Program Directors' Perspectives on Residency Applications in the Post‒United States Medical Licensing Examination Step 1 Era: A Case for Standardized Letters of Recommendation?

INTRODUCTION

The United States Medical Licensing Examination (USMLE) Step 1 test evolved into a key metric utilized by program directors (PDs) in assessing candidates for residency. The transition to a USMLE Step 1 binary pass/fail scoring system has resulted in a loss of an important objective assessment. With national movements toward pass/fail systems for clerkship grading and trends toward abandonment of class ranking, assessing residency applications has become increasingly challenging.

METHODS

The Society of Academic Urologists convened a task force to, in part, assess the perspectives of urology PDs regarding the importance of various aspects of a residency application for predicting clinical performance. An anonymous survey was disseminated to all urology PDs in the US. Perspectives on 11 potential application predictors of clinical performance and demographics were recorded. Descriptive statistics characterized PD responses. Friedman test and pairwise Wilcoxon tests were used to evaluate the relative ranks assigned to application elements by PDs.

RESULTS

There was a 60.5% response rate (89/147). Letters of recommendation (LORs) were ranked as the most important predictor, with a mean rank of 2.39, median of 2 (IQR 1-3). Clerkship grades and USMLE Step 1 were comparable and ranked second. Medical school reputation ranked the lowest. There was significant subjective heterogeneity among categories; however, this was less so for LORs, which predominated as the most important factor among application elements (P < .001).

CONCLUSIONS

To our knowledge, this is the largest sample size assessing PD perspectives on application factors that predict clinical performance. The second (clerkship grades) and third (USLME Step 1) most important factors moving toward binary pass/fail systems create an opportunity for actionable change to improve assessment objectivity. Our data demonstrate LORs to be the most important factor of residency applications, making a compelling argument for moving toward a standardized LOR to maximize this tool, mitigate bias, and improve interreviewer reliability.

The Effects of Single Accreditation and Pass/Fail Licensing Exams on Osteopathic Medical Students Applying to Surgical Residency Programs

OBJECTIVE

To examine the effects of single accreditation and pass/fail licensing exams on osteopathic (DO) medical students applying for surgical residency.

DESIGN

Electronic surveys were distributed to 1509 program directors (PD) in 10 surgical specialties. PDs were separated into 2categories based on their program's accreditation status prior to single accreditation: formerly accredited by the American Osteopathic Association (AOA) or not accredited by the AOA. Separate chi-squared and binomial tests were used to determine statistical differences between PDs in each category and within each surgical specialty.

SETTING

Voluntary, anonymous, electronic survey.

PARTICIPANTS

Three hundred survey responses were received (response rate 19.8%) and 234 responses were included in statistical analyses. Sixty-six responses were excluded because the survey was incomplete, the survey was not completed by a PD, or the PD indicated disqualification of DO applicants from matching at that program.

RESULTS

The majority of PDs in both categories recommend or require that DO students take both United States Medical Licensing Examination (USMLE) Step1 [Χ2 (2, N = 234) = 8.939, p = 0.011] and USMLE Step 2 CK [Χ2 (2, N = 234) = 4.161, p = 0.125] despite pass/fail outcomes only on Step 1 and Level 1. When deciding whom to interview, PDs in both categories highly ranked USMLE Step 2 CK scores and letters of recommendation (LOR). Formerly-AOA-accredited programs highly ranked COMLEX-USA Level 2 scores (p = < 0.001) and completion of an audition rotation (p = 0.001). Non-AOA-accredited programs highly ranked the Medical Student Performance Evaluation (MSPE) (p = < 0.001) and clerkship grades/evaluations (p = 0.001).

CONCLUSIONS

Significant differences exist in programs despite single accreditation. DO applicants should take both USMLE Step 1 and Step 2 CK to be considered competitive for any surgical specialty. Additionally, DO students should prioritize formerly-AOA-accredited programs for audition rotations.

Cost Analysis of High-Signal Approach in Otolaryngology-Head and Neck Surgery Residency

OBJECTIVE

The objective of this study is to analyze a high-signal approach for otolaryngology-head and neck surgery (OHNS) residency applicants and calculate cost savings for programs and applicants.

METHODS

Data from both the 2022-2024 Electronic Residency Application Service (ERAS) and a data model were used to demonstrate cost savings with a high-signal approach. Modeled data assumed that the number of applications per applicant would be equal to the number of signals allowed. Predicted and real-world cost savings across the five other specialties participating in a high-signal approach were calculated.

RESULTS

ERAS data cost savings for the entire OHNS applicant pool amounted to $365,950. In the modeled data, cost savings amounted to $825,921. When extrapolated to include all five high-signal specialties, total cost savings amounted to $2,570,464 (ERAS data) and $6,359,478 (modeled data). Otolaryngology programs were predicted to experience significant time savings, resulting in cost savings of $437,883 and $1,113,342 for ERAS data and modeled data, respectively.

CONCLUSIONS

The study highlights the advantages of a high-signal approach, including financial advantages or increased time for programs to engage in holistic review and diversify the pool of interview candidates. Cost savings in this study were shown to be significant when extrapolated across all specialties using a high-signal approach. Further research is needed to optimize the signaling system and confirm the favorable interview distribution and equity data from the low-signal OHNS experience with a high-signal approach.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2024.

The golden tickets: impact of preference signaling on obstetrics and gynecology residency applicants

BACKGROUND

With the residency selection process becoming more competitive and programs receiving unprecedented numbers of applications, some specialties have introduced preference signaling in an attempt to help applicants target programs of interest. In the 2022-2023 application cycle, obstetrics and gynecology also introduced a 2-tiered system with a limited number of gold signals (n=3) and silver signals (n=15).

OBJECTIVE

Given the novelty of preference signaling in the obstetrics and gynecology residency application process, this study aimed to (1) assess the effect of signals on interview offers and match and (2) discuss applicant attitudes toward this preference signaling system.

STUDY DESIGN

This was a voluntary cross-sectional survey study conducted in April 2023 that was open to all fourth-year medical students who applied to an obstetrics and gynecology residency in the United States. Self-reported demographics, signaling, interview, and match data were collected. In addition, students were asked about attitudes toward signaling on a 5-point Likert scale.

RESULTS

Of the 1507 applicants who entered an obstetrics and gynecology residency via match or Supplemental Offer and Acceptance Program process, 969 (64.3%) completed the survey. Moreover, an additional 22 applicants who did not match responded to the survey. More respondents used all 3 gold tokens (98.3%) and all 15 silver tokens (94.3%). The mean number of applications sent was 74.3±35.1, and the mean number of interviews received per applicant was 12.8±6.6. The interviews or token yields were 64.0%±31.5% for gold tokens, 43.8%±23.1% for silver tokens, and 9.8%±10.0% for no token. Of the survey respondents, 340/951 (35.8%) matched to a gold token program, 338/951 (35.5%) matched to a silver token program, and 244/951 (25.7%) matched to a nontoken program. Furthermore, 499/951 applicants (52.5%) reported feeling slightly positive or very positive about signaling.

CONCLUSION

Most obstetrics and gynecology applicants in this survey participated in preference signaling. Gold and silver tokens were associated with high ratios of interview invitations compared with no token. However, the overall number of applications did not decrease in the 2022-2023 cycle, and only half of survey respondents reported feeling positive about the signaling process. These results can inform program directors and students about application number and strategy in upcoming cycles.

Standing in Unity Amidst Change: A Group Mentorship Model that Addresses the Logistical and Emotional Needs of Applicants for Surgical Residency

OBJECTIVE

For medical students, applying to general surgery residency is a complex and multifactorial process that can be fraught with significant challenges. The COVID-19 pandemic generated additional uncertainty and distress for applicants given the temporary suspension of in-person clinical rotations and transition to virtual residency interviews. However, despite the significant changes introduced by the COVID-19 pandemic, our group mentorship model - originally developed to address the emotional and logistical needs of applicants - withstood national shifts in medical education. In this manuscript, we detail the rationale and design of our group mentorship model for fourth-year medical students with the hopes that other programs may implement our current resources and acquire insight from the lessons we learned amidst responding to the changing climate in surgical education.

DESIGN

Implementation of a longitudinal program utilizing a group mentorship model to provide students with emotional and logistical support during the residency application process.

SETTING

This program was implemented at the Boston University Chobanian & Avedisian School of Medicine.

PARTICIPANTS

Fourth-year medical students that are applying to general surgery residency.

RESULTS

The program consisted of 11 sessions, ranging from 1-2 hours in duration, and approximately 14-17 students participated in the program per year. The program was led by a mentor panel that consisted of a faculty advisor, resident physicians, and appointed student liaisons.

CONCLUSIONS

Group mentorship is a unique model that allows for multidirectional dissemination of advice and experiences amidst student participants and mentors. In times of shifts in medical education, the diverse mentor panel allows for the development of strategies to address unanticipated challenges encountered during the application process.

Does Geographic Region of Away Rotations Predict Otolaryngology Match Outcomes?

OBJECTIVE

To assess whether the geographic region where medical students complete an away rotation predicts the same site, region-specific, or overall interview offers and match success in otolaryngology.

STUDY DESIGN

Cross-sectional.

SETTING

US medical schools.

METHODS

We queried the Texas Seeking Transparency in Application to Residency database to analyze outcomes of otolaryngology applicants during the 2018 to 2020 and 2022 match cycles. Outcomes included a number of interviews offered, geographic location of interviews, and match results, including region-specific and overall match success rate.

RESULTS

Of 455 otolaryngology applicants, 402 (90.3%) completed an away rotation. Among these, 368 (91.8%) were offered an interview and 124 (30.9%) matched to the program where they completed an away rotation. Applicants who completed away rotations outside their home region received more interview offers from that region than those who did not (Northeast: 4.2 vs 2.9; South: 4.3 vs 3.0; Central: 4.8 vs 3.0; West: 3.8 vs 1.6, P < .01 for all). Completing a remote away rotation increased the odds of receiving an interview from and matching within that region. After excluding programs where an away rotation was completed, a remote away rotation increased the odds of receiving an interview in the central and western regions (Central: odds ratio [OR]: 1.2 [1.1, 1.5]); West OR: 1.9 [1.7, 2.2]; and the odds of matching in the western region (OR: 2.9 [1.2, 7.4], all P < .01).

