Letter to the Editor. The COVID-19 pandemic and the inequities of the neurosurgery match

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  • 1 Barrow Neurological Institute, Phoenix, AZ; and
  • 2 University of Pittsburgh Medical Center, Pittsburgh, PA
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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.

References

  • 1

    Bambakidis NC, Tomei KL. Editorial. Impact of COVID-19 on neurosurgery resident training and education. J Neurosurg. 2020;133(1):1011.

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  • 2

    Agarwal N, Choi PA, Okonkwo DO, Financial burden associated with the residency match in neurological surgery. J Neurosurg. 2017;126(1):184190.

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  • 3

    Mummareddy N, Zuckerman SL, Cavallo C, Scheduling neurosurgery residency interviews: avenues for improvement. World Neurosurg. 2019;130:589592.

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  • 4

    Pittman T. Improving the neurosurgery match. J Neurosurg. 2018;130(2):662664.

  • 5

    Daon Y, Thompson RN, Obolski U. Estimating COVID-19 outbreak risk through air travel. J Travel Med. 2020;7(5):taaa093.

  • 6

    Charting Outcomes in the Match: Senior Students of U.S. Medical Schools, 2020. National Resident Matching Program; 2020. Accessed November 2, 2020. https://www.nrmp.org/main-residency-match-data/

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  • University Hospitals Cleveland Medical Center, Cleveland, OH

Response

The authors raise several concerns regarding an upcoming unprecedented interview cycle. With the ongoing COVID-19 pandemic, protecting our medical students while adhering to public health measures remains paramount. As pointed out, variances in state-based quarantine requirements, home- and visiting-institution travel restrictions, and program density create varying advantages and disadvantages. Neurosurgery as a profession was quick to realize this, and The Society of Neurological Surgeons (SNS) quickly worked to develop an unprecedented consensus creating parity among programs and applicants. All training programs agreed to not host visiting medical students. Medical students are expected to rotate for 8 weeks at their home institution. Exceptions are allowed for students without a home neurosurgery program.1 This policy was created to ensure students receive an adequate duration of exposure to neurosurgery, while creating parity for both programs and students. Secondarily, the SNS has issued a standardized evaluation form and requirement of a third letter of recommendation from its core surgical rotation to ensure students are evaluated on the same metrics. Understandably, these changes occur with the consequence that students are unable to experience a diversity of programs. Additionally, programs, unable to host students, lose the opportunity to showcase their program to potential applicants.

These missed opportunities have created a new wave of networking and educational opportunities benefiting applicants, residents, and practicing neurosurgeons. Programs have utilized conferencing technology and social media to host lecture series, meet and greets, and virtual externships. Residents, realizing the importance of exposure to programs, created a central repository, Neurosurgery MedEd, listing events.2 The Congress of Neurological Surgeons hosted a national neurosurgery symposium in June, connecting programs and applicants. Although these arose in the wake of a global pandemic, they represent opportunities for the future.

However, as pointed out, rotations are only part of the equation. The Association of American Medical Colleges has recommended that all teaching institutions conduct interviews virtually.3 Though not a mandate, this recommendation should prompt the SNS to proffer an agreement between all neurosurgical programs. However, several potential downstream effects must be considered. First, the cost of traveling to interviews is no longer a factor. In addition, travel logistics may have previously required a student to choose between two concurrent interviews. Virtual interviews are likely to be of shorter duration than in-person interviews, and without travel, it would be possible for strong applicants to interview at significantly more programs than would have previously been affordable or possible. This could potentially increase the number of both unmatched applicants and unfilled programs. Rather than adhering to an unenforceable honor system among applicants, programs could offer interviews on pre-selected dates, forcing applicants to choose. This would resemble how applicants accepted interviews previously and be easier to enforce at a national level. Finally, understanding that students will inevitably be interested in seeing programs and cities while applying, it is imperative that we as a neurosurgical community support the public health of our students and communities to not host in-person visits for applicants.

References

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Contributor Notes

Correspondence Michael D. White: michael.white@barrowbrainandspine.com.

INCLUDE WHEN CITING Published online December 4, 2020; DOI: 10.3171/2020.9.JNS203365.

Disclosures The authors report no conflict of interest.

  • 1

    Bambakidis NC, Tomei KL. Editorial. Impact of COVID-19 on neurosurgery resident training and education. J Neurosurg. 2020;133(1):1011.

    • Search Google Scholar
    • Export Citation
  • 2

    Agarwal N, Choi PA, Okonkwo DO, Financial burden associated with the residency match in neurological surgery. J Neurosurg. 2017;126(1):184190.

    • Search Google Scholar
    • Export Citation
  • 3

    Mummareddy N, Zuckerman SL, Cavallo C, Scheduling neurosurgery residency interviews: avenues for improvement. World Neurosurg. 2019;130:589592.

    • Search Google Scholar
    • Export Citation
  • 4

    Pittman T. Improving the neurosurgery match. J Neurosurg. 2018;130(2):662664.

  • 5

    Daon Y, Thompson RN, Obolski U. Estimating COVID-19 outbreak risk through air travel. J Travel Med. 2020;7(5):taaa093.

  • 6

    Charting Outcomes in the Match: Senior Students of U.S. Medical Schools, 2020. National Resident Matching Program; 2020. Accessed November 2, 2020. https://www.nrmp.org/main-residency-match-data/

    • Search Google Scholar
    • Export Citation
  • 1

    SNS External Medical Student Rotations. Society of Neurological Surgeons. Accessed November 2, 2020. https://www.societyns.org/medical-students/external-medical-student-rotations

    • Search Google Scholar
    • Export Citation
  • 2

    Neurosurgery MedEd. National Neurosurgery Medical Educational. Accessed November 2, 2020. https://sites.google.com/view/nsgy/home

  • 3

    Conducting interviews during the coronavirus pandemic. Association of American Medical Colleges. Accessed November 2, 2020. https://www.aamc.org/what-we-do/mission-areas/medical-education/conducting-interviews-during-coronavirus-pandemic.

    • Search Google Scholar
    • Export Citation

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