Joseph Bernstein, MD
When I was a college student, I enjoyed going to New York City’s Shakespeare in the Park at the Delacorte Theatre. If nothing else, the price was right: The tickets were distributed free of charge.
When I started medical school, only 4 miles away, I stopped going to Shakespeare in the Park. It wasn’t because I lost interest; it was because I could not afford the free tickets. You see, the “free” tickets were not so free after all. To obtain a ticket, you had to wait in line for many hours. As a medical student, I just did not have the time to do that.
I was thinking about my pleasant times waiting in line in Central Park for my free ticket recently, while discussing career advice with one of my students. He reminded me that many orthopaedic surgery residency programs ration their seats (or at least interviews for those seats) based on Step 1 scores on the U.S. Medical Licensing Exam (USMLE). As such, he was planning to devote a full 10 weeks to studying for this exam—not so much to ensure passing (a foregone conclusion) but to ensure that he scored above 230 (the unofficial threshold for avoiding peremptory rejection of his residency application).
It struck me that his months of study are similar to my time in line in Central Park: a hassle endured to help obtain a scarce good that is not allocated by price. It further struck me that, side benefits notwithstanding (I got some fresh air in the park; he will re-learn the Krebs cycle), both were a colossal waste of resources.
In particular, I was willing to pay (and did), yet the theatre did not reap any gains from my expenditure; likewise, residency programs are not really benefiting from the students’ efforts. (I say “not really,” but that qualification is excessive: In more than two decades as a physician, I have yet to encounter the patient whose care was improved by my recollection that succinate is converted to fumarate. Or is it the other way around?)
Far better would it be for both Shakespeare in the Park and orthopaedic surgery residency programs to ration their valuable goods not by hassle, but by price. In plain terms: They should sell what they are distributing for free; they should charge money for what people are already willing to pay (albeit with hassle, not cash).
What's a fair price?
I won’t guess the fair price for a theatre ticket, but I do have a price in mind for an orthopaedic surgery spot: a 1 percent tax on future income as an orthopaedic surgeon. I therefore propose that all applicants be asked to pledge that, were they to match, they will donate 1 percent of their pretax income to orthopaedic surgery causes each year for the rest of their careers.
This will be on the honor system—no dunning letters will be sent. It will just be expected that all orthopaedic surgeons who sign this pledge will make these donations. As a default, I would suggest that the Orthopaedic Research and Education Foundation should be the designated recipient, but one’s alma mater or local hospital would be an equally apt beneficiary. Critically, this donation scheme must start in year one of residency; to be a habit of mind, and not a Rumpelstiltskin promise hauled out of memory.
The program that I propose is really commensurate to the efforts currently expended. Students are dedicating months of time to subvert the rationing of residency seats. This investment in time and effort goes beyond excessive studying for the USMLE. I know many students who have performed two or three away rotations, and I recall one student who could barely spell TGF-beta who took a year off to study growth factors in a basic science lab.
Four months engaged in gamesmanship—activities that are undertaken only to burnish one’s application—represent approximately 1 percent of a normal 30- to 35-year career. The pledge program just twists this in two positive ways: First, it lets the orthopaedic community harvest the fruits of this effort, rather than letting them go to waste; and second, it lets orthopaedic surgeons make this contribution later in life, when their work efforts can be so much more productive.
If someone says no
It is, of course, assumed that asking students to sign the pledge may deter some applicants. I am not yet ready to say “good riddance,” but I can say we can afford to lose them. These days, by my estimate, there are at least 1.5 qualified applicants for every residency slot. And that’s the number that remains after we actively dissuade some otherwise qualified students (such as those fail to score 230 or higher on the USMLE) and passively dissuade additional otherwise qualified students (such as those lacking an XY genotype).
My guess is that if orthopaedics were to engage students from the entire class, not merely the current applicant pool, we’d have three or more qualified applicants for each seat. In simple terms, even if the pledge requirement would depress applications by 50 percent, we could completely offset that by active recruitment.
Orthopaedic surgery residency seats are scarce and valuable. Matching in orthopaedic surgery is worth more (in terms of increased lifetime earnings) than even gaining admission to medical school itself. We ration these seats by wasteful means. The best way to ration most things is with money: Price conveys information about the avidity of demand and allocates resources accordingly.
If orthopaedics, as a profession, were not squeamish and in thrall to appearances, we would simply charge tuition for residency training. Yet because we don’t charge tuition, there is a mismatch between supply and demand, and wasteful queuing behavior ensues.
Instead, I say let’s ration our seats by some method which at least accrues some benefit to the profession and, in turn, to our patients and society. Applicants: Sign the pledge!
Joseph Bernstein, MD, is deputy editor for residents at Clinical Orthopaedics and Related Research and a clinical associate professor of orthopaedic surgery at the University of Pennsylvania School of Medicine. The opinions expressed here are his own.