Cardiovascular Disease Fellowship Interviews 2021: An Evolution in Process.

The 2021 Interview Season: Creating Certainty Amid Uncertainty

The COVID-19 pandemic abruptly shifted traditional norms in graduate medical education, not the least of which was a pivot from in-person interviews to a virtual-only platform for the 2020 interview cycle. Cardiovascular (CV) program directors have been contemplating the landscape of the upcoming recruitment season in the midst of the current COVID pandemic as well as the increased access to vaccinations and changing guidelines. Many factors will help shape the interview process, including but not limited to institutional guidance, local and state regulations, and national society and regulatory board recommendations. The Undergraduate Medical Education to Graduate Medical Education Review Committee of the Coalition for Physician Accountability, the Alliance for Academic Internal Medicine, and the American College of Cardiology Program Directors and Graduate Medical Educators Leadership Council all just recently endorsed an all-virtual recruitment for the upcoming season (1, 2, 3). In light of these recommendations, we believe it is important to consider the approach to the coming recruitment season. There are both opportunities and challenges to the virtual recruitment that affect programs and applicants. Although these virtual interviews may pose challenges for fellowship programs and feel somewhat discordant in a postvaccine world, implementation of the formal recommendations in this paper, based on our experiences and feedback from stakeholders, will help ensure standardization and optimize the experience for all participants.

Given the unique challenges that virtual interviews can pose for both fellowship programs and applicants, it is essential to build on experiences from last year and share best practices to promote fairness and achieve the desired goals of virtual recruitment for the upcoming interview season. With that, we will consider the viewpoints of both applicant and program as we embark on this process together.

Applicant Viewpoint: Defining the Ideal Virtual Experience

The virtual interview presents unique opportunities and challenges for applicants to meet faculty, interact with current fellows, and “tour” facilities. Outside the standard faculty interviews, programs should facilitate virtual interviews that help connect applicants with prospective mentors in their fields of interest and those with similar life experiences when possible. Applicants should meet with current fellows who can highlight a program’s academic environment and sense of community. Conversations between applicants and fellows, without faculty, in informational and informal sessions provides an important perspective. Limiting the number of applicants and fellows to a given virtual room can promote interactivity.

We may take for granted all the facilities that applicants have traditionally seen in person. Programs therefore should create virtual tours featuring community spaces, including work and call rooms, that exist outside of standard patient care areas (4). Programs should also ensure that all videos meet institutional privacy policies. These types of video tours are ideal for asynchronous viewing and can offer a more streamlined interview day that offers less “digital fatigue.”

Technological issues, such as interview disconnections, increase anxiety among applicants. A simple but well-developed backup plan presented to the applicants early on the interview day can stem this concern. The program coordinator should be readily available and “online” for general troubleshooting and directions. Providing interviewers easy access to applicants’ telephone numbers to quickly reconnect is important (5). Some programs also had fellows assist the coordinator with the logistics of the day.

The computer screen itself poses unique barriers. We should break down the “fourth wall” of virtual interviews by looking directly into the camera when speaking. However, this can be challenging, and subtle behavioral cues from in-person interviews may be difficult to replicate in a virtual format. These limitations should be kept in mind when evaluating applicants, and discussions with interviewers about new potential technological inequities and biases should be addressed early on (6). Finally, neutral, professional backgrounds can minimize distractions and ensure that the evaluative component of an interview is not influenced by external factors.

The Program Perspective: Unique Challenges

There are many challenges in the virtual environment that affect all programs. However, programs with fewer trainees, as well as those in less populous or more remote geographic regions, share unique challenges. For these programs in particular, virtual interviews may present new obstacles but also provide opportunities.

In previous years and traditional application cycles, applicants may have bypassed small programs because of several misperceptions. These include the belief that such programs were unable to provide the full breadth of training required to achieve career goals or that programs in smaller communities or remote locations offer fewer amenities outside of the training environment. However, last year’s virtual platform provided at least anecdotal evidence that virtual interviewing can increase initial interest because of reduced travel and time constraints (4). Moreover, there was also a perceived reduction in the not uncommon practice of cancellations.

Applicants may not have the familiarity with individual programs in the virtual-only experience. As such, the need to emphasize the unique characteristics and strengths of programs is paramount. It is particularly important to highlight the strength of the training environment and community. The thoughtful use of preinterview recorded materials and videos that advertise the benefits of the training program and the advantages of the community is key. These and similar materials should be shared across programs within an institution and augmented by civic and local productions aimed at recruitment of young professionals.

