Democratizing access to the residency application process: capitalizing on technology to improve information flow

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  • 1 Department of Neurosurgery, University of California, Los Angeles, California;
  • | 2 Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston;
  • | 3 Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
  • | 4 Department of Neurosurgery, Cleveland Clinic, Martin Health, Port Saint Lucie, Florida
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The Residency Application Process During COVID-19

Last year, more than 35,000 medical students matched into residency positions across the United States.1 The process of navigating the match is often fraught with uncertainty and incomplete, inaccurate, or secondhand information for applicants and programs alike. To gain firsthand knowledge, applicants and programs engage in a marathon of away rotations and interviews prior to committing to a residency spanning 3–7 years. As the 2020–2021 residency application cycle approached, COVID-19 restrictions barred rotations and in-person interviews, generating additional uncertainty and decreased firsthand information flow between residency programs and applicants. Applicants and programs consider “fit” a critical factor in their residency decision. Programs determine fit based on in-person interviews and review of either sub-internship or applicant materials, whereas applicants cite in-person interactions with current residents as one of the most important criteria for selecting a program.2

These restrictions on the 2021 application cycle could result in increased applications submitted per applicant, above the already-growing averages of 69.4 and 54.2 applications per applicant from US and international medical graduates, respectively, in 2020.3 This trend imposes substantial cost on applicants4 while unlikely to improve match rates. It also creates increasing burdens on program directors,5 who, without tools to differentiate between applicants in this increasing pool, may overemphasize United States Medical Licensing Examination (USMLE) Step 1 and 2 scores or use inconsistent, unreliable screening methods.

Solutions to the 2020–2021 Application Process

Proposed solutions such as delayed application timelines, modified application requirements, and a more holistic interview process5 may positively counteract COVID-19–related setbacks in the residency application process this year but do not address the decrease in first-hand knowledge acquisition due to COVID-19. Limits to the number of applications or caps on accepted interviews have also been proposed, given projected increases in application volume this year.5 These limits could, however, disproportionately favor certain applicants. Efforts by the Society of Neurological Surgeons to establish common national rules of engagement for sub-internship, interview, and match process etiquette have also tried to help address issues of unequal access. By improving bidirectional information flow between programs and applicants, these disparities could be further mitigated by additional efforts to enable early pairing of applicants and programs with aligned interests.

Firsthand, in-depth information about residency programs is typically only available to those who are able to interact with a department during a sub-internship or similar experience. In order to democratize access to, and information about, residency programs and equally distribute information about the residency application process for all interested medical students, we, with support from the Congress of Neurological Surgeons (CNS), implemented a National Virtual Medical Student Symposium for neurosurgery applicants. The event allowed for the virtual gathering of the majority of neurosurgery programs nationally into a compact “space” to generate informal and organic interactions between medical students, residents, and faculty in an unprecedented way to substitute and improve on the key exchange of qualitative information that would typically take place during this year’s cancelled away rotations. To our knowledge, this is the first such specialty-wide event of its kind.

Virtual Platform Implementation and Feedback

The 2-day virtual symposium (June 6–7, 2020), hosted over Zoom (Zoom Inc.), consisted of just under 500 medical student registrants with broad geographic representation (Supplementary Fig. 1) and 82 of the 114 (71.9%) neurosurgery residency programs with the goal of maximizing medical student exposure to both the specialty and individual programs. The registration of residency programs occurred largely through grassroots individual social networks of residents and attendings. Medical students were contacted through multiple mechanisms, including social media, program coordinator networks, and local medical student neurosurgery interest groups. Each program was allotted a 30-minute time slot, and the majority of program representatives were residents. Most programs presented prepared information about their program, followed by an open-ended question-and-answer session for medical student attendees. Medical students were assigned to multiple sessions based on their ranked preferences, prioritizing the preferences of 2021 neurosurgical applicants. Assignments were also scheduled to avoid overlapping sessions (usually 2, and occasionally 3 of the 82 sessions ran concurrently); 19–50 medical students were assigned to each session. The majority of students attended 7 sessions. In a postevent survey of medical student attendees (Supplementary Table 1), the majority of respondents stated that they ranked their program session preferences based on overall interest in the program, followed by program location. Respondents also stated that after the event they had an improved understanding of neurosurgery residency (82.3%) and different program cultures (87.4%), had a more positive perception of the neurosurgical community (73.0%), and had greater enthusiasm for neurosurgery (86.8%).

