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Rising Costs Without Rising Match Rates: Orthopedic Surgery Application Spending Before and After the USMLE Step 1
Sahil Garg1, Kyle Jamar2, Carson Keeter2
1The Steadman Philippon Research Institute, Vail, Colorado; The Steadman Clinic, Vail, Colorado.
Objective:
Orthopedic Surgery remains one of the most competitive specialties to match into, yet limited research has examined the financial element of the match process. This study aimed to analyze trends between applicant spending and match rates from 2017 to 2025, including before and after the USMLE Step 1 Pass/Fail transition.
Design:
Retrospective analysis of self-reported financial data from the Texas STAR database across nine application cycles (2017-2025). Financial variables included total application-related costs, encompassing ERAS fees, travel, housing, food, and second-look expenses. Independent t-tests compared average total costs between matched and unmatched applicants and between Step 1 scored and Pass/Fail cohorts, with significance set at p < 0.05. To account for inflation, figures were converted to 2024 dollars using federally reported inflation estimates, given the lack of finalized 2025 data.
Setting:
The Texas STAR database, a national, multi-institutional survey collecting self-reported application and financial data from residency applicants.
Participants:
1939 prospective Orthopedic Surgery residency applicants. Applicants who did not align with their expected Step 1 scoring system were excluded from primary analyses; a secondary analysis was performed to capture this data.
Results:
Cost figures are presented in 2024 pricing using aggregate inflationary adjustment. Of 1939 applicants, 1644 (84.8%) matched and 292 (15.1%) did not. Average total spending was $6983.55 (SD = $4692.42) for unmatched applicants and $7063.00 (SD = $4533.27) for matched applicants, with no statistically significant difference between groups (p = 0.80). When comparing applicants from the Step 1 scored era (2017-2022, n = 1168) to those from the Pass/Fail era (2023-2025, n = 484), average spending increased significantly from $6684 (SD = $4893.92) to $7625 (SD = $4225.33) (p < 0.001). Match status was not significantly associated with application cost in either the Step 1 scored or Pass/Fail cohorts (p = 0.20). An additional 284 applicants from 2023 to 2025 with a Step 1 score were analyzed separately, with mean spending of $7340.93 (SD = $3695.42), not statistically different from applicants who applied after Step 1 became Pass/Fail.
Conclusions:
There is not a statistically significant relationship between successful Orthopedic Surgery match status and capital spent on applications, travel, food, and housing; spending more money does not appear to directly influence an applicant's likelihood of matching. Since the implementation of a Pass/Fail Step 1 exam, average applicant spending has increased by approximately $941.00 in 2024 dollars after adjusting for inflation (p < 0.001). Based on these findings, the transition to a Pass/Fail for Step 1 appears to have increased the application costs for Orthopedic Surgery applicants, without improving match success. Applicants, on average, may anticipate spending around $8000 between application submission fees and costs associated with acting internships and interviews.