Dear AAMC: Please limit residency interviews [PODCAST]

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“The COVID-19 pandemic has turned medical education upside-down. From exclusively virtual pre-clerkship courses, to delayed clerkships, to canceled graduation proceedings, there has been massive disruption. Now, after weeks of speculation, we’ve learned how the pandemic will be disrupting the 2020-2021 residency application cycle. The Association of American Medical Colleges (AAMC) is now recommending that all residency interviews be conducted virtually. While this a wise recommendation, out of concern for public safety, I fear it will exacerbate long-standing problems in the residency application process and will have dire consequences for many applicants.”

Jordan Hughes is an emergency medicine resident.

He shares his story and discusses his KevinMD article, “To the AAMC: Recommend an interview limit or else this year’s residency match may be a disaster.”

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Jordan Hughes, who just started his emergency medicine residency. Congratulations.

Jordan Hughes: Thank you.

Kevin Pho: Welcome to the show.

Jordan Hughes: Hey, I’m glad to be here. I’m happy for the invitation and happy to share my story.

Kevin Pho: All right, so you wrote the KevinMD article “To the AAMC: Recommend an interview limit or else this year’s residency match may be a disaster.” So we’re going to get into that, but before we do, can you just share the story of who you are and your journey to where you got to today?

Jordan Hughes: Like you said, I just graduated from medical school in Texas, where I’m from, and was fortunate enough to match to a program here in Virginia for my emergency medicine residency. I’ve just gone through the slog of applying and interviewing for residency, so it’s fresh on my mind, and I wanted to weigh in for the folks who are going through it this year and next.

Kevin Pho: All right, let’s get right into it. I applied for residency 20 years ago, and I’m sure a lot has changed since then. So you wrote in the introduction of your article, “The Association of American Medical Colleges, AAMC, is now recommending that all residency interviews be conducted virtually. While this is a wise recommendation, out of concern for public safety, I fear it will exacerbate long-standing problems in the residency application process and will have dire consequences for many applicants.” So tell me what you mean by that.

Jordan Hughes: So actually, starting around the time that you applied for residency, since then there’s been a massive hyperinflation in the number of applications each applicant is applying to, or the number of programs they’re applying to. There are some increases, like in psychiatry, where they’re applying to 400 percent as many programs as they did when you applied. So there’s just been a massive inflation that’s been expensive and costly for both programs and applicants. So it’s kind of created a big problem, and this year is really where I think the consequences will bear out, because of these virtual interviews.

Kevin Pho: All right, so tell me some of those problems or consequences that you’re referring to.

Jordan Hughes: Because so many applicants are applying to many, many more programs, and they truly need to, there’s a great disparity between above-average applicants and below-average applicants in terms of how many interview invitations they get.

So, for instance, I have a friend who was a fantastic applicant to OB/GYN. She applied to the average number in OB, which is quite high, and she got 36 interview invitations, which is a ton. She does not need that many. Because of time constraints and cost concerns, she could not take all of them; she ended up taking about 18. But with all interviews going virtual this year, she could conceivably take all 36 from her couch, and there’s really no downside for her to do that. And so she would be taking away a lot of interviews from below-average applicants who would get those interview invitations once she turned them down.

Kevin Pho: So you think, from a residency standpoint, more applicants are better. And you’re probably seeing this in undergraduate education as well, where people can just apply electronically with one application to many more programs than they could have 15 to 20 years ago. So from the residency standpoint, isn’t it better just to have more applicants that they consider?

Jordan Hughes: Well, with more applicants, it’s hard to tell who’s actually interested in my program, right? And also it ends up creating an overreliance on certain quantitative metrics, like Step 1 scores and Step 2 scores. And so they have to create these cutoffs just because they don’t have the administrative capacity to actually holistically review every single applicant.

Kevin Pho: And you mentioned that it would increase a disparity between above-average applicants and people who were either average or below average. Can you share more details on that?

Jordan Hughes: Yeah, so I’m afraid that when the time comes for rank order lists to be submitted, there are going to be some people with close to 40 rank order list slots and some folks who just have five, just because they have not been able to get those interview invitations that have trickled down later in the season from applicants who have turned down those slots.

I imagine that we’re going to have a lot more people SOAPing this year. We may fill all of the residency slots that we would have in past years, because there are the same number of medical students graduating. The issue is we may be filling those slots through the SOAP rather than through the Match, because some people’s rank order lists are just not long enough to allow them to match.

