationale for Selecting Graduating US Medical Students who Ranked Neurosurgery as Preferred Choice The NRMP classifies applicants to the match into 2 broad categories: graduating US medical student and Independent. US allopathic medical schools sponsor graduating US medical students to apply for the match. Independent applicants are those in all categories other than graduating US students, including graduates from foreign medical schools, osteopathic medical schools, and previous US allopathic graduates. Since the NRMP often presents data on Independent applicants as 1 group, it is not possible to determine values for variables, such as USMLE Step scores and number of publications, for a subgroup within Independent applicants. Therefore, due to the heterogeneity of the Independent applicant data, we only analyzed data on graduating US medical students who ranked neurosurgery as preferred (first choice) specialty. Statistical Analysis Normality of variables was assessed using the Kolmogorov–Smirnov test. Means and percentages were calculated where appropriate. Two-tailed t-test was used to compare 2 normally distributed variables, whereas analysis of variance was used to compare 3 or more normally distributed variables. Data that were not normally distributed were analyzed using nonparametric tests (Wilcoxon rank-sum test for comparing 2 variables and Kruskal–Wallis test for comparing more than 2 variables). For categorical variables, percentages were calculated as appropriate, and statistical comparison was performed with Fisher exact test or chi-square test. Correlation between continuous variables was assessed using Pearson's test and reported as correlation coefficient (r). Statistical significance was defined as P < .05. Statistical analysis was performed using SPSS 21.0 (IBM Corp, Armonk, New York). RESULTS Trends in Number of Neurosurgery Programs, Positions, and Applicants From 2009 to 2017, the number of neurosurgery residency programs increased from 97 to 107 (r = 0.95, P < .001), and the number of residency positions increased from 191 to 218 (r = 0.98, P < .001; Table 1). However, there was no statistically significant trend in the total number of applicants (r = 0.54, P = .13), particularly graduating US medical students who ranked neurosurgery as their preferred (first choice) specialty (r = 0.56, P = .12). The total number of applicants varied from year to year, with 354 being the highest number in 2015 and 2016. Similarly, the total number of graduating US medical students who ranked neurosurgery as their preferred choice varied from year to year, with the highest number being 250 and 264 for 2015 and 2016, respectively. Of note, there were fewer graduating US medical student applicants in 2017 (210) than in 2009 (215). Graduating US medical students comprise the overwhelming majority of matched applicants, filling at least 87% of all positions since 2009, except in 2017 (84%). In 2017, the decrease in percentage of matched US graduating medical students was offset by an increase in that of US graduates (7%), a group consisting of US allopathic medical school graduates who previously failed to match. The number of unfilled positions has remained low since 2009, with the highest number of unfilled positions at 3 in 2010 and 2011 (Table 1). TABLE 1. Summary of Match Data From 2009 to 2017     2009  2010  2011  2012  2013  2014  2015  2016  2017  r  P value    Number of programs  97  97  98  98  99  102  102  105  107  0.95  <.001    Number of positions  191  191  195  196  204  206  210  216  218  0.98  <.001    Unfilled positions  0  3  3  2  1  0  2  2  0  −0.26  .50    Total number of applicants  317  309  283  318  314  335  354  354  311  0.54  .13    Graduating US Seniors who ranked neurosurgery as preferred specialty (% of all applicants)  215 (67.8%)  208 (67.3%)  202 (71.3%)  200 (62.8%)  238 (75.8%)  238 (71.0%)  250 (70.6%)  264 (74.6%)  210 (67.5%)  0.56  .12    Matched graduating US Seniors who ranked neurosurgery as preferred specialty  171  173  174  170  190  188  188  200  183  0.76  .02    Match rate for US Seniors who ranked neurosurgery as preferred specialty  79.5%  83.2%  86.1%  85%  79.8%  79.0%  75.2%  75.8%  87.1%  −0.20  .61    Applicant to position ratio for US Seniors who ranked neurosurgery as preferred specialty  1.12  1.09  1.03  1.02  