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The cost of applying to dermatology residency: 2014 data estimates

      See related article on page 775
      To the Editor: Current US medical school graduates enter residency with a median debt of approximately $170,000.
      • Youngclaus J.A.
      • Koehler P.A.
      • Kotlikoff L.J.
      • Wiecha J.M.
      Can medical students afford to choose primary care? An economic analysis of physician education debt repayment.
      Applying for dermatology residency poses a hefty and potentially long-term financial burden for US medical students. A 2011 survey estimated dermatology applicants' costs at $4,500,
      • Tichy A.L.
      • Peng D.H.
      • Lane A.T.
      Applying for dermatology residency is difficult and expensive.
      which we feel is an underestimate. We sought to perform an updated and more formalized estimation of these costs for US medical school seniors.
      We calculated overall costs for applying to dermatology residency for both matched and unmatched US applicants in 2014 as the sum of fees from the Electronic Residency Application Service (ERAS), National Resident Matching Program (NRMP), US Medical Licensing Exam (USMLE) reporting, the cost of away rotations, and interviews.

      Association for American Medical Colleges. The Cost of Applying for a Medical Residency. Available from: URL: https://www.aamc.org/download/94416/data/applyingformedicalresidency.pdf. Accessed September 13, 2015.

      The cost of away rotations was estimated, while interview costs were based on recent literature.
      • Nikonow T.N.
      • Lyon T.D.
      • Jackman S.V.
      • Averch T.D.
      Survey of applicant experience and cost in the urology match: opportunities for reform.
      In 2014, 463 US seniors applied to dermatology residency positions (352 matched, 111 unmatched
      National Resident Matching Program
      Results and Data: 2014 Main Residency Match.
      ; Table I). The total cost for matched and unmatched applicants was $11,324 and $9,058 per applicant, respectively, based on 72 and 81 median ERAS applications submitted for matched and unmatched applicants, respectively. This corresponds to a total cost of almost $5 million for all US medical school seniors applying to dermatology residency.
      Table IEstimated costs for US medical students applying to dermatology residency in 2014
      US medical school senior applicants
      MatchedUnmatched
      Number of applicants
      National Resident Matching Program. Results and Data: 2014 Main Residency Match. National Resident Matching Program, Washington, DC. 2014. Available at: URL: http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf. Accessed February 19, 2016.
      352111
      Median number of applications to programs
      National Resident Matching Program. Results and Data: 2014 Main Residency Match. National Resident Matching Program, Washington, DC. 2014. Available at: URL: http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf. Accessed February 19, 2016.
      7281
      Minimum number of applications to intern year programs based on prior median interview acceptance data
      Tichy AL, Peng DH, Lane AT. Applying for dermatology residency is difficult and expensive. J Am Acad Dermatol. 2012;66(4):696-697.
      66
      Estimated overall application cost
       ERAS: $95 + ($10 × 10) + ($16 × 10) + ($26 × ((72 or 81) − 30) + 95)$1,682$1,916
       USMLE fee: $75
       NRMP fee: $65
      Average number of interviews accepted (sum of both preliminary
      Tichy AL, Peng DH, Lane AT. Applying for dermatology residency is difficult and expensive. J Am Acad Dermatol. 2012;66(4):696-697.
      and dermatology averages
      National Resident Matching Program. Results and Data: 2014 Main Residency Match. National Resident Matching Program, Washington, DC. 2014. Available at: URL: http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf. Accessed February 19, 2016.
      )
      1510
      Estimated overall interview cost ($500 per interview)
      Nikonow TN, Lyon TD, Jackman SV, Averch TD. Survey of applicant experience and cost in the urology match: opportunities for reform. J Urol. 2015;194(4):1063-1067.
      $7,500$5,000
      Estimated away rotation cost$2,142$2,142
      Estimated overall cost per applicant
       Application, interview, and away rotation costs$11,324$9,058
      Estimated overall cost$3,986,048$1,005,438
      Estimated overall total cost for all applicants$4,991,486
      ERAS, Electronic Residency Application Service; NRMP, National Resident Matching Program; USMLE, US Medical Licensing Exam.
      National Resident Matching Program. Results and Data: 2014 Main Residency Match. National Resident Matching Program, Washington, DC. 2014. Available at: URL: http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf. Accessed February 19, 2016.
      Tichy AL, Peng DH, Lane AT. Applying for dermatology residency is difficult and expensive. J Am Acad Dermatol. 2012;66(4):696-697.
      Nikonow TN, Lyon TD, Jackman SV, Averch TD. Survey of applicant experience and cost in the urology match: opportunities for reform. J Urol. 2015;194(4):1063-1067.
      The estimated per applicant cost for a month-long away rotation, including lodging and travel, was estimated as the mean of the published monthly housing allowance between locations with extremely low and high costs of living (Texas A&M Health Science Center College of Medicine and University of California San Francisco, respectively). This value was $2,142. Direct application costs represented 15%-21% of the total cost incurred by students. The average number of (both preliminary and dermatology) interviews accepted by matched and unmatched US seniors was 15 and 10, respectively, with a per-interview cost estimated at $500.
      • Nikonow T.N.
      • Lyon T.D.
      • Jackman S.V.
      • Averch T.D.
      Survey of applicant experience and cost in the urology match: opportunities for reform.
      The subsequent estimated interview costs accounted for the majority of costs at 55%-66% of the total cost.
      Dermatology likely has the most expensive application process, given that applicants submitted the highest median number of applications