Kevin Pho: Now, do you see this happening across all specialties?

Jordan Hughes: Yes, I believe so, just because of the curves for how many contiguous ranks an applicant needs in order to successfully match. I’ve put the 95 percent confidence in matching as kind of my standard to see how many interviews an applicant needs, and some of those curves are pretty steep getting up to that 95 percent. So if someone, say, only gets eight, they may have only a 50 percent chance of matching, which is very low. I certainly would have not wanted a 50 percent chance of matching. And so I’m just afraid for many specialties that there will be a lot of unmatched applicants.

Kevin Pho: So obviously we’re in the midst of a pandemic. I don’t know what travel is going to be like in the fall or early next year during interview season. You did mention a solution in your article. Would you share what a proposed solution would be?

Jordan Hughes: So the issue of application hyperinflation has been going on, and people have suggested an application limit. But this year, in the midst of the pandemic, I think the best course of action would be to actually create an interview limit, where we say no more than 15 interviews for a given applicant for each specialty. Some people may apply to, say, a surgical subspecialty and internal medicine, or something like that, in which case they can do 15 interviews for each specialty. But if we don’t limit the number of interviews someone can take, we really will have that great disparity.

And so my proposal is to enforce that limit of around 15 by doing interview invitations through ERAS rather than third-party brokers like Interview Broker, and also the NRMP imposing a rank order list limit.

Kevin Pho: And how did you come up with that number, 15?

Jordan Hughes: Yeah, so I certainly don’t have all the data, so it may not be the perfect number. But I came up with it based on the most recent NRMP data that’s publicly available, saying 15 was actually the number that applicants needed in order to have a 95 percent chance of matching in every specialty except for neurosurgery and vascular surgery, which are very small fields. And I believe it’s vascular surgery where no number of interviews actually gets you to a 95 percent chance of matching. So I did it based on that NRMP data.

Kevin Pho: So since your article was published, what has the response been? And do you anticipate the AMC taking action against this problem?

Jordan Hughes: I certainly hope so. There’s been news from emergency medicine in particular. They have come out with a joint statement through all the stakeholders, including program directors, clerkship directors, and the American College of Emergency Physicians. They’ve come out with a joint statement saying they recommend 12 interviews for their specialty, with a max of 17, and that’s only reserved for people who are couples matching and those who are at severe risk of not matching.

Kevin Pho: And for those applicants who may not be above average, because let’s face it, above-average applicants will most likely match somewhere. But let’s say you’re an average or even a below-average applicant, and now you’re facing this problem of inflation of interviews. What kind of tips can you share with them as they enter the interview process?

Jordan Hughes: So be realistic. Speak with your clerkship director and understand the strength of your application. While it may be great to go to some of the big names, and I’m sure we all know what the big-name programs are for each specialty, the possibility of matching into those places is very slim. You may want to add two or three dream schools, but be kind of realistic about what tier you’re in. It can be based on what quartile of the class you’re in. And understand what programs you’d really be competitive for. Otherwise, you may end up with only a couple of interviews, and those are at your safety schools rather than kind of your aspirational programs.

Kevin Pho: So you are shortly starting your emergency medicine residency, so I just want to shift gears here. Tell me something that you’ve been passionate about or curious about recently.

Jordan Hughes: So I have been interested in quality improvement for a number of years now, and physician leadership in hospital systems, and so I kind of hope to continue that during residency. I think it’s very important in this time, especially as, you know, health care is changing. And you might even say this proposal that I’m making is a quality improvement measure for the Match, which I think is in desperate need of, even outside of COVID times, but especially now. So I’m hoping to continue that work.

Kevin Pho: And my final question: What’s your take-home message for the KevinMD audience?

Jordan Hughes: This is personal and perhaps a bit selfish, but don’t neglect your interns this year. We have been out of the hospital for months and months, and we’re going to have some rust to shake off. And some of us have not had the vacations and the weddings and the time off that we were looking forward to. So I’m hoping there’s not, but there may be some more burnout than program directors and faculty are accustomed to. So I’m just hoping for patience and kindness.

Kevin Pho: All right, sound advice. Well, thank you so much for joining the show. We have Jordan Hughes, who is an emergency medicine resident. He wrote the KevinMD article “To the AAMC: Recommend an interview limit or else this year’s residency match may be a disaster.” Thank you so much for joining us.

Jordan Hughes: Thank you for having me.

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