1.17  1.16  1.19  1.22  0.96  0.11  .78    Matches by applicant type                           Graduating US Senior (% of positions filled)  172 (90%)  173 (92%)  175 (90%)  170 (87%)  190 (93%)  189 (92%)  188 (90%)  200 (93%)  183 (84%)         US Graduate (%)  3 (1.6%)  7 (3.7%)  6 (3%)  5 (3%)  3 (1%)  7 (3%)  4 (2%)  3 (1%)  15 (7%)         Osteopathic graduate (%)  1 (0.5%)  1 (0.5%)  0  1 (0.5%)  2 (1%)  3 (1%)  0  0  2 (0.9%)         Canadian graduate (%)  0  0  0  0  0  0  1 (0.5%)  0  0         US IMG (%)  3 (1.6%)  3 (1.6%)  4 (2%)  5 (3%)  2 (1%)  1 (0.5%)  1 (0.5%)  3 (1%)  4 (2%)         Non-US IMG (%)  12 (6.3%)  4 (2.1%)  7 (4%)  13 (6.6%)  6 (3%)  6 (3%)  14 (7%)  8 (4%)  14 (6%)          2009  2010  2011  2012  2013  2014  2015  2016  2017  r  P value    Number of programs  97  97  98  98  99  102  102  105  107  0.95  <.001    Number of positions  191  191  195  196  204  206  210  216  218  0.98  <.001    Unfilled positions  0  3  3  2  1  0  2  2  0  −0.26  .50    Total number of applicants  317  309  283  318  314  335  354  354  311  0.54  .13    Graduating US Seniors who ranked neurosurgery as preferred specialty (% of all applicants)  215 (67.8%)  208 (67.3%)  202 (71.3%)  200 (62.8%)  238 (75.8%)  238 (71.0%)  250 (70.6%)  264 (74.6%)  210 (67.5%)  0.56  .12    Matched graduating US Seniors who ranked neurosurgery as preferred specialty  171  173  174  170  190  188  188  200  183  0.76  .02    Match rate for US Seniors who ranked neurosurgery as preferred specialty  79.5%  83.2%  86.1%  85%  79.8%  79.0%  75.2%  75.8%  87.1%  −0.20  .61    Applicant to position ratio for US Seniors who ranked neurosurgery as preferred specialty  1.12  1.09  1.03  1.02  1.17  1.16  1.19  1.22  0.96  0.11  .78    Matches by applicant type                           Graduating US Senior (% of positions filled)  172 (90%)  173 (92%)  175 (90%)  170 (87%)  190 (93%)  189 (92%)  188 (90%)  200 (93%)  183 (84%)         US Graduate (%)  3 (1.6%)  7 (3.7%)  6 (3%)  5 (3%)  3 (1%)  7 (3%)  4 (2%)  3 (1%)  15 (7%)         Osteopathic graduate (%)  1 (0.5%)  1 (0.5%)  0  1 (0.5%)  2 (1%)  3 (1%)  0  0  2 (0.9%)         Canadian graduate (%)  0  0  0  0  0  0  1 (0.5%)  0  0         US IMG (%)  3 (1.6%)  3 (1.6%)  4 (2%)  5 (3%)  2 (1%)  1 (0.5%)  1 (0.5%)  3 (1%)  4 (2%)         Non-US IMG (%)  12 (6.3%)  4 (2.1%)  7 (4%)  13 (6.6%)  6 (3%)  6 (3%)  14 (7%)  8 (4%)  14 (6%)      IMG, international medical graduate Preferred refers to first-choice specialty. View Large TABLE 1. Summary of Match Data From 2009 to 2017     2009  2010  2011  2012  2013  2014  2015  2016  2017  r  P value    Number of programs  97  97  98  98  99  102  102  105  107  0.95  <.001    Number of positions  191  191  195  196  204  206  210  216  218  0.98  <.001    Unfilled positions  0  3  3  2  1  0  2  2  0  −0.26  .50    Total number of applicants  317  309  283  318  314  335  354  354  311  0.54  .13    Graduating US Seniors who ranked neurosurgery as preferred specialty (% of all applicants)  215 (67.8%)  208 (67.3%)  202 (71.3%)  200 (62.8%)  238 (75.8%)  238 (71.0%)  250 (70.6%)  264 (74.6%)  210 (67.5%)  0.56  .12    Matched graduating US Seniors who ranked neurosurgery as preferred specialty  171  173  174  170  190  188  188  200  183  0.76  .02    Match rate for US Seniors who ranked neurosurgery as preferred specialty  79.5%  83.2%  86.1%  85%  79.8%  79.0%  75.2%  75.8%  87.1%  −0.20  .61    Applicant to position ratio for US Seniors who ranked neurosurgery as preferred specialty  1.12  1.09  1.03  1.02  1.17  1.16  1.19  1.22  0.96  0.11  .78    Matches by applicant type                           Graduating US Senior (% of positions filled)  172 (90%)  173 (92%)  175 (90%)  170 (87%)  190 (93%)  189 (92%)  188 (90%)  200 (93%)  183 (84%)         US Graduate (%)  3 (1.6%)  7 (3.7%)  6 (3%)  5 (3%)  3 (1%)  7 (3%)  4 (2%)  3 (1%)  15 (7%)         Osteopathic graduate (%)  1 (0.5%)  1 (0.5%)  0  1 (0.5%)  2 (1%)  3 (1%)  0  0  2 (0.9%)         Canadian graduate (%)  0  0  0  0  0  0  1 (0.5%)  0  0         US IMG (%)  3 (1.6%)  3 (1.6%)  4 (2%)  5 (3%)  2 (1%)  1 (0.5%)  1 (0.5%)  3 (1%)  4 (2%)         Non-US IMG (%)  12 (6.3%)  4 (2.1%)  7 (4%)  13 (6.6%)  6 (3%)  6 (3%)  14 (7%)  8 (4%)  14 (6%)          2009  2010  2011  2012  2013  2014  2015  2016  2017  r  P value    Number of programs  