Introduction
Securing a categorical general surgery residency position outside the NRMP is a recognized challenge. Vacancies arise from attrition, program expansion, or research sabbaticals, and programs must fill them quickly. However, little evidence guides which applicant characteristics predict success.
Previous studies have characterized factors influencing surgical resident selection within the formal NRMP process or the conversion of preliminary residents to categorical status. For example, strong in-training exam (ABSITE) performance has been associated with higher likelihood of a prelim resident earning a categorical spot, and letters of recommendation and interview assessments influence Match rank lists.1 It is unclear whether the same criteria apply to off-cycle hires, where time is limited and candidates often come from unconventional paths.
In off-match scenarios, PDs make rapid decisions with limited information, often favoring known candidates, while applicants emphasize scores or research, creating potential perception gaps.
To address this gap, we conducted a national survey of PDs and residents who secured off-cycle categorical positions. We aimed to identify factors PDs prioritize, understand resident perspectives on what contributed to their success, and assess how program characteristics influence these priorities.
Methods
Study Design and Participants
We performed a cross-sectional survey study targeting all ACGME-accredited general surgery residency programs in the United States. In early 2024, an anonymous electronic questionnaire was sent to program leadership (PDs and/or program coordinators) of 355 general surgery programs. Recipients were asked to forward a parallel resident-focused survey to any current residents in their program, to capture the applicant perspective. The survey stratified residents based on their tract and current categorical residents who matched outside the match process were identified. Participation was voluntary and responses were confidential. This study was approved by the University of Arizona Institutional Review Board (Study ID 00005768).
Survey Instrument
Two complementary survey instruments (PD survey and resident survey) were developed by the authors. The PD survey collected PD experience and program demographic information including type of institution (academic, community, etc.), geographic region, number of residency positions, and visa sponsorship policy. PDs were asked if they had ever needed to fill a categorical resident position outside the Match; those who responded yes were prompted to indicate reasons for the vacancy. PDs also reported which postgraduate year (PGY) level(s) they had to fill off-cycle (PGY-1 through PGY-4). Additional questions addressed PDs’ preferred methods for identifying off-cycle candidates.
The survey asked PDs to prioritize the importance of various candidate factors in their decision-making if filling a categorical position outside the Match. These factors included candidate’s research experience, any prior personal experience with the PD’s program (e.g. as a student or prelim), number of logged operative cases, strength of letters of recommendation, need for visa sponsorship (citizenship/visa status), ABSITE score, and type of medical degree (MD, DO, US vs foreign medical graduate). PDs rated each factor on a 0–100 sliding scale (0=not at all important, 100=extremely important) for both a junior-level opening (PGY-2 or PGY-3) and a senior-level opening (PGY-4 or PGY-5). The resident survey mirrored these questions and queried residents to rate how important they believed each factor was in securing their off-cycle position. Surveys were pilot tested, distributed electronically over 8 weeks, and collected anonymously.
Statistical Analysis
Survey data was analyzed using descriptive and comparative statistics. Categorical variables (e.g. institution type, vacancy reasons) are reported as counts and percentages. Continuous ratings of factor importance are reported as means and standard deviations. We compared PD vs resident mean importance ratings for each factor using independent-sample t-tests.
Within the PD cohort, subgroup analyses were performed stratifying responses by program characteristics: PD tenure (<2 years, 2–5 years, >5 years), institution type (academic vs community), and visa sponsorship policy (none vs J-1 only vs J-1/H-1B both). Analysis of variance (ANOVA) or appropriate nonparametric tests were used to assess differences across these subgroups. A two-sided p<0.05 was considered statistically significant. All analyses were conducted using SPSS version 29 (IBM Corp).
Results
Participant Characteristics
A total of 47 PDs (approximately 15% of U.S. general surgery programs) responded to the PD survey, and 59 surgery residents responded to the resident survey. Of which 51 respondents (88%) were categorical. Of those, 18% (10/51) matched outside the NRMP meeting the inclusion criteria (Table 1 and 2).
Among PD respondents, 55% were from academic programs, 23% from community programs, and 17% from hybrid or “mixed” institutions. PD experience was evenly distributed; 29% had <2 years in the role, 35% had 2–5 years, and 35% had >5 years as PD. Nearly three-quarters of programs offered some form of visa sponsorship for trainees with 51% sponsoring J-1 visas only, 26% sponsoring both J-1 and H-1B visas, and 23% that did not sponsor visas. On average, PDs reported that the composition of their current categorical residents was predominantly U.S. medical school graduates (mean 76% MD and 28% DO, with 19% international medical graduates) (Table 1).
