Reimagining residency selection: a lottery among the qualified

The residency selection process remains a significant barrier to the actualization of competency-based education across the continuum of medical education in North America. Current residency selection practices emphasize a narrow set of comparative achievements-standardized test performance, publication counts, and honor society memberships-within a norm-referenced system, which can divert attention from developing criterion-referenced competencies that indicate readiness to provide safe, high-quality care on day 1 of residency. In this manuscript, the authors argue that the residency selection process must change in order to facilitate a growth-oriented, competency-based undergraduate medical experience that ensures preparedness for residency training across all applicants to graduate medical education programs. The authors explore current issues in residency selection, particularly the use of current measures that are nonpredictive of future success, biased, and incentivize an achievement-oriented mindset. These measures focus students away from competency toward attaining a checklist of achievements such as honors society membership, research publications, and other merit badges that are far less relevant to patient care and residency preparedness, which is antithetical to a competency-based approach. The authors propose supplanting the current application review process with a modified lottery among students deemed on track to be qualified by their medical schools to begin residency based on competency-based criterion rather than normative measures. This lottery would be for interview positions and focus on aligning students geographically and from a shared interest perspective with programs where they would ideally thrive. These students would subsequently interview with residency programs as they normally would and enter the Match. The authors detail how a modified lottery would function, including allowance for student choices, enhanced equality, and attention to special circumstances such as couples matching and international medical graduates as well as presenting pitfalls to this approach.