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inancial and Educational Costs of theesidency Interview Process forrology Applicants

. Price Kerfoot, Kevin P. Asher, and David L. McCullough

BJECTIVES To investigate the financial and educational costs of the urology residency interview process, weperformed a survey of the applicants to the 2006 urology match.

ETHODS All applicants registered for the 2006 urology match were invited to participate. In January 2006prior to the match, an anonymous online survey containing 8 questions on the financial andeducational costs of the interview process was distributed via email.

ESULTS Survey response rate was 61% (287/468). The median educational debt of the applicants was$125,000 (IQR 65,000 to 160,000). Respondents reported having a median 12 interviews (IQR8 to 15) with urology residencies and spending a median 20 days (IQR 14 to 30) on the interviewtrail. The total cost of the interview process was a median $4000 (IQR 2000 to 5200) with amedian expense per interview of $330 (IQR 211 to 455). Applicants reported that travelexpenses accounted for a median 60% of overall interview expenses, whereas the remainder ofthe expense was accounted for by lodging (25%), food (10%) and clothing (5%). The money tocover these interview-related expenses was obtained primarily by loans. Forty-six percent of theapplicants reported that skipping medical school clerkships and classes for urology interviews was“not at all detrimental” to their medical education, whereas 1% reported that it was “greatlydetrimental.”

ONCLUSIONS The financial cost of the interview process for urology applicants is substantial, although the educationalcost appears to be limited. Efforts to reduce the financial impact of the interview process should be initiated

at both a regional and national level. UROLOGY 71: 990–995, 2008. © 2008 Elsevier Inc.

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edical education is becoming an increasinglyexpensive endeavor. The American Associa-tion of Medical Colleges (AAMC) recently

eported that median educational debt for private medi-al school graduates is approaching $120,000.1 For mostedical students, this substantial debt is financed by

oans,1 and this large educational debt load has beenound to influence the career choices of medical stu-

his study was supported by the Pellegrino Foundations, the American Urologicalssociation Foundation (Linthicum, MD), Astellas Pharma US, Inc., Wyeth, Inc. and

he Research Career Development Award Program from the Veterans Affairs Healthervices Research & Development Service.

The study protocol was reviewed and approved by the institutional review board atarvard Medical School.The views expressed in this article are those of the authors and do not necessarily

eflect the position and policy of the United States Federal Government or the Depart-ent of Veterans Affairs. No official endorsement should be inferred.Dr. Kerfoot had full access to all of the data in the study and takes responsibility for

he integrity of the data and the accuracy of the data analysis.From the Veterans Affairs Boston Healthcare System, Boston, Massachusetts;arvard Medical School, Boston, Massachusetts; Boston University Medical Center,oston, Masschusetts; and Wake Forest University School of Medicine, Winston-alem, North Carolina.Reprint requests: Kevin P. Asher, M.D., Department of Urology, Boston Medical

penter, 720 Harrison Avenue, Boston, MA 02118. E-mail: kevin.asher@bmc.orgSubmitted: October 24, 2007, accepted (with revisions): November 15, 2007

90 © 2008 Elsevier Inc.All Rights Reserved

ents.2 In addition, high levels of debt can contributeignificantly to stress among graduating medical studentsnd can negatively affect academic performance.3 Al-hough interviews are an integral part of the fourth-yearxperience for most medical students, the residency ap-lication process has the potential to substantially in-rease the financial burden on the new medical schoolraduate.

The interview process does have value: interviewsllow applicants to explore the range of settings avail-ble for postgraduate urology training, to interact withheir future instructors and colleagues, and to meetany of the leaders of contemporary urology. Residen-

ies, on the other hand, can identify those studentsest suited for their programs and publicize the great-ess of their institution to future urologists. With theevelopment of computerized applications, the poten-ial applicant can now apply to a large number ofraining programs. A 2000 survey reports an average of1 residency interviews for urology residents.4 Thenterviews may require extended time away from med-cal school training and often require significant ex-

enditure for travel and lodging. Multiple trips from

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he West Coast to the East Coast during a 6 to 8-weekeriod are not uncommon.To investigate the financial and educational costs of

he urology residency interview process, we performed aurvey of the applicants to the 2006 urology match.

