This new Resident Roundup post was submitted by Armin Pazooki, a first-year medical student at the University of Chicago Pritzker School of Medicine.
In an increasingly competitive match environment, I have watched students just a few years ahead of me, who had done everything “right,” not match into orthopaedic surgery. On the surface, the path to residency looks straightforward: strong clinical scores, meaningful research, sustained commitment to the field. It is easy to interpret not matching as an individual failure. Yet, when applicants who have done everything “right” by conventional metrics can end up on different sides of the match, it suggests that the metrics we rely on may have lost their ability to meaningfully distinguish between applicants, while shaping behavior in ways that pull us away from what we truly value in applicants.
In recent years, applicants have been running out of ways to distinguish themselves. The transition of USMLE Step 1 to pass-fail, along with a similar shift in core clinical clerkships, has decreased the number of standardized numeric metrics available to evaluate students. In their absence, residency programs naturally scrambled to identify new markers of merit to evaluate in their place.
Aside from the increased emphasis on Step 2, research output has, in many ways, filled this void. In part, this makes intuitive sense, given the sustained hard work and dedication needed to see a project to completion. However, it also reflects convenience, given that research remains one of the last few accessible metrics available to residency programs. In doing so, research output has now become a proxy for the very qualities that board and clerkship scores once signaled.
As programs rely on select measurable metrics to differentiate a growing pool of applicants, applicants, in turn, respond by optimizing their efforts for those same metrics. In this way, the process creates a “tragedy of the commons,” where rational decisions by individuals raise the baseline for everyone, subsequently eliminating any meaningful advantage. Orthopaedic surgery is no exception, with the average number of research items for matched applicants swelling from 4.1 in 2009 to 16.5 by 2022, a shift that existed even before Step 1 went pass-fail and one that now approaches a ceiling, with unmatched applicants reporting output similar to that of matched applicants. If anything, this trend has only intensified in the years since the transition of Step 1, with recent work suggesting that much of this reflects a growing emphasis on adding to the total count, often through non-peer-reviewed work.
At this point, what exactly are we looking for in applicants?
Even early in training, this pressure is internalized. Just months into medical school, I had already heard classmates speak as though taking a research year is inevitable—a reflection of how normalized this outlook has become. It subtly shapes how we spend our time, often pulling us away from the classroom, practicing clinical skills, and engaging in satisfying yet long-term projects.
There have been moments when I considered not pursuing projects I found more personally and professionally meaningful in favor of those more likely to be published quickly. The reality is that the projects most likely to generate multiple publications within a short time frame are not always the ones that ask the most meaningful questions. At the same time, longer-term studies, from basic science to prospective trials, often take years to complete. The result is a constant tension in deciding what to prioritize.
The solution to this problem is not easy. As long as residency applications remain competitive, programs will look for ways to differentiate among applicants, and applicants will respond to whatever seems emphasized. While attempts to curb this arms race have been proposed and changes to the Electronic Residency Application Service (ERAS) have been adopted, addressing this environment will ultimately require a cultural shift among both applicants and residency programs. For applicants, this means resisting the impulse to prioritize volume over value and to engage in experiences that are more personally meaningful, whether in research or elsewhere, even if they are less visibly emphasized. For programs, it means greater introspection about what they truly value in an applicant and being open to adopting a holistic view of applicants earlier in the selection process, as some have been increasingly advocating.
Orthopaedic surgery should remain a competitive specialty that demands merit and dedication. Yet if merit is defined by what is easy to measure rather than what is most meaningful, the system risks overlooking what truly makes a strong resident. The challenge, then, is not to ask less of applicants, but to ask the right things of them. It is not whether competition should exist, but how we choose to engage with it, and whether we are using it to build the kind of field we actually want.
Armin Pazooki is a first-year medical student and the President of the Orthopaedic Surgery Interest Group at the University of Chicago Pritzker School of Medicine.
For more on this topic, check out the recent Your Case Is On Hold podcast episode: Andrew and Ayesha Discuss Orthopaedic Residency Selection. Hosts Dr. Andrew Schoenfeld and Dr. Ayesha Abdeen share their insights.
Read other Resident Roundup posts here.
New posts welcome! Share your experience, connect with others in orthopaedic training, and add your viewpoint to the orthopaedic conversation. Find out more and submit a post here.