97  97  98  98  99  102  102  105  107  0.95  <.001    Number of positions  191  191  195  196  204  206  210  216  218  0.98  <.001    Unfilled positions  0  3  3  2  1  0  2  2  0  −0.26  .50    Total number of applicants  317  309  283  318  314  335  354  354  311  0.54  .13    Graduating US Seniors who ranked neurosurgery as preferred specialty (% of all applicants)  215 (67.8%)  208 (67.3%)  202 (71.3%)  200 (62.8%)  238 (75.8%)  238 (71.0%)  250 (70.6%)  264 (74.6%)  210 (67.5%)  0.56  .12    Matched graduating US Seniors who ranked neurosurgery as preferred specialty  171  173  174  170  190  188  188  200  183  0.76  .02    Match rate for US Seniors who ranked neurosurgery as preferred specialty  79.5%  83.2%  86.1%  85%  79.8%  79.0%  75.2%  75.8%  87.1%  −0.20  .61    Applicant to position ratio for US Seniors who ranked neurosurgery as preferred specialty  1.12  1.09  1.03  1.02  1.17  1.16  1.19  1.22  0.96  0.11  .78    Matches by applicant type                           Graduating US Senior (% of positions filled)  172 (90%)  173 (92%)  175 (90%)  170 (87%)  190 (93%)  189 (92%)  188 (90%)  200 (93%)  183 (84%)         US Graduate (%)  3 (1.6%)  7 (3.7%)  6 (3%)  5 (3%)  3 (1%)  7 (3%)  4 (2%)  3 (1%)  15 (7%)         Osteopathic graduate (%)  1 (0.5%)  1 (0.5%)  0  1 (0.5%)  2 (1%)  3 (1%)  0  0  2 (0.9%)         Canadian graduate (%)  0  0  0  0  0  0  1 (0.5%)  0  0         US IMG (%)  3 (1.6%)  3 (1.6%)  4 (2%)  5 (3%)  2 (1%)  1 (0.5%)  1 (0.5%)  3 (1%)  4 (2%)         Non-US IMG (%)  12 (6.3%)  4 (2.1%)  7 (4%)  13 (6.6%)  6 (3%)  6 (3%)  14 (7%)  8 (4%)  14 (6%)      IMG, international medical graduate Preferred refers to first-choice specialty. View Large Trends in Neurosurgery Match Competitiveness There was no statistically significant change in the applicant to position ratio for graduating US medical students who ranked neurosurgery as their preferred choice (r = 0.11, P = .78), although the ratio was lowest in 2017. Similarly, there was no significant change in the match rate for graduating US medical students who ranked neurosurgery as their preferred (first) choice (r = –0.20, P = .61). The match rate varied from year to year with the lowest at 75.2% and 75.8% in 2015 and 2016, respectively, and the highest at 87.1% in 2017 (Table 1). Matched Neurosurgery Applicants vs Overall Matched Applicants A comparison of the qualifications of matched graduating US medical students who ranked neurosurgery as their preferred choice to those of matched graduating US medical students across all specialties showed that matched neurosurgery applicants were more competitive (Table 2). Matched neurosurgery applicants on average ranked more programs (P = .001), had higher average USMLE Step 1 scores (P = .003), and had higher average number of abstracts, publications, and presentations (P = .006). In addition, matched neurosurgery applicants had a higher percentage of AOA students (P < .001), higher percentage of students graduating from top 40 NIH-funded medical schools (P = .001), and higher percentage of students with combined MD/PhD degrees (P < .001; Table 2). TABLE 2. Comparison of Qualifications of Graduating US Medical Students Matching in Neurosurgery to Those Matching Across all Specialties   2009  2011  2014  2016  P value  Number of contiguous ranked programs (mean)          .001   Neurosurgery  13.5  15.2  14.9  15.7     All  9.5  10.4  11.5  11.8    USMLE Step 1 score (mean)          .003   Neurosurgery  239  239  244  249     All  225  226  230  233    USMLE Step 2 score (mean)          .27   Neurosurgery  237  241  247  251     All  231  235  243  245    Number of abstracts, presentations and publications (mean)          .006   Neurosurgery  7.8  7.4  11.7  13.4     All  2.8  3.2  4.2  4.7    Percentage of AOA students          < .001   Neurosurgery  28.1  25.3  28.3  32.8     All  15.3  15  16  17.3    Percentage of students from top 40 NIH-funded medical schools          .001   Neurosurgery  50.3  44.8  41  47     All  35  34.4  32.7  32.1    Percentage of MD/PhD students          < .001   Neurosurgery  11.7  10.3  12.8  9.5     All  4.1  3.9  4.4  4.2      2009  2011  2014  2016  P value  Number of contiguous ranked programs (mean)          .001   Neurosurgery  13.5  15.2  14.9  15.7     All  9.5  10.4  11.5  11.8    USMLE Step 1 score (mean)          .003   Neurosurgery  239  239  244  249     All  225  226  230  233    USMLE Step 2 score (mean)          .27   Neurosurgery  237  241  247  251     All  231  235  243  245    Number of abstracts, presentations and publications (mean)          .006   Neurosurgery  7.8  7.4  11.7  13.4     All  2.8  3.2  4.2  4.7    Percentage of AOA students          < .001   Neurosurgery  28.1  25.3  28.3  32.8     All  15.3  15  16  17.3    Percentage of students from top 40 NIH-funded medical schools          .001   Neurosurgery  50.3  44.8  41  47     All  35  34.4  32.7  32.1    Percentage of MD/PhD students          < .001   Neurosurgery  11.7  10.3  12.8  9.5     All  4.1  3.9  4.4  4.2    AOA, Alpha Omega Alpha; NIH, National Institutes of Health; USMLE, United States Medical Licensing Examination View Large TABLE 2. Comparison of Qualifications of Graduating US Medical Students Matching in Neurosurgery to Those Matching Across all Specialties   2009  2011  2014  2016  P value  Number of contiguous ranked programs (mean)          .001   Neurosurgery  13.5  15.2  14.9  15.7     All  9.5  10.4  11.5  11.8    USMLE Step 1 score (mean)          .003   Neurosurgery  239  239  244  249     All  225  226  230  233    USMLE Step 2 score (mean)          .27   Neurosurgery  237  241  247  251     All  231  235  243  245    Number of abstracts, presentations and publications (mean)          .006   Neurosurgery  7.8  7.4  11.7  13.4     All  2.8  3.2  4.2  4.7    Percentage of AOA students          < .001   Neurosurgery  28.1  25.3  28.3  32.8     All  15.3  15  16  17.3    Percentage of students from top 40 NIH-funded medical schools          .001   Neurosurgery  50.3  44.8  41  47     All  35  34.4  32.7  32.1    Percentage of MD/PhD students          < .001   Neurosurgery  11.7  10.3  12.8  9.5     All  4.1  3.9  4.4  4.2      2009  2011  2014  2016  P value  Number of contiguous ranked programs (mean)          .001   Neurosurgery  13.5  15.2  14.9  15.7     All  9.5  10.4  11.5  11.8    USMLE Step 1 score (mean)          .003   Neurosurgery  239  239  244  249     All  225  226  230  233    USMLE Step 2 score (mean)          .27   Neurosurgery  237  241  247  251     All  231  235  243  245    Number of abstracts, presentations and publications (mean)          .006   Neurosurgery  7.8  7.4  11.7  13.4     All  2.8  3.2  4.2  4.7    Percentage of AOA students          < .001   Neurosurgery  28.1  25.3  28.3  32.8     All  15.3  15  16  17.3    Percentage of students from top 40 NIH-funded medical schools          .001   Neurosurgery  50.3  44.8  41  47     All  35  34.4  32.7  32.1    Percentage of MD/PhD students          < .001   Neurosurgery  11.7  10.3  12.8  9.5     All  4.1  3.9  4.4  4.2    AOA, Alpha Omega Alpha; NIH, National Institutes of Health; USMLE, United States Medical Licensing Examination View Large Averages and percentages for various applicant characteristics of matched graduating US medical students, including USMLE Step 1 and Step 2 scores, contiguous ranked programs, abstracts, presentations, and publications, AOA membership, graduation from top 40 NIH-funded medical school, and combined MD/PhD degree, for the years 2009, 2011, 2014, and 2016 are listed in Table 2. Although the average USMLE Step 1 score for matched neurosurgery applicants increased from 239 (2009) to 249 (2016), there was a parallel increase in the average score for matched applicants across all specialties from 225 (2009) to 233 (2016). Similar parallel increases were noted in average number of ranked positions, average USMLE Step 2 score, average percentage of students with AOA status, and average number of abstracts, presentations and publications. There was a parallel downward trend in the percentage of students graduating from top 40 NIH-funded schools. Predictors of Matching in Neurosurgery A comparison of the qualifications of matched vs unmatched graduating US medical students who ranked neurosurgery as their preferred specialty showed that higher number of ranked programs (P = .02), higher USMLE Step 1 score (P = .02), AOA membership (P = .02), and graduation from a Top 40 NIH-funded medical school (P = .02) are independent and statistically significant predictors of matching in neurosurgery. Of note, combined MD/PhD degree (P = .25) and number of abstracts, publications and presentations (P = .25) were not found to be predictors of matching in neurosurgery (Table 3). TABLE 3. Predictors for Matching in Neurosurgery for Graduating US Medical Students who Ranked Neurosurgery as Preferred Specialty   Matched  Unmatched  P value  Number of contiguous ranks (mean)  14.8  9.3  .02  USMLE Step 1 score (mean)  242.7  228  .02  USMLE Step 2 score (mean)  244  228  .06  Number of abstracts, publications and presentations (mean)  10.1  6.6  .25  Percentage of AOA students  28.6%  7.8%  .02  Percentage of students from top 40 NIH-funded medical schools  45.8%  29.5%  .02  Percentage of students with combined MD/PhD  11.1%  9.2%  .25    Matched  Unmatched  P value  Number of contiguous ranks (mean)  14.8  9.3  .02  USMLE Step 1 score (mean)  242.7  228  .02  USMLE Step 2 score (mean)  244  228  .06  Number of abstracts, publications and presentations (mean)  10.1  6.6  .25  Percentage of AOA students  28.6%  7.8%  .02  Percentage of students from top 40 NIH-funded medical schools  45.8%  29.5%  .02  Percentage of students with combined MD/PhD  11.1%  9.2%  .25  AOA, Alpha Omega Alpha; NIH, National Institutes of Health; USMLE, United States Medical Licensing Examination Preferred refers to first-choice specialty. View Large TABLE 3. Predictors for Matching in Neurosurgery for Graduating US Medical Students who Ranked Neurosurgery as Preferred Specialty   Matched  Unmatched  P value  Number of contiguous ranks (mean)  14.8  9.3  .02  USMLE Step 1 score (mean)  242.7  228  .02  USMLE Step 2 score (mean)  244  228  .06  Number of abstracts, publications and presentations (mean)  10.1  6.6  .25  Percentage of AOA students  28.6%  7.8%  .02  Percentage of students from top 40 NIH-funded medical schools  45.8%  29.5%  .02  Percentage of students with combined MD/PhD  11.1%  9.2%  .25    Matched  Unmatched  P value  Number of contiguous ranks (mean)  14.8  9.3  .02  USMLE Step 1 score (mean)  242.7  228  .02  USMLE Step 2 score (mean)  244  228  .06  Number of abstracts, publications and presentations (mean)  10.1  6.6  .25  Percentage of AOA students  28.6%  7.8%  .02  Percentage of students from top 40 NIH-funded medical schools  45.8%  29.5%  .02  Percentage of students with combined MD/PhD  11.1%  9.2%  .25  AOA, Alpha Omega Alpha; NIH, National Institutes of Health; USMLE, United States Medical Licensing Examination Preferred refers to first-choice specialty. View Large DISCUSSION In 2018, over 300 applicants, including graduates from international medical schools and from US allopathic and osteopathic medical schools, will be entering the NRMP neurosurgery match. The successful neurosurgical candidate is more likely to graduate from a US allopathic medical school, rank a higher contiguous number of neurosurgery programs, achieve AOA membership and score higher on the USMLE Step 1 examination than prior matched neurosurgery candidates. Practicing neurosurgeons who screen applications for residency positions often mention how grateful they are that they applied when they did, a sentiment rooted in the realization that current matched applicants are scoring higher on USMLE Step 1 than those of prior years. The steady rise in matched applicants’ USMLE Step 1 scores has therefore led to a perception that the neurosurgery match has become increasingly competitive. This analysis of neurosurgery NRMP data, however, debunks this perception by demonstrating that despite increasing USMLE scores and the addition of 10 new ACGME-accredited programs with 27 additional residency positions, neurosurgery has maintained a stable level of competitiveness from 2009 to 2017. Characteristics of Matched Neurosurgery Applicants From 2009 to 2016, the mean USMLE score increased from 239 to 249 for Step 1 and from 237 to 251 for Step 2 (Table 2). However, rising USMLE scores are not a trend unique to neurosurgery. Studies on trends in applicant characteristics for plastic surgery and emergency medicine demonstrate similar increases in matched applicants’ USMLE Step 1 scores.14,15 As listed in Table 2, from 2009 to 2016, the mean USMLE Step 1 score for matched applicants across all specialties increased from 225 to 233. The findings that combined MD/PhD degree is not a predictor of match success and that the percentage of matched applicants with combined MD/PhD degrees has progressively declined since 2009 