Frequency and Nature of Off-Cycle Vacancies
Over half of PD respondents (27 of 47 who answered, 57%) indicated they needed to fill a categorical residency position outside the Match during their tenure (Table 1). Many PDs experienced this more than once and at various training levels. Most vacancies occurred at the PGY-2 and PGY-3 levels, with fewer at senior or PGY-1 levels (Table 1).
The most cited reasons for open categorical positions were: an unexpected departure of a resident (51%), program expansion (30%), or a resident leaving for a dedicated research period (19%).
PD Factors for Filling Vacancies
PDs employ a range of strategies to identify candidates for unfilled positions. Figure 1 illustrates the ranked preferences of PDs for recruitment methods. Most PDs favored utilizing personal and internal networks over public announcements. The single most popular method for announcing or recruiting an open position was internal notification. Almost two thirds of PDs relied on personal connections (colleagues’ recommendations, word-of-mouth) to select either their top one or two candidates.
Formal postings was a less favorable recruitment strategy, as only 26% of PDs chose posting the position online (e.g. program website, APDS open positions list) as their first-choice approach. Social media was the least favored avenue for recruitment. These results suggest that PDs prefer to fill off-cycle spots by first looking internally or within trusted professional networks before turning to broader public recruiting.
PD vs Resident Perspectives on Important Selection Factors
PDs and successful off-cycle residents assigned broadly similar importance scores to most selection factors, but two statistically significant differences emerged. Visa or citizenship status received a mean rating of 47.9±35.2 from PDs versus just 3.7±1.9 from residents (p< 0.001), while type of medical degree was valued more by PDs (43.1±29.6) than by residents (18.8±19.3;p = 0.025). Ratings for program familiarity remained high in both cohorts (PD 57.7, resident 74.6) and ABSITE scores were rated similarly (PD 54.8, resident 56.8), with no significant group differences (all p> 0.05)
Detailed means for all seven factors, including research experience, logged operative cases, and letters of recommendation—which showed no significant PD-resident gaps—are provided in Table 3.
Considerations for Senior-Level Positions
Because these vacancies are uncommon, survey responses were limited, yet a clear pattern emerged. PDs gave their greatest weight to trusted endorsements and proven operative competence: letters of recommendation carried the highest mean importance score (74.3±19.2), followed by the candidate’s logged case volume (64.3±29.1). Factors such as program familiarity (54.6), ABSITE performance (52.4), and research experience (48.4) were rated as of moderate relevance, whereas visa or citizenship status (42.8) and medical-degree type (31.5) were lower-priority considerations.
Program-Level Differences in PD Priorities
We explored whether PDs from different types of programs or backgrounds emphasized selection factors differently.
PDs from academic programs generally placed higher importance on applicants’ research experience and prior program exposure. The mean importance assigned to research by academic PDs was 34 vs 20 by community PDs (p=0.24). Likewise, academic PDs rated familiarity with the program more highly (mean 61 vs 47 for community,p=0.4). Conversely, community PDs placed significantly greater emphasis on visa/citizenship status, with a mean importance of 71.0, compared to 40.6 for academic PDs (p=0.28) (Table 4).
There were subtle shifts in priority with PD experience. Though not statistically significant, newer PDs (<2 years) tended to give higher importance ratings to letters of recommendation (mean 70.5) than did PDs with >5 years’ experience (mean 59.7) (p=0.36). Newer PDs weighed degree type (MD vs DO) less heavily than veteran PDs (mean importance 33.6 vs 60.8,p=0.031) (Table 4).
PD responses differed dramatically when stratified by whether their program sponsors visas. Programs that do not sponsor visas overwhelmingly emphasized a candidate’s visa status as a key factor (mean importance 78.3,p=0.01). In contrast, PDs at programs that do sponsor visas (especially those offering both J-1 and H-1B) assigned very low importance to visa requirement (mean 48.7-19.9, p=0.01) (Table 4).
Discussion
This study clarifies how general surgery programs approach off-cycle hiring. PDs prioritize clinical competence and trusted endorsements, whereas residents view familiarity with the program and test scores as most important. Strong letters, especially from colleagues, provide assurance about work ethic and performance.
PDs favored clinical competence and strong letters, while residents emphasized familiarity and test scores. Strong letters proxy for traits like work ethic and teamwork, valued by PDs unfamiliar with the candidate.
