key: cord-0712581-ohwttanj authors: Dixon, Sarah M.; Binkley, Michael M.; Gospe, Sidney M.; Guerriero, Réjean M. title: Child Neurology Applicants Place Increasing Emphasis on Quality of Life Factors date: 2020-09-30 journal: Pediatr Neurol DOI: 10.1016/j.pediatrneurol.2020.09.012 sha: 987063cedb62735160a5c8e35dd84f6861b5a58e doc_id: 712581 cord_uid: ohwttanj BACKGROUND: Medical education, residency training, and the structure of child neurology residency training programs are evolving. We sought to evaluate how training program selection priorities of child neurology residency applicants have changed over time. METHODS: An electronic survey was sent to child neurology residents and practicing child neurologists via the Professors of Child Neurology distribution list in the summer of 2018. It was requested that the survey be disseminated to current trainees and alumni of the programs. The survey consisted of seven questions assessing basic demographics and a list of factors applicants consider when choosing a residency. RESULTS: There were 284 responses with a higher representation of individuals matriculating into residency in the last decade. More recent medical school graduates had a lower probability of considering curriculum as an important factor for residency selection (OR 0.746 [CI 0.568-0.98], p=0.035) and higher priority placed on interaction with current residents over the course of the interview day (OR 2.207 [CI 1.486-3.278] p<0.0001), sense of resident happiness and well-being (OR 2.176 [CI 1.494-3.169] p<0.0001), and perception of city/geography of the residency program (OR 1.710 [CI 1.272-2.298] p<0.001). CONCLUSIONS: Over time, child neurology residency applicants are putting more emphasis on quality of life factors over curriculum. To accommodate these changes, child neurology residency programs should prioritize interactions with residents during the interview process as well as resident wellness initiatives throughout residency training. The first child neurology training programs were established in the latter half of the 20 th century. Resident characteristics, curricula, and program oversight have evolved over time. These include increased representation of women and minorities in medical school classes 1 , duty hour restrictions, and a growing appreciation for physician burnout 2,3 with specific focus on the well-being of resident physicians. 4 In parallel, there have been changes in the child neurology residency application and matching process. Initially, there was no formal process, but in 2005 applicants were matched to programs by the San Francisco Residency and Fellowship Match Service with a subsequent transition to the current National Resident Matching Program (NRMP) in 2012. This most recent transition allowed for more cooperation between child neurology and pediatrics residency programs that eventually led to the categorical 5-year child neurology residency position. Over this time there has been an increase in number of child neurology residency positions offered and filled. 5 The gap between number of positions offered and those that are filled has narrowed over the years, however there are child neurology programs that remain unfilled in the match. There is growing variation between training programs in size and structure, including how time is divided between pediatric and adult neurology training. 6, 7 Some programs condense adult neurology into one year while others spread it out over three years. The Accreditation Council for Graduate Medical Education (ACGME) has set a minimum amount of clinical training (e.g. inpatient time and specific electives), but further inpatient clinical time, EEG training, research, and other electives vary between programs. With increasing adaptations to curriculum among child neurology residency programs, it is not clear how important these differences are to residency applicants, relative to other priorities. The NRMP residency match data from 2020 shows child neurology residency applicants demonstrated match rate of 90% for US allopathic seniors and 80% for US osteopathic seniors. 8 A relatively higher proportion of US allopathic seniors applying to child neurology also hold PhD degrees compared with other specialties and United States Medical Licensing Exam Step 1 scores that are on par J o u r n a l P r e -p r o o f with those matching into competitive fields such as anesthesiology, emergency medicine, and general surgery. 9 Medical school class composition continues to grow in diversity with increasing number of women and minorities represented in medicine. As of 2017, over half of all US medical school matriculants are women. 1 Electronic Residency Application Service (ERAS) data for child neurology residency applicants reveals a trend over the past 5 years of gradually increasing representation of female applicants, with the 2020 NRMP match consisting of 58% female applicants. 10 Child neurology workforce data from 2002 evaluating practicing physicians performing at least 20 hours of patient care per week showed overall male predominance (69.4% male out of 604 respondents), particularly those who had been practicing 15 years or longer (74% male). 