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    Applying to residency is tough even in normal times. The pandemic isn’t helping.

    This year, COVID-19 has ended in-person interviews, scrambled exam dates, limited ways to get recommendation letters, and more. What has to happen to make the residency application process smooth — and fair?

    A woman looks intently at a laptop while holding a piece of paper

    Last year, Samuel Bunting, a student at the Chicago Medical School at Rosalind Franklin University of Medicine and Science, spent his psychiatry clerkship helping LGBTQ+ patients handle such painful issues as family rejection, social stigma, and substance use. He quickly saw that working with this population was his calling. “I knew that if I had been a little less fortunate in how I grew up, that very easily could have been me,” says the fourth-year student. "It was one of the most meaningful experiences I’ve ever had.”

    Now, though, Bunting worries about landing a spot in a residency program that shares his values and supports his goals. Like tens of thousands of other residency applicants, Bunting fears the numerous ways that COVID-19 is hobbling this year’s application process.

    “Honestly, I’m not a good standardized test-taker, but I am an outstanding student by other measures like leadership,” says Bunting. “I worry that those won’t matter as much given the lack of in-person interviews and the many other changes in the application process that we’re seeing.”

    The transition to residency is tough even in normal times. It typically starts during the third year of medical school, when students gather key components — letters of recommendation, a personal statement, and more — that they can then load into the Electronic Residency Application Service® (ERAS®) starting in June. The goal is to land coveted interview invitations, which usually get taken almost as soon as they’re offered. Interviews begin in the fall, span months, and culminate, applicants hope, with offers from their top picks in the National Resident Matching Program® in March.

    But this year’s application cycle will be far from typical.

    “Program directors are stressed out about how we’re going to recruit and pick the right students for our programs — and the medical students are a thousand times more stressed than we are.”

    Melvyn Harrington, MD
    Program director for orthopedic surgery, Baylor College of Medicine

    “Clinical clerkships were disrupted, so applicants will have difficulty getting desired letters of recommendation, and many students had their board exams postponed, some more than once,” says Jessica Kovach, MD, director of the psychiatry residency program at Lewis Katz School of Medicine at Temple University. On top of that, the Coalition for Physician Accountability — a group of medical education organizations that includes the AAMC — recommended ending all in-person interviews and strictly limiting “audition” rotations at residency programs because of the pandemic.

    “This is a seismic shift,” says Melvyn Harrington, MD, program director for orthopedic surgery at Baylor College of Medicine. “Program directors are stressed out about how we’re going to recruit and pick the right students for our programs — and the medical students are a thousand times more stressed than we are.”

    Harrington and others worry that student stress may send application numbers skyrocketing. In fact, candidates were already submitting increasing numbers of applications even before COVID-19. That’s because the number of U.S. medical school students has grown 31% since 2002 — but residency slots have not kept pace, largely due to insufficient federal funding.

    Perhaps even more worrisome, experts say, is the potentially unequal impact of changes on certain students, including those from groups that are underrepresented in medicine, many of whom have been hit hard by COVID-19, racial injustice, and current social, political, and racial unrest.

    All this has sent leaders in academic medicine searching for effective solutions. ERAS extended its deadline from Sept. 15 to Oct. 21 to give applicants extra time to build their application portfolios. In addition, medical schools, program directors, and national organizations have been pumping out resources and recommendations to guide all involved through this unprecedented application cycle.

    “This year, there has to be robust engagement between schools, residency programs, and learners, and I’ve certainly been seeing this,” says Jennifer LaFemina, MD, general surgery program director at the University of Massachusetts Memorial Medical Center. “Sometimes, as we educators work to support our learners at different phases, we don’t always work in tandem, but now we must be collaborative every step of the way. If we don’t, we could lose sight of what this comes down to: safety and equity for all our learners.”

    The race for interviews

    For residency applicants, there are two basic stages in the quest for a slot: the steps leading up to landing an interview and then, hopefully, acing the interview.

    Several factors go into a program's decision to offer an interview, and many of those have been upended by the need to protect students and the public during the pandemic.

    Among the most influential metrics are scores on the United States Medical Licensing Examination (USMLE), which assesses such crucial areas as clinical knowledge. This year, the test-taking process has been unusually unnerving.

