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Integrated plastic surgery applications have skyrocketed—from 2016 to 2021, applicants increased by 59 percent, from 262 to 416.1 Yet, available positions grew by a mere 18 percent, from 152 to 180, yielding a 43 percent match rate.1 Aware of these intimidating odds, applicants are driven to achieve even more to be competitive applicants. As future plastic surgeons are selected, we must reflect with intentionality on the incentive structure in place and identify how it might exacerbate inequalities in the system. Previously, a high U.S. Medical Licensing Examination Step 1 score, high clinical rotation grades, and strong letters of recommendation were considered sufficient to match.2 However, the old order appears no longer adequate, as increasing competition requires applicants to seek new ways of differentiating themselves. Recently, applicants have improved their odds of matching through research productivity.3 Matched applicants in 2020 reported an average of 19.1 abstracts, presentations, and publications, compared to 11.9 in 2016.1 One can only assume that the transition of U.S. Medical Licensing Examination Step 1 to pass/fail in 2022 will fuel this research arms race. To gain a competitive edge, many applicants opt to complete a dedicated year of research, typically after the third year of medical school, extending their matriculation to 5 years. In a survey of 621 integrated plastic surgery applicants from 2013 to 2016, 25 percent of respondents participated in a dedicated research year, and of those, 97 percent matched, compared to 81 percent who did not pursue the additional year.4 While the field should value research participation, this trajectory threatens to exacerbate inequalities in the pipeline. Simply put, even if funded, taking a research year remains a costly endeavor. Applicants must consider the opportunity cost of deferring attending status another year, in addition to the extra year of interest accrual on education loans, which averaged $201,490 for 2019 medical school graduates.5 Moreover, a web search for “plastic surgery research fellowship” opportunities returned only five institutions, suggesting a dramatic mismatch between the number of publicly advertised, funded positions and the number of students completing a research year. Those not fortunate to acquire a coveted, funded research position must make the challenging decision to either apply in the traditional pathway (at a perceived disadvantage) or carve out their own 1-year research experience, supporting themselves out-of-pocket. As a result, the ability to take a research year favors students with higher familial socioeconomic status. The rapidly growing number of applicants sharply contrasted with the sluggish increase in intern positions has made research productivity an increasingly necessary metric to match—the goalposts have moved. Unfortunately, the limited number of funded research positions falls short of applicant demand, creating a differential in those who may choose to pursue a year compared to those who cannot. Our field must consider the implications of whether certain groups can pursue a research year given the financial downside. As we aim to make the pathway to plastic surgery equitable, we must ask ourselves: In which direction have the goalposts moved for all learners, and is this new emphasis truly beneficial to our specialty? DISCLOSURE This research did not receive financial support for the study, and the authors do not have any financial disclosures.
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