Our data confirm at-match selection literature suggesting that letters and interview impressions heavily influence rank lists.2–4 Residents attributed much of their success to being known quantities (having worked or rotated at the institution) and to objective metrics like ABSITE scores. External applicants might underestimate the importance of recommendation letters and overestimate the sufficiency of scores alone. Likewise, some applicants might not realize the importance of a prior connection to the program – a highly valued quality in the eyes of PDs that may not be available in external candidates.2,3,5
Another important discrepancy was in prioritization of visa status and international medical graduates. This study suggests that a candidate’s need for visa sponsorship is a major consideration for many programs. Roughly one-quarter of responding programs did not sponsor visas at all, effectively excluding foreign nationals. This is supported by the study by Datta et al., which highlights the challenges faced by international citizens in securing general surgery residency positions due to visa sponsorship policies.6 Even among sponsoring programs, some PDs indicated a preference for avoiding these circumstances, if possible. This is corroborated by a study by Khoshpouri et al. noting the barriers presented by visa-related bureaucratic and monetary hurdles.7
In contrast, residents who required visas and did obtain positions appeared to have success at programs receptive to international graduates, and thus they perceived this as less of a barrier. The implications of such a phenomenon may be the unintentional creation of a pipeline for foreign graduates or nationals to funnel through a few receptive programs. This is further supported by the work of Reddy et al., which found significant differences in the recruitment of IMGs to community-based versus university-based internal medicine programs.8 For applicants, early identification f programs with cumbersome visa policies is critical.
The reason for PDs’ preference towards U.S. medical graduates over DOs or IMGs is complex and not entirely captured by the scope of this study. Potential explanations could be self-selection, confidence in a known or familiar training background, and historical precedent. Interestingly, newer PDs seemed more open to non-MDs than veteran PDs, which may forecast a shift in attitudes as osteopathic graduates and IMGs become more prevalent in surgical training programs.9
Off-cycle vacancies are most often filled through informal and internal channels. Only one in four PDs used public web listings and virtually none relied on social media.10 This heavy dependence on institutional or personal networks explains to some extent why prior familiarity was so highly valued by both PDs and successful applicants. For external candidates, however, the strategy creates an access barrier. Applicants who lack exposure may consider building professional connections at conferences or through away rotations, collaborative research, scholarships, and travel grants to gain access to and familiarity within these networks. Although centralized open-position boards such as the APDS list-serv remain worth monitoring, they capture only a fraction of real-time vacancies, so proactive outreach remains essential.
At a program level with categorical vacancies, recruitment through a centralized platform may extend the pool of talent to a diversified, well-qualified group of external candidates, especially those without established connections. Sharing institutional experiences, policies, and selection rationale (e.g., through APDS discussion boards) may also broaden the candidate pool without compromising standards.
This study has several limitations. The response rate for PDs was modest. PDs who have a particular interest or more frequent experience in off-cycle matters may have been more likely to respond, thereby introducing bias.
The resident survey relied on forwarding via PDs/coordinators; therefore, we do not know the true denominator of off-cycle applicants; The resident perspective comes from a very small sample of 9 categorical residents out of 59 resident respondents. These residents likely skew toward those who recently secured spots (perhaps in the past 1–2 years) and their recollection or self-assessment may be subjective. Resident responses may be subject to recall bias. We did not directly pair PD and resident responses from the same program. Doing so might have provided interesting case-specific insights. Our approach instead aggregated the two groups separately to identify overall trends. Future research could attempt a matched design or qualitative interviews to delve deeper into PDs’ decision rationale and residents’ experiences.
Finally, while we identified differences in mean importance scores, we did not set out to determine which factors predict off-cycle hiring success, which would require data on candidates who applied but did not get selected). Our results should therefore be interpreted only as an exploration of perceptions, which are critical in understanding the off-cycle selection process.
Conclusion
Off-cycle categorical positions in general surgery are filled through a selection process that differs meaningfully from the NRMP Match and is shaped by applicant and program priorities. Through our survey data, we showed that these priorities do not necessarily overlap. PDs place greatest trust in demonstrable clinical competence and strong peer endorsements. Successful applicants perceive familiarity with the program and ABSITE performance as decisive. Many factors may influence the priorities of recruiting programs, including PD experience, program type, and visa sponsorship. Awareness of these priorities can guide applicants to strengthen candidacy in several ways.
Future studies may illuminate this field further by exploring qualitative, paired data, and longitudinally tracking both successful and unsuccessful off-cycle applicants. Ultimately this exploration serves as a small but necessary self-reflective step for our surgical training system in creating a fair and equitable recruitment for skilled surgeons.