    In March, as the pandemic spread, the company that runs USMLE test sites temporarily ended all exams in the United States and Canada. Sites began reopening in May, but many students have been affected by last-minute cancellations as the company has limited the number of test-takers to enable social distancing.

    “I was ready, but I didn’t know when I could take the test,” says Adiba Matin, a fourth-year student at the University of Missouri - Kansas City School of Medicine. “It was very stressful trying to keep all the information fresh in my mind,” she adds. “Ultimately, my test was postponed four times.”

    Also topping applicants’ worries are landing valuable letters of recommendation.

    “Students have a lot of anxiety about getting letters that reflect their true abilities,” says Angela Jackson, MD, associate dean of student affairs at Boston University School of Medicine. Much of the concern lies in lost opportunities to impress faculty as the pandemic shuttered clerkships for months this spring. “Even now that students are back, sometimes the volume of patients is down, so they have fewer chances to show their skills,” she notes.

    “It was very stressful trying to keep all the information fresh in my mind. Ultimately, my test was postponed four times.”

    Adiba Matin
    University of Missouri - Kansas City School of Medicine

    Students are also concerned about the canceling of away rotations — often called “audition rotations” — that work like weekslong trial runs at outside institutions. In 2019, 56% of medical students completed these rotations, and some did several.

    Now, 98% of responding schools have decided to curtail away rotations, according to an AAMC survey, with a number allowing exceptions for medical specialties that are unavailable at their own schools.

    Meanwhile, some students say they will take advantage of a new option: virtual away rotations. In fact, nearly 70 of these remote options have sprung up in more than a dozen specialties. How will they work? A program might send students information about patients and then ask them to present their treatment recommendations via Zoom, for example. It’s not the same as in-person interactions, students say, but they’re glad to have some creative alternatives.

    “Even though the experience will be remote, I believe it still can deepen my knowledge in my future specialty,” says Ushasi Naha, a fourth-year student at the University of Illinois College of Medicine. “I also like that virtual aways can provide me the opportunity to show interest in some of my top residency programs.”

    Virtual interviews, real decisions

    Before COVID-19, applicants attended 13 interviews on average and often spent thousands of dollars traveling to them. This year, as the pandemic has forced interviews online, students are thrilled with the cost-savings. But many also fear the downsides of going virtual.

    “People are concerned about conveying personality in a virtual interview,” Naha says. “Then there are worries about good lighting, good internet, and a quiet place to take an interview that could last all day.”

    Virtual interviews also mean applicants will lose traditional opportunities to size up programs, especially such intangibles as interpersonal dynamics that they might assess at pre-interview dinners and other informal events.

    Now, applicants are hoping for other ways to gain such glimpses. For example, students want private chats with existing residents where they can ask some tougher questions, says Robbie Daulton, a fourth-year University of Cincinnati (UC) College of Medicine student who surveyed fellow students for a paper on this year’s process.

    “People are concerned about conveying personality in a virtual interview. Then there are worries about good lighting, good internet, and a quiet place to take an interview that could last all day.”

    Ushasi Naha
    University of Illinois College of Medicine

    Meanwhile, as programs and applicants all gear up for interviews, they share one key concern: Will candidates accept many more interviews than before since they won’t have to travel?

    “Now it could be a lot easier for students to hold on to more invitations than they truly need,” says Aurora Bennett, MD, associate dean for student affairs at the UC College of Medicine. “Advisors will have to help more competitive students let go of some interviews,” she adds. “They need to identify a reasonable number to have a successful match and release others so their peers who need them can have them.”

    Finding ways forward

    Faced with unprecedented challenges, leaders in academic medicine say they’re working hard to determine how to ease application obstacles and assess students fairly.

    “Each program will determine how it can best address any current limitations in the process,” notes Alison Whelan, MD, AAMC chief medical education officer. “I continue to be impressed with the creativity, energy, and commitment that both schools and programs are using to overcome barriers and create a successful process. Some programs are considering such new approaches as requesting secondary essays about why an applicant is drawn to that institution.

    “Certainly, we hope programs will use holistic review, looking at a candidate’s full range of experiences and attributes — and we have heard of a variety of ways programs are tackling this, given their time limitations and stresses related to their current residents and the ongoing pandemic,” Whelan adds.

