Electronic Residency Application Service Application Fees in Surgical Subspecialties: A Barrier to a Diverse Healthcare Workforce?

Objective: To examine how the financial burden of residency applications disproportionately impacts students underrepresented in medicine, potentially limiting specialty diversity. Surgical subspecialties, known for their competitiveness, often compel applicants to submit a far greater number of applications than is typical for other specialties, thereby increasing costs and exacerbating disparities. Methods: Data from the National Resident Matching Program and the American Urological Association (2019-2024) were analyzed for 6 surgical subspecialties (Neurologic Surgery, Orthopedic Surgery, Otolaryngology, Plastic Surgery, Urology, and Vascular Surgery). Average number of applications per applicant, total applicants, and annual Electronic Residency Application Service fee structures were used to calculate both per applicant and total application fees by specialty and year. Trends and specialty-specific variations were described. Results: Orthopedic Surgery consistently incurred the highest total costs, with a mean per applicant fee of $1661 and total annual fees exceeding $2 million. Urology and Otolaryngology also demonstrated notably high per applicant costs, reflecting the financial strains of their competitive landscapes. In contrast, Plastic Surgery and Vascular Surgery were associated with fewer applications and lower fees. Introduction of residency program preference signaling appeared to reduce application volume and costs for specialties adopting this approach, while Neurologic and Vascular Surgery, lacking such interventions, did not exhibit similar declines. Conclusion: Significant variability in application costs exist among surgical subspecialties, contributing to financial barriers that undermine equitable access to training. Addressing these financial challenges, such as through targeted interventions and widespread adoption of program preference signaling, may help foster greater diversity and inclusion in surgical specialties.