ATERIAL AND METHODS

tudy Participantsll 459 applicants registered for the 2006 urology match as ofovember 2005 were invited to participate in the study. Ap-

licants were recruited by an email announcement. Their emailddresses and baseline demographic information were obtainedrom the American Urological Association (AUA), Linthicum,

aryland. Participation was voluntary. There were no exclu-ion criteria. Institutional review board approval was obtained.

urvey Development and Administrationhe anonymous survey asked the applicants for the name of

heir medical school, baseline demographic information, and 8uestions relating to the financial and educational costs of therology residency interview process:

How many urology residency programs did you visit for aninterview?Approximately how many days did you spend on the inter-view trail?What were your estimated total expenses for the interviewprocess?What accounted for your interview expenses? Please indicatethe percentage that each of the following contributed to thetotal expense: travel (plane, train, auto rental, gas, park-ing . . .), lodging, food, and/or clothes.How did you obtain the money to cover these interview ex-penses? (please select all that apply): loans from medical school,loans from lending institution (nonmedical school), loans fromparents, personal assets, and/or other (please specify).Please estimate the current total of your overall educationaldebt (medical school, college, etc).What medical school clerkships, classes, or other activitiesdid you miss while on the interview trail?If you did miss medical schools clerkships, classes or otheractivities to attend these interviews, to what degree was thisdetrimental to your medical education? (5-point Likert-type scale with 1 � not at all detrimental, 5 � greatlydetrimental).

The survey was reviewed for clarity and appropriateness by aanel of 13 urology experts (7 urology residents and 6 attendingrologists) and was revised based on their feedback. The surveyas placed online using the SurveyMonkey web-based platform

Portland, Oregon).In January 2006, the survey was distributed to the applicants

y an email containing a hyperlink to the online survey. Twoeminder emails were sent over the subsequent 2 weeks. Allmails were sent before the release of the 2006 urology matchesults.

ata Collection and Analysisll survey data were recorded electronically and anonymously

y using the SurveyMonkey web-based platform, thus blindinghe researchers to the applicants’ identities. Between the de-

elopment of the email list (November 2005) and the date of a

ROLOGY 71 (6), 2008

he 2006 urology match (January 2006), 9 more students ap-lied to join the match and were not invited to participate inhis study. The analyses of response rates are calculated out ofhis larger sample size of 468, with these 9 new applicantsreated as nonresponders.

tatistical Analysishen the Kolmogorov-Smirnov test revealed the data to be

on-normal in distribution, nonparametric statistical tests weresed, and the data were reported as the median and interquar-ile range (IQR). The amount that each applicant spent onravel, lodging, food, and clothing was calculated by multiplyinghe total cost of the interview process by the percentage thatach contributed to the total cost. To assess the relation be-ween the number of days on the interview trail and theducational impact ratings, the ratings were collapsed into 3ategories (ratings 4 and 5 combined with 3 because of smallumbers of responses in these groups), and the data werenalyzed by the chi-square test and the Mantel-Haenszel test forinear trend. Statistical calculations were performed by SPSS for

indows 13.0 (Chicago, Illinois).

ESULTShe survey response rate was 61% (287/468). Significantifferences in demographic characteristics were notedetween survey respondents and the overall applicantool (Table 1).Overall educational debt of the applicants was

125,000 (IQR 65,000 to 160,000, Table 2). Respon-ents reported having a median 12 interviews (IQR 8 to5) with urology programs and spending a median 20ays (IQR 14 to 30) on the interview trail. The total costf the interview process was a median $4000 (IQR 2000o 5200) with a median expense per interview of $330IQR 211 to 455). The total cost of the interview processas significantly correlated with both the number of

nterviews (r � 0.61, P �0.001, Spearman) and theumber of days on the interview trail (r � 0.66,�0.001), corresponding to 36% and 44% of the vari-

nce, respectively. Those applicants who were not from anited States-accredited MD-granting medical schoolad significantly fewer interviews, days on the interviewrail, and interview expenses (all P �0.001, Mann-Whit-ey U test, Table 2). There were no significant genderifferences in the number of interviews, number of daysn the interview trail, total cost of the interview process,nd overall educational debt.