11 The 2015 AAP/CNS Joint Taskforce survey reporting child neurology workforce data yielded responses from 523 practicing physicians and 97 trainees which showed sex distribution of 37.5% female practicing physicians and 64% female trainees. There was a higher predominance of physicians with MD/PhD degrees (5.9%) in the practicing physicians than trainees and trend for increasing representation of trainees with DO degrees (1.7% practicing physicians and 12.6% trainees). 12 Given the changes in applicant demographics and educational backgrounds, we questioned whether this his created a shift in training priorities. Several specialty-specific and multi-specialty studies have evaluated various applicant priorities in selecting a residency, including resident morale, [13] [14] [15] [16] [17] interpersonal fit, 14 faculty involvement/teaching, 13, 14 depth and breadth of faculty, 13 academic reputation, 17 career preparation, 13 interview day experience, 16, 17 geographic location, 13, 14, 18 and proximity to family. 18 A better understanding of child neurology residency applicant priorities would help to improve the match system and ensure programs are able to attract excellent candidates. In these shifting times, we sought to achieve better understanding of who our child neurology applicants are, where their priorities lie in crafting their rank lists, and how this has changed over time. The survey contained seven questions and took approximately 1.5 minutes to complete. Participants were asked to identify their year of graduation from medical school, age at time of residency application, degree obtained (MD, DO, MD/PhD), international medical graduate status, sex, and whether or not they participated in the couple's match. They were then asked to select the five most important factors in choosing a residency among the following options: residency size, number of faculty, clinical curriculum and training, sub-specialization of faculty, interactions with faculty, research opportunities, resident workload, resident happiness/wellness, interactions with residents, interactions with program director(s), perception of adult neurology training, post-graduate opportunities/fellowships, post-graduate resident jobs/placement, perception of city/geography, spouse/family reason, pediatrics training, and other (with free-text for specification). Due to the nature of the survey software, respondents could choose more or less than five items, if desired. We used a binary logistic regression model to examine the effect of medical school graduation year per decade and sex on the selection of clinical curriculum and training, faculty sub-specialization, interaction with faculty, interaction with residents, interaction with program director, resident happiness/wellness, and location. For the combined categories of work/life balance, academic factors, and interpersonal factors, a general linear model was used to model the data. Due to the variable amount of responses, a hypergeometric distribution was used to calculate deviation from assumed response rate within each category to actual response rate. Based on this method, each participant's preferential selection of the combined categories can be determined. Our institutional data was reviewed with descriptive statistics. A total of 284 responses were received for the "Child Neurology Applicant Priorities" survey. Respondent demographics are outlined in Table 1 Many factors contribute to resident well-being and happiness in any given training program, but strong social relatedness has been identified as a protective factor for resident burnout. 4 This sense of social relatedness may be crafted by multiple components including overall culture of a training program, relationships with faculty, co-residents, geography, and proximity to family and loved ones, which was evident on our institutional survey results, as well. Residency program directors will not be surprised to find that interaction with current residents is prioritized given this is highly emphasized on interview days. Residents get ample face time with applicants during scheduled social events and are encouraged to participate in casual conversations during applicant lunches and hospital tours. The increased emphasis on resident interaction may be a byproduct of how the interview day structure itself has evolved as opposed to a true change in applicant priorities. Regardless, this poses a particularly difficult challenge for residency recruitment in times of social-distancing due to the COVID-19 pandemic present at the time of writing this manuscript. With the likelihood that residency interviews will rely heavily on video conferencing, applicants will lack exposure to many of the interpersonal facets that come with in-person interview days. Programs will need to be more creative about attracting applicants to their program and applicants may need to invest more time remotely getting acquainted with programs and locations. Prioritizing quality of life features also speaks to the increasing attention of the medical community on physician burnout, which is becoming more frequently recognized, discussed, and J o u r n a l P r e -p r o o f addressed in residency programs with implementation of tools to identify residents in distress. 19 Physician burnout issues have entered the public eye through the lay press, as well. 20 Burnout prevalence and worklife imbalance are higher among neurologists than physicians in most other specialties. 