Ranking in Canadian gastroenterology residency match : What do residents and program directors want ?

1Department of Medicine (Gastroenterology), McMaster University, Hamilton; 2Department of Medicine (Gastroenterology), University of Western Ontario, London, Ontario Correspondence: Dr Khurram J Khan, Department of Medicine, McMaster University, Room 4W8, 1200 Main Street West, Hamilton, Ontario L8N 3Z5. Telephone 905-521-2100 ext 76768, fax 905-521-4958, e-mail khankj@mcmaster.ca Received for publication September 1, 2009. Accepted December 1, 2009 Gastroenterology (GI) is a competitive specialty among internal medicine trainees. In the United States, data from 2002 to 2003 (1) indicate that GI was the second most popular specialty after cardiology. This is a dramatic increase from earlier surveys performed in 1998 in which internal medicine trainees ranked GI/hepatology as the sixth most popular specialty (2). Although no Canadian data regarding the popularity of GI exist, trends from the United States may be highly suggestive of a similar pattern in Canada (3). Canadian fellowship positions are obtained through a postgraduate year (PGY)-4 match every November. Program directors are responsible for recruiting the best applicants into their program. The criteria for successful applicants are slightly different and depend on the goals of the program. Each applicant submits a curriculum vitae, letters of reference and a cover letter to all programs. Most programs conduct interviews; the total number of fellowship positions at any institution is not fixed. There is at least one guaranteed position per specialty oRiginal aRtiCle

program -the rest depend on the competitiveness among the GI applicants to other specialty applicants.
Once offered a fellowship position, applicants can hold the offer, accept it or decline.Only one offer can be held for the duration of the match (two weeks); a second offer can only be held for a maximum of 48 h.The ability of the candidate to choose theoretically gives the advantage of this match process to candidates and, potentially, places the burden of choice on them.The match process puts programs at a disadvantage because candidates can hold positions -this attrition allows the pool of competitive applicants to dictate who ultimately gets positions.The system will change for the 2010 match to an automated match based on rankings from both parties.
As the popularity of GI increases, program directors of GI training programs will endeavour to recruit the best applicants.Part of the struggle of the match program is the paucity of information regarding relevant factors in the decision-making process from both sides.In the present study, we elicited this information because transparency will facilitate achieving the desired objectives for both parties in the match process.

Methods survey design and development
Two questionnaires in the form of a survey were developed by the authors after collaboration with two former program directors and three current GI fellows.To improve the likelihood of higher response rates, consideration was given to limiting the self-administered survey to less than 20 questions and for it to take approximately 5 min to complete.No pretest validation or piloting of the surveys was undertaken.
The questionnaire for successfully matched applicants focused on several issues believed to influence the choice in accepting an offer from a particular program.These issues included training details, personal suitability and future goals (Table 1).The survey asked the applicants to consider the importance of the factors using a five-point Likert scale (4) in which 1 = not important at all; 2 = slightly important; 3 = somewhat important; 4 = moderately important; and 5 = very important.The questionnaire to program directors focused on several issues including trainees' interests, background and future prospects (Table 2).The survey asked program directors to consider the importance of these factors using the same fivepoint Likert scale.

initial recruitment of participants
In December 2006, survey participation of the PGY-4 match co-coordinators of all academic training programs in Canada was requested via e-mail for the successfully matched 2006/2007 applicants.They were asked to forward the link (hosted by the University of Western Ontario, London, Ontario [www.uwo.ca]) of an online survey to all PGY-3 residents who matched to the adult GI training program at their institution.
The program directors of all 14 accredited Canadian adult GI training programs (one program had codirectors) were also contacted by the author (KJK) and forwarded the link to the online survey in December 2006.

Follow-up recruitment
A second and final request was made by e-mail to the PGY-4 match coordinators to resend the link of the online survey to all applicants.For all program directors who did not respond to No efforts were made to contact the applicants who did not attend the course because attendance for the course was higher than 90% for first-year fellows across the country.Pediatric residents who completed the survey were not included in the analysis.
Responses to the surveys were recorded and analyzed using a speadsheet (Excel, Microsoft Corporation, USA).The factors were ranked based on the highest median score.The median absolute difference was also determined to assess the variability of the data set within each year.Using StatsDirect software (StatsDirect, United Kingdom), the Kruskal-Wallis test was performed to assess significant differences between years.Subgroup analysis using the Mann-Whitney U test was performed to investigate sex differences in the responses.

