Not the Last Word: Want to Match in an Orthopaedic Surgery Residency? Send a Rose to the Program Director

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Back in the day, before the advent of the Electronic Residency Application Service (ERAS), there were no charges for submitting a residency application, but the process was hardly free. Each program required completion of its own, unique form and a high price was paid in time and effort. In 1989, I applied to eight programs and not nine simply because I did not want to glower at the typewriter any longer, answering another set of just-slightly-different questions, making sure my responses fit into the allotted space on the page.
These days, the marginal cost of sending out an application is just one mouse click and 29 bucks. And because it has gotten easier to send out ever-increasing numbers of applications, ever-increasing numbers of applications have been sent. In orthopaedics, 88,169 applications were filed in 2015 by only 1058 applicants [7]—on average, more than 83 per person.
Applicants may be happy to be unshackled from the typewriter (assuming they even know what a typewriter is), but overall, ERAS has left many of them worse off. The fraction of the medical school class applying to orthopaedic surgery has remained stable at ˜ 4% for the past 30 years [7], and the slight increase in the number of residency positions across the country has been offset by a commensurate increase in the size of the graduating class nationally. That is, the odds of matching are unchanged, but now everyone who wants to keep even is forced to spend more than USD 1000. And while it is generally ludicrous to apply to 83 programs, in a world where everybody else is doing so, such numbers are not only smart but necessary. Indeed, another front in the residency arms race [2] has been opened.
Programs may appreciate getting applications in electronic form, but they too can be harmed by the new arrangement. Under ERAS, programs are inundated with applications—about 540 per program, on average [7]—and because applications are so easily submitted, programs have no means of inferring the applicants' particular interest. (Suffering at the typewriter is a mark of sincerity). Programs face two options: Reading a great deal of casually submitted applications or relying on arbitrary screening criteria that might filter out otherwise worthy and well-suited students.
There is a solution to this problem, and it comes to us from the world of online dating. There, one “applies” for a date by sending a message. These messages are free, and thus can be sent in great number. Desirable partners are inundated with messages and, lacking the means of inferring the senders' particular interest, thus face two options: Wading through a lot of casually submitted requests for dates, or relying on arbitrary screening criteria that might filter out otherwise worthy and well-suited potential partners.
The solution to the online dating problem is sending a rose. If users of the dating service are given a limited quantity of (electronic) “roses” that can be attached to a message, these users can, by expending a scarce resource, signal specific interest. And it works. In their study on signaling in an online dating market, Lee and Niederle note: “By sending a rose a person can substantially increase the chance of [a date proposal] being accepted … [and] roses increase the total number of dates” [6].
A similar approach has been applied in the more practical realm of job hunting by graduate students in economics [3]. Each year, more than 1000 newly minted PhDs hope to fill more than 1000 academic and industry positions.
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