Improving the Transition From Medical School to Residency in Obstetrics and Gynecology: Lessons Learned and Future Directions
Background
The transition from medical school to residency represents a significant milestone in a medical trainee’s career. However, inefficiencies in the residency application process have intensified competition and made the transition more challenging.1-3 These systemic issues have contributed to troubling outcomes, particularly affecting diversity, equity, and inclusion (DEI) efforts.4 This is particularly concerning given higher attrition rates documented for non-majority learners across specialties, including emergency medicine, general surgery, orthopedic surgery, and obstetrics and gynecology (OB/GYN).5-8 In the field of OB/GYN, declining numbers of Black residents and reports of inequitable preparation for residency based on racial and ethnic background underscore the need for improved, equitable transition pathways.9,10
Recognizing challenges in the transition from undergraduate medical education (UME) to graduate medical education (GME), the Coalition for Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee (UGRC) released 34 recommendations in 2021 aimed at creating a more transparent, fair, and supportive transition.11 Responding to all the above challenges, the Association of Professors of Gynecology and Obstetrics and the American College of Obstetricians and Gynecologists’ Council on Resident Education in Obstetrics and Gynecology partnered on a project termed “Transforming the UME to GME Transition: Right Resident, Right Program, Ready Day One” (RRR). This RRR initiative received funding from the American Medical Association (AMA) Reimagining Residency initiative to develop the comprehensive OB/GYN residency transition project. The RRR initiative set out to improve applicant experience, facilitate holistic application review, and ensure preparedness on day one of residency.12
Project Goals and Description
In 2019, a multidisciplinary team of OB/GYN educators—including program directors, department chairs, student advisors, deans, staff, and learner representatives—began an in-depth review of the UME-to-GME transition process. A robust management structure including a Joint Project Oversight Committee (n=9), Project Leadership Team (n=7), Workgroup Leaders Team (n=6), and Learner Advisory Panel (n=8) was established. Each workgroup of 10 to 15 volunteers and the Learner Advisory Panel provided input through multiple forums including annual surveys, focus groups, town hall meetings, and individual feedback throughout the project. Six domains for improvement were identified, each designed to address specific inefficiencies and foster a smoother applicant-centered transition. Below is a summary of each domain, its associated intervention, and key results.
1. Standardizing OB/GYN Application and Interview Processes
To alleviate applicant anxiety and improve process transparency, the project introduced universal application deadlines, interview offer dates, and 48 hours for applicants to respond to interview offers. Additionally, OB/GYN residency programs committed to limiting interview invitations to available slots, and they provided applicants with final status notifications so they would know if they were rejected or waitlisted. These standards were widely adopted by programs. On a survey completed by 56% (158 of 281) of program directors, 93% (147 of 158) reported that they had complied with at least one of the standards. In addition, of the applicants (904 of 2508, 36%), clerkship directors (105 of 225, 47%), and student affairs deans (34 of 155, 22%) who completed the survey, more than 90% reported that the standards reduced applicant anxiety.13,14 During the first years of the COVID-19 pandemic, a recommendation for virtual interviews was added to the standards and continues to date.
2. Application Review Metrics
A 4-domain model for holistic application review was developed by a group of 33 educators and learners working in UME and GME in a wide range of settings across the United States, with a focus on metrics, personal attributes, experiences, and alignment with program values15—including introduction of a Standardized Letter of Evaluation (SLOE) adapted from emergency medicine.16 The OB/GYN SLOE was widely adopted, with 94% (2285 of 2431) of applicants in the 2025 residency cycle including this letter, indicating strong acceptance within the field (personal communication with ResidencyCAS, Centralized Application Service).
3. Alignment Check Index
The Alignment Check Index (ACI; previously known as the Applicant Compatibility Index) was created to facilitate better alignment between applicants and programs. This tool enabled programs to weigh different applicant attributes (eg, research, service, lived experience) according to their mission and values.15 Applicants could then assess program alignment based on these metrics, enhancing fit and intentional application. The ACI saw high adoption, with 70% (204 of 292) of all OB/GYN programs nationally participating by providing their weights for inclusion in AMA’s FREIDA database for applicants to utilize while searching for programs during the 2025 application cycle.17
4. Program Signaling
Building on a concept championed by otolaryngology and piloted in a few specialties, program signaling allowed applicants to express genuine interest in specific programs,18,19 thereby reducing unnecessary applications. In 2022, OB/GYN implemented a 2-tiered signaling system, which successfully reduced applications per applicant from 75.6 in 2023 to 67.3 in 2024,20 and increased interview opportunities for applicants who signaled interest.21
5. Ready for Intern-Year Curriculum and Assessments
To ensure new residents were adequately prepared, a Ready for Intern-Year Curriculum and Assessments (RICA) curriculum was developed based on a needs assessment of residents and program directors.22 RICA was offered as a self-assessment tool and a structured curriculum covering essential skills including time management, resilience, and professional identity.23,24
6. Residency Learning Communities and Coaching
To facilitate the formation of residency learning communities (RLCs), the project team created a program for faculty development and a framework for coaching to allow faculty at different institutions to tailor a coaching curriculum to their contexts and programs. Group coaching begins when applicants match and continues through at least the first 6 months of residency.24 RICA and RLC were eventually combined into the OB/GYN New Resident After Match Program (ONRAMP) initiative. Through group coaching sessions, workshops, and self-directed learning resources, ONRAMP is intended to help incoming residents adjust to the demands of residency.25,26
Lessons Learned
The project team approached all work via a framework centered on evidence-based change management strategies, while prioritizing learners and equity at every stage.27 These strategies proved crucial to effective implementation of project initiatives and could prove helpful to other specialties considering similar improvements and reforms. In addition, to effectively implement and analyze the overall goal of matching the right resident to the right program, it became clear that a new application platform was necessary, including the addition of a holistic review tool.28 Other lessons learned from the use of these strategies are available in the online supplementary data Figure.
Applying these change management principles—engaging key constituencies, creating a clear vision, establishing governance, iterating based on feedback, fostering transparency, providing resources, and communicating successes—may be useful to other specialties when implementing similar initiatives. This structured approach to change management enhanced our UME to GME transition project and may also contribute to further uptake and new enhancements.
Future Directions
The outcomes of the OB/GYN residency transition project demonstrate that interventions targeted to difficult residency challenges can be collaboratively developed and adopted widely over a short period, within a specialty. Additional opportunities for cross-specialty collaborations should be considered. Other potential areas to explore include expansion of artificial intelligence use and data analytics, longitudinal long-term evaluations of changes to residency processes, and fostering DEI beyond the application process. Funding that was essential to support time for key leaders and for in-person convening of workgroups greatly facilitated our RRR project to improve the OB/GYN application and early residency experiences, and will be a challenge for future work (Box).
As other specialties consider similar reforms, lessons can be drawn from OB/GYN’s efforts to create its own targeted strategies for a more equitable, transparent, and supportive transition to residency. Continuous evaluation, engagement of key constituencies, and innovation will be essential to maintaining and building upon these successes and ultimately fostering a more inclusive medical education system.
Author Notes
