The moment I learned that the US Supreme Court ruled against affirmative action, the first thing that came to my mind was “the match.” Just moments before, I came across a tweet showing that those matching into surgical subspecialties averaged at least 10 research publications, presentations, and abstracts in 2022.¹ At first, this information felt mundane. Of course, residency is competitive. Especially urology programs.

Isn’t that what everyone, from fellow students to counselors, says? With time, however, I found I couldn’t stop pondering the US Supreme Court’s decision and how much research these applicants produced. I couldn’t help but connect the specter of educational inequity to the research frenzy that has become the norm in my own life and that of so many other medical students.

The National Residency Matching Program, whose data were shared in that tweet, showed that those matching into surgical subspecialties averaged no fewer than 10, and as high as 28, of these combined research metrics. A colossal number when you consider that unmatched applicants in 2022 produced more research than matched applicants in 2009.

What is mysterious is that data have shown that “research activities” is not one of the top factors that residency program directors list when considering applicants.² Instead, program directors named Step 2 scores, letters of recommendation, clerkship grades, and “perceived commitment” as being the most important factors come match season. However, even a quick Google search for “things that influence residency matching” will fill your screen with consulting agencies and journal articles extolling the importance of publications. This is supported by research corroborating the National Residency Matching Program’s trend of increasing publications in several specialties: mean number of research experiences was the factor most strongly associated with matching into surgical subspecialties.^3–5 This trend makes sense in the context of recent changes to both medical education and standardized testing.

Over the past decade, residency selection committees have been faced with a progressively more difficult task: selecting the best potential residents amongst an ever-growing pool of applicants while having fewer metrics by which to compare those applicants. Changes such as pass/fail grading, removal of AOA (Alpha Omega Alpha), and removal of Step 1 scores have all been seismic shifts in how medical students can represent their achievements during medical school. As a student, I can say that these changes are wonderful. They have significantly improved my quality of life and allowed me to focus on learning instead of studying minutiae for momentary achievement. In addition to reducing stress, these changes were meant to mitigate the systemic bias and inequity that often influenced residency placement. However, this movement towards equity did not affect the underlying reality of the match: supply of spots is far outweighed by demand. When these metrics were removed, it only shifted scrutiny onto the metrics left still in existence, notably, research output.

This is not to say that scholarly research is an inherently bad measure to use when evaluating medical students. While working with my research team, I have honed my ability to communicate with medical professionals at various levels of training, meet adversity with resilience, multitask, apply relevant data to clinical problems, and most of all, be patient; all skills that are applicable to demanding, team-based clinical work. Another important facet to research participation is its ability to facilitate connection with, and exposure to, specialties that may not exist at a student’s home institution. Furthermore, it can serve as a makeshift pipeline for international medical graduates to get a foothold in the American medical system, a huge boon for the diversity of the workforce. Finally, understanding the enterprise of scientific inquiry, and its shortcomings, is a fundamental part of practicing evidence-based medicine. All health professions trainees should understand how important discoveries are made and when to apply those findings to their patients.

Yet, as someone who loves both urology and believes in the benefits of academic research, I feel that the imperative to publish during medical school is not good for the field of urology. First, putting an emphasis on research output incentivizes high-quantity, low-quality contributions to the body of knowledge. This not only fills the research sphere with spurious and poorly designed research but also teaches future generations the wrong lessons about the research process. By extension, it does an injustice to those whose passion is forms of research that take longer to implement, such as basic science work or those in PhD programs. Second, it artificially narrows the definition of scholarly work. Academic contributions extend beyond publications on a resume and include quality improvement projects, patient counseling, medical education contributions, or implementation science projects. Most important of all, it makes surgical fields seem less interesting. As much as I may enjoy spending my time on PubMed, the same isn’t true of everyone, and that shouldn’t discourage them from considering fields like urology. Other passions, such as medical humanities or public health, can and should be desired within a field as uniquely demanding as urology. None of this is to mention the social determinants that influence a student’s ability to participate in research.

Research output is not exclusively a matter of potential, but often one of unequal opportunity. For those students who attend a top school, have access to prestigious research faculty, are allocated dedicated research time, have family members in medicine, or who can find mentors they can identify with, producing research is simply easier. These systemic, institutional, and personal privileges are least available to the most marginalized medical students, engendering the same inequity in the residency match that drove the decision to institute affirmative action in undergraduate admissions.

What ultimately saddens me about the focus on metrics like research in residency is that I find urology to be beautifully diverse. It demands the development of expert technical skills, cunning diagnostic reasoning, and interpersonal acumen. Urologists deal with health needs that sit at the cutting edge of need and taboo, healing serious urinary illness one day and affirming gender and sexuality the next. Yet, as our collective knowledge regarding matters of diversity and unequal opportunity flourishes, these data regarding research importance in urology threaten our ability to meet the needs of our patients.

So, what can we do?

In the absence of US Supreme Court intervention, many wonderful ideas have been proposed to make the match more equitable. There are data backing the use of standardized letters of recommendation, making all residency interviews virtual, and continuing the recent preference signaling changes that have been instituted in the urology match.^6,7 What has caught my attention, however, is a trend towards something called holistic review of applications. Holistic review, or review taking into account all aspects of an application in a standardized fashion, has been shown to lead to more talented and diverse student cohorts.⁸ By emphasizing teamwork, communication, and response to adversity in prospective urologists, pilot studies show that programs can identify applicants who possess skills that allow for broader contributions to clinical care, thrive under the demands of residency, and contribute to academic pursuits such as education and research.⁹ This naturally poses valid questions regarding how to best measure these traits. With regards to research, it would be worth attempting to replace the emphasis on research numbers with measures of impact or quality improvement. For less easily quantifiable qualities such as teamwork, technical proficiency, or empathy, we have historically relied upon clinical evaluations and letters of recommendation for reference. While these measures do capture some of these qualities, they are often filled with coded language and influenced by personal and systemic biases.

The inequity of using research production as a proxy for success extends well beyond medical school, however, and lasting change will need to be similarly extensive. Significant reform is needed of larger systems within nearly all academic fields where hiring, promotion, pay, and other benefits are routinely tied to the length of one’s CV. It took me years working in research to see this reality, and one interim solution is that residency programs should be honest with medical students about the expectations and incentive structures that exist within academic research. Additionally, medical professionals at all levels need to be vocal advocates for these reforms and for the validity of their nonresearch-related activities. Without advocacy, we cannot change the grant and money award systems that gave rise to the importance of these metrics in the first place.

Regardless of the approach taken, we cannot continue the research arms race that is feeding the homogeneity of surgical fields like urology. While research accolades may make for a better résumé, they do not necessarily make for a better urologist. If anything, we should hope to incentivize the kind of diversity in interest and background that mirrors the diversity of need represented by our patients.