AAIM Recommendations for the 2020-2021 Internal Medicine Residency Application Cycle in Response to the COVID-19 Pandemic.

This statement was released in June 2020 by the Alliance for Academic Internal Medicine to provide guidance for the 2020-2021 residency application cycle in light of the COVID-19 pandemic. While many of the recommendations are specific to this cycle, others, such as the Department Summary Letter of Evaluation, are meant to be an enduring change to the internal medicine residency application process. AAIM realizes that some schools may not yet have the tools or resources to implement the template fully this cycle and look toward collaboration within the internal medicine education community to facilitate adoption in the cycles to come.

In light of COVID-19, AAIM offers specific recommendations to guide the internal medicine education community during the upcoming interview season:

Limit away rotations.

Conduct virtual interviews.

Adopt a standardized Department Summary Letter of Evaluation.

Adjust requirements for Letters of Recommendation.

Reflect challenges related to acquiring fourth-year medical student experiences in program requirements.

Utilize data when advising students on number of applications.

Consider innovations in addressing application inflation.

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Introduction

The Alliance for Academic Internal Medicine (AAIM) empowers academic internal medicine professionals and enhances health care through professional development, research, and advocacy. Through the Administrators of Internal Medicine, the Association of Program Directors (APDIM), the Association of Professors of Medicine, the Association of Specialty Professors, and Clerkship Directors in Internal Medicine (CDIM), the Alliance includes more than 11,000 faculty and staff in departments of internal medicine at medical schools and teaching hospitals, representing the entire continuum of medical education from medical student to practicing physician. As such, AAIM has a stake in enhancing and fortifying the medical education continuum. A work group of CDIM (undergraduate education) and APDIM (residency education) leaders collaborated to develop this document to address key issues affecting applicants and training programs during the 2020-2021 application cycle. In these challenging times of coronavirus disease 2019 (COVID-19), we offer specific recommendations to guide the internal medicine education community of students, faculty advisors, and clerkship and program directors during the upcoming interview season.

Given the recent recommendations by the Association of American Medical Colleges (AAMC), the National Resident Matching Program (NRMP), and the Coalition of Physician Accountability, we recognize the urgent need to provide guidance for the upcoming recruitment cycle. Thus, we developed the recommendations below, incorporating key principles of our mission as medical educators in internal medicine:

We value the health and safety of our learners and programs as well as of the patients and communities they serve.

We aim to create an equitable application process for students and programs, recognizing the unique circumstances in internal medicine that make this challenging. Our community is diverse, and balancing the individual needs of students, along with varied program characteristics, is complex.

We selected areas that are within our scope of control and focus on providing guidance and highlighting flexibility within the current official policy developed by the Electronic Residency Application Service (ERAS; AAMC), NRMP, the Educational Commission for Foreign Medical Graduates, and other regulatory agencies.

We share the same goals as the overall medical education community: reducing unwarranted confusion, stress, and inequity for our students, our programs, and their directors and teams, while ensuring a successful internal medicine match despite the expected impacts of COVID-19. We realize there are no perfect solutions and no process will address all stakeholders’ needs. As such, AAIM developed these consensus recommendations to best represent the professional values of our internal medicine community. This document provides guidance based on currently available information.

Away Rotations

Due to the COVID-19 pandemic, it is necessary to support public health principles of avoiding unnecessary travel. In addition, medical schools are facing challenges in accommodating their learners’ needs to complete their clinical requirements for graduation. However, AAIM acknowledges that a few schools require away (extramural) rotations to meet graduation and accreditation requirements. In addition, there may be unique factors for some residency programs that warrant special considerations (for example, hosting international medical students).

Recommendation

AAIM strongly recommends that no in-person away rotations be allowed or encouraged unless there are unique residency program level considerations or student curricular requirements or experiences that cannot be met at a learner's host institution. If such unique requirements exist, rotations should be limited in number and conducted at geographically proximate institutions if possible.

Virtual Interviews

Public health and medical experts predict the COVID-19 outbreak to continue through the fall and winter, with geographic hotspots or a national resurgence compounded by coincident influenza. If there are geographic outbreaks with stay-at-home orders and limitations on traveling, holding in-person interviews with some, but not all, applicants creates disparities. Accordingly, internal and external (local and distant) candidates should be treated the same. Although virtual interviews are suboptimal for both the applicant and the program, the recruitment process should be as equitable as possible. In addition, if there is a second wave of the pandemic later in the year and adjustments must be made mid-season, the disruption would be challenging for both applicants and programs. A smooth and consistent process is key to a successful recruitment season for applicants and programs.

A secondary consideration is that virtual interviews offer a more cost-conscious option in a time when pandemic-induced financial hardships may make traveling and hosting prohibitive. Especially during this uncertain time, virtual interviews also allow for more flexibility in accommodating students’, program directors’, and faculties’ schedules.

AAIM strongly recommends that residency programs eliminate in-person interviews and adopt virtual platforms to conduct all interviews and site visits, including those for learners at their own institution.

AAIM recognizes that there are advantages and disadvantages to this new paradigm. We know programs will need faculty development and increased administrative and technical support. Students also need increased guidance and faculty support. AAIM encourages the creation and sharing of resources, tools, and best practices for virtual interviewing with the rest of the internal medicine community, for both programs and applicants.

DOM Summary Letter of Evaluation

In 2013, APDIM and CDIM updated their joint guidelines for the Department of Medicine (DOM) Summary Letter. However, wide variations still exist as to how these guidelines are incorporated, and many program directors remain unsatisfied with the lack of a standardized format, redundancy in the Medical Student Performance Evaluation, the lack of graphical data on grade and objective assessment distributions, including National Board of Medical Examiners Internal Medicine Subject Examination scores, and missing descriptions of the roles and responsibilities of students on core clerkships and acting internships.

