key: cord-0828412-c8p83rei
authors: Raj, Jaya M.; Lai, Cindy J.; Higgins, Stacy; Chretien, Katherine C.; Barton, Todd; Kroker-Bode, Claudia A; Calderon, Alvin; Apaloo, Catherine; Shaheen, Amy W.
title: AAIM Principles and Recommendations for the 2021-2022 Internal Medicine Residency Interview Cycle in Response to the Continued COVID-19 Pandemic
date: 2021-08-16
journal: Am J Med
DOI: 10.1016/j.amjmed.2021.07.011
sha: c64606dbacc94e3cfaa7cfff091ac4d1e92a87d8
doc_id: 828412
cord_uid: c8p83rei

nan

The COVID-19 pandemic in 2020 led to swift collaboration between the undergraduate medical education (UME) and graduate medical education (GME) communities to support an all-virtual residency interviewing process. Although outcomes, such as new intern performance or satisfaction with virtual interviews, are not yet known, the medical education community must make decisions early in the process to allow students, internal medicine clerkships, and internal medicine residency programs to prepare for the 2021-2022 application season.

In 2020, the Alliance for Academic Internal Medicine (AAIM), a national organization representing leaders in undergraduate and graduate internal medicine education, published recommendations for the 2020-2021 internal medicine residency application cycle in response to the COVID-19 pandemic. The recommendations addressed multiple aspects of the application process, including conducting all-virtual interviews, suspending outside rotations, utilizing a standardized letter of evaluation (SLOE), advising students on the number of programs to which they should apply, and considering innovations to mitigate application inflation (1) . In May, 2021, AAIM convened a new writing group of UME and GME educators and charged them to develop a set of recommendations to advise residency programs and medical schools how interviews should be conducted during the 2021-2022 recruitment season. Using feedback gathered in informal conversation, discussion forum posts, and a multi-institutional survey of medical students who applied to residency during the 2020-2021 recruitment season (R.

Abraham, personal communication, April 26, 2021), AAIM first composed a list of advantages and challenges associated with virtual interviews (Table 1) .

Based on this past year's residency interview cycle and previous experiences, the potential advantages afforded to applicants and programs by virtual interviewing are significant. Probably the most impactful and well-recognized advantages are the cost and time savings to applicants. A study conducted in 2015 by the Association of American Medical Colleges (AAMC) found that medical students spent an average of $3,422.71 on residency interviews, with the bulk of the expense attributed to travel and lodging (2) . In the same study, medical students also reported that financial constraints limited their choices in where to apply and interview; by removing travel-related expenses, virtual interviews may allow students to apply and interview at programs they would not have otherwise considered. Additionally, the reduced financial burden on applicants can help promote equity by removing some of the barriers faced by students with limited resources. Finally, the reduced time needed for travel to interviews may allow medical students to be more present and engaged in their rotations.

There are also advantages of virtual interviewing to residency programs, including considerable cost savings and increased flexibility in scheduling interviews, since program directors and faculty can conduct virtual interviews from any location. Because residents would not be required to conduct in-person tours, travel between campuses, or go to offsite locations for meals and other recruitment events, a virtual recruitment season may afford residents and faculty more time to focus on clinical activities and other academic responsibilities.

The challenges posed by virtual interviews to applicants and residency programs are equally important to consider. In a virtual interview, both applicants and programs may have difficulty assessing a student's ability to thrive in their particular training environment. Applicants who apply to programs in unfamiliar geographic areas must contemplate relocating without having visited in person, which can have a negative effect on applicants as well as on programs in less popular locations. Moreover, programs may be limited in their ability to highlight intangible aspects, such as culture and residency camaraderie, in the virtual format, which may be a particular disadvantage for smaller, lesser known, and community-based programs. From an equity standpoint, applicants who are less comfortable with videoconferencing may not communicate optimally in a virtual interview, which can lead to potential bias from interviewers (3). Finally, residency programs across specialties struggle to deal with rising numbers of applications and the transition to all-virtual interviews this past year may have contributed to a tendency for students to apply to and interview at many more programs than they needed to match.

In addition to weighing the potential advantages and challenges associated with virtual interviews, AAIM developed a set of guiding principles to inform the recommendations. These principles were agreed upon as essential to preserving the integrity of the resident recruitment process and the public good.

imperative that the interview process avoids placing any population at significant risk.

2. The residency application process should be viewed through the lens of equity. Recommendations must take into account the potential positive or negative impact on equity among individual applicants as well as among residency programs.