Interestingly, all respondents wanted this virtual event to continue annually, as it affords much greater exposure than what is possible with traditional in-person events, especially for medical students without a home program (which accounted for at least 36 of the medical students in attendance). Even those with a home program stated how “siloed” or “single-minded” their single-institution experiences had been. Students stated their surprise at easily perceiving cultural differences and “fit” within programs, even over video.

Reasons to Replicate Across All Specialties

Decreased Financial Burden

Prior to the pandemic, medical students chose sub-internships and residency programs based on very limited personal data, with competitiveness and uncertainty driving increasing numbers of applications per applicant to highly selective specialties, along with increased financial burden. Among applicants to surgical fields, nearly 20% spent more than $7000 on the interview process in 2014, and 14% required additional loans to support these interview-related expenses.5 Given this substantial burden, some applicants may limit their away sub-internship or residency interviews due to monetary restrictions. The virtual format was lauded for removing strict cost limitations associated with obtaining “face-time” during a sub-internship or interview and allowed participants to not only find programs with a good “fit” but also, just as importantly, to rule out programs, without associated travel costs in addition to the known large amounts of medical student debt.

Increased Accessibility

Given the wide representation of programs (> 70% of the neurosurgery programs), survey data revealed that medical students felt the virtual format improved and equalized medical student access to programs, possibly leading to increased equity in disparities in access and exposure. These disparities may be secondary to a lack of applicant’s resources,6 lack of a subspecialty residency at a given medical school (i.e., lack of a “home” neurosurgery program), or, specific to this year, the severity of the pandemic outbreak in a given city and COVID-19–related away sub-internship cancellations.

When not limited by the pandemic, medical students commonly completed 2–4 neurosurgery sub-internships to learn about other programs, interacted directly with residents and faculty, and obtained letters of recommendation from a variety of neurosurgeons. Due to the virtual nature of this event, we were able to offer medical students direct access to 2–3 times as many programs as in a typical year, as most students attended 7 sessions. With greater resources in the future, this could easily be expanded, especially if programs were interested in offering more than one information session. This event also offered the converse opportunity for programs to interact with anywhere from 19 to 50 medical students per session in advance of interview season, which is several times greater than the typical number of sub-interns they would accept and interact with during a typical year. At the time of the symposium, residency programs in states most severely impacted by COVID-19 outbreaks (namely, New York, New Jersey, and Massachusetts) expressed strong interest in future similar events to increase exposure and student interactions, without significantly compromising student safety or expenditure of thinly stretched resources by students or programs.

Increased Bidirectional Information Flow

Finally, concentrating the programs in a 2-day event allowed participants to directly compare program personalities and potentially differentiate programs based on their personal interests prior to finalizing their application or interview lists. Equally valuable, these early interactions create an infrastructure by which program directors can begin to evaluate, even coarsely, interested students, and broadly advertise to a wider array of applicants. To further increase the bidirectional flow of information, medical students were queried for all programs of interest and programs were provided with these students’ contact information to establish smaller breakout events. Over half of the neurosurgery programs nationally have since held individual program–organized breakout events following this symposium. These sessions have provided an additional opportunity for direct engagement between students, residents, and faculty to gauge interest and evaluate common priorities.

Virtual Engagement Is Broadly Applicable and Necessary Despite COVID-19

Future events could expand this structure and platform and could be restructured for individual specialty needs. Inquiries received from other specialties interested in replicating this event have been demonstrative of its broad appeal. A national bidirectional exchange of information may particularly benefit subspecialty programs where smaller applicant pools most often apply to large numbers of programs, such as orthopedic surgery, otolaryngology, or urology.

