Emerging from the Pandemic: AAIM Recommendations for Internal Medicine Residency and Fellowship Interview Standards.

New standards are needed moving forward to guide residency and fellowship interviews in response to Coalition for Physician Accountability recommendations and dramatic changes in the interview landscape over the past 2 years.

Processes should be based on principles of equity for applicants and programs while taking into consideration personal and public health and safety.

Ongoing evaluation of advantages and disadvantages of interview practices should continue with iterative adjustments in guidance based on available data.

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Background

Traditionally, graduate medical education (GME) programs have conducted applicant interviews via in-person format. The coronavirus disease 2019 (COVID-19) pandemic transformed the process for interviewing residency and fellowship applicants during the 2020-2021 and 2021-2022 recruitment seasons. Applicants and programs developed new approaches for the application and recruitment process; interviews were conducted almost exclusively via a virtual or online format.1, 2, 3 Early data from all-virtual GME interview experiences suggest that virtual interviews are widely acceptable to applicants as well as to program directors and allow both groups to adequately learn about each other.4, 5, 6, 7, 8, 9, 10 New recommendations are needed to guide what successful elements of virtual season interview cycles should continue as travel restrictions end.

The Alliance for Academic Internal Medicine (AAIM), a national organization composed of educators and administrators from all specialties of internal medicine involved in both undergraduate medical education (UME) and GME, created a task force in November 2021 to develop inclusive and equitable interview standards across internal medicine residency and fellowship programs in response to recommendations from the Coalition for Physician Accountability (CoPA). This task force developed recommendations to guide the internal medicine education community, specifically residency and fellowship applicants, faculty advisors, medical schools, residency programs, and fellowship programs, during upcoming interview seasons.

These recommendations were developed under the assumption that there are no COVID-19 pandemic-related restrictions required from a public health and safety standpoint. The safety of applicants and program interview participants as well as that of the communities of the applicants and program participants are paramount. Health and safety considerations should supersede the guidance offered by these recommendations.

AAIM acknowledges that there are no perfect solutions, and no process will address all stakeholder preferences. AAIM developed these consensus recommendations to best represent the professional values of the internal medicine community. This guidance is based on information available as of June 2022.

Principles

AAIM recognizes the need to provide updated guidance for residency and fellowship interview standards in response to recommendations from CoPA as well as changes in recruitment processes that have taken place over the past 2 years. These recommendations (Table ) consider the complex and evolving nature of this current landscape while incorporating key principles of our mission as medical educators in internal medicine:1, 2, 3 AAIM developed a set of principles to guide the development of recommendations. The alliance shares the same goals as the overall medical education community: standardizing the interviewing process to reduce unwarranted confusion, stress, and inequity; and safeguarding the health of applicants, educators, and staff while ensuring productive internal medicine residency and fellowship matches amid the complexities of the application process in the current landscape.

Table

Summary of AAIM Recommendations for IM Residency and Fellowship Interview Standards

• AAIM recommends residency and fellowship programs conduct virtual interviews for all applicants, including learners at their own institution and applicants visiting the institution through away experiences.• Without further evaluation of safeguards to maintain equity for applicants, AAIM recommends against in-person visits as part of the interview process, including in-person interviews, open houses, or program-sponsored second looks.• AAIM recommends residency and fellowship programs adopt common interview standards that include clear communication on their website, social media, and other relevant platforms regarding the date and time that they will release the first wave of interview offers.• AAIM recommends that residency and fellowship programs adopt clear standards for communicating interview status (ie, invitation, waitlist, or rejection) with applicants and describe their communication process on their program's website.• AAIM recommends medical schools, residencies, and institutions provide resources to help residency and fellowship applicants prepare for interviews.• AAIM recommends GME programs provide training for faculty and staff on strategies to mitigate implicit bias in interviews and on appropriate interview and postinterview communication.

AAIM is committed to the following principles:

An equitable process for individual applicants: Fairness, equity, and consistency are fundamental in the interview process for applicants who have diverse experiences, backgrounds, and resources. The risk of inequity exists with hybrid interviewing (virtual and in-person interviews occurring in the same year or same program).

An equitable process for training programs: Training programs are diverse with different locations, types, sizes, needs, and resources. Institutions should have the opportunity to showcase their programs adequately.

Personal health and safety, including mental health and well-being of applicants: Medical school and residency training are challenging and stressful; and in-person interviews can exacerbate stress and affect emotional well-being due to financial cost, time commitment, and impact on clinical rotations.

Public health and safety: The importance of the well-being and health of all persons involved in the interview process, including administrative staff and the community, is critical.

Preservation of educational and clinical mission: It is important to minimize disruptions to applicant and faculty commitments to clinical, educational, and academic responsibilities and not overextend them with interview activities, while supporting applicants in career decision-making.

