The findings, led by Neil S. Zhang and Atif Qasim of the University of California, San Francisco, along with collaborators at Creighton University and the Kirk Kerkorian School of Medicine at UNLV, are striking in their clarity. Overall, 32,091 of the 38,179 applicants, or 84.1 percent, successfully entered the subspecialty to which they applied. But that aggregate success rate conceals dramatic differences among applicant groups. Research productivity emerged as the single most powerful predictor: applicants with 11 or more publications had 4.18 times higher odds of success compared with those who had none, a stronger association than any other characteristic examined.

The study leveraged a unique combination of databases. Applicant characteristics came from the Electronic Residency Application Service, or ERAS, administered by the Association of American Medical Colleges, and were linked to the AAMC’s Graduate Medical Education Track, a national registry of trainees at every residency and fellowship program. An applicant was defined as successful if he or she appeared in GME Track as a fellow in the same subspecialty during the corresponding appointment year. The researchers excluded applicants who applied to more than one subspecialty, applied in multiple years, or had masked ages, yielding a cohort of single-time applicants to cardiovascular disease, endocrinology, gastroenterology, hematology and oncology, infectious disease, pulmonary and critical care medicine, nephrology, and rheumatology.

Statistically, the team used multivariable logistic regression to isolate the effect of each characteristic while adjusting for all others, along with the subspecialty and application year. Predictive margins were estimated to calculate adjusted probabilities of success for different applicant groups across publication categories. The cohort had a median age of 31 years, and 41.2 percent were female, 9.5 percent identified as underrepresented in medicine, and 39.6 percent were international medical graduates. Chief resident status, additional graduate degrees such as a PhD or master’s degree, and training in larger residency programs with 55 or more residents all independently boosted the odds of success.

Against these advantages, several groups faced measurable headwinds. Each additional year of age was associated with lower odds of success. After adjustment, female applicants had 0.89 times the odds of success, underrepresented-in-medicine applicants 0.84 times, osteopathic DO graduates 0.53 times, and international medical graduates just 0.44 times the odds of their counterparts. Graduates of community-based residency programs and community-based, university-affiliated programs were likewise significantly less likely to succeed than those from university-based programs, a pattern the authors attribute in part to the weight program directors place on the perceived reputation of the training institution.

The subspecialty-level breakdown sharpened the picture. The disadvantage for female applicants was most pronounced in cardiovascular disease and gastroenterology, where women had 0.79 times the odds of success, while the penalty for underrepresented-in-medicine applicants was especially evident in pulmonary and critical care medicine, at 0.59 times the odds. The payoff for research output also varied: the association between 11 or more publications and success was particularly strong in gastroenterology, pulmonary and critical care medicine, and endocrinology, though notably absent in infectious disease. Analyses restricted to the four most competitive subspecialties suggested that many of these disadvantages grew even larger in the toughest markets.

One of the most consequential findings concerns whether publications can compensate for baseline disadvantage. Predictive margins showed that success rose with publication count for every applicant group. For underrepresented-in-medicine applicants, the gap with non-underrepresented peers appeared to narrow at higher publication counts, although interaction testing did not reach statistical significance, likely because few such applicants reached the highest publication category. More sobering was the finding that the disadvantages experienced by female and DO applicants persisted at every level of research productivity, showing no attenuation whatsoever. International medical graduates gained more from each additional publication than their MD counterparts, yet even this larger benefit failed to erase their baseline gap entirely.

The authors frame these results as evidence of a self-reinforcing research arms race. Program director surveys consistently rank research involvement and perceived interest in scholarship among the most important selection factors, prompting applicants to accumulate ever more publications, which in turn pushes programs to value the metric even more. Prior work suggests many of these entries are never cited, raising concerns about the quality of the science behind the numbers. The ERAS publications variable aggregates journal articles, abstracts, book chapters, and presentations into a single count, so a first-author paper in a major journal currently carries the same statistical weight as a poster at a regional meeting, a limitation the researchers say should be addressed in future studies.

As a remedy, the study advocates for Mission-aligned Selection, a framework promoted by the AAMC that emphasizes individualized, systematic review of applicants’ experiences, attributes, and academic metrics in light of each program’s mission. Early adopters offer encouraging signals: after one pulmonary and critical care fellowship implemented holistic review practices, its faculty ranked publications among the least important metrics, and a pediatric surgery fellowship reported that the caliber of its interviewees actually improved. The authors also point to preference signaling, now available in several internal medicine subspecialties, as a tool that may reduce defensive over-application, though its effects on equity remain unproven. They caution that qualitative materials central to holistic review, such as letters of recommendation, have been shown to contain biased language toward female and underrepresented applicants, so standardization efforts must accompany any shift away from raw publication counts.

The study’s limitations are worth noting. Because direct match data were not available, success was defined as entering the subspecialty rather than formally matching, though out-of-match placements likely represent a small minority. Factors such as board scores, honors, interview ratings, and personal statements were unavailable, leaving room for residual confounding. Still, as the first comprehensive, individual-level national analysis of its kind, the work makes the structure of the fellowship selection process unusually visible. Its message is twofold: research output overwhelmingly determines who gets in, and the system as currently constituted systematically favors younger, male, non-underrepresented, US MD graduates at large university programs. Whether programs and their governing bodies embrace mission-aligned processes may determine not only individual careers but also the future diversity and representativeness of the internal medicine subspecialty workforce.