2 It is perhaps not surprising that child neurology applicants would seek to protect themselves from burnout by looking for wellness initiatives being supported and showcased during interviews and prioritizing these qualities when crafting their final rank list. The increased priority placed on quality of life measures may be occurring at the expense of decreased interest in institutional-specific curricula. This decreasing emphasis may be related to overall increasing homogeneity of child neurology residency training. Programs are adapting to ACGMEmandated changes in structure, including decreased adult neurology time and increased duty hour restrictions that results in fewer differences between programs in outpatient and inpatient clinical demands. The decrease is unlikely to be related to an applicant's desire to be "less academic," as child neurology training programs are predominantly at moderate and large academic hospitals and the specialty remains a common destination for MD/PhD applicants. 9 Similarly, our institutional survey data supports a continued priority placed on research opportunities. Over time there has been an increased number of female applicants for residency training programs in child neurology. This follows the same trend as demonstrated by national data for pediatrics and pediatric subspecialties. 1 The only difference between sexes in priorities we identified was a higher emphasis placed on interaction with faculty by females. At present, with growing appreciation for wage gaps and gender bias in academic medicine, 21 mentorship is a proposed method to address the barriers to advancement of female physicians. 22 Thus female applicants may be looking for representative role models, particularly women in positions of leadership, who would serve as mentors. With survey respondents skewing toward more recent graduates, there were some factors such as increasing weight placed on residency program size and the impression of the preliminary training in general pediatrics that were more likely to be reflections of graduation date, as these features were not a Finally, generational differences may impact applicant priorities as the Millennial workforce may be fundamentally different than prior generations. Millennials (those born between 1981 and 1999) have been noted to show increased need for affiliation with teams, strong peer bonds, sociability, and work-life balance as compared to Generation X (those born between 1965 and 1980). 23, 24 Additionally, a relatively high proportion of applicants with PhD degrees entering child neurology may contribute to a sense of delayed gratification regarding work/life balance, prompting more priority to be placed on these program qualities. There are several limitations to this study. We were reliant on others to distribute the survey, which is reflected in the lack of a responder rate and the inability to confirm which programs sent out the survey. It is also likely that there are institutional differences in the accuracy of alumni distribution lists and many graduates may not have received the survey. This is reflected in the increased number of responses from more recent medical school graduates, as current trainees and recent residency graduates are easier to contact than graduates from decades past. Applicants from over a decade ago also may have J o u r n a l P r e -p r o o f more consistency or historical bias given the longer time between their residency application and data collection. Those who have been in practice for longer may report factors that reflect their current values more so than their values at the time of residency application. The inability to have respondents select only five responses made statistical analyses more challenging. Imposing limits to responses on future surveys would help to better standardize data. Future surveys should also include racial demographic information. Our internal post-match surveys were primarily collected for our own recruitment development and predominantly contained qualitative data, which could impart unintended bias as answers were analyzed. Finally, there may have been program characteristics influencing applicants' choices that were not included in this survey. Survey respondents demonstrated an increased emphasis on quality of life and work/life-balance factors with decreasing weight on curriculum/academic factors. Resident happiness and well-being, interactions with residents, and geographic location all have increased over time as priorities when selecting a residency training program. This trend may be influenced by shifting demographics of residents, increasing awareness of physician/resident burn-out, and an emphasis on resident well-being. Ultimately, the information collected by this survey allows for all child neurology residency programs to optimize commonly desired aspects of residency training and highlight these features during the interview process. J o u r n a l P r e -p r o o f Trends are displayed for all respondents (dashed line) and by sex (males: blue and females: red). There was a decrease over time in the odds of applicants ranking curriculum (A) and significant increases over time in ranking interaction with residents, residency location and resident happiness (B, C, D). 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Bradley Schlaggar and Soe Mar for their thoughtful input and feedback during the creation of the survey and manuscript preparation.