CONCLUSION

Away rotations are associated with increased odds of interviewing and matching at that away program, with possible associations across the region, most evident for the West coast.

Current practices and perspectives on clerkship grading in obstetrics and gynecology

BACKGROUND

Clerkship grades in obstetrics and gynecology play an increasingly important role in the competitive application process to residency programs. An analysis of clerkship grading practices has not been queried in the past 2 decades in our specialty.

OBJECTIVE

This study aimed to investigate obstetrics and gynecology clerkship directors' practices and perspectives in grading.

STUDY DESIGN

A 12-item electronic survey was developed and distributed to clerkship directors with active memberships in the Association of Professors of Gynecology and Obstetrics.

RESULTS

A total of 174 of 236 clerkship directors responded to the survey (a response rate of 73.7%). Respondents reported various grading systems with the fewest (20/173 [11.6%]) using a 2-tiered or pass or fail system and the most (72/173 [41.6%]) using a 4-tiered system. Nearly one-third of clerkship directors (57/163 [35.0%]) used a National Board of Medical Examiners subject examination score threshold to achieve the highest grade. Approximately 45 of 151 clerkship directors (30.0%) had grading committees. Exactly half of the clerkship directors (87/174 [50.0%]) reported requiring unconscious bias training for faculty who assess students. In addition, some responded that students from groups underrepresented in medicine (50/173 [28.9%]) and introverted students (105/173 [60.7%]) received lower evaluations. Finally, 65 of 173 clerkship directors (37.6%) agreed that grades should be pass or fail.

CONCLUSION

Considerable heterogeneity exists in obstetrics and gynecology clerkship directors' practices and perspectives in grading. Strategies to mitigate inequities and improve the reliability of grading include the elimination of a subject examination score threshold to achieve the highest grade and the implementation of both unconscious bias training and grading committees.

Improving Transparency in the Residency Application Process: Survey Study

BACKGROUND

Increasing numbers of residency applications create challenges for applicants and residency programs to assess if they are a good fit during the residency application and match process. Applicants face limited or conflicting information as they assess programs, leading to overapplying. A holistic review of residency applications is considered a gold standard for programs, but the current volumes and associated time constraints leave programs relying on numerical filters, which do not predict success in residency. Applicants could benefit from increased transparency in the residency application process.

OBJECTIVE

This study aims to determine the information applicants find most beneficial from residency programs when deciding where to apply, by type of medical school education background.

METHODS

Match 2023 applicants voluntarily completed an anonymous survey through the Twitter and Instagram social media platforms. We asked the respondents to select 3 top factors from a multiple-choice list of what information they would like from residency programs to help determine if the characteristics of their application align with program values. We examined differences in helpful factors selected by medical school backgrounds using ANOVA.

RESULTS

There were 4649 survey respondents. When responses were analyzed by United States-allopathic (US-MD), doctor of osteopathic medicine (DO), and international medical graduate (IMG) educational backgrounds, respondents chose different factors as most helpful: minimum United States Medical Licensing Examination (USMLE) or Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Step 2 scores (565/3042, 18.57% US-MD; 485/3042, 15.9% DO; and 1992/3042, 65.48% IMG; P<.001), resident hometown region (281/1132, 24.82% US-MD; 189/1132, 16.7% DO; and 662/1132, 58.48% IMG; P=.02), resident medical school region (476/2179, 22% US-MD; 250/2179, 11.5% DO; and 1453/2179, 66.7% IMG; P=.002), and percent of residents or attendings underrepresented in medicine (417/1815, 22.98% US-MD; 158/1815, 8.71% DO; and 1240/1815, 68.32% IMG; P<.001).

CONCLUSIONS

When applying to residency programs, this study found that the factors that respondents consider most helpful from programs in deciding where to apply differ by educational background. Across all educational groups, respondents want transparency around standardized exam scores, geography, and the racial or ethnic backgrounds of residents and attendings.

Medical student advising during virtual residency recruitment: results of a national survey of internal medicine clerkship and sub-internship directors

INTRODUCTION

The residency application process is a critical time for medical students. The COVID-19 pandemic prompted changes to the residency recruitment procedures with the conversion of interviews to a virtual format. For medical school advisors guiding students on an all-virtual residency application process brought uncertainty to their advising practices. Thus, this study aimed to identify advising practices during the 2021 virtual application cycle.

METHODS

We administered an IRB-exempt national survey through the Clerkship Directors in Internal Medicine to 186 internal medicine core/co-/associate/assistant clerkship directors and sub-internship directors representing 140 Liaison Committee on Medical Education-accredited U.S./U.S.-territory-based medical schools in spring 2021. The 23-question survey was designed and pilot-tested by faculty-educators and leaders with expertise in undergraduate medical education. Data analysis included paired t- and z-tests and thematic analysis of open-ended questions.

RESULTS

The institutional response rate was 67% (93/140) and individual rate 55% (103/186). Half of the respondents felt prepared/very prepared (40% and 13% respectively) for their advising roles. Compared to pre-pandemic cycles, respondents advised a typical student in the middle-third of their class at their institution to apply to more residency programs (mean 24 programs vs 20, p < 0.001) and accept more interviews (mean 14 interviews vs 12, p < 0.001). Sixty-three percent (64/101) of respondents spent more time on student advising; 51% (51/101) reported more students asked them for informal advice. Fifty-nine percent (60/101) of respondents reported their advisees were able to assess a residency program 'somewhat well;' 31% (31/101) expressed that residency recruitment should remain entirely virtual in the future.

CONCLUSION

The transition to virtual residency recruitment due to COVID-19 prompted advising practices that may have contributed to application inflation and increased advising workload. Future studies should explore longitudinal outcomes of virtual interviews on student success to guide best practices in how to advise students during residency recruitment.

Assessing the Accuracy of Otomatch.com Data for Individuals Applying to Otolaryngology Residency

OBJECTIVES

Otomatch.com is an online forum for residency applicants to discuss the otolaryngology match process including academic metrics. The purpose of this study is to assess the accuracy of self-reported match data on Otomatch relative to official data reported by the National Residency Match Program (NRMP) and the Association of American Medical Colleges (AAMC).

METHODS

Data was collected from publicly editable Otomatch forums (2017-2018, 2018-2019, 2019-2020) and curated Otomatch survey responses (2018-2019, 2019-2020) whose results are released after Match Day. Aggregated data was collected from the NRMP 2018 and 2020 Charting Outcomes in the Match and AAMC Report on Residents (2017-2018, 2018-2019). Measures of interest included Step 1 scores, Step 2 CK scores, publications, number of interview invitations, number of interviews attended, and AOA status. ANOVA and 2 tailed T tests were performed to compare variables within each match year.

RESULTS

Average Step 2 CK score was significantly higher on publicly editable Otomatch forums than AAMC in 2017-2018 (257vs 253, P < .05) and 2018-2019 (258vs 252, P < .05). Interviews attended were significantly higher on Otomatch survey responses than the publicly editable forum in 2019-2020 (13vs 9, P-value < .05). Step 1 scores, interview invitations, and AOA status were not statistically significantly different when data was available.

CONCLUSION

Applicant statistics from online forums, online surveys, NRMP, and AAMC are consistent, except for Step 2 CK scores. Self-reported data on the Otomatch forum is an accurate estimate of academic metrics of otolaryngology residency applicants.

Trends in successfully matched neurosurgery residency applicants

OBJECTIVE

The United States Medical Licensing Examination (USMLE) Step 1 recently transitioned to a pass/fail outcome, renewing interest in how programs select neurosurgical residents. This study investigates the association between match status and key academic metrics over time.

METHODS

Data are from the National Resident Matching Program from 2009 to 2022 for matched and unmatched US allopathic (MD) seniors. Investigated metrics included the mean number of contiguous ranks; mean number of distinct specialties ranked; mean USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores; mean number of abstracts, presentations, and publications; mean number of research, work, and volunteer experiences; Alpha Omega Alpha status; attendance at a top 40 NIH-funded institution; PhD degree; and other degree. Multiple linear regression without an interaction term was used to evaluate how these have varied between the two groups during the study period and whether there is a difference between unmatched and matched MD seniors applying for a neurosurgical residency. Multiple linear regression with an interaction term was then used to test whether the difference in variables between the two groups changed over time.

RESULTS

Regardless of match status, MD senior neurosurgical residency applicants exhibited an increase in USMLE Step 1 and 2 scores; average research experiences; abstracts, presentations, and publications; and work and volunteer experiences (p < 0.001). The percentage of applicants from a top 40 NIH-funded school decreased (p = 0.018), and the percentage who held an additional degree increased (p = 0.007). Between groups, there were significant differences in all categories except work experiences and other degree obtained. Over time, the difference between USMLE Step 2 scores between matched and unmatched seniors diminished (p = 0.027); in contrast, the difference in abstracts, presentations, and publications between the two groups increased over time (p < 0.001).

CONCLUSIONS

From 2009 to 2022, neurosurgical residency applicants grew in their achievements across many metrics. In the advent of Step 1 becoming pass/fail, this study suggests that Step 2 is not viewed by programs as an adequate replacement. However, the Step 1 grading transition may serve as an opportunity for other factors to be considered that may better predict success in neurosurgical residency.

Obstetrics and gynecology clerkship directors' experiences advising residency applicants

BACKGROUND

The evolving landscape of application processes for obstetrics and gynecology residency applicants poses many challenges for applicants and advisors. The lack of data coordination among national groups creates crucial gaps in information for stakeholder groups.

