2018 Residency Match Update

The National Resident Matching Program Advance Data Tables for the 2018 Main Residency Match again show an increase in the number of first-year positions offered, going from 28,849 in 2017 to 30,232 this year.

Of the 18,818 seniors graduating from US allopathic medical schools, 17,740 (94.3%) matched, 1078 (5.7%) did not match, and 474 withdrew or did not submit a rank list. The 5.7% who went unmatched was identical to last year’s figure.

The 1511 graduates of US allopathic medical schools from previous years did not fare as well with 43.8% matching and 56.2% going unmatched—slightly worse than the 2017 percentages.

The lost sheep: They’re MDs but can’t find residency positions

I haven’t written about offshore medical schools since this post back in January, but yesterday I received communications from two graduates of those schools which moved me. Both are edited for length and clarity.

This was an email. I read your article on Physician’s Weekly about unmatched MDs. I am a bit down and looking for advice. I graduated from a Caribbean Med school. I have failed attempts and many gaps. Academically I dug myself into a deep dark hole, but my desire to practice medicine kept me going. I recently took Step 3 and just received my scored (failed by 2 points). I do not know anyone in medicine that can help me get a residency. I know I will be a great physician. I am just a horrible test taker.

I didn't apply for the match since I was told that I needed to pass Step 3 to even try to match which would still be almost impossible even with a good score. I know many people who have not matched and have just given up on it. I have so much debt and no way of paying for it. What do you suggest I do? A friend thinks I should just take it again and apply, but I no longer have the funds especially since my chances are so low. I wish there was something more for me.

Any words of advice would be really appreciated.

What were attrition rates in surgical residency programs 25 years ago?

Last month I blogged about the 20% attrition rate of general surgery resident over the last 25 years, and a recent paper presented at a national meeting that found after following the general surgery resident class of 2007, 20% had dropped out for one reason or another.

A reader who calls himself Artiger commented on that piece asking, “Is there any data on resident attrition prior to 1992? Just curious if this has been a problem for more than the past 25 years.”

I responded that I wasn’t aware of any such studies but I would try to find out.

Most of the few papers written about attrition back in the day focused on one residency program or one medical school’s graduates.

Until the middle of the 1990s, many surgical residency programs were pyramidal—that is, they took more categorical first-year residents than they had chief residency positions. For example, when I began my training in 1971, my program had 12 first-year residents, decreasing to 8 in the second-year and only 4 chiefs.

How to fix the problem of general surgery resident attrition

Over the last 25 years, about 20% of general surgery residents have failed to complete their five years of training. This compares unfavorably to other specialties such as orthopedics, obstetrics-gynecology, and medicine with attrition rates of < 1%, 4.5%, and 5%, respectively.

A paper presented at the American Surgical Association in April looked at the factors associated with attrition in one year’s resident class. In 2007, 1047 residents began their training and after 8 years of follow-up, 80% had become surgeons. How many non-finishers left programs by their own choice is not clear.

Some highlights of the research are as follows:

24% of women and 17% of men left general surgery training.

Size mattered because 23% of men and 25% of women left large programs compared to both sexes leaving smaller programs at a rate of just 11%.

Can a med student who flunked Step 1 still become a surgeon?

I received these emails (italics) recently. The writer gave me permission to publish them. They have been edited for length and some details have been changed to protect his anonymity.

I'm a third year medical student at an allopathic state medical school. I've always wanted to do surgery. My problem is I failed USMLE Step 1 the first time and got a 207 on my second attempt. I hadn't failed anything else throughout first and second year, with the majority of my grades being my school's equivalent of Bs.

My surgery shelf exam was a week after I received my Step 1 score and, despite studying hard, my low score on that exam got me the equivalent of a C in surgery even with very good clinical evaluations. The rest of my third year has been good with most evaluations saying I'm well-liked and a team player.

Should I give up and go into a different specialty with better odds of matching? Apply to prelim surgery programs and categoricals? Or even apply to all of those things at once? I'm in a large pickle, paralyzed with indecisiveness, and would immensely appreciate your advice.

Disclaimer: This is my opinion. I do not presume to speak for all program directors. I'm going to be honest.

Surgical fellowship match results for 2017

Two weeks ago, I reviewed the preliminary results of the 2017 main NRMP match. Data for the specialty match, also known as the fellowship match, recently became available. Here are the outcomes for the subspecialties of general surgery.