may reflect applicants’ lack of interest in pursuing a PhD degree in the face of a 7-yr residency, the longest of any specialty in medicine. The decreasing percentage of matched neurosurgery applicants from top 40 NIH-funded medical schools reflects an overall increase in the number of US allopathic medical schools. The lack of association between number of abstracts/publications and matching in neurosurgery perhaps indicates that applicant attributes other than research, such as interviewing skills and letters of recommendation, may ultimately play an important role in matching into neurosurgery. Neurosurgery Match Competitiveness Since 2009, there has been a net increase in 27 neurosurgery residency positions across the country. This increase in positions has resulted largely from ACGME accreditation of 10 new neurosurgery programs since 2009. This study demonstrates that neurosurgery match rates and applicant to position ratios do not demonstrate a trend towards increased competitiveness. The number of applicants varied from year to year, leading to inconsistent match rates. The year 2017 is an example of an anomalous year with the highest ever match rate (87.1%) due to a dramatic drop of 55 applications from graduating US medical students compared to the previous year. The year 2017 followed 2015 and 2016, the 2 most competitive years, with match rates of 73% and 75%, respectively. Due to the highly competitive 2015 and 2016 neurosurgery matches, it is possible that less competitive applicants may have been discouraged from entering the 2017 match, which may explain the steep drop in the number of applicants. Graduating US medical students enjoy a distinct advantage among all applicants to the neurosurgery match. For example, in 2012, graduating US medical students made up 62.8% of all applicants but accounted for 87% of all filled positions. Similar trends are true across all years analyzed in this study, as demonstrated in Table 1. Reasons for this trend may include language and cultural barriers faced by IMGs, or the stigma of failure to match for former applicants (referred to as US Graduates in NRMP reports), or a sense of obligation felt by those making match decisions to offer graduating US medical students the first right of admission. The Future of the Neurosurgery Match In 2014, the AOA, the American Association of Colleges of Osteopathic Medicine, and the ACGME agreed to form a single accreditation system for graduate medical education (GME) by 2020. The single GME will be under the supervision of the ACGME; as a result, by June 30, 2020, all AOA-accredited residency programs are required to obtain ACGME accreditation, which will lead to an increase in ACGME-accredited neurosurgery programs. In the current system, osteopathic students are eligible to apply to both AOA-accredited and ACGME-accredited programs, but only 10 osteopathic students have matched in ACGME-accredited programs since 2009 (Table 1). However, for the academic year starting in 2020, all osteopathic and allopathic medical students will be entering a single NRMP match for ACGME-accredited neurosurgery programs. It remains to be seen how the influx of osteopathic medical students into the NRMP neurosurgery match will impact neurosurgery match competitiveness. A similar analysis to assess neurosurgery match competitiveness will be valuable in the years following the formation of a single accreditation system. Limitations Data collection was restricted to the information available in NRMP-published documents. Applicant demographical information is not available; therefore, we are unable to comment on applicant age, gender, and location. Data regarding graduating US medical student applicant characteristics, such as USMLE scores and AOA status, are released approximately every 2 yr. Since neurosurgery joined the NRMP in 2009, only 4 data points are available for various applicant characteristics, which limits the statistical analysis. All applicants other than graduating US medical students are categorized as Independent; therefore, we are unable to analyze match data for subgroups, such as foreign medical graduates, within the Independent category. The NRMP does not report on several factors that may contribute to applicant competitiveness, such as letters of recommendation, medical student performance