OBJECTIVE

This study aimed to identify the current state of the advising milieu for obstetrics and gynecology residency applicants and their career advisors, the annual Association of Professors of Gynecology and Obstetrics survey focused on US clerkship directors' experiences advising students through these processes.

STUDY DESIGN

A 23-item anonymous survey was developed that asked respondents about demographics and outcomes for the students that they advised through the 2021 application process and their experiences with dual applicants and students not matching. The survey was sent electronically to all obstetrics and gynecology clerkship directors with active Association of Professors of Gynecology and Obstetrics memberships in April 2021.

RESULTS

Of 224 total clerkship directors, 143 (63.8%) responded to the survey, Of the 143 respondents, almost all (136 [95.1%]) served as career advisors, and 50 (35.0%) were aware of students dual applying. Furthermore, obstetrics and gynecology was rarely the backup to a more competitive specialty. For the 2021 application cycle, 79 of 143 respondents (55.2%) reported having students not successfully match into obstetrics and gynecology, with "academic concerns" followed by "poor communication skills" as the primary reasons cited for students not matching.

CONCLUSION

This snapshot of clerkship directors' experiences advising students in the residency application process reveals notably high rates of dual applicants and students not matching into obstetrics and gynecology. This work fills key gaps in our knowledge of current processes and highlights the importance of career advising at multiple points during the application process.

Key factors for residency interview selection from the National Resident Matching Program: analysis of residency Program Director surveys, 2016-2020

CONTEXT

As the number of medical school graduates continues to outpace the available residency training positions, applying for residency in the United States has become a highly competitive process, often associated with a low rate of selection and invitation for interview. The National Resident Matching Program (NRMP) Program Director survey provides data assessing factors considered by Program Directors (PD) in selecting and inviting candidates for interview. Assessing the evolution of these factors over time is efficacious to inform and guide prospective applicants toward improving preparation for residency application.

OBJECTIVES

We aim to synthesize NRMP data showing factors that PDs reported and rated as important in their decision to select and invite applicants for interview.

METHODS

Data from residency PD surveys from 2008 to 2021 were accessed, but after applying inclusion/exclusion criteria, only the data from 2016 to 2020 were reviewed and analyzed. The NRMP survey reports provided two metrics that characterized PDs' evaluation of the residency factors for interview, namely, "percent citing factor" and "average rating" on a 0 to 5 Likert-type scale. These two metrics were combined into an aggregate measure of importance (AI), and another measure of relative importance (RI) was constructed from normalizing the AI of each individual factor to the sum of the AI within each survey year.

RESULTS

The top ranked factors were United States Medical Licensing Examination (USMLE) Step 1/Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 1, Letter of Recommendation (LOR) in the specialty, Medical Student Performance Evaluation (MSPE/Dean's Letter), and USMLE Step 2 Clinical Knowledge (CK)/COMLEX Level 2 Cognitive Exam (CE) score, any failed attempt in USMLE/COMLEX, and perceived commitment to specialty. Factors rising in importance were Audition Elective/Rotation Within Your Department, Personal Statement (PS), Perceived Commitment to Specialty, Perceived Interest in Program, LOR in the Specialty, Other Life Experience, and Personal Prior Knowledge of the Applicant. Factors with declining importance were Interest in Academic Career, Awards or Special Honors in Basic Sciences, Graduate of Highly Regarded US Medical School, Awards or Special Honors in Clinical Clerkships, Lack of Gaps in Medical Education, Awards or Special Honors in Clerkship in Desired Specialty, and Consistency of Grades. Compared to the 2021 PD survey, our findings show continued predictive consistency, particularly related to specialty and program commitment.

CONCLUSIONS

The factors identified for the selection of medical school graduates for interview into a residency program reveal that PDs move toward a more integrated approach. Specifically, PDs are placing increasing emphasis on factors that border on subjective qualities more so than the more traditional, quantitative, and objective metrics. Medical students and educators need to continually apprise themselves of the NRMP data to inform students' preparation endeavors throughout medical school to strengthen their application portfolios and enhance their competitiveness for the matching process.

Local Culture and Community Through a Digital Lens: Viewpoint on Designing and Implementing a Virtual Second Look Event for Residency Applicants

BACKGROUND

The COVID-19 pandemic altered how residency interviews occur. Despite 2 years of web-based interviews, these are still perceived as inferior to in-person experiences. Showcasing a program and location is critical for recruitment; however, it is difficult to highlight the program's location and community digitally. This article presents the authors' viewpoints on designing and implementing a virtual second look for residency applicants.

OBJECTIVE

Our objective was to host a web-based event to feature the benefits of living in Winston-Salem, North Carolina, for residency applicants, enhance recruitment efforts, and ensure a successful residency match. The goal was to cover topics that interested all applicants, highlight how Winston-Salem is a special place to live, involve current residents, and engage community members.

METHODS

Three programs-child neurology, neurology, and family medicine were chosen for a pilot virtual second look. All residency program directors' were asked to recommend community contacts and help identify residents and faculty who may serve as content experts on one of the topics in the panel discussions. A total of 24 community leaders from restaurants, venues, schools, and businesses were contacted, and 18 agreed to participate. The panel discussions included living in and raising a family in Winston-Salem, experiencing Winston-Salem arts and music, where to eat and drink like a local, and enjoying sports and outdoors in the area. The 2-hour event was hosted on Zoom. Postevent feedback assessments were automatically sent to each registrant through Research Electronic Data Capture (REDCap). This study was deemed exempt from Wake Forest University Health Sciences institutional review board review (IRB00088703).

RESULTS

There were 51 registrants for the event, and 28 of 48 registrants provided postevent feedback, which was positive. The authors found in the MATCH residency results that 2 of 2 child neurology positions, 4 of 6 adult neurology positions, and 1 of 10 family medicine positions attended our second look event. One adult neurology resident who did not participate was an internal candidate. All respondents agreed or strongly agreed that the session was valuable, well organized, and met their expectations or goals. Furthermore, all respondents gained new information during this web-based event not obtained during their interview day.

CONCLUSIONS

The virtual second look event for residency attendees featured the benefits of living in Winston-Salem, and the perspectives of current residents. Feedback from the session was overall positive; however, a top desire would be devoting more time for the applicants to ask questions directly to the community leaders and our resident trainees. This program could be reproducible by other institutions. It could be broadened to a graduate medical education-wide virtual second look event where all medical and surgical programs could opt to participate, facilitating an equitable opportunity for prospective applicants.

Away Rotations in Obstetrics and Gynecology: A Survey of Program Directors

OBJECTIVE

To evaluate residency program director views on the purpose and value of an away rotation for students applying to a residency application in Obstetrics and Gynecology (OBGYN).

DESIGN, SETTING, AND PARTICIPANTS

The Council on Resident Education in Obstetrics and Gynecology administered a 28-question survey to current U.S. program directors in OBGYN in 2022. Program directors were asked if they offered away rotations to visiting medical students and if so, what the purpose the rotation played in their application process and whether rotating students were automatically offered a residency interview. Program characteristics such as program size, geographic location, and program type (university, community, or military based) were ascertained. A test of proportions was utilized to understand the relationship between program description and survey responses.

RESULTS

Seventy-nine percent (224/285) of OBGYN PDs responded to the survey and consented to participation. Programs were representative of the types of training program, size of programs, and geographic location. Of respondents, 77.2% (173/224) of PDs indicated that away rotations were offered at their institution, but only 26.6% (46/173) of residency PDs assessed prospective candidates for away electives. The opportunity to provide students an audition for a residency position was the most common reason to offer an elective. Only 34.7% (60/173) of OBGYN PDs guaranteed an interview to students who completed away electives at their institution. The majority (118/173, 68.2%) of PDs indicated less than 25% of their current residents had completed an away rotation with their program.

CONCLUSIONS

Many residency programs offered away electives to prospective applicants, but the majority did not personally assess applicants for competitiveness or guarantee interviews to students completing electives. To increase transparency in the application process, programs should publicize the purpose of away rotations and provide information on the number of interviews granted to students who complete away rotations.

Additional Considerations for US Residency Selection After Pass/Fail USMLE Step 1. Comment on "The US Residency Selection Process After the United States Medical Licensing Examination Step 1 Pass/Fail Change: Overview for Applicants and Educators"

Collapse

The Importance of Research Experience With a Scoreless Step 1: A Student Survey at a Community-Based Medical School

PURPOSE

As of January 26, 2022, the United States Medical Licensing Examination (USLME) step 1 exam went from a scored test to pass-fail step 1 (PFS1). The authors were interested in surveying medical students at a community-based medical school to observe their perceptions of the importance of student research given this recent change.

METHOD

A Qualtrics survey was disseminated to medical students (years 1-4) via school emails. Data were analyzed using the Mann-Whitney test to assess Likert scale scores, and narrative comments were grouped as qualitative feedback. Survey dissemination and analysis of data were both conducted at a large community-based medical school.

RESULTS

The survey sampled 104 students categorized into pre-clerkship (PC) and clerkship (CL) years, with a response rate of 33%. A contradiction was found, as indicated by the higher number (p = 0.047) of clerkship students interested in Primary Care/Family medicine residency compared to pre-clerkship students at 41% and 59%, respectively. Whereas participants who indicated they are interested in pursuing a competitive specialty for residency were 51% of pre-clerkship students over 41% of clerkship students (p = 0.047). Additionally, given the assessment change to pass/fail, students did in fact believe that residencies would now view research as a higher assessed component than before (79% pre-clerkship and 72% clerkship). However, a minority of students said that they increased their research efforts (41% and 47%). Most students supported the research opportunity improvements proposed in our survey.

CONCLUSIONS

Efforts to make the step 1 exam pass/fail may have alleviated some stress related to performance but may have increased the perception of the importance of other components in a student's residency application. Our survey highlights how medical students at a community-based medical school perceive this change and how it has affected their research efforts.

