Q&A: Pandemic’s lasting impact on the future of residency selection

Brendan Murphy , Senior News Writer

The process of matching residency applicants and programs is a lengthy one. Due to the COVID-19 pandemic, it was upended the 2020–2021 residency selection cycle.

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In-person interviews were moved to virtual forums. As a result, application totals are likely to increase. How have residency programs responded to the challenge of going through the Match during a pandemic? Which of those changes will stick? Patrick M. Cocks, MD, an AMA member and director of the internal medicine residency program at New York University Langone Health, offered key insights on the pandemic’s lasting impact on residency selection.

AMA: The pandemic hit right as the last Match was concluding. At what point did you know this 2020-2021 Match was going to require some changes?

Dr. Cocks: By the beginning of the summer, it became clear that in-person interviews were unlikely and we recognized we needed to revamp our whole interview process for the virtual realm. We had a small committee of faculty member and chief residents who got together so we could brainstorm how we could take advantage of the opportunity to improve our process.

AMA: Interviews were clearly the most disrupted part of the process. What type of technology did you pivot to?

Dr. Cocks: We used the pre-existing Zoom platform for our virtual space for interview. Our med school had been using an application software portal that we are trying to adapt for the GME [graduate medical education] world. It’s a way to share files, evaluations, collate scoring in a relatively seamless way. Previously we had email PDFs, we had created various spreadsheets, we had hand-entered evaluation forms. It took a lot of backend work to collate and sort it all before we ultimately entered it into the NRMP [National Resident Matching Program]. We hope to increase efficiency by using it. Absent of the pandemic we likely would not have done that.

AMA: Were there any changes to interview content or process with the format moving to a virtual one?

Dr. Cocks: We looked at our previous interview structure, which we called conversational interviews. Questions like, “Tell me a little about yourself and what’s your future in medicine?” The evidence is starting to show that the traditional back and forth is potentially fraught with bias. We had always talked about doing the multiple mini-interview format, but because of the scope and scale in our interview process it was intimidating.

The virtual world has allowed us to move to a format where we incorporated structured interviewing and MMIs with the hopes to add standardization to our process and mitigate any bias in the process. That was another opportunity we could not have taken advantage of if we didn’t have the virtual realm.

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AMA: Have virtual interviews changed the way you evaluate?

Dr. Cocks: We always talk about holistic review. The pandemic has forced us to spend more time reviewing the application, spend more time thinking about our selection process. It is forcing us to be much more thoughtful within the process.

I would say that the vast majority of our selection process is based on attributes that were gleaned from ERAS [Electronic Residency Application Service]. They were academic accomplishments and metrics. But by introducing this blended interview process we can begin to assess value in areas that aren’t captured through the application. Things like an applicant’s adaptability, approach to learning and problem solving and response to feedback. We’re excited to see how it plays out. This is still just the beginning.

AMA: Do you see virtual interviews remaining part of the residency selection process when restrictions on travel—and the pandemic’s spread—have been curtailed?

Dr. Cocks: For some individuals, because of cost, time and convenience they truly benefit from the virtual interview. We have begun to start initial conversations about what parts of this process do we want tocontinue with. Offering opportunities for on-site visits on a different date than the interview is one way we are considering altering the future interview process.

I do believe that the campus visit is important and I do believe it should at least be an option going forward. It adds depth to the applicant’s understanding of the educational opportunities a program offers. Being on site watching the housestaff and the faculty direct in a noninterview, nonformalized way is an important element of evaluating a program in terms of whether a resident would succeed there.

AMA: Have you seen application inflation? How is it impacting selection process?

Dr. Cocks: Our applicant numbers are up a little bit. It’s really hard in the current application setup to glean interest from an applicant, from their file or their interview day. Post-Match, we might have a better sense of an applicant’s true interest in the program.

AMA: Is that because you’ll have more insight on rank-order lists?

Dr. Cocks: Yes.  We can review our Match list to see where candidates were ranked to Match ended up.  Potentially showing us that they ranked the other program in a higher position.

AMA: Do you think that interventions that communicate applicant interest could be helpful in the Match?

Dr. Cocks: I am in favor of a signal process that allows for individuals to spend the most time interacting with programs and applicants that are most aligned with their interest. Anything we can do to create more meaning in the process is a good thing. I can imagine a process where there’s a first-pass interview, a shared interest in moving forward and maybe those people come in [for an in-person interview] at a later day.

AMA: What, in your view, is the biggest downside of virtual interviews? Dr. Cocks: Personally, it’s getting to interact with the applicants in more than just one on one. I enjoy the conversation around the table of the day. I enjoy hearing each one speak to the remarkable accomplishments they’ve had. I enjoy the community that begins to form on interview day. As much as we’ve been able to create an environment that facilitates transfer of information and one-on-one connections, it’s harder to create these shared learning communities.

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AMA: New York, at the outset of the pandemic, was hit as hard as any city in the world. How has that experience changed your residency-selection process? Dr. Cocks: We have been very explicit about the impact the pandemic has had on our residents and our educational systems. We shut down for a third of the year. Conferences were shut down, our assessment shut down, residents were being supervised by faculty members from different departments and different institutions.

When that settled down, we started to think about the lessons learned and how we might apply that should the pandemic return to our communities with the force it did in the spring. ... As for the potential impact of COVID on educational systems, we are going to hold true to some of the things we’ve learned. We can’t shut down all of our education systems. We have to be mindful of unit cohesion because of the important role that plays in getting through challenges together. Making sure our residents rotate together that they are on the same teams, it was something that we did not pay attention to in the past. Those have been guiding principles as we begin next-step planning, and we have been explicit with our applicants about that. It’s important to be open about that.

AMA: Are you seeing a different applicant mindset as due to the pandemic?

Dr. Cocks: It’s a little early for me to see it. We see it in their activities during medical school, how many contributed in meaningful ways in the care of COVID patients in their hospitals systems, whether it be through clinical services or information activities like connecting with patients.  It’s been remarkable to see how engaged this group has been in the evolving care and research.

AMA: When you get through the selection process, you’ll bring in a new class of residents. What will be different for that class?

Dr. Cocks:  We made many assumptions about infection control for years. We assumed people knew how to wash hands and put on and take off gowns. We made assumptions that they wore masks properly. In the age of COVID, we must ensure that this is a true competency. That interns coming in in July have demonstrated competence in personal protective equipment. It became part of our orientation and onboarding. ... Perhaps in perpetuity it will be as important as teaching a surgeon how to scrub in.