evaluations, medical school grades, and faculty interviews. Future studies involving surveys of neurosurgical faculty are required to determine the impact of letters of recommendation and interview on applicant ranking. CONCLUSION Despite implementation of residency duty hour restrictions and increase in the number of ACGME-accredited programs and residency positions from 2009 to 2017, there has been no statistically discernable change in the level of competitiveness in the application process for neurosurgery. Analysis of characteristics of matched US medical graduates demonstrates an upward trend in USMLE Step 1 scores and number of contiguous ranked programs. The current analysis suggests that neurosurgery match competitiveness would be maintained even if the number of neurosurgery positions is further expanded. Medical student advisors and prospective applicants will benefit from these data as they prepare for future NRMP neurosurgery residency matches. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. National Resident Matching Program. Results and Data: 2009 Main Residency Match® . Washington, DC: National Resident Matching Program; 2009. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 2. National Resident Matching Program. Results and Data: 2010 Main Residency Match® . Washington, DC: National Resident Matching Program; 2010. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 3. National Resident Matching Program. Results and Data: 2011 Main Residency Match® . Washington, DC: National Resident Matching Program; 2011. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 4. National Resident Matching Program. Results and Data: 2012 Main Residency Match® . Washington, DC: National Resident Matching Program; 2012. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 5. National Resident Matching Program. Results and Data: 2013 Main Residency Match® . Washington, DC: National Resident Matching Program; 2013. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 6. National Resident Matching Program. Results and Data: 2014 Main Residency Match® . Washington, DC: National Resident Matching Program; 2014. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 7. National Resident Matching Program. Results and Data: 2015 Main Residency Match® . Washington, DC: National Resident Matching Program; 2015. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 8. National Resident Matching Program. Results and Data: 2016 Main Residency Match® . Washington, DC: National Resident Matching Program; 2016. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 9. National Resident Matching Program. Results and Data: 2017 Main Residency Match® . Washington, DC: National Resident Matching Program; 2017. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 10. National Resident Matching Program. Charting Outcomes in the Match for U.S. Allopathic Seniors, 2009 . Washington, DC: National Resident Matching Program; 2009. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 11. National Resident Matching Program. Charting Outcomes in the Match for U.S. Allopathic Seniors, 2011 . Washington, DC: National Resident Matching Program; 2011. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 12. National Resident Matching Program. Charting Outcomes in the Match for U.S. Allopathic Seniors, 2014 . Washington, DC: National Resident Matching Program; 2014. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 13. National Resident Matching Program. Charting Outcomes in the Match for U.S. Allopathic Seniors, 2016 . Washington, DC: National Resident Matching Program; 2016. Available at: www.nrmp.org/report-archives. Accessed October 10, 2017. 14. Abraham JT, Nguyen AV, Weber RA. Integrated plastic surgery residency applicant trends and comparison with other surgical specialties. Ann Plast Surg . 2017. doi: 10.1097/SAP.0000000000001199 (published online ahead of print). 15. Manthey DE, Hartman ND, Newmyer A et al.   Trends in NRMP data from 2007-2014 for U.S. seniors matching into emergency medicine. WestJEM . 2017; 18( 1): 105- 109. doi:10.5811/westjem.2016.10.31237 Google Scholar CrossRef Search ADS PubMed  16. Schrock JB, Kraeutler MJ, Dayton MR, McCarty EC. A comparison of matched and unmatched orthopaedic surgery residency applicants from 2006 to 2014. J Bone Joint Surg . 