The prevalence and cost of medical student visiting rotations

Winterton et al. BMC Medical Education (2016) 16:291 DOI 10.1186/s12909-016-0805-z RESEARCH ARTICLE Open Access The prevalence and cost of medical student visiting rotations Matthew Winterton, Jaimo Ahn and Joseph Bernstein* Abstract Background: Performance on visiting rotations during the senior year of medical school is consistently cited by residency program directors as a critical factor in selecting residents. Nevertheless, the frequency with which visiting rotations are undertaken and the associated financial costs they impose have not been systematically examined. Method: Under the auspices of the Electronic Residency Application Service, a survey was sent in March 2015 to all U. S. applicants for residency programs in the 2014-15 academic year. Students were asked how many visiting rotations they performed; the estimated cost of performing each rotation; their perception of their educational value and primary motivation for performing them; and the Match outcome of their residency application. Results: The survey was completed by 2817 applicants, yielding a response rate of 11.3 %. 1898 applicants (67.4 %) performed visiting rotations: 647 applicants (30.0 %) performed one; 640 (22.7 %) performed two; 322 (11.4 %) performed three; and 289 (10.3 %) reported four or more. When accounting for potential response bias, the true prevalence of away rotators was estimated to be 58.7 % of all fourth-year medical students (95 % CI 54.0–63.4 %). The mean number of rotations for participating students was 2.1. Most students performed rotations equally as an audition for residency placement and for education, with some of the more competitive subspecialties reporting more of an audition experience. The mean estimated cost for performing a single rotation was $958. Thirty-six percent of applicants reported matching at an institution where they had rotated, either their home institution or one at which a visiting rotation was performed. Conclusions: Visiting rotations are prevalent, expensive, and only partly educational. As such, these rotations may impede optimal use of the senior year of medical school and limited student financial resources. Keywords: Visiting student rotation, Away rotation, Residency, Residency application, Medical school, Medical education Background According to Ludmerer, the basic structure of medical school curricula was established in the 19th century: “The first 2 years contained the pre-clinical disciplines….[and the] last 2 years provided instruction in the various clinical subjects” [1]. Within that broad partition, the initial 2 years were subdivided into the study of normal biology in the first year and diseases in the second; and within the latter half, the third year was devoted to “major” clerkships and the fourth year left open for electives. Although the fourth year has been “relatively ignored in curricular reforms” [2], it has been implicitly modified by changes made to the other years’ content and structure. For one thing, at many schools, traditional third year clinical clerkships now start before the third academic year. (At our institution, clerkships begin in January of the second year.) And because the clerkships likewise end earlier, the fourth year is for many students an expanded 18 month-long segment, replete with opportunities for electives. One such opportunity opened to students is the freedom to visit other medical schools, outside of the * Correspondence: Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, 424 Stemmler Hall, Philadelphia, USA © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Winterton et al. BMC Medical Education (2016) 16:291 students’ home institution, often in conjunction with application to residency programs [3]. We have observed informally that visiting rotations have become increasingly popular. At our home institution, for example, over the years 2012 to 2015, there was a near doubling of the number of visiting rotations [Helene Weinberg, Registrar; personal communication]. Along those lines, in the 2014–2015 application cycle alone, 129,874 applications for visiting rotations were submitted by 13,273 applicants through the Visiting Student Application Service [Association of American Medical Colleges Visiting Student Application Service Database, as of 5/28/2015. Last updated 5/28/2015]. There is, of course, a good reason for the popularity of visiting rotations among students: namely, the popularity of visiting rotations among program directors who select residents. Surveys of program directors [4–9] demonstrate that performance on a visiting rotation is one of the most important factors in selecting candidates for interview [10], especially in some competitive specialties [8, 11]. Despite the apparent increasing importance of visiting rotations in residency placement, we have found no reports of the overall prevalence of these visiting rotations; and while there have been reports on their purported benefits [12], we have not found reports on the costs associated with performing these visiting electives. We address these questions here. Methods Under the auspices of the Electronic Residency Application Service (ERAS®, the Association of American Medical Colleges service for residency applications) an anonymous web-based survey was sent in March 2015 to all U.S. applicants for allopathic residency programs in the 2014-15 academic year. This survey asked students how many visiting rotations they performed; the estimated dollar cost of performing each visiting rotation; their perception of the educational value of these rotations; and the match outcome of their residency application. Pearson’s chi-square test was used to examine the goodness-of-fit of the distribution of respondents disclosing their primary specialty in which they applied and the actual distribution of applicants within each specialty nationally, as gathered by the National Resident Matching Program® [13]. Significance level was set at P = 0.05. Statistical analysis was performed using Microsoft Excel (Microsoft Corporation, Redmond, WA). To evaluate potential non-response bias, we distributed a second survey 2 weeks later to those students who did not originally respond asking how many visiting rotations they performed. Using a variable response propensity model [14] to correct for survey non-response, Page 2 of 7 we estimated the propor (...truncated)