Applicant responses
The online applicant response rate was 16 of 25 (64%) for the 2007 applicants.Twenty-four of 26 (92%) participants in the 2008 cohort, and 24 of 34 (71%) participants in the 2009 cohort, completed the paper survey.The overall response rate was 64 of 85 (75%).The responses in three surveys were illegible and, therefore, invalid.Of the 64 total surveys, 41 were completed by men, 16 were completed by women and seven surveys were completed with sex not specified.
The most important overall applicant factor (ie, median score = 5) was suitable location for spouse, partner or family.The least important factor (median score = 2) was the opportunity for a pediatric elective.Comparing the results between years shows consistent median values for most factors.Those with slight differences (median ± 1 from total) include very good reputation, opportunity for third-year funding and programs whose previous trainees were successful in obtaining further fellowships (Table 1).
Analysis of the median absolute variance within each year showed no difference (variance = 0) for all factors.Between cohorts, the only significant difference was demonstrated in 2007 and 2009 for 'programs with a very good reputation' (P=0.039).Subgroup analysis between sexes demonstrated that women showed a slight preference (median difference +1) for programs with a very good reputation; with a GI ward; outpatient fellow clinic; and success of previous trainees in fellowship positions.Only preference for a GI ward showed statistical significance (P=0.008)(Table 1).

Program directors' responses
The program director response rate was 11 of 15 (73%).One program had responses from two active program directors.All but one of the program directors who responded were men.The most important factors (median score = 5) influencing the ranking of applicants were the ability to get along with others, outstanding reference letters, exceptional curriculum vitae and knowing the trainee is applying to only one specialty.The least important factors (median score = 2) included the trainee having completed their training at more than one school and having a Masters degree or PhD (Table 2).

disCussion
Using a survey methodology, we addressed the important question of what influences the ranking of programs and applicants during the Canadian GI match.The response rate to our survey was excellent, owing to the approach of recruitment at the endoscopy course and following up with online surveys.
We collected data from three sets of applicants to assess consistency and validity.We hypothesized that the resident responses varied year to year because applicants' concerns and personal beliefs would be different.We found similar results among residents from three years that indicated most values remained constant.For applicants, the suitability of the residency training program location for loved ones was the most important factor in the ranking.Unfortunately, this is a nonmodifiable variable for programs.However, programs could direct more attention to what the location has to offer applicants.Specific program factors such as endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, nutrition and pediatric electives were the least significant factors (Table 3).You believe the trainee will stay in your community after his or her fellowship 3 0 The trainee shows excellent leadership and communication skills 4 0 The trainee has demonstrated the ability to get along with others 5 0 The trainee performs well during the interviews 4 0 The trainee has done an elective in your school 3 0 The trainee has done electives outside of their own school 3 0 The trainee has NOT done all of their previous training with one school 2 0 The trainee has a Masters degree or PhD 2 0 The trainee has an interest in basic science research 3 0 The trainee has an interest in clinical research 4 0 The trainee has published in a peer-reviewed journal 4 0 The trainee has attended a meeting/conference in gastroenterology 4 0 The trainee has attended the Scholars' Program at Canadian Digestive Diseases Week 3 0 The trainee has a strong personal letter 4 0 The trainee has outstanding reference letters 5 0 The trainee has an exceptional curriculum vitae 5 0 The trainee has a high probability of accepting an offer 4 0 The trainee has a high probability of making a decision on an offer within 48 h 3 0 The trainee is only applying to one subspecialty 5 0 The differences in responses according to sex were minimal; however, the sample size of the women was approximately onethird of the sample size of the men.This may be reflective of the overall balance of sex split in GI in Canada.Trends are suggesting that this is changing, with data from the United States (5) showing that the number of female GI residents doubled from only 56 in 1996 to 129 in 2006.

Responses presented as median scores based on a five-point
Program directors are usually stationed at their position for a few years.Results should not vary year to year.There is limited information and transparency regarding the ways in which an applicant can boost their chances of gaining acceptance to a program.We found that the factors most important to an application were associated with reputation, merit on paper and commitment expressed in the desire to pursue only one specialty.Potential applicants can now appreciate what is important in the application.Although GI is a competitive specialty, it is not out of reach and individuals should not be discouraged to apply.Furthermore, a Masters degree or PhD is not even required!The data also afford program directors the opportunity to optimize their programs based on residents' concerns and aim to attract the best candidates in future matches.

Likert scale in which 1 =
not important at all, 2 = slightly important, 3 = somewhat important, 4 = moderately important and 5 = very important.MAD Median absolute difference This suggests that trainees are less interested in details of the training program or a perception that all training programs provide sufficient training for competency in GI.

TABLE 1 Applicant responses
Responses Statistically significant differencethe first request within one month, a second request was made and the survey link was sent again.Finally, to further recruit nonresponders, the author (KJK) presented a paper version of the survey at the Program Directors' meeting during the Canadian Digestive Diseases Week 2007 annual meeting in Banff, Alberta, two months after the original request was sent.For the 2007/2008 and 2008/2009 matches, applicants who attended the McMaster University (Hamilton, Ontario) introductory endoscopy course in July were provided with the survey at the course.
presented as median scores based on a five-point Likert scale in which 1 = not important at all, 2 = slightly important, 3 = somewhat important, 4 = moderately important and 5 = very important.Median absolute difference for all values was zero (not shown).*