Subject of Research: Factors associated with successful entry into internal medicine subspecialty fellowships

Article Title: Characteristics and Success of Internal Medicine Applicants to Subspecialty Fellowships

Article References: Zhang, N. S., Tun, K. M., Batra, K., Babik, J. M., Huppert, L., Singh, A., Wahi-Gururaj, S., & Qasim, A. (2026). Characteristics and Success of Internal Medicine Applicants to Subspecialty Fellowships. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10688-w

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10688-w

Keywords: internal medicine, fellowship match, graduate medical education, publications, underrepresented in medicine, international medical graduates, osteopathic medicine, mission-aligned selection, ERAS, cardiology, pulmonary critical care, workforce diversity

Dermatology has long been among the most competitive specialties in the National Resident Matching Program. With a limited number of positions, high board scores historically expected, and a lifestyle that attracts large applicant pools, the field has developed one of the most demanding unofficial credential portfolios in graduate medical education. Previous analyses, including work published in JAMA Dermatology, documented a steady rise in the research output of medical students matching into dermatology between 2007 and 2018, a trend some commentators have described as research fever. The new study asks whether that fever intensified once Step 1 scores could no longer differentiate applicants numerically.

The rationale for the investigation rests on a simple structural fact. Before the transition, a high Step 1 score served as a widely used screening filter, allowing program directors to rank candidates quickly and giving applicants a clear, if stressful, way to demonstrate academic strength. When scoring became binary, that signal disappeared. Students who might once have relied on a strong score to compensate for thinner research records suddenly faced a signaling vacuum, and many appear to have responded by accelerating their publication efforts. The SUNY Downstate team set out to quantify whether the applicants entering elite dermatology programs indeed became more research-productive in the immediate aftermath of the change.

Methodologically, the researchers constructed an applicant-level dataset by tracing publication records through PubMed, the publicly accessible bibliographic database maintained by the National Library of Medicine. By linking successful applicants to the top Doximity-ranked dermatology programs with their indexed scholarly records, the team could count manuscripts, characterize authorship positions, and compare productivity across the pre-transition and post-transition eras. The compiled dataset was analyzed to detect shifts in the volume and pattern of research output, with the authors reporting their comparisons in graphical form across two figures in the short report. The use of PubMed as the source of publication records means the analysis captures indexed journal articles, the most verifiable form of student research output.

The study’s central observation is that research productivity among applicants to top-ranked dermatology programs did not decline after Step 1 became pass/fail; rather, the pressure to publish appears to have persisted or grown in the immediate post-transition period. This aligns with what residency directors anecdotally report: when one differentiator is removed from the application, others expand to fill the space. Publications, particularly peer-reviewed manuscripts with meaningful authorship roles, offer a quantifiable, durable signal of initiative, intellectual curiosity, and the capacity to complete a long-term project, qualities that a pass/fail exam can no longer convey with any granularity.

The findings carry particular weight because dermatology sits at the extreme end of the competitiveness spectrum. Prior work by Behbahani and colleagues in the International Journal of Women’s Dermatology analyzed the number of manuscripts in successful dermatology applications and found that publications were a common feature of matched candidates. A related 2025 analysis by Abizadeh and colleagues, which included several of the same SUNY Downstate investigators, documented similar dynamics in ophthalmology, another highly competitive specialty that also experienced the Step 1 transition. Together, these studies suggest a broader pattern across competitive fields: the removal of numerical Step 1 scores has shifted, not lightened, the burden of differentiation onto other parts of the application.

That shift has consequences for equity. Research productivity is not distributed evenly across medical students. Access to mentorship, dedicated research time, institutional funding, and proximity to academic medical centers all shape a student’s ability to publish before applying. Students at resource-rich institutions with established dermatology departments can more easily find projects, co-authors, and submission support, while students at schools without such infrastructure face structural barriers. If publications become the dominant differentiator in the post-pass/fail era, the authors’ findings imply that the transition may have amplified existing inequities rather than reduced them, a concern echoed in a 2023 JAMA Dermatology commentary describing research fever in dermatology as a symptom of a larger problem within the specialty’s selection culture.

The study also speaks to the ongoing debate about holistic review in residency selection. Proponents of the Step 1 pass/fail change argued that it would reduce student stress, discourage rote test preparation, and encourage programs to evaluate candidates on a broader set of attributes, including clinical performance, letters of recommendation, and personal qualities. The SUNY Downstate results suggest that at least one intended consequence, a de-emphasis on credential accumulation, has not materialized in elite dermatology recruitment. Instead, the credential economy appears to have migrated from the exam score to the curriculum vitae, with students responding rationally to the incentives programs continue to reward.

For medical educators and advisors, the practical implications are immediate. Students targeting competitive specialties now need earlier and more deliberate research planning, ideally beginning in the preclinical years, to build a publication record that can withstand comparison in a post-transition applicant pool. Programs, meanwhile, face a choice: continue to reward publication counts, thereby sustaining the arms race, or develop more structured ways to assess the quality and authenticity of research experiences, such as standardized descriptions of the applicant’s actual role and contribution. The authors of the current study, funded by the SUNY Downstate Health Sciences University Dermatology Department, frame their work as a snapshot of a system in transition, and they note that longer-term follow-up across additional match cycles will be needed to determine whether the patterns observed immediately after the change persist, stabilize, or prompt reform in how dermatology programs select the next generation of specialists.

Subject of Research: Research productivity of applicants to top Doximity-ranked dermatology residency programs in the USA before and after the Step 1 pass/fail transition

Article Title: Research productivity among applicants into top Doximity-ranked dermatology programs in the USA before and immediately after step 1 transition to pass/fail scoring

Article References: Research productivity among applicants into top Doximity-ranked dermatology programs in the USA before and immediately after step 1 transition to pass/fail scoring. (n.d.). https://doi.org/10.1007/s00403-026-04893-0

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04893-0

Keywords: dermatology, residency match, Step 1 pass/fail, research productivity, medical education, NRMP, publications, Doximity rankings, USMLE, competitive specialties, PubMed, SUNY Downstate