The Matthew Effect: Prevalence of Doctor and Physician Parents among Ophthalmology Applicants

Objective  This article determines the prevalence of physician parents among ophthalmology residency applications. Design  Retrospective, single-center cohort study. Subjects  All applicants to the University of Kentucky Ophthalmology Residency between 2018 and 2023. Methods  Residency applications were reviewed, with data collection including applicant gender, self-identified Under-Represented in Medicine (URiM) status, United States Medical Licensing Examination (USMLE) Step 1 score, USMLE Step 2 score, and whether the application identified a doctor or physician as a parent. Doctor was defined as a profession requiring a doctorate degree, and similarly, physician as a profession requiring a medical degree. Results  A total of 2,057 applications were reviewed, representing 54% of all match participants during the study period. Fourteen percent (296) of applications indicated a parent was a doctor and 12% (253) a parent was a physician. There were no differences between gender, URiM, USMLE Step 1, and Step 2 scores between applicants indicating a doctor or physician as a parent and those that did not ( p all > 0.4 and Cohen's d all < 0.02). Of the type of doctors, 85% (253) were physicians, 6% (17) optometrists, 6% (17) Doctors of Philosophy, 3% (8) dentists, 1% (1) pharmacist, and 1% (1) veterinarian. Eighty-six percent (217) of applications with a physician parent provided the type of physician, with ophthalmologist the most common (93, 43%). Ninety-eight percent (249) of applications with a physician parent provided the gender of the parent, with father (168, 68%) more common than mother (42, 17%) or both parents (39, 16%). Conclusion  Physician parents are substantially overrepresented in ophthalmology residency applicants. This raises concerns regarding diversity and inclusion efforts for recruitment in medicine.

Association of Virtual Away Rotations With Residency Applicant Outcomes in Otolaryngology

Objective

To examine how virtual away rotations might influence interview and match outcomes in otolaryngology.

Study Design

Cross-sectional retrospective analysis of survey-based study.

Setting

United States medical students applying to otolaryngology residency in the 2020 to 2021 cycle.

Methods

The Texas Seeking Transparency in Application to Residency database was queried to identify otolaryngology applicants during the 2020 to 2021 cycle. The primary outcome was mean number of interview offers. χ 2 tests, 2-sided t tests, logistic regression models, and ordinary least squares regression models were used to examine associations with virtual away rotations.

Results

Among 115 otolaryngology applicants identified, 35 (30.4%) applicants reported completing 1 or more virtual away rotations. Applicants who completed at least 1 virtual away rotation received significantly more interview offers than their counterparts who did not participate in virtual away rotations (mean [SD], 14.9 [8.2] vs 11.6 [7.9]; P < .03). Each virtual away rotation completed was associated with an incremental increase of 2 additional interview offers (β coefficient: 2.29 [95% confidence interval, CI: 0.8-3.7; P < .01]). Applicants who completed a virtual away rotation were more likely to receive an interview from that program (62.7% vs 16.8%, P < .01) and to match there (odds ratio 7.7 [95% CI: 2.7-21.7]; P < .01) when compared to applicants who had not done the away rotation. Participation in virtual away rotations was not associated with significant improvement in match success (82.9% vs 67.5%; P = .09).

Conclusion

Virtual away rotations were associated with improved program-specific interview and match outcomes, as well as a higher overall number of interview offers.

Advice and perspectives from navigating the couples match in otolaryngology: A qualitative pilot study

Introduction

There is a lack of qualitative analysis of the personal experiences within Couples Matching. In this qualitative study, we aim to record personal attitudes, reflections, and advice on experiences with the Couples Match process.

Methods

Our survey, consisting of two open-ended questions regarding the experience of Couples Matching, was distributed from January 2022 to March 2022 via email to 106 otolaryngology program directors across the nation. Survey responses were analyzed iteratively using the constructivist grounded theory to construct themes related to pre-match priorities, match-related stressors, and post-match satisfaction. Themes were developed inductively and refined iteratively as the dataset evolved.

Results

18 Couples Match residents responded. In response to the first question: "What was the most difficult part of the process for you and/or your partner?", we identified the following themes: cost and financial burden, increased stress on the relationship, sacrificing top choices, and finalizing the match list. In response to the second question: "Using your experience as a previous applicant, what advice would you give to another couple planning on couples matching?", we identified four common themes: compromise, advocacy, dynamic conversations, and applying broadly.

Conclusion

We sought to understand the Couples Match process through the perspective of previous applicants. Analyzing the views and attitudes of Couples Match applicants, our study captures the most challenging aspects of the experience and highlights possible areas to improve advising for couples, including important factors to consider when applying, ranking, and interviewing.

Relationship Between Residency Match Distance From Medical School and Virtual Application, School Characteristics, and Specialty Competitiveness

INTRODUCTION

The COVID-19 pandemic has disrupted the residency match process by eliminating away rotations and changing from in-person to virtual interviews. In this study, we explore the impact of the COVID-19 pandemic on the geographic match distance of United States (US) senior medical students across all specialties.

METHODS

We collected publicly available student match data between 2018 and 2021 from US allopathic medical schools and calculated match distance between medical school and residency training using a novel metric - the "match space." Match space was codified by whether the student matched at their home institution, home state, adjacent state, same or adjacent US census division (non-adjacent state) or skipped at least one US census division. Adjusting for covariates, ordinal logistic regression correlated school and specialty characteristics with match distance pre- and post-pandemic for all specialties. We defined and ranked specialty competitiveness using predictive values from factor analysis.

RESULTS

A total of 34,672 students representing 66 medical schools from 28 states matched into 26 specialties in 50 states and Canada. Fifty-nine percent of students were from public institutions, and 27% of schools ranked in the top 40 for research. The mean percentage of in-state students by school was 60.3% (range 3-100%). Match space was lower after the pandemic (adjusted odds ratio (OR) 0.94, 95% CI 0.90-0.98; p=0.006), from schools with higher in-state percentages (OR 0.74, 95% CI 0.72-0.76), from top National Institutes of Health-funded institutions (OR 0.88, 95% CI 0.85-0.92), from the Northeast (OR 0.71, 95% CI 0.67-0.75; Midwest reference), and the West (OR 0.67, 95% 0.60-0.74). Match space was higher for students graduating from private schools (OR 1.11, 95% CI 1.05-1.19), from the South (OR 1.62, 95% CI 1.2-1.33), and matching into more competitive specialties (OR 1.08, 95% CI 1.02-1.14). The top five most competitive specialties were Plastic Surgery, Neurosurgery, Dermatology, Orthopedic Surgery, and Otolaryngology. Internal Medicine ranked eighth.

CONCLUSIONS

After the COVID-19 pandemic, students graduating from US allopathic schools matched closer to their home institution. Students attending public schools, schools with more in-state matriculants, and schools with higher research rankings also matched closer to their home institutions. Specialty competitiveness and US census region also impacted match distance. Our study adds insight into how geographic match patterns were influenced by school, specialty choice, and the pandemic.

Changes in United States Residency Program Online Presence Following COVID-19

PHENOMENON

The 2020-2021 residency application cycle was subject to major alterations following the COVID-19 global pandemic. This study determined the online presence of US-based residency training programs during this time period.

APPROACH

An official list of accredited US residency programs for 24 medical specialties was obtained through the Electronic Residency Application Service Programs' online presence and was evaluated for website ownership in addition to Twitter, Instagram, and Facebook account ownership. Date of social media account foundation and virtual opportunities offered were recorded. Doximity Residency Navigator for 2020-2021 was used to determine program rank, and programs were stratified by location using Association of American Medical Colleges regions. Program rank and geographic location were used to determine potential trends in online presence. This study was performed during the residency application cycle from September 2, 2020, to November 29, 2020, during which applications were submitted and the interview cycle began.

FINDINGS

Fifty-seven percent of the 4,562 programs had a presence on social media. One-third of all accounts were created after March 1, 2020, and most (58%) were residency program-associated. A total of 1,315 programs offered virtual open houses through Twitter (829), Instagram (792), and Facebook (295). First-quartile programs had significantly more social media accounts per program on average (1.8) than those in subsequent quartiles, and Western region programs had significantly more accounts per program on average (1.3) than the Central (1.0), Northeastern (1.0), and Southern (1.1) regions.

INSIGHTS

US residency programs created social media accounts and online opportunities for applicants following March 1, 2020. Online interactions may serve as substitutes at a time when in-person interaction is not possible. Future studies may examine the influence and impact of virtual interactions.Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2022.2047050.

USMLE Step 1 Pass/Fail is Here: Are Plastic Surgery Applicants Really Better Off?

OBJECTIVE

As of January 26, 2022, the United States Medical Licensing Examination(USMLE) Step 1 score reporting will be changed from a numeric scoring system to pass/fail. Although the new scoring policy is expected to benefit medical students, there is concern that it will also amplify preexisting disadvantages and worsen disparities for students applying in the already-competitive plastic surgery match. Whether the reporting change will tangibly benefit applicants to plastic surgery has yet to be elucidated.

DESIGN

A cross-sectional survey was distributed to medical students and graduates via social media platforms. Data were analyzed using Student t test and Chi-squared statistic, with an alpha level set at 0.05.

SETTING

Data collection and analysis was performed at Johns Hopkins University School of Medicine.

PARTICIPANTS

This study included a sample of 120 American Medical Trainees (AMTs) and International Medical Trainees (IMTs) who are interested in plastic surgery.

RESULTS

The plurality of respondents were against the new Step 1 score reporting (AMT: 40.7%; IMT: 44.3%), but differences existed between AMTs when compared to IMTs, especially regarding opinions about the reporting change on stress levels and competitiveness of highly competitive specialties. Regardless of training status, respondents felt that the pass/fail scoring system would increase their likelihood to engage with more research, dual apply, prioritize studying for Step 2 CK, and consider a dedicated research year.

CONCLUSIONS

While a pass/fail reporting system for Step 1 may alleviate some stress for medical trainees, other issues arise that may perpetuate disparities and bias against students with little resources in the field of plastic surgery. Residency programs should offer anticipatory guidance regarding prioritization of aspects of application to ease this psychosocial and financial pressure, as well as help students reorganize their constrained time.