Conclusions

COVID-19–related social distancing restrictions have galvanized a widely adopted technology age in medicine. Using this momentum, we fostered national engagement in a virtual environment to improve information flow and decrease applicant uncertainty about neurosurgical residency programs. This symposium provided unprecedented, direct medical student access to a traditionally difficult-to-navigate sub-internship and residency selection process and serves as a proof-of-concept and opportunity to bridge a known information gap inherent in the match process, worsened this year due to COVID-19–related away sub-internship and in-person interview cancellations. Increasing medical student engagement early in the application process would empower applicants and programs to determine program “fit” and guide early decision-making in future application cycles. Information flow, engagement, and discourse are essential for applicants to narrow their programs of interest and for programs to select the best applicants. Now that we are widely virtually connected because of the pandemic, we should continue to use technology to reach a larger, broader, and better-informed medical student audience. This technology revolution should not end with COVID-19; we must continue to innovate to improve the match process.

Acknowledgments

We would like to thank Dr. Steven Kalkanis, Dr. Lissa Baird, Regina Shupak, David Berg, and Alicia Skulemowski from the CNS for their support of this proposal and event. Zoom hosting was enabled by the CNS, a branch of organized neurosurgery.

Disclosures

Dr. Segar: ownership in Saturn5 Corp.

Supplemental Information

Online-Only Content

Supplemental material is available with the online version of the article.

References

  • 1

    Press Release: Thousands of resident applicants celebrate NRMP Match results. Match National Resident Matching Program. March 15, 2019. Accessed December 29, 2020. https://www.nrmp.org/one-nine-press-release-thousands-resident-physician-applicants-celebrate-nrmp-match-results/

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  • 2

    Marasa LH, Pittman TA. Factors neurosurgery candidates use when choosing a residency program. J Neurosurg. 2014;120(1):167172.

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    ERAS Statistics. AAMC. Accessed April 22, 2021. https://www.aamc.org/data-reports/interactive-data/eras-statistics-data

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    Benson NM, Stickle TR, Raszka WV Jr. Going “fourth” from medical school: fourth-year medical students’ perspectives on the fourth year of medical school. Acad Med. 2015;90(10):13861393.

    • Crossref
    • PubMed
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  • 5

    Hammoud MM, Standiford T, Carmody JB. Potential implications of COVID-19 for the 2020-2021 residency application cycle. JAMA. 2020;324(1):2930.

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    Lobel DA, Kahn M, Rosen CL, Pilitsis JG. Medical student education in neurosurgery: optional or essential?. Teach Learn Med. 2015;27(2):201204.

    • Crossref
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Illustration from Fan et al. (pp 1298–1309). Copyright Jun Fan. Published with permission.

  • 1

    Press Release: Thousands of resident applicants celebrate NRMP Match results. Match National Resident Matching Program. March 15, 2019. Accessed December 29, 2020. https://www.nrmp.org/one-nine-press-release-thousands-resident-physician-applicants-celebrate-nrmp-match-results/

    • Search Google Scholar
    • Export Citation
  • 2

    Marasa LH, Pittman TA. Factors neurosurgery candidates use when choosing a residency program. J Neurosurg. 2014;120(1):167172.

  • 3

    ERAS Statistics. AAMC. Accessed April 22, 2021. https://www.aamc.org/data-reports/interactive-data/eras-statistics-data

  • 4

    Benson NM, Stickle TR, Raszka WV Jr. Going “fourth” from medical school: fourth-year medical students’ perspectives on the fourth year of medical school. Acad Med. 2015;90(10):13861393.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Hammoud MM, Standiford T, Carmody JB. Potential implications of COVID-19 for the 2020-2021 residency application cycle. JAMA. 2020;324(1):2930.

  • 6

    Lobel DA, Kahn M, Rosen CL, Pilitsis JG. Medical student education in neurosurgery: optional or essential?. Teach Learn Med. 2015;27(2):201204.

    • Crossref
    • Search Google Scholar
    • Export Citation

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