    Richard Church, MD, emergency medicine residency director at the University of Massachusetts Medical School, is determined to give every application its due. “This year, I have to be even more diligent, examining every single part of applications,” he says. The increased load may require him to enlist additional application readers — an option that may not be feasible for all programs, he notes.

    Church advises this year’s residency hopefuls to think carefully about how to highlight key achievements in their ERAS applications.

    A lot of applicants went to great lengths to do something productive with themselves [when clerkships closed], so even if it’s not the usual type of experience, they should present that. And if they didn’t do much, they should explain why.”

    He also notes that letters will be particularly important to him this year in the absence of some other metrics. “I’d tell applicants to put serious thought into who you want to write your letters. Look for people who can speak to you as a student as well as to you as an individual.”

    On his end, Harrington predicts research output will play a larger role since students could perform duties like literature reviews online during the pandemic. “We will, of course, continue to look at grades and traits like leadership,” he adds. “Also, I think applicants will need to be creative with their personal statements to really tell their individual stories and help them stand out.”

    As programs and applicants feel their way forward, national organizations are providing guidance and support. For one, USMLE leaders say they are committed to testing applicants in time for scores to reach programs in October.

    Meanwhile, the AAMC and other groups are working to create resources to support students and programs in navigating the many changes. For one, the AAMC and several other organizations recently began providing a tool called Residency Explorer to help candidates apply more effectively. The AAMC also released resources on virtual interviews and issued guidance for explaining students’ pandemic-related limitations on the Medical Student Performance Evaluation, a structured assessment provided by an applicant’s medical school.

    “They’re not going to believe me until it’s over, but it’s going to be okay. I tell them it’s our job to help make sure it’s okay.”

    Angela Jackson, MD
    Associate dean of student affairs, Boston University School of Medicine

    In addition, many medical specialty organizations have issued COVID-19-related suggestions, such as that programs loosen rules around numbers and types of recommendation letters.

    Medical schools are stepping up to help as well. For example, Boston University’s Jackson is offering various application-related events, including a virtual-interview workshop featuring tips from broadcast journalists. The office also is increasing the number of scheduled guidance sessions and connecting students with recent alumni who can provide insights as applicants assess whether a program might make a good fit.

    Jackson says she’s determined to help students succeed despite any obstacles. “They’re not going to believe me until it’s over, but it’s going to be okay,” she notes. “I tell them it’s our job to help make sure it’s okay.”

    Helping those hit hardest

    As leaders strive to help all applicants, they worry in particular about those who may be most affected by the pandemic, including students of color.

    “There’s an ongoing sense of exhaustion from having to deal with racism in this society,” says Alex Lindqwister, national chair of the AAMC’s Organization of Student Representatives. “On top of that, there’s COVID-19, which disproportionately affected African American students, many of whom also live in cities that have been affected by police brutality and recent protests,” he adds. “I hope holistic review will help, that programs will look at the context in which applicants managed to make their achievements.”

    Harrington worries that some students who lack connections will be at a disadvantage. “With so many changes, I’m concerned that things are going to fall back a bit to the old boys’ club of who's making phone calls or sending emails for you.” In his field of orthopedic surgery, national organizations dedicated to diversity are trying to mentor students and reach out to programs on their behalf, he notes.

    Economic disparities play a role as well, say observers. For example, some students may have weak Wi-Fi or other less-than-ideal at-home interviewing conditions. “Maybe someone is in their small childhood bedroom for their virtual interview, but someone else is at their parents’ lake house, so that’s their beautiful backdrop,” says Daulton.

    In response, schools are working to offer students campus spaces for their interviews. Daulton makes another suggestion: Schools or programs should provide a standardized interview backdrop to level the playing field. "We’re also recommending anti-racism and implicit bias training for people involved with application evaluation.”

    Individuals from lower-income backgrounds also sometimes attend lesser-known medical schools, which could hurt their chances, says Lindqwister. “A lot of these issues all tie in together as certain students face multiple inequities.”

    Matin says she attends a lesser-known school, and she worries that given all the COVID-19-related changes, “programs are going to look at names and numbers a little bit more intensely this cycle.”

    Still, Matin remains optimistic. “At the end of the day, I’m confident I’ll match somewhere,” she says. “I know I’ll be able to help patients, which is really all I want to do.”