2017; 99( 1): e1. doi: 10.2106/JBJS.16.00293 Google Scholar CrossRef Search ADS PubMed  17. Henry T. Single accreditation system for graduate medical education: What to know. AMA Wire. Available at: https://wire.ama-assn.org/education/single-accreditation-system-graduate-medical-education-what-know. Published April 5, 2016. Accessed November 20, 2017. 18. Agarwal N, Choi PA, Okonkwo DO, Barrow DL, Friedlander RM. Financial burden associated with the residency match in neurological surgery. J Neurosurg . 2017; 126( 1): 184- 190. Google Scholar CrossRef Search ADS PubMed  COMMENTS The authors have taken on an important task in examining NRMP trends for neurosurgery applicants going back to 2009 using publicly available data. They should be commended for applying sound statistical techniques to their analysis and providing a succinct summary of the available information. This commentary does have limitations which are largely due to the limited nature of the data provided, as discussed in the manuscript. The NRMP surveys were only administered during a limited number of years, and it was an opt-in process, meaning that they were not quite comprehensive. Future studies using independently collected data over consecutive years from the students together with companion surveys administered to senior faculty would add value to this investigation. Nonetheless, this report as it is currently constituted presents an important baseline from which to proceed with studying the factors that are likely to make an applicant successful in the neurosurgical match process. Edjah Kweku-Ebura Nduom Bethesda, Maryland This is an important and very well executed analysis of the neurosurgery NRMP data since 2009. It is important to publish this data for the neurosurgery community and the general public to see. It is not surprising that US graduates who matched were from better medical schools, had higher board scores and were more likely to be selected for AOA. It would be interesting in the future to try and include an the influence of medical school grades or class standing. Whereas interviews are critical, this would be very difficult to quantify. Even though number of abstracts, presentations, and publications and MD/PhD status did not demonstrate an advantage in those matching, neurosurgery was nevertheless much higher in these categories than all other specialties. It appears that we are still attracting the “best and the brightest” and will need to attract even more in the future. William F. Chandler Ann Arbor, Michigan The authors conducted an important, well-designed, well-written, and timely manuscript aiming to highlight trends in the neurosurgery match and document characteristics of matched graduating students. They found that the level of competitiveness in the application process for neurosurgery residency has not statistically changed from 2009 to 2017 despite implementation of duty hour restrictions and increase in the number of ACGME-accredited programs and residency positions. They also found that higher USMLE Step 1 score, AOA membership, and graduation from a Top 40 NIH-funded medical school were independent predictors of matching in neurosurgery. Surprisingly, MD/PhD degree and number of publications and presentations were not found to be predictors of matching in neurosurgery. Although the goals of the manuscript was only to examine global trends in NRMP match data for graduating US medical students, future studies including demographic data and additional information provided by the ‘Annual Survey Report’, are necessary to identify other potential predictors of matching in neurosurgery. This will enable future medical graduates to be better prepared for a successful application. Finally, this study raises important questions: How the number of neurosurgery residency positions may be effectively increased in a way that will not lead to the production of poorly trained neurosurgeons? Should this increase be regulated by the AANS or may the free market play a role in this process, especially in those counties with no neurosurgeons? These questions remain to be answered. Francisco Vaz-Guimaraes Alfonso Fuentes Houston, Texas Copyright © 2018 by the Congress of Neurological Surgeons

Journal

NeurosurgeryOxford University Press

Published: Apr 28, 2018

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