In Reply to Maroongroge

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The spirit of Mr. Maroongroge’s critique is consistent with my initial point regarding the need to revamp the residency application system.1 I believe that for both of us, the ultimate goal is to spur reforms in the system such that program directors are incentivized to give comprehensive consideration to all applicants, and medical students are incentivized to submit, at minimal cost, applications to the specialties and programs for which they are best suited. Mr. Maroongroge is correct that in a monetized approach (i.e., charging increasingly higher fees for multiple applications), the elasticity of demand would be a key factor in determining the equilibrium fee. Nevertheless, a new residency application system is needed, and economic approaches should be employed in its design.
The current system has spawned an overemphasis on United States Medical Licensing Examination Step 1 scores.2 The behavior of both applicants and program directors is rational, given the current system; however, the system itself is suboptimal for allowing program directors to give thorough, multifaceted attention to all applications. I assert that the new design should address this situation as a resource allocation problem. Applicants currently have few constraints on how many programs to which they may apply, but program directors are restricted in the time and effort they can devote to evaluating those applications.
Rather than resorting to a quota on applications or other artificial constraints that do not accommodate the wants or needs of individual applicants, I propose that an allocation system (whether monetary or not) should be devised. In such a system, applicants would make strategic allocation decisions about the specialties and programs to which they most want to apply, rather than the almostunrestrained “scatter shooting” approach that is currently in vogue. Subsequently, program directors should reallocate their limited resources to comprehensive evaluation of this smaller pool of applicants.
To design the mechanics of a new residency application system, we should draw on other disciplines, such as behavioral economics, for guidance. Change is desperately needed to mitigate the impacts of the current system, which has subverted the essential outcomes of medical education.
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