For abdominal transplant surgery, 36 of 58 programs filled, comprising 51 of 74 positions. There were 75 applicants with 24 going unmatched. The number of transplant programs has dropped from 69 in 2013 with a concomitant decrease in the number of available positions from 84 to 74. Applicants numbered 116 in 2013, and except for a slight upturn in 2016, interest has steadily declined. Consistent with the previous four years, US grads filled 31% of the positions in 2017.

Colon and rectal surgery filled all 56 programs and all 95 positions; 35 of the 130 applicants failed to match. Colorectal has filled 100% of positions available in three of the last five years. US grads filled 75% of the slots which is fairly consistent with previous years.

Pediatric surgery’s 44 programs filled all but one of the 45 available positions. This is the first time in the last five years that pediatric surgery did not fill 100% of its slots through the match. There were 96 applicants this year, and 52 of them did not secure a position. US grads filled 80% of the slots which is a slightly lower percentage than previous years.

Brief summary of 2017 residency match data

Here are some snippets from the NRMP Advance Data Tables for the 2017 Main Residency Match.

The number of PGY-1 positions offered was the highest total ever. US allopathic medical school seniors in the match numbered 18,539, which is also a new high. Only 5.7% of US seniors failed to match. That was a slightly lower percentage compared to 2016 and 2015.

The numbers were not as good for previous graduates of US allopathic medical schools with only 46% of 1472 applicants matching. Osteopathic graduates fared better with 81.7% of 3590 applicants matching.

I have blogged about the prospects for international medical school graduates. Of the 5069 US citizen graduates of international medical schools, 54.8% matched—a rate consistent with the totals for the last four years.

Caribbean medical schools: A look inside

Did you know that several Caribbean medical schools provide postgraduate premed courses so students can complete their science requirements? At least one school’s nearly year-long premed curriculum includes 8 hours per day of classroom work, rudimentary general chemistry and organic labs, and a physics lab with 40-year-old equipment. The fee is more than $30,000 cash, no loans. That's a lot to pay for courses that are not accredited and credits transferable only to other Caribbean schools.

The goal of these premed programs is to prepare students to take the Medical College Admission Test (MCAT). However, some schools require only that applicants take the MCAT but do not reject anyone on the basis of their scores. 

A former student said, “Little did I know that a [Caribbean school] acceptance was the equivalent of a lottery ticket. They actually attempted to weed us out of the small (and unaccredited) pre-med class! It took me a month to figure it out.” One of his professors told him the administration said not to pass everyone in the premed course into the first year of medical school.

He struggled through the premed requirements and wound up at a different school. The dean at that school spoke to the students about USMLE testing and what to expect in the clinical years. Many times during the talk, that dean referred to the school’s “top students” in a way which implied that only the best students were likely to match to a residency position.

Another school administrator told him that some residency programs would not even look at his application if there was an F on his transcript. While most program directors would probably verify that statement, it was not widely known among the students at his medical school. Some had even failed a course but were still planning to become surgeons.

Regarding his struggles in the second year of medical school, the student said the volume of material was overwhelming, everyone in his class was stressed, and approximately one-third had dropped out. He observed that students who were doing well were “type A personalities who had some measure of prior academic success…and could make it through any US or Canadian program with ease.”

He barely made it through the first year with mostly C grades. During his second year he dropped two courses and had to repeat them.

After eventually withdrawing from that school, he applied to another and was turned down.

He warned that those who are thinking about going to school in the Caribbean don’t understand how many don’t make it through.

Dropouts and accurate figures on what percentage of each graduating class passes all USMLE steps and matches to a residency program are unknown.

Meanwhile tuition debt keeps accruing and doesn't go away. The student has over $200,000 to pay off and will be doing so without the benefit of a physician's income. He is now trying to get a job related to his undergraduate major—business.

Regarding the offshore medical school experience, the student had the following observations:

The schools accept many students who they know will not make it through to fill up the class and make a lot of money in the process.

I didn’t find the material in medical school to be all that difficult; it’s the volume of the material and the time constraints that are the problem.

I could not figure out why my studying was only yielding C's when some people were getting the A's and B's. I'm starting to believe people are born smart.

I am not a good test-taker. I make the process harder than it is. The right answer might stare me in the face but I'll always second guess it.

