Insights on Residency Training

Dr. Khan is an Internal Medicine Chief Resident at Houston Methodist Hospital in Texas.

About 10 minutes into my virtual fellowship interview, I hear a whimper from under the desk. Confusion turns quickly into panic as I feel the tiny paws of my puppy grab at me for attention, and I realize she has somehow escaped her playpen and sneaked into my interview room. I try to keep my cool as I sit there in my tiny closet-turned-office, a small space with great acoustics but faulty door hinges, apparently.  I consider coming clean immediately, but so many thoughts run through my head: What if the interviewer hates dogs? What if this is so unprofessional that it is seen as a red flag? (Or worse, if it’s seen as incompetence. If she can’t keep track of a puppy, how can she keep track of the wire during a cath?) I decide to keep the puppy’s appearance to myself and trudge on. Luckily, apart from some stiff answers on my part, the interview went fine.

I tell this story to my co-residents as we share our experiences from the fellowship interview season. Another resident shares her experience about when her apartment complex began testing the building fire alarm every few minutes during her interview: Each time she tried to answer a question, a loud siren would blare in the background. “Maybe they thought you were getting bleeped out by Zoom for cursing,” I said. Now that we have several thousand hours of collective Zoom/Webex hours under our belt, we can laugh and reflect on the growing pains of this past virtual fellowship interview season. Furthermore, despite some minor hiccups here and there, we agree on the benefit of the cycle being virtual, and we hope it stays that way.

Pippa, the Interview Crasher, being rewarded with a walk at Hermann Park.

As a PGY-3 chief recruiting for the next intern class while simultaneously interviewing for cardiology fellowship, I tried to take the positives from interviewing experiences of my fellowship-bound classmates and incorporate them into our own residency recruitment, while lobbying for the removal of the aspects that fell flat. Here are some reflections from the season, and insights as to why I hope this opportunity to improve a clunky, outdated process isn’t wasted by reverting back to in-person interviewing.

The Price of Admission

Applying and interviewing for the next step in your career shouldn’t be a financial undertaking. Removing the barrier associated with cost is an obvious advantage, not only for the financial well-being of applicants, but more importantly, for diversity and equity. Programs that were previously out of reach for applicants that may not have the financial ability to take flights, rent a car, and book a hotel on top of the base fees for applying to each program are finally within reach. Not to mention, there are only a certain amount of days allotted for interviews and carefully planning flights to not use more of your PTO than necessary is a stressor that won’t be missed. That is not to minimize the unique stressors of interviewing virtually (e.g., technical difficulties, securing an appropriate space to conduct the meeting) but I would rather battle Zoom fatigue than airline customer service for a delayed flight.

Is A 2D View Enough? The Culture Behind the Screen

Applicants have a few concerns with the virtual platform. Chiefly, they feel uneasy basing an opinion about a program and a city on a virtual interview day. After all, if you’re spending the next 3 years (or more) of your life in a city that is completely foreign to you, you probably want to see it. Most of the downside and hesitation stems from what may have been missed from the virtual display of interview day. Was everyone being honest, or was someone from the program standing behind the camera, staring the fellows down as they answered questions? Less obvious is the difficulty of picking up a stuffy vibe in the room. However, in my experience, asking the fellows candid questions generally yielded candid answers, especially if the program uses techniques like break out rooms where the setting was more intimate. Additionally, the virtual season actually allowed for more interaction with fellows, as people logged in from their cars, homes, or short breaks in the clinic to weigh in on their program. I actually think I got a better view on the culture of the program because of this feature. While the physical atmosphere is difficult to recreate in the 2D space, I found pre-made hospital tours (or impromptu walking tours) to be really helpful in that regard.

The Effect of Increasing Accessibility on Match Rates

Another issue is that of “interview hoarding.” For competitive specialties in particular, the concern is that top-tier applicants will over-apply and subsequently stockpile all extended interviews, thereby eliminating the trickle down effect of having interview spots open up where such applicants previously would have canceled. The simple answer to this would be to cap the number of interviews any one candidiate can amass, but the reality is much more nuanced, especially with the increasing competitiveness with each cycle. Also, the number of interviews needed to match differs for U.S. MDs, DOs, and IMGs. From a recruiting perspective, with such a high number of applications to sift through, adding more filters is the logical way to trim down the numbers to a digestible amount, which could adversely affect applicants that don’t fit stringent profiles. Moreover, after an interview, it’s difficult to gauge genuine interest if the applicant doesn’t have overt ties to the area or has never even been to the program’s city. Even if an applicant has serious interest in a program, having no ties appears to be a disadvantage that is underscored by a virtual cycle.

Troubleshooting Issues

Several specialties for the residency application cycle tried to account for these issues by implementing a supplemental application. Applicants indicated 2 out of 10 possible geographic regions in the U.S. as their preferences and then were able to send preference signaling tokens to a few programs of their choosing. Although it did circumvent some of the “pan applying,” it also offered up more areas of overthinking in a group of people who are particularly prone to overthink. At a glance, it would seem that signaling would increase the likelihood of getting an interview from that particular program, but it is hard to say how much of a negative effect not signaling has. Another proposal is to create a hybrid experience with virtual interviews having an in-person option. Though it provides the much desired facetime, it is hard to see a reality where the in-person applicants aren’t viewed more favorably, and even harder to imagine applicants willing to take that risk. A two-step process has also been suggested, where after the virtual interviews, a second round of limited in-person interviews is conducted in hopes of trimming down to those who are truly interested. Theoretically, this is more reasonable, but realistically, it prolongs the interview process where residents are already scraping together days off service to interview, and would now potentially have to use twice as much time.

 Where Do We Go From Here?

Whether applications stay virtual, requiring programs to begin investing in social media to recruit the ideal fit, or if a reasonable combination is implemented (such as an in-person open-house prior to the start of the season or after ROLs are submitted), the moment of reckoning for the match system is here. Let’s not waste a pandemic! Let’s seize this occasion to reimagine a system for the future, even if it means experimenting for a few more cycles.