Mistakes, Misrepresentation, and Misunderstanding on Applications to a Canadian Diagnostic Radiology Residency Program

Purpose: Determine the educational background, research publications/presentations experience, and rates of research publication and presentation inaccuracies in applications to a Canadian diagnostic imaging residency program. Method: The education and publication/presentation sections of the Canadian Resident Matching Service form for all applicants to the University of Saskatchewan diagnostic imaging residency program from 2019-20 and 2020-21 were reviewed. Number of advanced degrees (Master's/PhDs), publications, and presentations were recorded. Accuracy of publications listed was confirmed via PubMed-MEDLINE, journal's website, or internet searching. Accuracy of presentations was confirmed via society and residency program websites. Inaccuracies of non-authorship, incorrect authorship order/status (self-promotion or demotion), and nonexistence of article/presentation from a verifiable source were recorded. Result: There were a total of 106 applicants. Thirty (28%) had advanced degrees. There were 230 publications from 61 applicants with inaccuracies in only 5 (2%) of the publications (2 self-promotion, 3 self-demotion). For the 77 publications listed as pending, 25 (31%) were published within 6 months of applications deadlines with 1 non-authorship, 1 self-promotion, and 1 self-demotion. For scientific presentations, there were 467 listed presentations by 91 applicants. Two hundred and twenty-one presentations were from verifiable sources with inaccuracies in 28 (13%) of presentations (9 self-promotion, 9 self-demotion, 1 non-authorship, and 9 non-existence). Conclusion: Despite some uncertainty with scientific articles reported as pending and scientific presentations, radiology residency applicants are accurately representing their published articles with a negligible number of misrepresentations. Canadian radiology residency programs should regard the publication profiles of the applicants with a high level of confidence.

Navigating the Ophthalmology & Urology Match with a Significant Other

OBJECTIVE

Medical students with a significant other in medical school face challenges when applying for residency as they attempt to match in proximity to their partner. The National Resident Matching Program (NRMP) offers a Couples Match to aid such applicants. This system is not available for ophthalmology and urology because these specialties utilize match systems outside the NRMP and have an early match timeline. The purpose of this study is to analyze usage of the Couples Match and assess ophthalmology and urology applicant viewpoints on the Couples Match system.

DESIGN & SETTING

First, NRMP data on the Couples Match from 1987 to 2021 was reviewed. Second, an online survey was sent to 559 ophthalmology and 321 urology applicants to The Johns Hopkins University School of Medicine in the 2021 match cycle.

PARTICIPANTS

342 ophthalmology and urology applicants (39% response rate).

RESULTS

There is increased usage of the Couples Match over time. In response to the survey, 89% of participants agreed that a Couples Match should be implemented in their specialty. 107 (31%) had a significant other in medicine. 78% of 68 respondents whose significant other also applied in 2021 reported that they would have used the Couples Match had it been available. 21% of those with a significant other considered not applying to ophthalmology or urology because there was no Couples Match. There are mixed responses regarding whether the early match timeline is beneficial to couples. Female applicants were more likely to report hesitancy about mentioning a significant other during the application process.

CONCLUSIONS

The Couples Match is highly desired by applicants to ophthalmology and urology, and the lack of such a system is a deterrent to pursuing these fields. Future studies will help elucidate how the match system can be leveraged to aid individuals applying with a significant other.

An Assessment of Pediatric Residency Applicant Perceptions of "Fit" During the Virtual Interview Era

PURPOSE

Residency recruitment events and interviews are widely considered an integral component of the residency match experience. Due to the COVID-19 pandemic, residency recruitment and interviewing throughout the 2020-2021 academic year were performed virtually, which created challenges for applicants' ability to discern "fit" to a program. Given this change, it is reasonable to suspect that applicants would be less able to discern program fit. Therefore, this study evaluated how virtual interviews impacted pediatric residency applicants' ability to assess factors contributing to fit and subsequently how applicants assessed their self-perceived fit to their top-ranked programs.

METHODS

An online, anonymous survey was distributed to all residency applicants who applied to any specialty at our large academic institution. The survey utilized a 5-point Likert-type scale to evaluate qualities of fit as well as the applicants' self-perceived ability to assess these qualities through a virtual platform.

RESULTS

1,840 surveys were distributed, of which 473 residency applicants responded (25.7% response rate). Among these responses, 81 were pediatric applicants (27.6%). Factors deemed most important in determining fit included how well the residents get along with one another (98.8%), how much the program appeared to care about its trainees (97.5%), and how satisfied residents were with their program (97.5%). Qualities deemed most difficult for applicants to discern included the quality of facilities (18.6%), patient diversity (29.4%), and how well the residents got along with one another (30.2%). When compared to all other residency applicants, pediatric applicants placed more value on whether a program was family-friendly (p = 0.015), the quality of the facilities (p = 0.009), and the on-call system (p = 0.038).

CONCLUSION

This study highlights factors that influence pediatric applicants' perception of fit into a program. Unfortunately, many factors deemed most important for pediatric applicants were also among the most difficult to assess virtually. These include resident camaraderie, whether a program cares about its residents, and overall resident satisfaction. Taken together, these findings and the recommendations presented should be considered by all residency program leaders to ensure the successful recruitment of a pediatric residency class.

Understanding General Surgery Applicant Expectations and Perceptions in the Virtual Interview Process

OBJECTIVE

The COVID-19 pandemic has played a lasting role on residency recruitment through the virtual interview process. The objective of this study was to 1) examine general surgery applicants' priorities and perceptions following pre-interview virtual open houses and 2) to assess applicant expectations and efficacy of the virtual interview day process.

DESIGN/SETTING/PARTICIPANTS

This study utilized two voluntary and anonymous cross-sectional surveys administered via email to evaluate the virtual interview process of a general surgery residency program. The first was administered to registrants following completion of three open houses of various topics. The second was administered following each interview day. The post-open house survey had 78 respondents, two excluded for no open house attendance. The post-interview survey was completed by 44 applicants (62.9% response rate).

RESULTS

Majority of respondents reported that attending virtual open houses made them want to apply to (90.9%) and improved their perception of the program (94.7%). Applicants who felt a sense of obligation to attend open houses (68.4%) were significantly more likely to feel that they contributed to the stress and time commitment of applications (81.8% vs 18.2%, p=0.028). Interview expectations were identified in recurrent themes: 1. Clear organization with breaks, 2. Interactive resident sessions, 3. Meetings with program leadership, 4. Additional information unavailable on other resources. The pre-interview social and interview day improved 90.2% of the applicants' perceptions of the program. The interview significantly improved applicants' ability to assess nearly all aspects of the program, notably resident camaraderie and culture (30.8% vs 97.4%, p=0.01) and strengths and weaknesses (30.8% vs 92.3%, p=0.04).

CONCLUSIONS

While virtual open houses can improve applicants' perceptions and desire to apply to a program, the associated stress and obligation should be considered. Virtual interviews should provide information unavailable using other resources and provide avenues for conveying the resident culture and camaraderie.

How We Do It: Student Perspectives on Changes to the Obstetrics and Gynecology Residency Application Process

OBJECTIVE

To describe the perspectives of obstetrics and gynecology (OBGYN) residency applicants regarding new standards for the 2019 to 2020 application cycle.

DESIGN

An anonymous electronic survey was sent to all OBGYN residency applicants to US programs retrospectively evaluating 5 new recommended standards for the application process. This 15-item survey assessed the importance of the proposed standards and their impact on applicants' anxiety.

SETTING

The OBGYN residency application process is marked by increasing application numbers and no standardization for managing interview offers. The Association of Professors of Gynecology and Obstetrics (APGO) received a 5-year Reimagining Residency grant from the American Medical Association to improve the transition from undergraduate medical education (UME) to graduate medical education (GME) within OBGYN. The multiphase project, "Transforming the UME to GME Transition for Obstetrics and Gynecology- Right Resident, Right Program, Ready Day One (RRR)," began with Standardizing the OBGYN Application and Interview Process (SOAIP). This group recommended 5 new standards for all US OBGYN residency programs and applicants.

PARTICIPANTS

Applicants for US OBGYN residency programs for the 2019 to 2020 application cycle completed the survey, with a 904/2508 (36.0%) response rate, including 762 complete responses (30.4%).

RESULTS

Applicants reported that all 5 of the new standards would cause the least self-perceived anxiety (range 76.8% - 96.5%). The impact of the standards on perceived anxiety varied by student group, with International Medical Graduates (IMGs) and students with USMLE Step I scores <200 describing lesser impact compared to others. Despite these differences, all 5 standards were consistently noted to cause the least anxiety for all groups. Despite varying degrees of effects in different groups, the new OBGYN residency application standards caused the least anxiety for all subgroups of applicants.

CONCLUSIONS

Implementing universal standards for the OBGYN residency application process was favorably perceived by applicants and caused the least anxiety for applicants.

Supplemental Essays for Residency Applications: The Modern Day Typewriter

OBJECTIVE

The purpose of this study is to evaluate one institution's use of a supplemental essay and its effect on the total number and demographics of applicants as compared to previous years.

DESIGN

A retrospective cohort review of candidates applying to our institution's Orthopedic Surgery residency program in the 2020 to 2021 cycle was performed. All applicants were presented a prompt for a short supplemental essay. Only candidates who completed the essay were considered for an invitation to interview. Differences in proportions of female and under-represented minority (URM) applicants associated with the year of application and with essay completion were evaluated. A similar analysis was also performed to assess differences in demographics of interviewees between years.

SETTING

A single academic medical center providing tertiary care.

PARTICIPANTS

All orthopedic residency applicants from the 2019 to 2020 and 2020 to 2021 cycles.

RESULTS

Of 863 applicants in 2021, 506 (59%) completed the supplemental essay. URM status was significantly associated with application year and essay completion. However, demographics of eligible applicants and interviewees were not significantly associated with the application year, nor were the proportion of female or URM candidates offered an interview.