I was informed that residency programs look at more than STEP scores. I was actually under the impression that no matter what red flags I had on my transcript, my STEP scores would decide my future, but I was told by other students that residency programs will look at pre-clinical grades and I even heard from one student that an IM program asked for college transcripts! If that is the case, I would never stand a chance.

I wanted to be a primary care physician. Was all this stress worth it to go into primary care?

I keep reading that the match will continue to get harder and harder.

I have blogged about the decreasing number of residency positions available for international medical graduates.

Despite the recent ban on immigrants from certain countries, I do not expect the situation to change much for US citizen IMGs.

If it comes to a decision about whether to attend an offshore school or not, do your homework. Talk to people who have been there. It's not all palm tress and sunsets. 

Breaking residency placement fever

 By Francis Deng* and Skeptical Scalpel

A recent opinion piece entitled “Residency Placement Fever” in the journal Academic Medicine by Gruppuso and Adashi noted a recent intensification in the volume of residency applications submitted and interviews offered/attended per applicant.

For keen observers of the Match process, this trend is neither a secret nor a surprise. The Electronic Residency Application Service (ERAS) has seen an increase in applications filed per US medical school graduate from an average of 30.3 in 2005 to 45.7 in 2015.

Inflation of residency applications is getting out of control these days. Time for a limit in ERA$ pic.twitter.com/AsRn8c3fgd

— Francis Deng, MD (@francisdeng) October 31, 2016

The prospects for switching to a different specialty

Could you comment on how an applicant switching into general surgery compares to one that applied directly from medical school would be viewed? I had a very difficult time choosing between specialties and have been regretting my decision not to apply into surgery. I am currently in a prelim year in medicine and am currently matched into radiology. I want to reenter the match process this year but am nervous to give up my guaranteed radiology position at a top program for an unknown where I can go unmatched or matched into an undesirable program. I graduated from a US med school. My USMLE Step 1 score was 235, Step 2 252, and I have published 2 articles in a surgical sub-specialty field.

You are what is known to the National Resident Matching Program (NRMP) as an "independent applicant" (graduate of a US med school going back into the match).

Go to the NRMP website, download the PDF "Main match results and data 2016" and look at Figure 6, you will find that 52.2% of independent applicants in general surgery failed to match compared to only 9.9% of US seniors.

 

This holds true for most specialties. Note that 43% of independent grads did not match in neurology.

Your USMLE scores are quite good, and the fact that you have published to articles will probably help a little. However, the reality is that you probably have about a 50-50 chance of matching in general surgery.

I wish I could explain why this is. All I know is it has been this way for years.

I can't tell you what to do. I suggest you give this some serious thought. It is probably not ethical for you to reenter the match and not tell your anesthesia program that you are doing so, but I suppose that is an option. If you don't match in general surgery, you would still have your anesthesia spot, but if you do match, you will leave your anesthesia program high and dry.

If you decide to apply to general surgery, you should go with mostly community hospital programs and send out lots of applications. By lots, I mean more than 50 or as many as you can afford.

You will be able to better assess your chances as you see how many interviews you are offered.

Good luck with your decision and please let me know how it turns out.

 

Audition electives, applying to programs, and interviewing

By now most rising fourth-year medical students have chosen a specialty and are busy preparing residency applications. A paper from October of last year in Academic Medicine sheds some light on the process.

Researchers from Mass General and the University of Vermont surveyed 2884 fourth-year students from 20 US medical schools in 2014; 1367 (47.4%) responded—52% of them were female.

Just over half of the students applied to internal medicine, pediatrics, or surgery residencies.

While the average number of programs applied to was 36.4, those seeking surgery applied to a mean of 58.2 programs, significantly more (p < 0.001) than those applying to any other specialty.

Except for radiology, for which applicants averaged 16.9 interviews, all other specialties including surgery had a mean of about 12 interviews per applicant.

Of those who answered the survey, only 71 (5.2%) did not match in the specialty they wanted.

Can a US IMG with a marginal USMLE Step 1 score still match in surgery?

A US IMG with a USMLE Step 1 score between 200 and 210 wrote me with several questions.

Disclaimer: This is my opinion which may not be shared by the majority of surgical program directors. The questions are italicized.

Is there a way to find programs that don't have Step 1 cut offs? No.

Should I email them my 230 on the USMLE practice test? That would be of no use.