Applicants reported that travel expenses (plane, train,uto rental, etc) accounted for a median 60% (IQR 50 to0) of overall interview expenses, whereas the remainderf the expense was accounted for by lodging (median5%, IQR 20 to 30), food (10%, IQR 5 to 10), andlothing (5%, IQR 5 to 10). The money to cover thesenterview-related expenses was obtained by loans fromhe medical school (48% of respondents), personal assets39%), loans from a lending institution [including creditard financing] (34%), and loans from parents (31%).ther sources of funding include income from work (2%)

nd income from military service (1%).

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There were significant differences in expense per in-erview for applicants from different regions of thenited States (P �0.001, Kruskal-Wallis test), with ap-

licants from northeastern medical schools with the low-st (median $243, IQR 120 to 375, Table 3). There werelso significant differences in travel expenses betweenegions of the country (P � 0.001, Kruskal-Wallis, Table 3),ith applicants from northeastern medical schools againith the lowest travel expenses.The educational costs of leaving medical school to

ttend urology interviews appear to be limited. Forty-sixercent of applicants reported that skipping medicalchool clerkships and classes for urology interviews wasnot at all detrimental” to their medical education,hereas only 1% reported that it was “greatly detrimen-

al” (Fig. 1). In addition, there was no significant linearrend between the educational impact ratings and theumber of days on the interview trail (P � 0.23, chi-quare; P � 0.22, Mantel-Haenszel test for linear trend).

OMMENThese survey data demonstrate that the urology residency

nterview process demands a substantial investment ofoney and time from the applicants. Applicants spent aedian $4000 and left medical school for a median 20

ays to complete the process. Most applicants financedhese expenses through loans, adding to their alreadynormous educational debt (median $125,000). Al-hough most applicants did not find the time away fromheir medical school curriculum to be detrimental toheir overall education, this lost time still represents aubstantial opportunity cost given that the average an-ual expense of medical school is $34,000 per year.1

These results are consistent with prior studies investi-ating the urology residency interview process. In 2000,eichman et al.4 conducted a survey of 519 urologyatch applicants to examine the behavior and attitudes

mong applicants and program directors. In that study,

Table 1. Characteristics of applicant pool and survey resp

Match Appl

Overall 468Gender

Female 99Male 369

DegreeM.D. (M.D., M.D./Ph.D.) 454D.O. 14Other/no information 0

Medical school locationUnited States 370International 98No information 0

United States medical school statusAccredited M.D.-granting 350Nonaccredited 20

he mean number of interviews per candidate was 11. e

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eventy-five percent of applicants spent $1001 to $5000n interview-related expenses, and 12 applicants spentore than $5000. A large number of applicants and

everal program directors suggested that the interviewrocess had become too expensive. An additional con-ern cited in this study was the high number of interviewsor a very limited number of positions, leading to ineffi-iency and increased expenses for candidates that hadittle chance of matching at a particular institution.ur study underscores these findings and indicates that

he interview process continues to be quite expensive.omparative data from other specialties are extremely

imited.5,6

Urology applicants from the northeastern part of theountry had significantly lower interview costs. This find-ng is not surprising given the dense distribution of med-cal schools and residency programs in this particularegion of the country—28 of the nation’s 125 medicalchools and 34 of the 119 urology residency programs areocated in a span of less than 500 miles in the northeast-rn United States. For applicants from this region, it isossible to travel inexpensively to a number of inter-iews. In contrast, numerous trips to the East Coast fornterviews can become extremely expensive for appli-ants from western parts of the country. The degree tohich this cross-country travel expense limits the inter-iews that these applicants can attend is not known, butt is a potential concern for program directors seeking theest applicants on a national level.To our knowledge, there are no prior published data

