Considering recent recommendations, medical schools, students and residency programs are adjusting the final year of training and the residency application process in unprecedented ways. Leading thinkers in medical education recently weighed in on what the changes will mean and how medical schools, residency programs and Match applicants can adjust.

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They did so during a recent AMA Innovations in Medical Education Webinar, focusing specifically on changes to away rotations and residency interviews. A recording of the webinar is available in the resources area of the Accelerating Change in Medical Education Community (registration required). The community is also hosting an ongoing discussion with leaders in medical education about the impact of the COVID-19 pandemic on training. 

How the educational cycle is being disrupted

Due to the COVID-19 pandemic, “limitations placed on learners’ ability to work in the clinical learning environment, restrictions on individual travel, and the inability to complete assessments and educational requirements will render the traditional selection process impossible to replicate this cycle,” said Susan E. Skochelak, MD, MPH, the AMA’s group vice president for medical education.

In response to those realities, the Coalition for Physician Accountability, a cross-organizational group of medical education stakeholders of which the AMA is a part, has recommended changes. The coalition is calling for residency interviews to be conducted virtually, across the board, for the 2021 residency application cycle and for away rotations to be drastically reduced for the coming year.

How to supplement the away rotation

Often referred to as audition rotations, away rotations give students a chance to showcase their ability at a desired residency program, confirm their specialty choice, get a sense of a given program’s culture and solicit letters of recommendation from physicians in their desired specialty. The elimination of away rotations for most students will make all these purposes difficult.

Letters of recommendation serve as a crucial part of a residency application. According to a 2018 survey of residency program directors conducted by the National Resident Matching Program, they serve as one of the top criteria for how an applicant is weighed.

In emergency medicine, letters of recommendation were highlighted by program directors as the top factor for selecting which applicants are interviewed. The specialty’s Standardized Letter of Evaluation (SLOE)—which factors teamwork, bedside manner, work ethic, among a number of factors—is a primary reason for that, according to Liza Smith, MD. Dr. Smith directs undergraduate medical education in the Department of Emergency Medicine at the University of Massachusetts Medical School—Baystate Health (UMass).

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“These letters have essentially become the currency by which students apply to emergency medicine programs,” Dr. Smith said.

Historically, Dr. Smith said UMass advises students to complete two or three emergency medicine rotations early in the application cycle. In the current climate, that is an impossibility. Interestingly, there has historically also been some concern among educators that taking multiple rotations in a single discipline detracts from one’s general preparation for internship.

To adjust, emergency medicine programs have altered their requirements for applicants. Among the key changes, students will only need to complete a single emergency medicine rotation to be eligible at most programs, and additional weight would be given to non-SLOE letters of recommendation.

Faculty members in emergency medicine also worked to make a more universal format for letters of recommendation.

“We have a team of EM educators working on adapting the SLOE format to a template that can be used by non-EM letter writers with the hope being that by being specific about what we want to know, they can tailor their feedback more towards the qualities and attributes that are actually informative for us,” Dr. Smith said. 

Seeing the upside to virtual interviews

With 13 categorical positions, the University of Texas Southwestern Medical Center (UT Southwestern) general surgery program is the biggest in the country. The program also has 15 post-graduate year 1 preliminary positions. According to Kareem Abdelfattah, MD, the program’s director, they had trouble filling those 15 slots via traditional interviews and applications.

That changed in 2017, when UT Southwestern incorporated video interviews as part of their residency application process.

“We were able to identify around five times as many acceptable applicants after offering virtual interviews, and we were able to complete many more of these interviews,” Dr. Abdelfattah said. “Along with the increase in applicants, we also had an increase in being able to match applicants through the main NRMP Match process,” instead of using the Supplemental Offer and Acceptance Program.

In looking at how virtual interviews will be conducted on a national scale during the 2021 residency application cycle, Dr. Abdelfattah highlighted three key factors: that the process is equitable, accessible to all students and provides security for all trainees.

“It’s also worth framing the issue our students are going to be dealing with this year,” he said. “We are going to be asking them to make long-term decisions about their lives and careers with possibly less information than ever before. While one component will be getting them ready for the interviews themselves, another major component is how we advise the students.”

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From working with residents in his program who are doing virtual interviews for fellowship opportunities, Dr. Abdelfattah has found they are having a harder time choosing.

“It’s just different when they haven’t been able to visit campus and look future colleagues in the eye,” he said. “The amount of time spent walking trainees through these decisions has increased quite a bit for our program, and medical schools are going to have to consider how they are going to advise students on how to rank programs on the limited information they have.”

The AMA has curated a selection of resources to assist residents, medical students and faculty during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events at this time.

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