Should I explain my situation or will that seem like a sob story? I've had bad luck but just a string of it and I feel like it would sound like I was making too many excuses. As I read your story, it did sound like too many excuses. The problem for you is that there are numerous other candidates out there who don’t have these issues and have better scores.

Should I strategically book rotations during interview season and hope they decide they want me (does that happen and do you have any tips on this)? The value of so-called “audition electives” is controversial. I never put much stock in them, but I think many program directors do. If you decide to do some audition electives, you should focus on smaller community hospital programs. Many programs list where their residents went to medical school on their websites. You should pick places that have taken US IMGs recently.

What are the residency prospects for graduates of offshore medical schools? 2016 update

Since I blogged about this two years ago, there is new data that may help clarify the situation for those who graduate from non-US medical schools. That post has had over 44,000 page views and 91 comments, some of which are responses from me to reader questions.

The National Resident Matching Program (NRMP) has published a 290-page summary [Characteristics of Applicants Who Matched to Their Preferred Specialty in the 2014 NRMP Main Residency Match (5th edition)] of the 2014 match, the latest year for which complete information has been analyzed.

The number of US graduates participating in that year's match was 17,374 compared to 16,896 graduates of other schools including non-US IMG's (7334), US IMGs (5133), DOs (2738), US graduates from previous years (1662), fifth pathway students (15), and Canadian grads (14).

From the Main Match Results Data for categorical general surgery in 2014:

One way to look at these numbers is that if you are US senior applying for a categorical surgery position, you have a 922/1274 or a 72% chance of matching. If you are in the "others" category, it's 283/1108 or a 25.5% chance of matching.

FAQs from IMGs about applying for surgery training

Here are some of my responses to common questions from international medical graduates (IMGs) looking to match in categorical general surgery residency programs.

1. Which programs should I apply to?

You should apply to a number of second and third tier programs, especially if you USMLE Step 1 scores are not outstanding.

2. What would you consider second and third tier academic programs?

There is no short answer to this question. I suggest you go to Doximity’s residency navigator and look at their list of surgery programs. You should start at the bottom and work your way up. Doximity’s list is not perfect, but it is better than any other one I have looked at.

3. How much of a level playing field is the interview process?

I’m not sure what you mean by this question. The object is to get some interviews. Most programs will not waste their time interviewing people they have no interest in. If you are offered an interview, you should obviously make the best impression you can.

4. What about observerships?

So you got into medical school… Now what?

"So you got into medical school… Now what?" is a book written by Dr. Daniel R. Paull, a recent med school graduate. His aim was to inform newly matriculating medical students about what to expect and how to survive. For the most part, he succeeds.

The first four chapters are a bit on the dry side because Dr. Paull tries to simplify such complex things as how to live with anxiety in the first two years of medical school. He also spends a bit too much time on how to study. I agree with him that studying in medical school differs from studying in college, and that sticking to a schedule is a sensible way to organize time. However, I think that most people will figure out what works best for them on their own.

The book picks up steam starting with Chapter 5 on how to prepare for USMLE Step 1. I get a lot of questions about USMLE, and with no recent experience, I sometimes find them difficult to answer. Dr. Paull takes care of that quite nicely.

The remaining chapters offer plenty of practical advice on transitioning to the clinical years, clerkships and how to arrange them, studying for the two parts of USMLE Step 2, the fourth year of medical school, and finally how to arrange and succeed in the all-important residency interview process.

Regarding clerkships, Dr. Paull wisely recommends that students ask their residents and attendings for feedback during the rotation instead of waiting until the end to find out that their performance was not up to par. He gives some specifics like asking for feedback about H&P's and presentations and how to improve on them.

The pros and cons of away rotations are discussed in some detail and should help any student who is conflicted about whether to do one or not.

He explains how the National Resident Matching Program works and offers some hints about ranking programs which echo similar comments I have made on this blog.

The book is in trade paperback format and inexpensive at a list price of $19.95. It's also available in a Kindle edition.

My only other criticism of the book is that Dr. Paull relies a little too much on an alarm clock about to go off or going off as a way to introduce a challenge he is trying to help students deal with.

Why should we believe anything Dr. Paull says? Well, he has a bachelor of science degree in physics from New York University, graduated from the University of Miami School of Medicine, and is currently an orthopedic resident at the University of Toledo in Ohio. In case you hadn't heard, orthopedic residencies are highly competitive.