Given the truncated time to review applications in this upcoming recruitment cycle, it is essential that program directors receive objective data presented in a standardized format. If no additional objective data to guide decisions is available, residency programs are left to rely only on available data, such as US Medical License Examination (USMLE) scores. Unfortunately, data such as USMLE scores and class quartiles have limitations and will be more difficult to interpret this year. DOM Summary Letters should provide additional standardized, objective student data to facilitate holistic review. In particular, program directors desire information about a student's accountability and commitment to growth, as well as teamwork and communication skills. All stakeholders want students to attain a match that will facilitate success during residency.

We propose adopting a DOM Summary Letter of Evaluation (LOE) using a standardized template. A standardized LOE template should increase the quality of letters, decrease time to prepare letters, and decrease variability and time needed in interpretation of letters. Further, by the inclusion of a comparative scale for characteristics of particular importance to internal medicine program directors and the use of concise written comments to provide context to any outstanding circumstances or particular strengths, program directors can determine if they feel they can provide a good fit for candidates to ensure their success. A standardized template is provided for use starting this application cycle, including a section for noting COVID-related changes. The template, as well as a sample mock-up letter, are shown in the Appendix (available online).

AAIM plans to support program directors and Department Summary LOE writers on using the template through virtual workshops and resource development.

Letters of Recommendation (LORs)

With the COVID-19 pandemic, students have had truncated or revised clinical experiences, including sub-internships. These changes may limit the ability for some students to obtain a clinical LOR from their Internal Medicine clerkship. This may be especially true for preliminary Internal Medicine applicants who may complete sub-internships in their primary specialty. In addition, Internal Medicine faculty are being stretched personally and professionally due to the pandemic and may have limited time to write letters.

Program directors aspire to perform a holistic review of applicants and value quality letters of recommendation over quantity. Currently, program directors receive thousands of applications and are unable to comprehensively review each application despite the best of intentions. A provision of fewer but higher-quality LORs would be of benefit. Guidelines and best practices on completing letters of recommendations have been shared at previous AAIM workshops.

Current recommendation for most categorical programs is 2 LORs (with at least one representing a clinical internal medicine experience) and one DOM Summary Letter. Some programs have exceptions, such as asking for an additional LOR.

Current recommendations for preliminary programs differ across programs; usually 3 LORs, with some preferring a DOM Summary Letter. Internal medicine departments vary on whether they provide DOM Summary Letters for preliminary applicants.

Recommendations

Categorical Internal Medicine Applicants

2 required letters: 1 clinical LOR from an internal medicine faculty + 1 DOM Summary Letter of Evaluation

1 optional LOR, could be from clinical faculty or scholarly project mentor

Preliminary Internal Medicine Applicants

2 required Letters: 1 clinical LOR from an internal medicine faculty + 1 clinical LOR from any specialty

Fourth-Year Medical Student Experiences

As the pandemic has significantly impacted the ability of many medical students to complete clinical experiences in internal medicine, including reduced availability of sub-internships (acting internships) and scheduling delays, AAIM recommends flexibility in program requirements at the time of application review. In addition, AAIM recognizes the ongoing challenges in securing USMLE testing slots for Step 2 Clinical Knowledge (CK) and the suspension of Step 2 Clinical Skills (CS) testing.

Step 2 CK/CS

Waive any program requirements for Step 2 CK to be completed by the time of initial application review.

Waive any program requirements for Step 2 CS.

Sub-Internships

Waive any program requirements that a sub-internship be completed by time of initial application review.

Number of Applications Per Candidate

Several factors are likely to contribute to a more stressful and potentially less holistic application review process this cycle, including:

A compressed application review period for program directors due to delays in the ERAS timeline

Competing demands of managing residency programs through a predicted resurgence of COVID-19 cases

Increased application submissions due to heightened uncertainty (including changes to clinical skills assessments, visa delays, or other COVID-related factors)

Increased application submissions due to the perceived ease of virtual interviews

It is essential that our community take steps to prevent application inflation. Although limiting the number of programs a student can apply to through ERAS has been proposed in the literature and on various discussion boards, there are few data and little consensus to guide equitable imposition of limits given the heterogeneity of applicants and residency training programs. AAIM recognizes the diverse requisites of stakeholders, which adds layers of complexity to producing solutions for the application inflation conundrum. As such, exploring creative options during this period should be considered in order to improve the application cycle in the years to come.

Schools of medicine leaders and advisors should use AAMC application data and USMLE scores to advise students on the appropriate number of programs to apply to. Submitting a higher number of applications than necessary limits the ability of programs to perform holistic reviews.

With the support from the AAIM community, internal medicine could function as a pilot specialty in the 2020-2021 cycle to address application inflation.

There is opportunity to improve the process for a student to demonstrate interest in a program as well as a program to assess fit by instituting a process in ERAS whereby applicants have the option to include desired program characteristics, such as state, geography, request for a “couples match,” etc. AAIM highly encourages ERAS and other stakeholders affiliated with the Match process to create optional geographic or other “special circumstance” preference fields in ERAS visible to all programs.

AAIM strongly recommends that ERAS, NRMP, the Educational Commission for Foreign Medical Graduates, and other stakeholders develop options for programs to conduct a holistic review of applicants. A tiered application system, early acceptance, multiple match cycles, or other innovations are worthy of exploration. Such approaches should inform programs of which applicants have sincere interest in the program while not disadvantaging any applicants.

ERAS should consider a pilot in one of these areas. While this would not necessarily mitigate the number of applicants to a given program, it may provide opportunity to more efficiently filter through thousands of applications and holistically focus on applicants with genuine interest in particular programs.