Acknowledgment of organizational changes: Organizations underwent significant change during the pandemic, with more faculty and staff working effectively in remote settings. The increased capacity, utility, and use of video conferencing platforms that occurred during the pandemic has changed the technological landscape for learners and programs.

Clear communication among all stakeholders, including but not limited to applicants, faculty, and administrators.

Environmental health: Carbon dioxide (CO2) emissions associated with interview travel exceed the annual maximum CO2 emissions per capita necessary to limit global warming.13, 14, 15, 16

Recommendations

Virtual Interviews

Recommendation: AAIM recommends residency and fellowship programs conduct virtual interviews for all applicants, including learners at their own institution and applicants visiting the institution through away experiences.

Based on considerations of equity, financial cost, and environmental impact, all interviews should be conducted in a virtual format. A dramatic change in interviewing has taken place over the past 2 years in response to the COVID-19 pandemic wherein internal medicine residency and fellowship interviews have been conducted almost exclusively via virtual or online format. Advances in videoconferencing technology and widespread familiarity with these platforms have facilitated the use of virtual interviewing.

Virtual interviewing offers an efficient and widely acceptable format for both applicants and programs.4, 5, 6, 7, 8, 9, 10 The efficiency offered by virtual interviews results in time savings for applicants, minimizing time away from their clinical education and training as well as greater flexibility in interview scheduling. All-virtual interviews reduce financial costs associated with the interview process for both applicants and programs. Several studies have reported the significant environmental impact associated with CO2 emissions during the traditional medical interview process and report that CO2 emissions associated with interview travel exceed the annual maximum CO2 emissions per capita necessary to limit global warming.13, 14, 15, 16

Applicants have variable financial resources and ability to take time off rotations and clinical training for interviews. All-virtual interviews serve to decrease inequity in these areas by offering a cost-effective and time-saving approach to interviews. Additional research is needed to specifically study the impact of all-virtual interviews on the recruitment of applicants from underrepresented groups; although, 1 study that sought to evaluate gaps in equity of virtual interviews by gender, underrepresented in medicine (URiM) status, race, or rural, urban, or suburban location found no significant differences.

Other implications of all-virtual interviews warrant further evaluation. The number of applications per candidate has increased over the past 2 years and the ease of all-virtual interviewing may have contributed to this “application inflation.” , In theory, programs may be able to increase their geographical reach by interviewing applicants who previously would not have had the time or financial means to travel greater distances. However, the ease of virtual interviews may make it difficult for programs to gauge the genuine interest of a candidate in a given program , , Virtual interviews have the potential to place some applicants at a disadvantage because a subset of applicants may receive a larger proportion of interviews and be able to do more interviews, which could lead to applicants holding onto more interviews than they need to successfully match. Additionally, there is the potential for inequity among training programs, as some programs may feel they are not able to adequately showcase their unique program attributes, experiences, and culture through an all-virtual format. , , Finally, some program directors have raised concerns in their ability to gauge an applicant's communication and interpersonal skills virtually. , These challenges as well as potential solutions should be formally evaluated.

Other reported challenges encountered with virtual interviewing that may exacerbate inequities among applicants include time zone differences, access to an appropriate interview setting, and reliable internet access. Programs should consider scheduling activities to accommodate applicants in different time zones.

In-Person Visits

Recommendation: Without further evaluation of safeguards to maintain equity for applicants, AAIM recommends against in-person visits as part of the interview process, including in-person interviews, open houses, or program-sponsored second looks.

AAIM understands the desire of some programs to offer in-person visits to showcase their training experiences or local communities as well as the desire of some applicants to visit their prospective institution or communities. However, program-sponsored in-person visits without safeguards, such as scheduling rank order list deadlines for programs earlier than rank order list deadlines for applicants, may negate gains in equity offered by all-virtual interviews. Programs may view applicants who are able to attend in-person visits differently than those who are not able to attend such visits, thus leading to inequity between candidates. Hybrid interviewing models that offer both virtual and in-person options during the same interview season increase financial and time costs and also have the potential to lead to confusion for applicants and program staff. Without safeguards in place, applicants may feel obligated to attend in-person “second-look” visits, effectively attending two separate interviews and significantly increasing time costs and time away from educational and clinical activities.

Although mechanisms to separate deadlines for program and applicant rank order lists are not currently in place, the feasibility and acceptability of such separation should be evaluated by all key stakeholders. Separation of the deadlines for program and applicant rank order lists would permit time for applicants to participate in optional in-person second-look visits during the gap between those due dates without fear of added bias as the applicant's visit would not influence a program's rank order list. Although in-person visits would be optional, the added cost and time burdens for applicants should be evaluated, as should the varying ability of applicants to take time away from their clinical and educational responsibilities. A final consideration to evaluate is the potential impact on training programs of having multiple residents requesting leave during a condensed time frame.

Of note, applicants retain the option to visit cities, communities, and institutions on their own.