Also, I have read the book myself and think most med students will find value in it.

Disclosure: I received a complimentary copy of the book from the author.

2015 Match Review

Continuing grim news for international med school grads and some US grads too

There were a lot of happy faces on March 20th as depicted in this brief video of the excitement on the campus of the University of Rochester School of Medicine. Similar scenes took place at every US medical school because 93.9% of the 18,025 graduates of US allopathic medical schools matched in a specialty.

But for the 1093 (6.1%) US graduates who didn't match things were not so bright. These applicants had to go through the Supplemental Offer and Acceptance Program (SOAP) which connects unfilled programs with unmatched students.

Because there were over 8600 unmatched graduates from schools all over the world vying for about 1200 unfilled first-year residency positions, even some US med school grads did not secure a position. One of these unfortunate souls tells her story in this blog.

The 7400 or so new MDs left out in the cold will not be able to pursue their careers. They will not progress into any specialty, nor will they be able to obtain licenses to practice medicine anywhere in this country. Those with substantial tuition debt will have no way to pay off their loans.

The percentage of unmatched US graduates has been relatively stable over the last five years, ranging from 4.9% to 6.3% while the number of first-year residency positions offered has steadily increased by nearly 4000 from 23,420 in 2011 to 27,293 this year.

Graduates of osteopathic medical schools didn't fare quite as well. Of the 2949 osteopathic school applicants, 610 (20.7%) went unmatched, but this percentage has steadily declined from a high of 28.3% in 2011.

International med school grads were much worse off; 2354 (46.9%) US citizens and 3725 (50.6%) non-US citizen graduates of international medical schools did not match. Both of these groups also had declining percentages of unmatched applicants. In addition, about 1900 US citizen graduates of offshore schools either withdrew or did not submit a rank list compared to almost 2700 non-US citizen international graduates who did likewise.

Reentering the match next year is an option, but spending a year outside of clinical medicine greatly reduces one's chances of finding an accredited position.

If you factor in the number of applicants who either withdrew from the match for did not submit a rank list. graduates of international medical schools have well below a 50% chance of matching.

In previous posts here and here, I have warned about the risks involved with attending an offshore medical school. If you are considering attending such a school, I urge you to look at the numbers and think long and hard about your decision.

Source: Advance Data Tables 2015 Residency Match

Cautionary tales about the matching process

Within the next two weeks, anxious fourth-year medical students will submit their residency choices to the National Residency Matching Program. I have written many posts about how to investigate residency programs and the workings of the match.

Here are a couple of stories about deception and disappointment. The first appeared as an anonymous comment on a post I wrote about how to rank surgical residency programs.

I am the spouse of a surgical resident halfway through their residency. When I hear of the idea of "vetting" the residency program as med school graduate, it makes me laugh and cringe. It's not really possible.

We were extremely concerned about not getting stuck in a malignant or toxic program. But these people must have been aware of how bad the program was, we thought the place had the happiest, friendliest people. What a facade.

More about offshore med schools and residency prospects

Back in April, I blogged about the prospects for graduates of Caribbean medical schools matching in categorical surgical positions and estimated that graduates of two of the more prominent Caribbean schools, St. George's and Ross, had a 2.5 to 3% chance.

What about some of the other Caribbean schools? Hard data are difficult to obtain since most of the schools do not publish match statistics, and in particular, the number of graduates who don't match in any specialty.

Here is what one recent commenter on that April post had to say:

My girlfriend studied at University of Medicine and Health Sciences (UMHS)-St.Kitts in the Caribbean. She is a very hard worker and studied well. All of my savings are gone and extra bank loans add up. No match, no residency, and no more hope. Applied for medical lab tech and waiting. In my opinion, IMG is not an option, try local medical schools and if not try something else.

The UMHS website says 59 of its graduates matched in a specialty in 2014, 2 in preliminary surgery and 2 in general surgery, presumably categorical. The number of graduates of UMHS is not listed although the school apparently has three graduations per year reflecting its three different starting dates for students per year.

Another school, Medical University of the Americas on the island of Nevis, had about 90 matched graduates for 2014, 2 of whom obtained positions in surgery—both preliminary.