n the educational impact of time spent away fromedical school on the interview trail. The fact that the

ast majority of urology applicants reported little-o-no detriment of this lost time on their educationay reflect the limited educational value of the fourth-

ear medical school curriculum. A common strategysed by medical students from our institution is tochedule “easier” courses during interview season, inn effort to minimize time spent away from more

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287 61%

70 71%217 59%

277 61%2 14%8

256 69%28 29%

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UROLOGY 71 (6), 2008

Table 2. Survey response data by medical school of applicant

Medical School StatusNo. of Responding

ApplicantsNo. of

InterviewsNo. days on

Interview TrailInterview-Related

ExpensesExpense per

Interview Total Educational Debt

All respondents 287 (100%) 12 (8–15) 20 (14–30) $4,000 (2,000–5,200) $330 (211–445) $125,000 (65,000–160,000)United States accredited M.D.-granting

medical school253 (88%) 13 (9–15) 20 (17–30) $4,000 (2,000–6,000) $330 (211–442) $130,000 (80,000–170,000)

United States nonaccredited medicalschool

3 (1%) 2 (0–7) 9 (4–42) $700 (500–2,000) $175 (100–250) $90,000 (0–160,000)

International medical school 28 (10%) 1 (0–2) 2 (1–4) $500 (200–1,150) $400 (225–613) $0 (0–10,000)

Results are expressed as medians, with interquartile range in parentheses.Three respondents (1% of total) did not report medical school information.

Table 3. Interview costs for applicants from medical schools located different regions of the United States

All United States Regions West Midwest South Northeast P value*

No. of applicants 255† 26 (10%) 74 (29%) 85 (33%) 70 (27%) —No. of interviews 13 (9–15) 12 (10–14) 13 (10–16) 12 (9–15) 12 (9–16) 0.297Total Expenses $4,000 (2,000–5,900) $4,000 (2,875–5,375) $4,000 (2,000–6,000) $4,000 (2,500–6,375) $3,000 (1,700–4,500) 0.008Expense/Interview $324 (211–440) $333 (260–422) $300 (200–419) $368 (300–484) $243 (120–375) �0.001Travel $2,100 (1,250–3,500) $2,400 (1,545–3,510) $2,400 (1,500–3,600) $2,425 (1,594–3,600) $1,500 (1,000–2,750) 0.001‡

Lodging $975 (463–1,500) $1,000 (500–1,550) $975 (400–1,350) $1,200 (500–1,750) $700 (400–1,200) 0.032‡

Food $300 (125–500) $390 (200–625) $250 (125–480) $350 (159–600) $250 (100–400) 0.034‡

Clothing $200 (0–400) $200 (0–420) $160 (20–400) $138 (0–400) $220 (78–395) 0.481‡

Results are expressed as medians, with interquartile range in parentheses.* Statistical comparisons between regions performed by Kruskal-Wallis test.† One applicant from a medical school in Puerto Rico was excluded from these analyses.‡ To correct for multiple subgroup comparisons, the threshold for statistical significance is P � 0.013.

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A coordinated approach to urology residency inter-iews has been implemented in the Canadian Urologyair.7 This program was developed in 1994 by Canadianrology residency programs with a primary goal of mini-izing financial burden applicants and reducing time

way from medical school. Each of the 9 residency pro-rams and all candidates come together at a centralocation to conduct information sessions and interviewsn 1 day. In the 2001 Fair, the average cost for applicantsas $367 (Canadian dollar) compared with an estimatedost of $2065 (Canadian dollar) to visit each programndividually. Ninety-six percent of applicants in 2001avored the process, and 56% reported no adverse effectsn not visiting the physical site of proposed residencyraining. These findings must be interpreted with cau-ion: of the 56% who reported no adverse effects of theentralized process, 73% had arranged clinical rotationst the programs of interest, which may have led tonancial costs not captured in the interview expenses.ven so, this coordinated, organized approach appearedo greatly reduce financial burdens on the applicants andas clearly favored by both applicants and program di-

