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You missed a late-night email. Could you lose your dream residency?

Jesse Burk Rafel, MD, MRes
October 4, 2019

In the race to grab residency interview slots, medical students often forgo sleep, studies, and more to quickly reply to invites. A recent applicant lays out a plan to fix a badly broken system.

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Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.

I had just driven six hours to Chicago, Illinois, for my seventh residency program interview in about a month. Already a bit depleted, I took a seat at yet another preresidency dinner, and even started enjoying a conversation about research interests. Then my phone suddenly vibrated with an unmistakable pattern: three short, three long, three short buzzes. It was the “SOS” ringtone I’d set for emails containing the words “residency” and “interview.”

I felt a rush of anxiety as I considered my options: Pull out my phone, which I decided was too rude, or step away to the bathroom. I certainly couldn’t afford to hesitate. I was waiting for interview invites from other programs, and if I didn’t respond immediately, I might miss out on one of the interview spots that — in first come, first served fashion — routinely fill within minutes.

[I]f I didn’t respond immediately, I might miss out on one of the interview spots that — in first come, first served fashion — routinely fill within minutes.

In the cramped bathroom, I confirmed a new invite and began quickly working through the online scheduling form, cross-referencing my existing interview dates with my personal and medical school calendars. My rapid response was fortunate: I managed to grab a date that looked good. Still, I wasn’t sure that I’d be allowed to miss several days of a fourth-year elective to attend. I headed back to dinner, my mind still swirling with scheduling worries.

As I was leaving the restroom, I noticed another candidate who also appeared to be scheduling an interview. He and I — and tens of thousands of other applicants — were caught up in a badly broken residency interview process.

The interview race

Residency candidates submit their applications on Sept. 15. Then they spend the next several months anxiously waiting to hear if they’ve landed interviews, a key part of the competitive selection process.

The stress can be huge. Desirable time slots get grabbed quickly, and because some programs extend more interview offers than they actually host, delaying can mean losing out entirely. What’s more, interview season has no clear end, leaving applicants who haven't heard from a program wondering whether they’ll still hear back.

And because an invite can arrive at any time on any day, most students are tied to a smartphone 24/7 during interview season.

The stress can be huge. Desirable time slots get grabbed quickly, and because some programs extend more interview offers than they actually host, delaying can mean losing out entirely.

One peer reported checking for invites during rounds and excusing herself while presenting to “go to the bathroom” to respond. Others lost sleep because of compulsive nighttime checking, and many were distracted during classes and studying. Some reported passing up opportunities to scrub into surgery. And another created an email account linked to his brother’s and girlfriend’s phones so they could answer invites if he was unavailable. Despite this, a few minutes’ delay once left him on a waitlist, and when his team accidentally double-booked other interviews on the same day, he had to awkwardly ask a program to reschedule.

In sum, the current interview process has applicants nervously checking their phones at all hours, wary to go on rounds, scrub into surgery, or go to sleep — and gives unfair advantages to those with loved ones who can monitor their email. This is unacceptable for a profession that is committed to fairness and student well-being.

What fuels the problem?

The broken residency interview offer process is spurred by broader residency application issues, including leaps in application numbers. Applicants who successfully matched in 2019 submitted a median of 39 applications, up from 22 a decade prior (yet match rates have stayed the same).

Students feel like prisoners of the process, caught in an arms race in which applying to more programs — and accepting more interviews — seems essential. Students routinely attend interviews at programs that don’t really interest them, putting a strain on their energy and bank accounts.

Applicants say they might apply and interview less if they better understood which programs would likely be interested in them. Some new resources, such as the Residency Explorer, may help. But just as booklets on the benefits of quitting smoking do little to motivate my patients, additional information alone probably won't dramatically change student application behaviors.

Programs also struggle. For example, they worry about having unfilled interview slots if applicants cancel interviews at the last minute after hearing from a preferred program. Of course, they also need to wade through a flood of applications and try to assess candidates’ true degree of interest. Therefore, some programs feel a need to invite more people than they can interview — and to shoot out invites as soon as they've identified candidates that seem like a good fit.

Let's fix this

To tackle application overload, stakeholders have proposed sweeping changes like caps on applications or interviews, an early decision process analogous to undergraduate admissions, or a “star system” that would help programs measure applicants’ genuine interest. Such moves will be necessary to fix the broader system — but simpler steps could make interview season more humane as soon as the 2020 application cycle.

Here’s what I propose:

  • Setting common dates and times for extending interview offers (e.g., every Tuesday and Thursday at 5 p.m. local time), so students spend less time glued to their phones
  • Providing a clear and adequate timeframe for students to respond to invites, such as 48 hours
  • Committing that invites will not exceed the number of interview slots
  • Rejecting first come, first served scheduling
  • Establishing a common deadline by which programs will tell all applicants whether they are invited, waitlisted, or rejected

For this to work well, all programs in a specialty would need to buy in. Otherwise, many students will remain constantly vigilant, waiting to hear from programs that don’t agree to the guidelines. The organization representing internal medicine program directors provided a similar set of recommendations in 2018, but so far not all programs follow it.

Professional bodies representing OB-GYN faculty and residents also recently issued recommendations that are even more comprehensive, including two common interview release dates for all OB-GYN programs and a mechanism for students to provide real-time feedback on the process. Other stakeholders have recommended establishing just one interview offer week for all specialties, but that could place undue strain on programs working to achieve holistic review of applications in a short time frame.

Adoption of standards like the ones I suggest would free students to focus more fully on preparing for residency rather than on their phones.

Importantly, whatever the interview-offer time range, programs need to figure out how to replace first come, first served scheduling. That's because, even if other concerns are addressed, students will still feel pressure to respond quickly to secure an interview date that suits their schedules.

So, what are the options?

One approach would be for programs to collect ranked interview date preferences from invited students and then assign interview dates at the end of the offer window. This isn’t perfect, though: Students would still face stress while waiting to learn their scheduled date and would also risk double-booking interview dates. Alternatively, programs could provide invited applicants with nonoverlapping scheduling windows, set either by random lottery or by a rank order of students created by the program.

As stakeholders explore these and other possible solutions, the pilot for OB-GYN programs this year can inform discussions and decisions. Feedback from applicants will be crucial in identifying pitfalls of those preliminary steps as well as those programs with exemplary approaches.

Such efforts offer hope. The current residency interview process certainly does not serve medical students or residency programs. Adoption of standards like the ones I suggest would free students to focus more fully on preparing for residency rather than on their phones. What’s more, we owe it to our future physicians to treat them with the same dignity throughout the residency application process that we hope they will one day extend to their patients.

Photo of Jesse Burk Rafel, MD, author of this piece.

Jesse Burk Rafel, MD, MRes, is an internal medicine resident at NYU Langone Medical Center, an assistant editor for trainee engagement at Academic Medicine, and a member of the National Board of Medical Examiners’ RENEW taskforce on trainee wellness.

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