Specialty Competition and Residency Strategizing

PART 1

Reddit continues to provide interesting discourse that makes for decent research and blog posts.

Most recently, THIS was posted, which shows skyrocketing step 2 scores (250 is now barely average). People have tried to stratify competitive residencies here and there, but I couldn't find anything organized, logical, or properly quantified.

So I set about making one. You may recall that an object's instantaneous speed is a far less useful metric than its acceleration when predicting its future trajectory. Knowing a specialty is difficult right now is a snapshot. It is what every knows well. Simply pull up the NRMP data, and you can view the statistics. The more important question is, what has its competitiveness been doing for the last ten years? Is it accelerating at a rapid rate? Because then we can see a trend.

Specialty Competitiveness Index (SCI), a metric that measures not static difficulty, but competitive momentum. The SCI is a weighted metric that calculates the velocity of Step 2 score inflation (how fast is it rising?) by taking the slope of the rise; the alarming acceleration of the research arms race; and the rising tide of applicant interest relative to the stagnant number of available positions. A high SCI score indicates a field where the barriers to entry are rising at a hysterical pace.

You can find full table HERE

If you look, you'll find some nuggets of reality that we've all come to appreciate as med students reading forums: Ortho bros are trailblazing, but fields like Rad Onc and Ophthalmology, once hyper-competitive darlings, have fallen by the wayside (tightening market, overtraining, reimbursement cuts). A thorough discussion will take a whole post of its own, so I will not bother. Feel free to discuss in comments though.

So many paths/specialties/choices in the wonderland of residencies

PART 2:

While quantifying competitiveness (and momentum) based on this is fine and dandy, what should we do as medical students who are in the rat race? Well, let's begin with why this all even started. The entire residency selection process has devolved into what is a "wasteful arms race" (nice doomer video from SherrifofSodium HERE). Since the benevolent overlords of medical education decided that a three-digit score (Step 1) was too stressful/unfair, it was made Pass/Fail. Many rejoiced in the streets. For about 5 minutes. Because it was immediately replaced with a system that is somehow even more stressful. The new landscape is a chaotic hellscape of escalating Step 2 scores and a demand for research so intense that I suspect some programs are merely printing out ERAS applications and using them to support their drooping monitors. The pressure that medical students felt while preparing for Step 1 has migrated, like a metastatic tumor, to Step 2 CK and "research". Do you really want to be publishing garbage like, "Apply XGBoost to find dehydrated elderly patients in nursing homes and IV treatment via Tesla Bot: A review?"

So, we’re all screwed, right? Well, maybe not. Amidst this chaos, we have to be strategic. Forget just chasing the specialty with the highest prestige or the one your parents brag about at dinner parties.

It’s time to think like an investor.

Here it is, Effort-to-Reward (ETR) Framework. I would have called it the Grand Unified Theory of Not Hating Your Job, but the acronym was less catchy.

The methodology is simple:

• Effort (Applicant Investment Score - AIS): A weighted metric that measures the quantity of your soul you must incinerate to match into a given specialty. It includes board scores, research demands, the necessity of being anointed into secret societies like AOA, and the raw probability of matching (available on NRMP and other data sources).

• Reward (Professional Outcome Score - POS): A composite score measuring the spoils of your sacrifice. It is weighted 70% toward financial compensation and 30% toward "work-life balance," which I believe is a myth, but it’s one that we all seem to value.

By dividing the Reward by the Effort (POS÷AIS), we get a simple ratio. This ratio tells you the value proposition of a specialty choice.

While you can write a whole other post on the interesting data points visible in the "Match Matrix" here, what really becomes obvious are the high "ROI" specialties. The specialties that offer the most efficient conversion of Effort into Reward are not the glamorous ones: Psychiatry (benefitting from Telepsych and other models), Family Medicine (DTC models, concierge) are a few that stand out.

All of this is a lot to take in, but you can be sure that I will be adding this post to my CV...gotta count this as a pub, no?

A few details: AIS has factors like match rate to capture “risk” of not matching. For example, no matter HOW good you are, at the right tail of competition you run the risk of not matching. Additionally, there is “Applicant Demand Index” which is Applicant-to-Position Ratio for Each Year: For every match year in the ten-year analysis (2014, 2016, 2018, 2020, 2022, and 2024), a simple ratio is calculated.

• The numerator is the number of U.S. MD seniors who ranked that specific specialty as their first choice on their rank order list.

• The denominator is the total number of PGY-1 positions offered in that specialty for that year's match.

It measures whether applicant interest is growing faster than the number of available slots, which is a direct measure of rising competitive pressure, regardless of whether the specialty is large or small. So low IQ reddit folks don’t come here telling me BrO Ct SuRgeRy iS tHE hArDesT.