ectors. The principal difficulty in implementing a similarystem in the United States is the much larger number ofrograms (112) and applicants (476).8 Regional coordi-ation of interviews by AUA Section designations rep-esents a potential solution. Still, for many applicants, aisit to the potential site of their training for the next 5ears may be worth the expense.

There are several limitations to our study, includinghe moderate response rate and possible volunteerism

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igure 1. Educational costs of the interview process. On a-point Likert-type scale, applicants were asked to rate the

ollowing: “If you did miss medical school clerkships,lasses or other activities to attend these interviews, tohat degree was this detrimental to your medical educa-

ion” (1 � not at all detrimental and 5 � greatlyetrimental).

ias. It is possible that those applicants who experience a

94

reater financial burden were more likely to participate,hus overestimating the true costs experienced by appli-ants. Because the survey responses were anonymous, weere not able to compare the financial and educationalosts between those applicants who successfully matchednd those who did not.

The substantial financial burden reported by the re-pondents to our survey continues to support the modi-cations to the interview process that were originallyuggested in 2000 by Teichman et al.4 These measuresnclude interviewing only those candidates with a rea-onable chance of being ranked, arranging to have appli-ants hosted by residents with appropriate incentives,nd negotiating with area hotels to provide reduced roomees. The AUA could negotiate discounts with the air-ines. In addition, a popular discussion board amongrology residents has developed on the World Wide Webhat has allowed candidates to pool their resources.9

ONCLUSIONSlthough the educational cost of the interview process

ppears to be limited, its financial impact is substantial. Inoday’s practice climate, urologists are looking to containosts on many fronts. We owe it to the youngest urologistsmong us to minimize that burden that comes with landingheir first (and arguably most important) urology position.

cknowledgment. We thank Jessica E. Hyde for administra-ive support, the American Urological Association for provid-ng the email addresses of the applicants to the 2006 urologyatch, and the members of the Boston University Department

f Urology for their assistance in development of the surveynstrument.

eferences. Association of American Medical Colleges (AAMC), Medical Ed-

ucational Costs and Student Debt: A Working Group Report to theAAMC Governance (March 2005). Available at: https://services.aamc.org/Publications/showfile.cfm?file�version35.pdf&prd_id�121&prv_id�137&pdf_id�35. Accessed on August 9, 2007.

. Tonkin P: Effect of rising medical student debt on residency spe-cialty selection at the University of Minnesota. Minn Med 89: 46,2006.

. Ross S, Cleland J, and Macleod MJ: Stress, debt and undergraduatemedical student performance. Med Educ 40: 584, 2006.

. Teichman JM, Anderson KD, Dorough MM, et al: The urologyresidency matching program in practice. J Urol 163: 1878, 2000.

. Marciani RD, Smith TA, and Heaton LJ: Applicants’ opinions aboutthe selection process for oral and maxillofacial surgery programs.J Oral Maxillofac Surg 61: 608, 2003.

. Hammoud DA, Yousem DM, and Schaefer PW: Neuroradiologyfellowship match: year 4 applicants’ perceptions. J Am Coll Radiol2: 696, 2005.

. Grober ED, Matsumoto ED, Jewett MA, et al: The Canadian Urol-ogy Fair: a model for minimizing the financial and academic costs ofthe residency selection process. Can J Surg 46: 458, 2003.

. American Urological Association (AUA), Urology Match Statistics.Available at: http://www.auanet.org/residents/resmatch.cfm#statistics.Accessed on October 17, 2007.

. UrologyMatch.com. Available at: http://urologymatch.com/. Ac-

cessed on October 17, 2007.

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