Communication of Interview Offers and Status

Recommendation: AAIM recommends residency and fellowship programs adopt common interview standards that include clear communication on their website, social media, and other relevant platforms regarding the date and time that they will release the first wave of interview offers.

Applicants may experience unnecessary stress and disruption of clinical and educational activities while awaiting communications regarding initial interview offers.19, 20, 21 Current procedures surrounding both timing and methods of communication of interview offers are complex and lack regulation. The development of common interview standards and policies could minimize educational disruptions and mitigate applicant stress. Crucial scaffolding can include relaxing time-limited responses (providing at least 48 hours), capping interview invitations to the number of interview slots, and scheduling offer release times to the late afternoon when applicants are more likely to be done or to have more flexibility with their clinical duties. Disclosing offer release dates and times can decrease unnecessary stress for applicants and may decrease communication burdens on programs.

Recommendation: AAIM recommends that residency and fellowship programs adopt clear standards for communicating interview status (invitation, waitlist, or rejection) with applicants and describe their communication process on their program's website.

Applicants may experience unnecessary stress while awaiting decisions regarding their ongoing interview status.19, 20, 21 Although some programs communicate interview status to all applicants at once (ie, invitation, waitlist, or rejection), this is not the standard practice. Applicant frustrations regarding unknown statuses (ie, waitlist or rejection status, or the likelihood of coming off of the waitlist) lead to uncertainties about how to communicate with programs, which may increase the number of communications programs receive from or on behalf of applicants. Programs should adopt clear standards for communicating interview status with their applicants, including anticipated dates and times of when this communication will occur. These processes should be communicated in a transparent fashion to applicants and be publicly available on their program's website. Implementing these standards and setting clear expectations will decrease unnecessary stress for applicants and likely decrease communication burdens on programs.

Interview Resources for Applicants

Recommendation: AAIM recommends medical schools, residencies, and institutions provide resources to help applicants prepare for interviews.

Medical schools and residencies should provide students and residents with resources to help them prepare for and participate in virtual interviews. , These resources should include preparation education, reasonable time away from clinical training, and technical support. Specifically, medical schools and residency programs should work with their institutions to provide students and residents access to a private and appropriate interview location, technology with video conferencing capabilities, and reliable internet access. The institutional provision of these resources mitigates the potential for technology bias that may exist when applicants have different technology or financial resources. Because international medical graduate (IMG) residency applicants may be disadvantaged without these resources, those applicants who are working or affiliated with institutions in the United States ideally should have access to the same institutional resources. Additional collaboration and research is needed with stakeholders that support international medical graduates to secure equivalent resources for applicants not currently affiliated with a US medical institution.

Training for GME Program Faculty

Recommendation: AAIM recommends GME programs provide training for faculty and staff on strategies to mitigate implicit bias in interviews and on appropriate interview and postinterview communication.

Problematic communications have been reported during and after residency and fellowship interviews. Faculty involved in interviewing applicants should receive education on implicit biases influencing the interview process. Additionally, without appropriate education, faculty interviewers may inadvertently violate match agreements by inquiring into such topics as rank order lists, locations of other interviews, or geographic preference questions. Postinterview communication also has the potential to create confusion and stress for applicants and can be perceived as coercive or disingenuous. GME programs should train faculty and staff on appropriate interview and postinterview communication to minimize inappropriate communications. Further, medical schools and residencies should share resources for applicants on how to respond to inappropriate communication if it occurs. Resources and training materials are available on the AAIM website.

Future Directions

Additional interview standards should be evaluated, including consideration of a cap on the number of applicant interviews and an assessment of the merits of uniform interview offer day(s).

Future AAIM initiatives should focus on engaging the internal medicine education community to discuss and research the merits behind additional interview standards. Numerous medical education leaders have proposed and advocated for a cap on the number of interviews allowed for applicants.26, 27, 28, 29 Additionally, other subspecialties have instituted a uniform interview offer date, or dates, to issue the initial wave, or waves, of interview invitations to benefit both programs and applicants. Interview standards that include a predetermined universal offer date are likely to result in decreased anxiety and stress among applicants as well as improved educational engagement. In addition, this process may enable applicants to better identify which invitations to accept and decline at an earlier time, which may help programs elucidate candidates most interested in matching at their program.30, 31, 32

Conclusion

Updated recommendations for interviewing candidates are necessary to develop equitable interview standards across internal medicine residency and fellowship programs in response to recommendations from the CoPA and in light of dramatic changes in interviewing processes and technology over the past 2 years. AAIM acknowledges the complex and evolving nature of this current landscape. Recommendations are made in the spirit of equity and transparency for the community of applicants, educators, staff, and others involved in the interview process. Evaluation of advantages and disadvantages of interview practices should continue on an ongoing basis with iterative adjustments made in future guidance for GME programs based on available data.