Implications of COVID-19 on the General Surgery Match.

The COVID-19 pandemic will have lasting implications that span the breadth of healthcare in the years to come. As a byproduct of multiple factors, including supply chain preservation, potential for asymptomatic spread, and a desire to minimize risk to individuals not required for care provision, medical students have largely been sidelined during this crisis. Although medical educators continue to develop virtual solutions to adapt the medical school curriculum, 1 concern that arises is how the COVID-19 pandemic will affect the process of medical student career planning, especially recruitment into surgery. In this article, we discuss some of the foreseeable challenges related to medical student careers and propose solutions to mitigate its impact.

THE PROBLEM

Limited Exposure to Surgery

In accordance with Association of American Medical Colleges guidelines, most medical students are currently being kept out of hospitals across the country.[1] This strategy was implemented to protect students from exposure and to preserve limited personal protective equipment. For medical students, this is occurring during a time when they would otherwise be immersed within the hospital on core clerkships, including general surgery. Although creation of a “virtual” surgical curriculum would be beneficial,[2,3] the exposure to actual surgery cannot be replicated with any available virtual surrogate and as such, surgical disciplines are disproportionally affected by the inability to experience the hospital setting firsthand.

Strategies to account for these missed opportunities must be developed given the critical importance that core clerkships ultimately have on medical students’ decision-making in choosing career specialties. Numerous studies have demonstrated the impact that a surgical clerkship rotation has on inspiring career choices for medical students.[4] Exposure to the operating room environment, in particular, remains critical to fully appreciate a surgical career, and with current tools it is impossible to completely replicate it virtually. With limited exposure to a hands-on surgical clerkship, medical students may not be as confident or well-informed in their decision to pursue a 5–7 year residency in surgery, with repercussions for students entering the match in general surgery for the next 1–2 years after the height of the COVID-19 pandemic.

Impact on Sub-internships (sub-Is)

In addition to the impact on core clerkship rotations, there is a simultaneous effect on students with an expressed interest in surgery with planned sub-Is. These rotations provide critical experiences during which students gain a deeper appreciation for the field of surgery to learn if it is an appropriate “fit” for them as a career choice.[5] Sub-I's also provide many students foundational knowledge to help prepare them for surgical training. Furthermore, the added exposure a student gains to their home department can prove critical in their quest to identify advisors, mentors, and advocates to help them navigate their future professional endeavors. Reciprocally, these rotations provide an opportunity for faculty to evaluate students’ performance, offer them guide advice as to ideal characteristics of residency programs, and generate the content of letters of recommendation (LOR). Many students undertake multiple sub-Is within their desired specialty, which start as soon as April, to maximize opportunities before submitting their applications. Because many surgery residency programs use a rolling residency application deadline, students often feel obligated to submit their applications as soon as the electronic residency application service (ERAS) site opens. Unfortunately, the current pandemic has placed a halt on sub-Is, which has considerable implications for the downstream application components. The questions that therefore, arise are how can the educational system compensate for these losses and will the value of a LOR be diminished as a result? More importantly, how will the students gather an acceptable portfolio of information about specific disciplines to make informed choices about their optimal career?

Decreased Availability of Away Rotations

The decreased availability of sub-I rotations also adversely affects “away” rotations, which are likely to be difficult to arrange even after core clerkship rotations have resumed due to ongoing travel restrictions. For most students, the away rotation is an opportunity to audition at specific programs of interest or to demonstrate their interest in a particular geographic location, and it provides an exploration of “fit” in otherwise unknown programs.[6] This added obstacle will further exacerbate the challenges evolving in students’ decision making as access to data about outside programs erodes even further. Similarly, for residency programs that utilize these rotations to evaluate prospective applicants from around the country, programs will have to create new opportunities to recruit the best students from across the country and abroad.

PROPOSED SOLUTIONS

Given the above highlighted challenges that may have a substantial impact on downstream resident recruitment for years to come, we propose the following potential solutions:

Modify Core Clerkship Schedules

Serious consideration should be given to shortening the duration of each core clerkship and/or enabling students to tailor their clerkship schedule to their clinical interests. For example, a student interested in surgery may wish to spend more time on this clerkship and correspondingly less time on another clerkship in which they have less interest.

Delay the ERAS Application Submission System to Allow for Completion of Sub-Is

By delaying the date when programs can receive ERAS applications from September 15th to October 15th, and by delaying the date when the Medical School Performance Evaluation (“Dean's letter”) becomes available from October 1st to November 1st, fourth year medical students would have an additional month to finalize their specialty choice, to complete their desired sub-I rotations, and to obtain the necessary LORs for their ERAS applications. This option would also permit medical students to graduate on schedule without the emotional stress of feeling rushed to choose a specialty or to submit an incomplete application.

Transform the Traditional Sub-I Experience

To meet the need of available sub-I rotations and to still provide appropriate educational experiences, changes to the current structure of sub-Is may be necessary. Although sub-I rotations are often 1 month in length, it may be beneficial to shorten sub-Is to 3 weeks for the upcoming academic year. This would still provide fourth year medical students with adequate exposure to the specialty, whereas allowing for the participation in more rotations in a shorter period of time. Additionally, this would increase the availability of positions for other sub-Is and visiting students. Ideally, this change in length would be adopted by all programs across the country to level the playing field and offer maximal benefit to all students. Should certain programs not be able to accommodate this, their flexibility would be appreciated in letting their students do this nontraditional rotation and count the credits equally. Alternatively, the structure of sub-Is could be changed to an “apprentice style” in which the student rotates with just a single faculty member, thereby enabling more students to complete sub-Is on a given service. Sub-Is will also require clearly defined goals and learning objectives with explicit institutional guidelines regarding how COVID-19 exposure is managed, including any required testing and/or quarantine time either before or after the sub-I.[7]

Offer Virtual Opportunities to Speak With Residents and Program Directors In Lieu of Away Rotations

Residency programs should consider hosting a virtual “meet and greet” where potential applicants can ask questions of current residents to obtain answers regarding the culture and “fit” of each program. Although this does not make up for the lost audition of the away rotation for some students, it will at least allow students to express interest and can help them assess the “fit” of a given program for them. Ideally, these sessions would follow a standardized format to enable the student to make fair comparisons between programs.

Adapt the Residency Interview Process

Modifying the traditional interview process may be necessary. In congruence with the delayed availability of the ERAS applications, the interview season could be postponed by 1–2 months, extending even into early February. This short delay would still allow enough time for rank list submission by the end of February and for the Match to occur as usual in mid-March. Additionally, should pandemic restrictions persist, it may be necessary to transition to virtual interview platforms. Programs might even consider an initial round of virtual interviews in October or November as a screening process to choose a smaller number of students to invite later for an in-person interview. Flexibility on behalf of residency programs is paramount, as virtual interviews may be consciously or subconsciously evaluated differently than in-person interviews. Thoughtfulness in the selection of interview dates will be necessary to minimize overlapping interviews between programs, and consideration to conducting interviews at the conclusion of a student's sub-I rotation should be considered.

Although this is not an exhaustive list of possible solutions, the importance of anticipating, mitigating, and planning accordingly will allow surgery programs to address the needs of medical students at a time of great uncertainty. It is imperative to maintain continuity of medical student education, engagement, and recruitment into surgery during this difficult time, and we encourage our national surgery education organizations to maintain an active role in this process.