CONCLUSIONS

Our analysis based on use of the supplemental essay in one application cycle demonstrated that it was effective in reducing the application review burden by approximately 41.4% without adversely affecting the demographics of the interviewee pool.

Impact of COVID-19 on Radiology Residency Selection Process: A Survey of Radiology Residency Programs in the US

Rationale and Objectives

Virtual residency interviews have become crucial in maintaining CDC-recommended precautionary measures throughout the ongoing COVID-era. However, scant literature exists regarding the direct impact the pandemic has had on the radiology program selection process, including preferred modalities of residency interviews and social media utilization. This survey aimed to understand how radiology programs adapted to changes in the 2020–2021 virtual application cycle.

Materials and Methods

A 32-question survey was distributed to 194 residency programs between July and August of 2021. Data were analyzed primarily by using descriptive statistics and Paired Student's T-testing.

Results

A total of 31 programs completed the survey, yielding a response rate of 16%. When queried about the perceived success of virtual interviews during the 2020–2021 application cycle, 21 programs (68%) said the new interview format was very successful. Twenty-seven of the programs (87%) believed they were able to adequately gauge applicants through virtual interviews. However, when surveyed about personal preferences for interviews, the responses were more evenly distributed between virtual (11/31, 35%) and in-person (14/31, 45%). Pre-COVID, the top three criteria programs used to rank candidates were USMLE Step 1 score (20/31, 65%), letters of recommendation (17/31, 55%), and MSPE (12/31, 39%). Within the virtual, COVID-19 era, these criteria remained statistically unchanged (p = 0.22): USMLE Step 1 score (21/31, 68%), letters of recommendation (17/31, 55%), and MSPE (14/31, 45%). About half of programs who had not previously utilized social media (12 of 23, 52%) created accounts, mostly via Twitter or Instagram.

Conclusion

The primary findings indicate that programs perceived success with virtually interviewing and ranking applicants, the criteria to rank applicants remain unchanged despite the virtual environment, and programs’ social media utilization increased.

Compliance with CDIM-APDIM Guidelines for Department of Medicine Letters: an Opportunity to Improve Communication Across the Continuum

BACKGROUND

With rising applications to internal medicine programs and pending changes in United States Medical Licensing Examination Step 1 score reporting, program directors desire transparent data for comparing applicants. The Department of Medicine Letters of Recommendation (DOM LORs) are frequently used to assess applicants and have the potential to provide clearly defined data on performance including stratification of a medical school class. Despite published guidelines on the expected content of the DOM LOR, these LORs do not always meet that need.

OBJECTIVES

To better understand the degree to which DOM LORs comply with published guidelines.

METHODS

We reviewed DOM LORs from 146 of 155 LCME-accredited medical schools in the 2019 Match cycle, assessing for compliance with published guidelines.

RESULTS

Adherence to the recommendation for DOM LORs to provide a final characterization of performance relative to peers was low (68/146, 47%). Of those that provided a final characterization, 19/68 (28%) provided a quantitative measure, and 49/68 (72%) provided a qualitative descriptor. Only 17/49 (35%) with qualitative terms described those terms, and thirteen distinct qualitative scales were identified. Ranking systems varied, with seven different titles given to highest performers. Explanations about determination of ranking groups were provided in 12% of cases.

CONCLUSIONS

Adherence to published guidelines for DOM LORs varies but is generally low. For program directors desiring transparent data to use in application review, clearly defined data on student performance, stratification groupings, and common language across schools could improve the utility of DOM LORs.

Review of the Medical Student Performance Evaluation: analysis of the end-users' perspective across the specialties

The Medical Student Performance Evaluation (MSPE) is an important tool of communication used by program directors to make decisions in the residency application process. To understand the perspective and usage of the MSPE across multiple medical specialties now and in anticipation of the planned changes in USMLE Step 1 score-reporting. A survey instrument including quantitative and qualitative measures was developed and piloted. The final survey was distributed to residency programs across 28 specialties in 2020 via the main contact on the ACGME listserv. Of the 28 specialties surveyed, at least one response was received from 26 (93%). Eight percent of all programs (364/4675) responded to the survey, with most respondents being program directors. Usage of the MSPE varied among specialties. Approximately 1/3 of end-users stated that the MSPE is very or extremely influential in their initial screening process. Slightly less than half agreed or strongly agreed that they trust the information to be an accurate representation of applicants, though slightly more than half agree that the MSPE will become more influential once USMLE Step 1 becomes pass/fail. Professionalism was rated as the most important component and noteworthy characteristics among the least important in the decision-making process. Performance in the internal medicine clerkship was rated as the most influential while neurology and psychiatry performances were rated as less influential. Overwhelmingly, respondents suggested that including comparative performance and/or class rank would make the MSPE more useful once USMLE Step 1 becomes pass/fail. MSPE end-users across a variety of specialties utilize this complex document in different ways and value it differentially in their decision-making processes. Despite this, continued mistrust of the MSPE persists. A better understanding of end-users' perceptions of the MSPE offers the UME community an opportunity to transform the MSPE into a highly valued, trusted document of communication.

Resource Utilization and Emergency Medicine Advisors' Approach to Video Interview Preparation

Introduction The Standardized Video Interview (SVI) was a residency application component introduced by the Association of American Medical Colleges (AAMC) as a supplement to the existing process, which aimed to measure knowledge of professional behaviors and interpersonal skills. Given its novelty in both aim and execution, little advice or experience was available to inform preparation strategies. We sought to perform a cross-sectional analysis to explore advisors' practices in guiding students' preparation for the SVI. Methods An electronic questionnaire was developed and piloted for flow and usability, then distributed to all members of the Council of Residency Directors in Emergency Medicine (CORD EM), the professional society for emergency medicine educators, via listserv, comprised of 270 residency programs. Questions were both open- and closed-ended and therefore analyzed in a mixed-method fashion.  Results We received 56 responses from a listserv representing 270 residency programs. Respondents cited personal experience and consensus opinions from national organizations as the primary sources for their advice. The most common resources offered to students were space for completing the SVI (41%) or technical support for completing the SVI (47%). The time committed to student advising specifically for the SVI ranged from zero to 20 hours. Estimated associated costs of preparation ranged from zero up to $10,000 (time plus resources). Two individuals reported recommending commercial preparation resources to students.  Conclusion The SVI was a novel attempt to augment the resident application process. We found variability in resources and advice offered to students, including broad ranges of time dedicated, the monetary value of resources contributed, and the types of resources utilized. As the global COVID-19 pandemic has inspired a wave of innovation and process changes, we present this data for consideration as a snapshot of the variable responses to a single uniform process change.

General Surgery Residency Match: Time for More than a Virtual Change

The 2020-2021 General Surgery Residency Match presents unique challenges in the setting of the COVID-19 pandemic and highlights pre-existing concerns. In order to move toward an equitable and manageable surgical residency application process for both programs and applicants, systemic change is warranted.

Don't Judge a Letter by its Title: Linguistic Analysis of Letters of Recommendation by Author's Academic Rank

OBJECTIVE

This study analyzed the linguistic differences in letters of recommendation (LORs) for general surgery residency applicants written by authors of various academic ranks. Given that many general surgery residency programs require a LOR from the Chair of surgery, this study also examined whether LORs written by the Chair demonstrate linguistic differences to support this practice.

DESIGN

A single institution, retrospective review analyzed LORs from two application cycles of general surgery residency applicants who were selected for interview at a large academic institution. Word count (WC) and linguistic characteristics of LORs were analyzed with a previously developed institution-specific dictionary using the Linguistic Inquiry and Word Count software (LIWC2015; Pennebaker Conglomerates, Inc., Austin, Texas). WC and linguistic characteristics of LORs reported as frequencies of terms within twenty-four categories were examined based on the letter authors' academic rank. Further examination compared LORs written by a Chair of surgery with those written by non-Chairs.

SETTING

A single large, Midwestern academic general surgery residency program PARTICIPANTS: Four hundred and sixty-five letters of recommendation received during two interview cycles were included for analysis.

RESULTS

A total of 465 LORs written by assistant (n = 82), associate (n = 94), and full professors (n = 289) were included in the study. No statistically significant difference was noted in the WC of LORs based on the letter writers' academic ranks (p = 0.95). Assistant professors utilized grindstone, communal, and technical skill terms with higher frequencies compared to associate professors and full professors. LORs written by assistant professors demonstrated the highest authentic variable score followed by associate professors then full professors (4.94, 3.92, 3.28, p < 0.01). LORs written by Chairs (n = 128) had lower authentic variable scores compared to LORs written by non-Chairs (n = 337; 2.71 vs. 3.91, p = 0.001). Only 50 (39%) LORs written by Chairs indicated working directly with the applicant, and sub-group analysis demonstrated a higher authentic variable score in this group compared with LORs written by Chairs who did not indicate having worked directly with the applicant (3.51 vs. 2.5, p = 0.01).

CONCLUSIONS

Linguistic analysis of LORs for general surgery residency applicants demonstrated minor yet statistically significant differences based on the author's academic rank. If applicants can obtain linguistically similar LORs from surgeons of any academic rank, but less authentic LORs from writers with higher academic ranks, these LORs may be less valuable for the residency programs when evaluating applicants. Based on the subgroup analysis, less than 40% of Chair LORs indicated that the Chair worked directly with the applicant, calling into question the utility of the Chair LORs as meaningful evaluation of applicants. Further study to compare LORs of applicants selected and not selected for interview may add additional insight into linguistic differences in LORs written by authors of different academic ranks.

Evaluating Applicant Perceptions of the Impact of Social Media on the 2020-2021 Residency Application Cycle Occurring During the COVID-19 Pandemic: Survey Study

BACKGROUND

Due to challenges related to the COVID-19 pandemic, residency programs in the United States conducted virtual interviews during the 2020-2021 application season. As a result, programs and applicants may have relied more heavily on social media-based communication and dissemination of information.

