AAIM Principles and Recommendations for the 2021-2022 Internal Medicine Residency Interview Cycle in Response to the Continued COVID-19 Pandemic

Clinical Significance•Residency programs should conduct all interviews virtually during the 2021-2022 recruitment season.•Medical schools should advise students on the number of applications to submit and the number of interviews to accept.•Medical schools should offer students coaching on virtual interviews.•All interviewers should be educated about identifying and mitigating unconscious bias.•There is insufficient data to make recommendations about optional in-person activities. •Residency programs should conduct all interviews virtually during the 2021-2022 recruitment season.•Medical schools should advise students on the number of applications to submit and the number of interviews to accept.•Medical schools should offer students coaching on virtual interviews.•All interviewers should be educated about identifying and mitigating unconscious bias.•There is insufficient data to make recommendations about optional in-person activities. The coronavirus disease (COVID-19) pandemic in 2020 led to rapid 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 and 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, advising students on the number of programs to which they should apply, and considering innovations to mitigate application inflation.1Chretien KC Raj JM Abraham RA et al.AAIM recommendations for the 2020-2021 internal medicine residency application cycle in response to the COVID-19 pandemic.Am J Med. 2020; 133: 1223-1226Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar 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 on 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).TableVirtual Interviewing: Potential Advantages and ChallengesAdvantagesChallengesCost and time savings for applicants and programsFlexibility for programs and applicants in scheduling interviewsAllows students, including those with limited financial resources, to interview at a wider range of programsLess disruption to medical students’ clinical rotationsLess disruption to residents’ and faculty's schedules on interview daysDifficult for applicants to gauge culture and their own ability to thrive at programs without an in-person visitDifficult for programs to convey intangibles to applicants, such as culture and camaraderieApplicants must consider relocating without having visited the program's locationInterviews of applicants with limited experience in videoconferencing may be subject to biasApplication “inflation” (tendency to apply to more residency programs than needed)Interview “inflation” (tendency to interview at more residency programs than needed) Open table in a new tab This past year's residency interview cycle and previous experiences suggest that the potential advantages afforded to applicants and programs through virtual interviewing are significant. Perhaps 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 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.2Fried J. Cost of applying to residency questionnaire report. Available at: https://www.aamc.org/system/files/c/2/430902-costofapplyingtoresidency.pdf. Accessed June 24, 2021.Google Scholar 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 in virtual interviewing for residency programs, including considerable cost savings and increased flexibility in scheduling interviews because 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 resident 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 introduce potential interviewer bias.3Marbin J, Hutchinson YV, Schaeffer S. Avoiding the virtual pitfall: identifying and mitigating biases in graduate medical education videoconference interviews.2021.Google Scholar 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. •Preserving the health and safety of individuals and communities is paramount. It is imperative that the interview process avoids placing any population at significant risk.•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 and among residency programs.•Preserving the educational mission during the recruitment season is important for the entire medical education community, including students, residents, faculty, and staff.•Both applicants and residency programs should have the opportunity, within the constraints of the COVID-19 pandemic, to determine if the applicant would thrive in that program's learning environment. The COVID-19 pandemic has led to surges across the globe, with emerging variants and peaks at different times in different parts of the United States and internationally. Although vaccines have reduced infection rates in the United States, vaccine distribution varies among regions and worldwide. It is difficult, if not impossible, to predict which areas will experience a surge during the upcoming recruitment season. In 2020, many countries, states, cities, and institutions imposed strict travel restrictions and limits on group gatherings, and these restrictions may be repeated in 2021-2022. Consequently, some international medical graduates may not be able to travel to the United States during the pandemic; because international medical graduates are an essential part of the internal medicine physician workforce, it is critical to remove potential barriers to interviewing them for residency. To allow applicants and programs to plan ahead, AAIM recommends that all programs conduct their interviews virtually this season, including interviews of students matriculating, visiting, or rotating at their institution. This modification would also mitigate disparities among applicants in terms of access to travel (e.g., due to differences in travel restrictions between countries) and would allow all applicants to interview at the programs of their choice regardless of their location. In addition, virtual interviewing may help institutions achieve a reasonable balance between the time requirements of interview season and ongoing clinical demands, thereby helping to promote full faculty, resident, and student engagement in clinical rotations. In 2021, there were 24,509 applicants to internal medicine residency programs, compared with 21,947 applicants in 2016. In addition, the number of applications submitted per applicant increased from 57.8 in 2016 to 71.8 in 2021 and was up 11% from 2020.4Huppert LA Santhosh L Babik JM. Trends in US Internal Medicine Residency and Fellowship Applications During the COVID-19 Pandemic vs Previous Years.JAMA Netw Open. 2021; 4e218199https://doi.org/10.1001/jamanetworkopen.2021.8199Crossref PubMed Scopus (17) Google Scholar Medical school 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 the data from previous years 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 declining 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, professional-appearing 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 through videoconferencing.3Marbin J, Hutchinson YV, Schaeffer S. Avoiding the virtual pitfall: identifying and mitigating biases in graduate medical education videoconference interviews.2021.Google Scholar 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, online modules, or both.5Addressing implicit bias in virtual interviews. https://www.aamc.org/what-we-do/mission-areas/medical-education/conducting-interviews-during-coronavirus-pandemic#implicit. Accessed June 1, 2021.6.Google Scholar There are also general resources available for program leaders and faculty describing best practices for virtual interviewing.6Conducting interviews during the coronavirus pandemic. Available at: https://www.aamc.org/what-we-do/mission-areas/medical-education/conducting-interviews-during-coronavirus-pandemic#program. Accessed June 24, 2021.Google Scholar Coaching on how to undergo 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 or faculty present on the call), how to enter and exit breakout rooms, and when to use the chat box or raised hand vs 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.6Conducting interviews during the coronavirus pandemic. Available at: https://www.aamc.org/what-we-do/mission-areas/medical-education/conducting-interviews-during-coronavirus-pandemic#program. Accessed June 24, 2021.Google Scholar,7Huppert LA Babik JM. Best practices to successfully navigate a virtual interview: a five-step guide for hematology/oncology fellowship applicants.J Cancer Educ. 2020; 35: 860-861Crossref PubMed Scopus (3) Google Scholar Although the pandemic remains a threat to public safety at this time, rates of COVID-19 infection have decreased and vaccination rates have 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 in-person visits. It will also be important for programs to be transparent and to communicate clearly with applicants about the activities that 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 for 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, including recommendations for all-virtual interviews during the 2021-2022 recruitment season and ongoing research to study Match outcomes.8Initial summary report and preliminary recommendations of the Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC). Available at: https://physicianaccountability.org/wp-content/uploads/2021/04/UGRC-Initial-Summary-Report-and-Preliminary-Recommendations-1.pdf. Accessed June 1, 2021.Google Scholar In addition, AAIM released recommendations for the 2021‐2022 internal medicine fellowship application cycle, which includes a strong recommendation that fellowship programs conduct virtual interviews for all applicants, including learners at their own institution.9AAIM recommendations for the 2021-2022 internal medicine fellowship application cycle in response to the continued COVID-19 pandemic. Available at: https://www.im.org/resources/ume-gme-progra-resources/resources-fellowship-application. Accessed June 29, 2021.Google Scholar As the medical education community plans for another interview season during the COVID pandemic, it is important to learn from the experiences of the past year and to keep the principles of guarding public safety, promoting equity, preserving the educational mission, and providing applicants and programs with the best opportunity for an optimal match in 2022 at the forefront.