TO THE EDITOR: The coronavirus (COVID-19) pandemic has transformed the landscape of medical education. As previously introduced in the Journal of Neurosurgery COVID-19 collection, medical education in the field of neurosurgery has changed significantly, with reduced surgical case volumes and fewer in-person learning opportunities in an attempt to maximize hospital safety (Bambakidis NC, Tomei KL. Editorial. Impact of COVID-19 on neurosurgery resident training and education. J Neurosurg. 2020;133[1]:10–11).¹ As a consequence of these shifting priorities, a multitude of new challenges face medical students pursuing neurosurgery. The public health risk of travel during this time has necessitated major changes to the format of the application cycle, most prominently including the cancellation of in-person interviews and visiting subinternships. This presents obvious challenges for applicants as they try to find a residency program that fits their career goals and personality without being able to see the hospitals or meet the residents and faculty in person. Further, the COVID-19 pandemic has created a situation in which the impact of long-standing inequities in the neurosurgical match process is set to be magnified. There has been much discussion in previous years over inherent disparities in how the match process is run,^2–4 and the ongoing pandemic will likely exacerbate these without a unified stance from all residency programs. As residents who have recently experienced the application process, we see two important topics that we ask our neurosurgical community to address in order to allow our match process to remain fair and equitable this year.

First, we are concerned by the trend toward unofficial visits as applicants seek to evaluate programs and make themselves known in the absence of any in-person opportunities. This comes at a time when travel presents an unprecedented risk to public health.⁵ Students are facing a fundamental inner conflict between taking every opportunity to make a lasting impression on residency programs and weighing such action against the health risks and ethical dilemmas of traveling during the ongoing pandemic. This disproportionally affects students with health conditions, the economically disadvantaged, and those abiding by the social distancing and travel recommendations. Students may also have unequal opportunities to engage in unofficial visits based on geographic location, including the regional COVID-19 burden and the density of programs in various areas of the country. Also concerning is the potential for breaking state quarantine laws. Many states, including Arizona, Utah, and Massachusetts, for example, require travelers to self-quarantine for 2 weeks upon arrival. Given the time constraints of the match process, there is a very real risk that applicants may not abide by these rules, especially those traveling to multiple unofficial visits or traveling between states that have self-quarantine requirements. For the sake of student safety and public health and to prevent applicants from breaking the law, neurosurgery needs to take a strong and unified stance against hosting students for unofficial visits. Preventing these visits altogether not only creates a fair environment for this unique match cycle but also is in the best interest of everyone’s safety.

The second major challenge in this year’s match comes from the downstream effects of all-virtual interviews. The built-in barriers associated with in-person interviews, including the time and cost expenditures associated with travel, inherently limit the number of interviews applicants can attend. However, these barriers disappear in the setting of virtual interviews, and the natural consequence will be students accepting and attending far more interviews, a situation that presents significant risk to the integrity of the neurosurgical match process. A group of the most-qualified students will now have the opportunity to interview at significantly more programs than in previous cycles. And this group of applicants will engage interviews that would otherwise go to other applicants, resulting in many programs having their interview spots filled by applicants who are only interviewing for “insurance” against not matching. Students having virtually unlimited interview opportunities, in the setting of programs offering a fixed number of interviews, could also create a scenario of many unfilled spots. To address these critical issues, we propose two potential solutions. First, applicants could be limited to attending only 20 interviews this season. Analysis of match data has demonstrated that students ranking 20 programs have a match rate of 95%, which suggests that ranking additional programs will have minimal impact on the chances of matching.⁶ The challenge with this solution is enforcement, but applicants could be asked to sign a pledge to remain within this maximum before undertaking virtual interviews, with their integrity as collateral to ensure compliance. However, this would require consensus from all training programs to ask this of their applicants. Alternatively, programs could increase the number of interview spots availabel. In many cases, this would require using only a subset of the department on each interview day and would involve substantially more time on the part of department leadership, including program directors. However, without taking some substantial action, there are significant risks to a fair and equitable neurosurgery match this year.

As a field, we need to take a unified approach to address the inequities that are certain to be exacerbated in this year’s cycle. Organized neurosurgery has made an effort to meet this challenge by offering a series of webinars to help prepare students for this unique application cycle and provide consistent expectations. The burden of consistency also lies with programs, which must adopt a cohesive approach to the execution of interviews and associated match activities this year. There is no better time than now to address these disparities and create a more equitable match process for this year, as well as the years to come.

Acknowledgments

We thank Dr. Lola B. Chambless for her input and discussions in the development of this letter.

Disclosures

The authors report no conflict of interest.