OBJECTIVE

We sought to determine social media's impact on residency applicants during an entirely virtual application cycle.

METHODS

An anonymous electronic survey was distributed to 465 eligible 2021 Match applicants at 4 University of California Schools of Medicine in the United States.

RESULTS

A total of 72 participants (15.5% of eligible respondents), applying to 16 specialties, responded. Of those who responded, 53% (n=38) reported following prospective residency accounts on social media, and 89% (n=34) of those respondents were positively or negatively influenced by these accounts. The top three digital methods by which applicants sought information about residency programs included the program website, digital conversations with residents and fellows of that program, and Instagram. Among respondents, 53% (n=38) attended virtual information sessions for prospective programs. A minority of applicants (n=19, 26%) adjusted the number of programs they applied to based on information found on social media, with most (n=14, 74%) increasing the number of programs to which they applied. Survey respondents ranked social media's effectiveness in allowing applicants to learn about programs at 6.7 (SD 2.1) on a visual analogue scale from 1-10. Most applicants (n=61, 86%) felt that programs should use social media in future application cycles even if they are nonvirtual.

CONCLUSIONS

Social media appears to be an important tool for resident recruitment. Future studies should seek more information on its effect on later parts of the application cycle and the Match.

PGY1 Resident-Led Mock Virtual Interviews to Prepare for the 2022 Otolaryngology Residency Virtual Interviews

Due to the ongoing coronavirus disease 2019 pandemic, virtual interviews are planned for the 2021-2022 residency application cycle. The virtual interview will remain novel to applicants for each match cycle until the graduating medical student class has experience from virtual interviews during their medical school admissions. The virtual interview poses unique challenges that are unique from in-person formats. Given the lack of experience of applicants in the 2022 match, practicing interviewing skills prior to the actual date is vital to success. We describe a postgraduate year 1 (PGY1)–run mock interview session for applicants preparing for the 2021-2022 otolaryngology interview cycle and discuss the methodology. Deliberate practice with PGY1 residents who have just recently undergone the virtual interview process can better prepare applicants for their virtual interviews, improve on-camera behaviors, and ameliorate mental health challenges unique to the virtual format.

National Resident Matching Program Performance Among US MD and DO Seniors in the Early Single Accreditation Graduate Medical Education Era

Introduction: As of the 2020 National Resident Matching Program (NRMP), nearly all applicants are evaluated together for graduate medical education (GME) candidacy. We set out to characterize US MD and DO Senior residency match performance in the single-accreditation GME era.

Methods: A retrospective study was conducted in 2021 utilizing data collected from the 2018 and 2020 NRMP Charting Outcomes in the Match publications aggregated and subdivided into three groups based on competitiveness: low (LC), moderate (MC), and high (HC). Nonparametric analysis was performed using Chi square or Fisher exact tests if counts were less than five. Significance was determined at p < 0.05.

Results: A total of 46,853 candidates were included, with 36,194 (77.3%) US MD and 10,659 (22.7%) DO Seniors. Match rates for US DO Seniors were lower than US MD Seniors across all competitiveness strata (p < 0.0001). Research item production, national licensing examination scores, and mean number of contiguous programs ranked were lower for matched US DO Seniors compared to matched US MD Seniors, with significant differences depending on competitiveness group.

Conclusions: With recent changes to GME and its application process, understanding how various groups compare will be increasingly important. US DO Seniors have lower first-rank match rates for all specialty competitiveness levels. This may be due to lower research output or nuanced specialty selection. This study could aid GME stakeholders to more effectively allocate resources and better prepare residency candidates.

Social Media Changes in Pediatric Residency Programs During COVID-19 Pandemic

OBJECTIVE

To describe pediatric residency program's virtual presence and opportunities for the 2021 application cycle.

METHODS

A total of 202 pediatric residency programs from the Electronic Residency Application Service (ERAS) were reviewed for departmental and residency Twitter, Instagram, and Facebook accounts. These accounts, residency websites, and the Visiting Student Application Service (VSAS) were reviewed for open house opportunities and virtual subinternships. All data were collected from October 12-15, 2020.

RESULTS

A total of 261 social media accounts were identified. 123 (61%) programs had at least one account, with 32 (16%) programs having presence on all 3 platforms. 68 (34%) programs established new accounts after March 1, 2020. Instagram appeared most utilized with 106 (52%) programs having accounts. A total of 115 virtual open house opportunities were offered with most offers on Instagram by 61 (30%) programs. Only 2 virtual subinternships were listed on program websites, 2 on Twitter, 1 on Instagram, and 1 on Facebook.

CONCLUSIONS

COVID-19 increased the number of social media accounts used by residency programs. Approximately one-third of all accounts were created after March 1, 2020. However, only 16% of residency programs have a presence on all 3 platforms, allowing for more online growth.

Exploring Students' Perspectives on Well-Being and the Change of United States Medical Licensing Examination Step 1 to Pass/Fail

In February 2020, the Federation of State Medical Boards and National Board of Medical Examiners announced that Step 1 of the United States Medical Licensing Examination would transition from a three-digit numerical score to a pass/fail outcome. While several opinion pieces have been authored on the potential implications of this change, no study has formally assessed the student voice. The purpose of this study is to explore medical students' perspectives of a pass/fail Step 1, with an emphasis on how this transition will impact their well-being. Approach: We conducted virtual focus groups from May 2020-June 2020 with first- and second-year medical students from six institutions (n = 30). We analyzed focus group content following the inductive and iterative constructivist approach to produce a thematic analysis. Findings: Participants included females (50%), males (47%), and one non-binary student. The majority were Caucasian (57%), followed by Asian (27%), African American (10%), and Hispanic or Latino/a (7%). Overall, students were confused regarding the decision to transition Step 1 to a pass/fail outcome. They expressed anxiety over the uncertainty of how a pass/fail Step 1 may impact future residency applications and pressure to re-allocate time and resources to other academic pursuits that would make them competitive. Students explicitly stated skepticism or disbelief that a pass/fail Step 1 would improve their well-being. Insights: While the decision to make Step 1 pass/fail was in part intended to decrease stress associated with performance on a single high-stakes exam designed for licensing purposes, it has led to increased worries for students, and secondary, unanticipated consequences remain to be seen. In this new setting, it will be imperative to provide clarity regarding the metrics used to evaluate students and to incorporate their perspectives in future policy changes.

Information Quality for Residency Applicants in Fellowship and Residency Electronic Interactive Database (FREIDA) and Program Websites

Background Today's residency applicants submit more applications than those in the past. To facilitate holistic review, many program directors have encouraged applicants to submit fewer applications. However, whether programs provide sufficient information to help applicants determine where to apply is unclear. Objective To evaluate the frequency of missing information on residency program websites and in the Fellowship and Residency Electronic Interactive Database (FREIDA). Methods We used FREIDA to identify all categorical pediatric residency programs in the United States. We noted the presence of information programs reported in each FREIDA data field. We compared information available on the program website for consistency with the information in FREIDA and additionally searched for current resident information and any description of the qualities of applicants/residents desired on the program website. Results Two hundred and eleven pediatric residency programs were included in FREIDA. Approximately 25% of programs did not include basic information such as number of first year residents, salary, work hours, or consideration of applicants requiring work visas. Over half of programs did not report minimum licensing examination scores required for interview consideration. Discrepancies between information on program websites and FREIDA related to work visas occurred in 6-8% of programs. While 88% of program websites included information on current residents, only 17% included any description of the applicant attributes sought by the program. Conclusions Many pediatric residency programs do not provide much of the information that applicants need to help determine if a program is a good fit or whether their application is competitive.

Application Fever: Reviewing the Causes, Costs, and Cures for Residency Application Inflation

Over the past decade, the number of residency applications submitted per applicant has nearly doubled. This epidemic of “Application Fever” is expensive for applicants, burdensome for programs, and ultimately does not improve overall Match outcomes. In this review, we discuss the phenomenon of Application Fever, with a focus on contributing factors and costs of this behavior. Application Fever has its origins in the early 1990s. At that time, the number of residency applicants began to outpace the number of available positions. Because an applicant who applies to more residency programs has a greater probability of securing a residency position than an otherwise equivalent applicant who applies to fewer, "overapplication" became a dominant strategy and residency applicants began to apply to more residency programs each year. This trend was enhanced and enabled by the introduction of the Electronic Residency Application Service (ERAS). Although Application Fever is a rational decision for applicants, it imposes a substantial evaluative burden on program directors and necessitates the use of convenience screening metrics. We then briefly review potential solutions, including informational strategies, application limits, and marketplace incentives to reduce application numbers. Although a fixed cap on applications would reduce application numbers and facilitate a holistic selection process, greater transparency from residency programs regarding their selection criteria would be required to help applicants choose where to apply. To improve the residency application process for programs and applicants alike, we call upon the medical community to further study Application Fever and carefully consider solutions, including fixed application caps.

A Special Thank You to the Plastic and Reconstructive Surgery Medical Education Community During the COVID-19 Pandemic

ABSTRACT

In light of the most competitive match in history, the plastic and reconstructive surgery application process is in the midst of unprecedented times due to the COVID-19 pandemic. In-person visiting subinternships and interview processes have transitioned to online formats. The American Council of Academic Plastic Surgeons, program directors, coordinators, faculty, and residents have demonstrated an outstanding commitment to providing meaningful experiences for prospective applicants. The passion of the field of plastic and reconstructive surgery is palpable, and the innovative virtual experiences have resulted in the formation of a community despite the lack of in-person experiences.