3. Preserving the educational mission during recruitment season is important for the entire medical education community, including students, residents, faculty, and staff. advisors should draw on their school's specialty-specific match data to estimate how many programs an individual student should apply to and interview with, while acknowledging the limitations of available data from last year. Drawing on prior year data would help advisors provide more specific guidance to students across the academic spectrum. In addition, creating a process to collect real-time data from students-and giving advisors access to this data-would allow them to provide individual recommendations to students about keeping or releasing interviews, thus potentially opening up interviews for other applicants while ensuring that students have a sufficient number of interviews to secure a successful match.

The success of virtual interviews is dependent on many external variables, such as the quality of visual and audio equipment, a reliable Internet connection, and access to a quiet, professionalappearing space that is free from distractions. Applicants with limited access to these resources are disadvantaged during virtual interviews and would benefit from having spaces provided for them by their school or institution. Medical schools can also provide students with a standard video conferencing background which could be used for all interviews.

Program directors and faculty interviewers have implicit and explicit biases that may be introduced or amplified when interviews are conducted by videoconference (3). Residency programs should require faculty interviewers to engage in education in identifying and mitigating bias in virtual interviews. This faculty development can be conducted through in-person training and/or online modules (5) . There are also general resources available for program leaders and faculty describing best practices for virtual interviewing (6).

Coaching on how to conduct a successful virtual interview should be provided by medical school advisors who are experienced in this area. Students should be directed to move the camera to eye level and to ensure optimal lighting and sound. Advisors should also discuss virtual etiquette, e.g. how to interact when there are multiple applicants and/or faculty present on the call, how to enter and exit breakout rooms, and when to use the chat box or raised hand versus speaking out loud, depending on the situation. Mock virtual interviews may be offered to students, with coaches paying attention to these details and giving feedback. Advisors should also encourage students to make use of online resources that guide them through the virtual interview process (6, 7) .

While the pandemic remains a threat to public safety at this time, rates of COVID infection have decreased and vaccination rates increased in many states in the United States. It is possible that interstate and even international travel may resume safely during the 2021-2022 interview season. In that case, AAIM may issue an addendum to these recommendations, including consideration of optional in-person recruitment activities or second-look visits. However, it is essential that programs apply the principle of equity in any future decisions about optional inperson visits. It will also be important for programs to be transparent and to communicate clearly with applicants about activities which are strictly optional and will not affect their rank on the rank list.

Collaboration between the UME and GME communities during the 2020-2021 recruitment season was essential to ensuring a smooth process for the 2021 Match. Once again, residency program directors and clerkship directors should work together to find solutions, share best practices, and meet common goals. Other organizations, such as the Coalition for Physician Accountability, have effectively used this approach to issue a preliminary set of recommendations for guiding the UME to GME transition, which includes recommendations for all-virtual interviews during the 2021-2022 recruitment season and ongoing research to study Match outcomes (8) . In addition, AAIM released recommendations for the 2021-2022 internal medicine fellowship application cycle, which includes a strong recommendation for fellowship programs to conduct virtual interviews for all applicants, including learners at their own institution (9) . As the medical education community plans for another interview season during the COVID pandemic, it is critical to learn from the past year's experiences and to keep the principles of guarding public safety, promoting equity, preserving the educational mission, and providing applicants and programs the best opportunity for an optimal match in 2022 at the forefront. 

Cost and time savings to applicants and programs Flexibility for programs and applicants in scheduling interviews

Allows students, including those with limited financial resources, to interview at a wider range of programs Less disruption to medical students' clinical rotations Less disruption to residents' and faculty's schedules on interview days

Difficult for applicants to gauge culture and their own ability to thrive at programs without in-person visit

Difficult for programs to convey intangibles to applicants, such as culture and camaraderie

Applicants must consider relocating without having visited the program's location.

Applicants with limited experience in videoconferencing may be subject to bias.

Application "inflation" (tendency to apply to more residency programs than needed for a specific student)

Interview "inflation" (tendency to interview at more interviews than needed for a specific student)

AAIM Recommendations for the 2020-2021 Internal Medicine Residency Application Cycle in Response to the COVID-19 Pandemic

Cost of Applying to Residency Questionnaire Report

Avoiding the Virtual Pitfall: Identifying and Mitigating Biases in Graduate Medical Education Videoconference Interviews

Trends in US Internal Medicine Residency and Fellowship Applications During the COVID-19 Pandemic vs Previous Years

Addressing implicit bias in virtual interviews

Conducting Interviews During the Coronavirus Pandemic

Best Practices to Successfully Navigate a Virtual Interview: a Five-Step Guide for Hematology/Oncology Fellowship Applicants

Initial Summary Report and Preliminary Recommendations of the Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC)

AAIM Recommendations for the 2021-2022 Internal Medicine Fellowship Application Cycle in Response to the Continued COVID-19 Pandemic