Many programs proportionately increased the number of interviews last year because of the fear of unmatched positions in the face of initial concerns that the ease of virtual interviews would lead to “interview hoarding.” Interestingly, reports from program director forums suggest similar or better match outcomes compared to pre-COVID recruitment years. Additionally, many smaller programs believed that they had a greater number of underrepresented minorities and women apply. Previous limited experience with virtual interviews have indeed confirmed that reduced financial travel burden can promote applicant diversity (6). Further cardiology-specific data need to be collected to understand if the current recruitment environment contributed to more diversity, equity, and inclusion. This will be particularly important as we look toward the future in which virtual interviews may continue to play an important role in recruitment.

Putting It All Together: Lessons Learned

Fellowship programs across the country learned valuable lessons in recruitment during the COVID pandemic that will serve all stakeholders well for the future. These included improvements in online presence, technical components to the online interview, and the structure of the interview day (Table 1 ).

Table 1

Key Recommendations for Program Directors to Prepare for the 2021 Virtual Interview Season

Before Interview Day	Interview Day
Prepare for an all-virtual interview season to promote equity and ensure consistency	Create a technical troubleshooting plan detailed to both interviewers and applicants
Anticipate a larger volume of applicants	Ensure time between applicants and current fellows, preferably without faculty
Use websites/social media to highlight the training environment and community	Facilitate interviews that connect applicants with prospective mentors and faculty with similar life experiences
Develop a virtual facility tour that includes work and call rooms	Accommodate applicants from various time zones in scheduling
Consider mock interviews with faculty, fellows, and program administration to test software	Look directly into the camera and consider a neutral, professional background in a well-lit room

Online presence, including websites and social media that highlight distinct attributes, is essential even before application season. It provides a prime opportunity to feature cultural aspects of an institution that would otherwise receive limited exposure in the virtual environment. Programs should engage their fellows in this process whenever possible.

Once applications become available for review, programs should anticipate that there may be more received than customary (7). Although this may enhance applicant pool diversity, review committees may require more time to accommodate this increase. Fortunately, programs will have approximately 3 additional weeks in the 2021 season to evaluate applications.

Technical aspects of the interview day should be well defined in advance of the interview day. Many different formats are available; the type of software used is not as important as ensuring participants’ ability to use it. Mock interviews with faculty, the program director and coordinator, and fellows are particularly helpful to better understand all platform features (3). Having one “host” responsible for moving all participants is important, as is structuring the interview day to minimize applicant navigating. Furthermore, clarity on interview duration, particularly when and how each interview will end, can help participants better transition the conversation to its conclusion.

Both synchronous and asynchronous interview options can work well. Fellowship programs should consider which type will best suit their specific needs. Although synchronous options provide real-time interactions between interviewers and applicants, asynchronous models can involve pre-established interview questions. Applicants then answer these questions and submit via recorded video. Unique to the virtual interview, accommodating different time zones is an important consideration for synchronous interviews.

It is also important to be mindful of both the total number and the length of each interview during the interview day. To avoid “digital fatigue” for both applicants and faculty, the ideal day should last no more than 4 to 6 hours and allow adequate “off-camera” time between interviews for restroom and stretch breaks. Videos detailing unique aspects of the program, medical center, and community are preferably viewed via links that can be accessed on the applicants’ own time.

Looking to the Future

In its recent statement, the Undergraduate Medical Education to Graduate Medical Education Review Committee recommended “to ensure equity and fairness, there should be ongoing study of the impact and benefits of virtual interviewing as a permanent means of interviewing for residency.” The virtual platform provides certain benefits to both applicants and CV programs by enabling greater access to all applicants and should be considered in future recruitment cycles. A major hurdle will be addressing the potential cognitive bias in evaluating applicants who travel to interviews and those who do not. This platform may also result in a potential separation of applicants based on socioeconomic status, which could undo efforts that promote diversity in Cardiology. Recognizing the desire of applicants to visit institutions and communities before committing to years of training is also essential. The conversation for a hybrid interview platform must begin now. The CV fellowship community has a real opportunity to shape this process so that it provides advantages to both applicants and programs.

As this process continues, we are still faced with an upcoming recruitment season that will be virtual. The medical education community, applicants and programs alike, have learned many lessons and best practices in just 1 year. There is no doubt that building on those experiences will only help to find the best “match” for all.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.