Updated Trends in Orthopaedic Surgery Residency Selection: Insights After the United States Medical Licensing Examination Step 1 Pass/Fail Transition.

Abstract

In 2022, the United States Medical Licensing Examination (USMLE) Step 1 examination transitioned to a pass/fail format, altering the residency application process. Simultaneously, reforms to the application process, including the introduction of preference signaling, have also added a level of complexity. In orthopaedic surgery, these changes have influenced applicant behavior and program director (PD) priorities. This study examined the effect of the USMLE Step 1 scoring transition on orthopaedic surgery residency applicant characteristics and PD selection criteria, with particular attention to trends in USMLE Step 2 Clinical Knowledge (CK) scores, research productivity, and evolving PD preferences. We conducted a retrospective cohort study analyzing aggregate data of orthopaedic surgery applicants in the National Resident Matching Program from 2014 to 2024 and the 2024 National Resident Matching Program Program Director Survey. From 2014 to 2024, the average Step 2 CK score of matched orthopaedic surgery applicants increased markedly, from 251 to 257 (P < 0.05). Research productivity also surged, with the mean number of abstracts, presentations, and publications increasing from 6.7 to 23.8 (P < 0.05) and mean number of research experiences increasing from 3.7 to 8.1 (P < 0.05) in the same period. Participating PDs prioritized Step 2 CK scores (94%), and a lesser percentage endorsed research involvement (64%) as important for interview. The Step 1 scoring has prompted shifts in applicant behavior, including increased research involvement and a maintained focus on Step 2 CK scores. The surge in research productivity suggests an increased focus on academic achievements in the absence of Step 1 scores. However, current data suggest a possible disconnect between applicant efforts and PD priorities, highlighting the need for greater participation in future research to clarify how these evolving priorities will influence selection practices.