Letter: Approaches to Mitigate Impact of COVID-19 Pandemic on Neurosurgical Residency Application Cycle.

To the Editor:

The increased risk of the hospital environment and the nationwide advisory for social distancing has led many medical schools to cancel clinical rotations. Herein, we propose approaches to mitigate the disruptive impact of the widespread cancellation of neurosurgical sub-internships that the COVID-19 pandemic may have on the 2020 to 2021 neurosurgery residency application cycle.

LETTERS OF RECOMMENDATION BY FACULTY

Letters of recommendation (LoRs) from neurosurgical faculty shed light on applicants’ personalities and behaviors of those without a neurosurgical program at their home institution. Alongside USMLE Step 1 score, LoRs are the only other factor cited by 100% of program directors in selecting which applicants to interview, ranking it at 4.6/5 importance.[1] While LoRs are crucial in interviewee selection, their impact on rank-list position falls behind performance on interview day.[1] Accordingly, the goal is to preserve the quality of selected interviewees in the absence of sub-internship LoRs. For certain applicants, outstanding sub-internship performance and strong LoRs are key in securing them an interview invitation; these may include under-represented minorities and those with non-traditional backgrounds.

Since objective metrics (eg, board scores) have shown poor correlation with performance in residency,[2,3] now, more than ever before, is the time to adopt a wholistic review of applicants’ profiles; this includes close review of performance on third year clinical rotations and involvement in their medical school and local communities. In addition to research LoRs, students should be encouraged to solicit LoRs from non-neurosurgical mentors who can comment on their personal attributes and interpersonal skills.[4]

Another consideration is how to compare students who have LoRs from pre-COVID-19 sub-internships to those who do not. To level the playing field, one option is to categorically not consider sub-internship letters in determining who merits an interview. Alternatively, a tiered review process could be used where applications are first reviewed without looking at sub-internship LoRs, and that these are only consulted (if available) when they may benefit an applicant (ie, when they would otherwise not be invited to interview).

Lastly, programs could elect to increase the number of applicants they interview. This comes with added cost to an already costly process for both programs and applicants in terms of time and money.[5] A potential solution would be a 2-step process wherein a larger pool of applicants is invited to an online screening interview, and a smaller cohort is subsequently invited to the on-site interview day. Some advocate for the use of validated online personality assessment tools as a way to evaluate applicants’ personality, and that these may be superior to LoRs, as they are standardized across applicants and thus, less prone to implicit biases that may be held by letter writers.[2]

EXPOSURE TO SPECIFIC PROGRAMS OF INTEREST

Sub-internships allow students to explore different kinds of programs and serve as a way for students to express interest in specific programs. Most applicants rank as number one a program where they completed a sub-internship.[6] To maintain engagement of interested students, programs could consider inviting interested students to join their e-conferences. Programs may also organize online teaching or Q&A sessions about the program for interested applicants, or even invite would-be sub-interns to present about a clinical/research topic via Zoom. Altogether, such e-conferences would allow students to get a sense of departmental culture and teaching style, and to make themselves a ‘familiar face’ to specific programs.

PRESENTING A UNITED FRONT THROUGH ORGANIZED NEUROSURGERY

Students are already expressing anxiety about what they should do given the disruptions to the upcoming residency application cycle.[7] Herein, we proposed several strategies to lessen the negative impact of sub-internship cancellation; there is no one-size-fit all solution, and it is likely that a combination of strategies will be needed. While different programs may adopt different strategies, a unified response and corresponding direction provided to aspiring neurosurgery applicants during this time is likely to benefit us all.

Disclosures

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.