      National Resident Matching Program
      Results and Data: 2014 Main Residency Match.
      and interview at both dermatology and intern year programs, as students cannot pursue dermatology residency training without completion of an internship. This financial burden may be in part due to the incorrect belief that applying to a large number of programs increases the probability of matching, though data on this relationship only supports a weak correlation.
      • Clarke J.T.
      • Miller J.J.
      • Sceppa J.
      • Goldsmith L.A.
      • Long E.
      Success in the dermatology resident match in 2003: perceptions and importance of home institutions and away rotations.
      Anecdotally, many applicants ultimately match in programs where they have connections, often at regional programs. Additionally, performing an away rotation at an institution is one of the most important selection criteria for program directors,
      • Gorouhi F.
      • Alikhan A.
      • Rezaei A.
      • Fazel N.
      Dermatology residency selection criteria with an emphasis on program characteristics: a national program director survey.
      and increasing the number of away electives increases one's odds of matching.
      • Baldwin K.
      • Weidner Z.
      • Ahn J.
      • Mehta S.
      Are away rotations critical for a successful match in orthopaedic surgery?.
      If all applicants could have hypothetically interviewed at 4 large, multi-institutional regional interview days rather than the 10-15 interviews the average applicant attends, per applicant savings are estimated at $5,500 and $3,000 for matched and unmatched applicants, respectively (Table II). To ease this cost burden, we suggest multi-institutional or video-conferenced interviews and coordination of interview dates for various regions across the United States. Additionally, capping the number of applications submitted per applicant (for instance, at 30 programs) is another possible partial solution. Assuming applicants would have received 2 fewer interviews on average, this would have saved $2,092 and $2,326 for matched and unmatched applicants, respectively. If both changes had been implemented, the total savings would have been $6,592 and $4,326 per matched and unmatched applicant, respectively, or $2.8 million in savings for all applicants nationwide.
      Table IIEstimated costs for US medical students applying to dermatology if modifications were made to the application and matching systems
      Cap of 30 applicationsMulti-institutional regional interviewsBoth scenarios
      MatchedUnmatchedMatchedUnmatchedMatchedUnmatched
      Number of applicants
      National Resident Matching Program. Results and Data: 2014 Main Residency Match. National Resident Matching Program, Washington, DC. 2014. Available at: URL: http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf. Accessed February 19, 2016.
      352111352111352111
      Applications submitted (dermatology only)303072813030
      Intern year applications
      Tichy AL, Peng DH, Lane AT. Applying for dermatology residency is difficult and expensive. J Am Acad Dermatol. 2012;66(4):696-697.
      666666
      Estimated overall application cost$590$590$1,682$1,916$590$590
      Estimated overall interview cost ($500 per interview)
      Nikonow TN, Lyon TD, Jackman SV, Averch TD. Survey of applicant experience and cost in the urology match: opportunities for reform. J Urol. 2015;194(4):1063-1067.
      $6,500$4,000$2,000$2,000$2,000$2,000
      Estimated away rotation cost$2,142$2,142$2,142$2,142$2,142$2,142
      Estimated overall cost per applicant$9,232$6,732$5,824$6,058$4,732$4,732
      Per applicant savings$2,092$2,326$5,500$3,000$6,592$4,326
      Estimated overall total cost for all applicants$4,025,159$2,750,729$2,219,159
      Estimated overall total cost savings for all applicants$994,570$2,269,000$2,800,570
      National Resident Matching Program. Results and Data: 2014 Main Residency Match. National Resident Matching Program, Washington, DC. 2014. Available at: URL: http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf. Accessed February 19, 2016.
      Tichy AL, Peng DH, Lane AT. Applying for dermatology residency is difficult and expensive. J Am Acad Dermatol. 2012;66(4):696-697.
      Nikonow TN, Lyon TD, Jackman SV, Averch TD. Survey of applicant experience and cost in the urology match: opportunities for reform. J Urol. 2015;194(4):1063-1067.
      Other suggestions for decreasing costs include increased program transparency regarding interview selection criteria or capping the number of interviewees by residency programs to lessen these costs for both programs and applicants and minimize the long-term financial burden placed upon future dermatologists.
      We would like to thank Drs Alan Menter and John Griffin for their ideas and editorial assistance with a previous project of a similar nature.

      References

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        • Koehler P.A.
        • Kotlikoff L.J.
        • Wiecha J.M.
        Can medical students afford to choose primary care? An economic analysis of physician education debt repayment.
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        • Tichy A.L.
        • Peng D.H.
        • Lane A.T.
        Applying for dermatology residency is difficult and expensive.
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        • Nikonow T.N.
        • Lyon T.D.
        • Jackman S.V.
        • Averch T.D.
        Survey of applicant experience and cost in the urology match: opportunities for reform.
        J Urol. 2015; 194: 1063-1067
        • National Resident Matching Program
        Results and Data: 2014 Main Residency Match.
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        • Miller J.J.
        • Sceppa J.
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        Success in the dermatology resident match in 2003: perceptions and importance of home institutions and away rotations.
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        • Alikhan A.
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