Improving the online presence of residency programs to ameliorate COVID-19's impact on residency applications

Objectives: The coronavirus disease 2019 (COVID-19) pandemic has created several challenges for residency programs and prospective interns alike during the upcoming application cycle, including the cancellation of away sub-internships and in-person interviews. Given prior research documenting that applicants' application and ranking decisions are significantly influenced by residency webpages, a potential solution to the loss of in-person experiences during the pandemic is the expansion of residency programs' online presence through their program websites, provision of virtual grand rounds and pseudo-away rotations, and enhancement of virtual interviews. This study seeks to summarize the existing literature on these areas and provide concrete suggestions for improving programs' virtual presence.Methods: The authors summarize earlier literature querying the content of program websites across 14 medical specialties, which documented significant gaps in the content of interest to applicants.Results: Among 14 analyzed specialties, the majority of programs had a functional website (>90%), with the exception of interventional radiology (73.9%). However, significant gaps in content were documented, with the percentage of content variables contained on websites ranging from 33.3% to 70.5% (median = 47.0%, interquartile range = 37.8-52.6%). Program websites were also limited by underrepresentation of content most valued by applicants as well as potential areas of inaccurate or outdated information.Conclusions: There are several interventions programs can undertake to address existing gaps in online presence. During an application cycle facing unprecedented resource strain, bolstering the online presence of programs may facilitate an improved fit between programs and future residents.

Red Flags, Geography, Exam Scores, and Other Factors Used by Program Directors in Determining Which Applicants Are Offered an Interview for Anesthesiology Residency

Objective

The goal of this study was to measure the most important factors in candidate applications that anesthesiology program directors (PDs) use to decide who to invite for an interview, and how that might change once the United States Medical Licensing Examination (USMLE) Step 1 is only reported as pass/fail.

Design

Based on a literature review, a comprehensive list of 27 factors used by PDs to select candidates for the interview was developed. An anonymous survey link was emailed to PDs of all Accreditation Council for Graduate Medical Education (ACGME) accredited Anesthesiology residencies. The survey asked PDs to rank order the top 10 factors they currently consider for making interview invitation, and then to repeat the rank ordering as if the USMLE Step 1 score was instead reported as pass/fail as will be done beginning in 2022.

Results

Forty-five of 159 (28%) PDs responded, with 82% disagreeing with changing the Step 1 score to pass/fail. 84% consider the Step 1 score (77% for Step 2) moderately or very important for selecting an applicant for an interview. The most frequently mentioned “red flags” were failure of a licensing exam, failure of a medical school course, gaps in education without explanation, and criminal history. 69% of PDs agreed that applicants coming from the medical school affiliated with their program would have an advantage over other applicants. Although, the three factors most commonly ranked in the top 10 in importance were the Step 1 score, followed by letters of recommendation, and then the Medical School Performance Evaluation, variability exists in how PDs ranked factors. For example, of the PDs that had Step 1 in the top 10, 27% had it ranked between the 6th and 10th most important. 9% of PDs did not have Step 1 score in the top 10. Core clinical clerkship grades were one of the top 5 factors by 49% of PDs, yet overall was the 6th most common top 10 factor as 36% of PDs did not have core clerkship grades at all in the top 10. Once Step 1 is reported only as pass/fail, PDs had letters of recommendation, Step 2, and the Medical School Performance Evaluation as the most frequently ranked factors in the top 10. 64% of the PDs supported restricting the number of programs a candidate can apply to, with the majority suggesting a limit of 15 to 20 programs per applicant.

Conclusion

Variability exists among anesthesiology PDs in the key criteria for offering an applicant an interview. Once Step 1 is reported as pass/fail, there will be an increased emphasis on Step 2 scores.

The Evolving Impact of COVID-19 on Medical Student Orthopedic Education: Perspectives From Medical Students in Different Phases of the Curriculum

Introduction:

The world-wide lockdown caused by Coronavirus Disease 2019 (COVID-19) has upended the trajectories of lives everywhere. The medical profession has been on the front lines of this rapidly developing situation, which in turn has called for unprecedented changes in the medical school curriculum. These changes have severe implications for medical students interested in applying to competitive surgical specialties like orthopedics.

Methods:

As medical students in 3 different class years pursuing orthopedic surgery, we provide our perspectives on the impact that COVID-19 has had on medical student orthopedic education.

Results:

With the removal of away rotations and a shift to virtual interviews, rising fourth year medical students are arguably the most impacted as they prepare for the orthopedic residency application process. Third year students, who are in the exploratory phase of choosing a specialty, also face uncertainties in the shift to a “new” clerkship experience that may (1) be of shorter duration, (2) implement shifts to limit overcrowding of clinical space, and (3) increase the use of telehealth over direct patient contact.

Discussion:

The COVID-19 pandemic has altered the course of medical students’ orthopedic education in unprecedented ways. We believe the following suggestions may be helpful for students seeking alternative, supplemental ways of learning: (1) read up on major orthopedic journals, (2) reach out to orthopedic surgeons in areas of interest, (3) reach out to program directors/medical clerkship directors/program coordinators for opportunities to attend their educational curriculum virtually, (4) attend online lectures and hospital grand rounds, and (5) practice suturing technique with a practice kit.

Conclusions:

While the medical education landscape remains uncertain amid the evolving conditions of COVID-19, as medical students we strive to learn from this pandemic and respond to future unforeseen challenges with resilience, dedication, and compassion: all qualities we admire in orthopedic surgeons.

COVID-19 Implications on Clinical Clerkships and the Residency Application Process for Medical Students

The coronavirus disease 2019 (COVID-19) pandemic has caused significant disruption to undergraduate medical education (UME). Although the immediate scheduling challenges are being addressed, there has been less discourse regarding how this pandemic will impact medical students in their preparation for and application to residency programs. While some historical disasters and pandemics provide a loose precedent for UME response during COVID-19, the impact of the current pandemic has surpassed any other events. COVID-19 will likely impact UME in the suspension of clinical rotations, alterations in grading, suspension or elimination of away rotations, changes in medical licensing exams, and ramifications on mental health. This review assesses governing medical bodies' recommendations regarding UME during the COVID-19 pandemic and how this may impact preparation for residency. In particular, residency programs will likely have to create new guidelines for assessing applicants during this unique cycle.

Perspectives From Rising Fourth Year Medical Students Regarding Strategies to Counteract the Effects of COVID-19 on Medical Education

The COVID-19 pandemic has put those who oversee medical education in a challenging position. Medical school administrators, students, and national governing bodies have been forced to make difficult decision as a result of public health concerns and government-enforced restrictions. We, as rising fourth-year medical students, would like to shed light upon the hard work that many of those in leadership positions have done as well as lay out some concerns that medical students who are preparing to apply to residency have. Additionally, we would like to suggest several potential approaches that attempt to address some of the problems arising from the pandemic. Continuing to balance education with the hurdles presented by COVID-19 will require a multi-faceted and coordinated approach. We believe that implementing virtual rotations, delaying the opening of the application, decentralizing clinical skills evaluations, and modifying graduation requirements are possible options among many that could aid in addressing some of the current challenges presented by COVID-19.

The association between United States Medical Licensing Examination scores and clinical performance in medical students

Purpose: United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) scores are frequently used to evaluate applicants to residency programs. Recent literature questions the value of USMLE scores for evaluation of residency applicants, in part due to a lack of evidence supporting a relationship with clinical performance. This study explored the relationship between USMLE scores and medical students' clinical performance, as measured by the count of honors grades received in core clinical clerkships. Methods: USMLE Step 1 and Step 2 CK scores and number of honors grades per student in seven core clinical clerkships were obtained from 1,511 medical students who graduated in 2013-2017 from two medical schools. The relationships between variables were analyzed using correlation coefficients, independent-samples t-tests, and hierarchical multiple regression. Results: Count of honors grades correlated with both Step 1 (R=0.480, P<0.001) and Step 2 CK (R=0.542, P<0.001). After correcting for gender, institution, and test-taking ability (using MCAT scores as a proxy for test-taking ability) in a hierarchical multiple regression model, Step 1 and Step 2 CK scores together explained 22.2% of the variance in count of honors grades. Conclusion: USMLE Step 1 and Step 2 CK scores moderately correlate with the number of honors grades per student in core clinical clerkships. This relationship is maintained even after correcting for gender, institution, and test-taking ability. These results indicate that USMLE scores have a positive linear association with clinical performance as a medical student.

Use of Standard Guidelines for Department of Medicine Summary Letters

Phenomenon: Fourth-year medical students obtain Department of Medicine (DOM) letters ("Chair" letters) to support their residency applications. Writing and interpreting DOM letters are challenging. There is heterogeneity in the letters that makes it difficult to both write and read these letters.

APPROACH

The purpose of this study is to determine the value of new guidelines developed by a task force of clerkship directors and program directors in internal medicine and assess the implementation of these guidelines. The Clerkship Directors in Internal Medicine performed a cross-sectional survey of internal medicine clerkship directors at U.S. and Canadian medical schools in 2014. In addition, the primary author's institution reviewed 1,347 DOM letters between 2012 and 2014 to assess the implementation of these guidelines.

FINDINGS

The survey response rate was 78%. DOM letter writers reported the guidelines were better, easier to implement, and more compatible with the purpose of DOM letters than previously. Most letter readers reported that letters using the guidelines were more credible. Writers of DOM letters in lower academic ranks rated the letters with guidelines higher in several domains than those in higher academic ranks. Readers of DOM letters in higher academic ranks rated the letters with guidelines higher in several domains than those in lower academic ranks. In the DOM letters examined, the odds of meeting each guideline increased with each additional year. However, for 3 guidelines there was an initial decline in adherence from 2012 to 2013 before increasing again in 2014-the recommended length, clerkship description, and detailed narrative guidelines. Letters solely written by a chair were less likely to incorporate the guidelines. Insights: Clerkship directors often write the DOM letters and identify with the purpose of the guidelines. As writers, lower ranking academic faculty value the guidelines more than higher ranking academic faculty. As readers of DOM letters, higher academic ranking faculty value letters that incorporate the guidelines more than lower academic ranking faculty. DOM letters implemented more guideline criteria since the guidelines were released. If implementing the guidelines, chairs should solicit the help of their clerkship director or educational representative when writing DOM letters. Although many clerkship directors read letters for their residency programs, additional program directors' opinions are needed.