An additional commenter on my April post, who turned out to be the owner of a different Caribbean school, said this:

Caribbean medical school is best platform and nice and informative….. Successful communication is key in every successful business…. Understanding your subject and having good knowledge on your blog topic is always essential for a successful blog… Thanks for this post…..

Normally I would have blocked this comment as spam, but before I did so, I googled his school, the American Global University School of Medicine, located in the Central American country of Belize. The International Medical Education Directory lists its total enrollment as 100 students. The school's website does not provide any details about match results for its graduates or much of anything else, such as names of faculty or specific hospitals where students do clinical rotations in the US.

I found some other interesting links—too many to list here—about the school, its officials, and its standing in Belize. You would be wise to google it too, or you can see some links in my comment to the school's owner on my April post.

If you have any interest in attending this or any other school not accredited by the Liaison Committee on Medical Education (LCME), you should do a thorough Internet search before going ahead with an application. Do not send money unless you are certain that the school is legitimate and that most of its graduates are obtaining residency positions.

Keep in mind that the number of residency slots available for international graduates will decline even further over the next few years because several new US medical schools will be producing graduates, and many established schools have expanded their classes.

What can be done about letters of recommendation?

Many surgical educators feel that letters of recommendation are not particularly helpful in evaluating applicants or predicting eventual resident performance.

Among the issues are lack of uniformity of content, excessive use of superlatives, reliability—if the writer is not known to the recipient—and more.

Even if the writers are well-known academic surgeons, the degree of their personal knowledge of the applicants is not always clear.

During an extensive Twitter discussion over the weekend, someone mentioned that in an attempt to deal with this problem, emergency medicine had developed a standardized letter of recommendation.

A recent paper from the EM Standardized Letter of Recommendation Task Force shows that there is still work to be done. From the abstract:

For the question on "global assessment," students were scored in the top 10% in 234 of 583 of applications (40.1%), and 485 of 583 (83.2%) of the applicants were ranked above the level of their peers. Similarly, >95% of all applicants were ranked in the top third compared to peers, for all but one section under "qualifications for emergency medicine."

I've written before that dean's letters are more like public relations press releases than accurate assessments of a student's performance. You will rarely find negative comments in them. But another recent paper by a group of psychiatrists found that The presence of any negative comments in the dean's letter yielded significant correlations with future problems. Further, those applicants with future major problems had significantly more negative comments in the dean's letter than did those with future minor problems. Other factors such as USMLE scores, failed courses, letters of recommendation, and interviewer ratings and comments did not predict future problems.

These problems are not new. A 1983 New England Journal opinion piece about recommendation letters entitled "Fantasy Land" is remarkable for its validity even today. Here are a few choice quotes.

It's a land where everyone is "a pleasure to work with," has "excellent initiative," is "enthusiastic and conscientious," and possesses and "above-average fund of knowledge."

No one is ever poor, fair, or average; they are all "very good" or "excellent."

The author, Dr. Richard B. Friedman, said letters of recommendation were useless and advocated doing away with them.

A brief JAMA essay by Dr. Henry Schneiderman in 1988 called for more openness in describing students but acknowledged that negative comments were often "the kiss of death."

He proposed a new system of categorizing medical student performance. Here are just a few examples.



@AmirGharferi suggested this:

"Dr.G, do you feel comfortable writing me a strong letter?"
"No."
"Ok, I'll find someone who is."

That works if the student is aware enough to ask, and the faculty member is honest enough to say no. In my experience, even the most marginal of students can find someone—in addition to the dean, of course—to write a good letter.

I am no longer involved in the process of selecting residents. I have no suggestions.

What is your solution to this problem?

True grit

In case you haven't noticed, a hot new topic in education is "grit." In order to reduce the long-standing 20% attrition rate of surgical residents, some say we should select applicants who have more grit or conscientiousness.

A recent paper in Surgery reported residents who dropped out of programs had decreased levels of grit as measured by a short-form survey. But due to unexpectedly low attrition rates in the surgical programs participating in the research, the study was underpowered to show a statistically significant difference in outcomes of high- vs. low-grit individuals.

It's hard to argue with the premise that choosing applicants with high reserves of grit might lead to better retention and performance of residents.

I blogged about this three years ago in a post called "Harvard says train residents and medical students like Navy SEALs."

Unfortunately, identifying who has grit will be much more difficult than simply testing those applying for surgical residency training.

Below is the eight-item grit survey, which is scored on a 1 to 5 Likert scale.