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COVID-19: Beyond Tomorrow
June 3, 2020

Potential Implications of COVID-19 for the 2020-2021 Residency Application Cycle

Author Affiliations
  • 1University of Michigan Medical School, Ann Arbor
  • 2Eastern Virginia Medical School, Norfolk
JAMA. 2020;324(1):29-30. doi:10.1001/jama.2020.8911

In the 2020-2021 academic year, more than 40 000 medical students and physicians will apply for residency positions in the United States. Yet due to the effects of the novel coronavirus disease 2019 (COVID-19) pandemic, the experience will be distinctly different for applicants and programs than in previous years. How will the residency application process be affected by COVID-19? While the pandemic will stress the residency selection process, it will also provide the opportunity for change and systemic improvements.

Even before COVID-19, calls to reform the residency selection process were becoming more frequent.1,2 Many issues are related to the increasing number of programs to which applicants apply. In 2019-2020, applicants from US medical schools applied to an average of 65 programs, and international medical graduates (IMGs) applied to an average of 137 programs.3 This number of applications likely does not improve match rates and imposes a substantial cost on applicants and a potentially unmanageable load on program directors.

It is possible that the disruptions caused by COVID-19 may result in an increase in the number of applications and further stress this already challenged system. Due to testing center closures, many applicants have been unable to take portions of the United States Medical Licensing Examination (USMLE). This is especially critical for IMGs, who must pass the Step 2 Clinical Skills Examination to obtain certification from the Educational Commission for Foreign Medical Graduates and apply to US residency programs. Additionally, medical schools have shortened clerkships, shifted to virtual rotations, and canceled away electives, all of which may reduce student opportunities to obtain meaningful faculty evaluations, letters of recommendation, and signal their interest to programs. Students will encounter significant uncertainty regarding how their applications will be evaluated and may respond by applying to even more programs.

Program directors may have difficulty identifying applicants to interview without use of traditional screening metrics. Yet, challenges will persist even after interviews are offered; if travel disruptions and social distancing persist into the interview season, programs may be unable to offer in-person interviews. Temporary solutions, such as conducting virtual interviews or waiving requirements for USMLE scores and letters of recommendation, will be necessary for the selection process to function. But these stopgap solutions may exacerbate existing problems with residency selection and lead to undesirable consequences. For instance, the use of virtual interviews could result in applicants participating in more interviews. Currently, the number of interviews an applicant attends is limited by time and travel expense, but these constraints will be less relevant with virtual interviews. Yet because many programs rely on the same screening metrics, many programs already overinvite the same pool of highly-qualified applicants, with just 7% to 21% of the applicant pool filling half of all interview slots in some specialties.4 The result of those applicants accepting more interview invitations could be an increase in both the number of unmatched applicants and unfilled programs.

Similarly, while pledges to not rely upon USMLE scores or evaluation of away rotations may be reassuring to students, such policies do not address the primary question of what criteria will programs use to evaluate applicants. Giving already overburdened program directors more applications to evaluate with potentially less information may result in reliance on even less valuable metrics such as school reputation.

Amidst these challenges, there are opportunities to improve this process. To both mitigate the immediate effects of COVID-19 on the residency selection process and improve this system more broadly, several potential measures may be helpful.

  • Adjust the residency application timeline

    • Delaying the release of student applications to residency programs by several weeks could allow students more time to complete clinical rotations, obtain letters of recommendation, and receive scores from standardized tests.

  • Modify application requirements

    • Programs could consider applications from students who have been unable to receive USMLE Step 2 scores, complete away or “audition” rotations, or obtain certain specialty-specific letters of recommendation. Given the disparate regional effects of COVID-19, insisting on traditional requirements will most likely disproportionately affect students from areas most affected by the pandemic.

  • Encourage holistic review

    • Because COVID-19 has affected myriad components of the student application process, program directors could rely less on screening metrics and instead embrace holistic reviews that consider an individual applicant’s attributes, aptitudes, and experiences in the context of the unique focus and mission of the residency program. This could include applying more emphasis on narrative aspects of the application, including the personal statement and meaningful research, as well as educational or leadership experiences. Additionally, programs could incorporate principles from standard virtual interviews, a preinterview screening tool in which raters have completed implicit bias training to evaluate applicants on scoring rubrics created by faculty.5 These interviews may provide information about applicants’ noncognitive abilities to serve as a useful adjunct in the evaluation process. However, the feasibility of wide-scale implementation of this tool would need further consideration.

  • Limit the number of applications

    • Holistic review is difficult without a reduction in the number of applications. Achieving this will require, at minimum, collaborative counseling between deans, advisors, and residency programs. Advisors could counsel students to use resources such as National Residency Matching Program (NRMP) charting outcomes in the match6—focusing less on the number of applications submitted and more on the nature of programs to which the student should apply. Consideration also could be given to proposals that limit the number of applications students can submit, such as an optional early result acceptance program.2

  • Expand program information available to applicants

    • To enable students to submit fewer applications, residency programs could expand the information available to applicants, especially about the unique missions of the programs and the type of applicant they seek. For instance, programs could commit to presenting any strict screening criteria they use to offer interviews, such as a record of peer-reviewed publications or research expertise. In addition, programs could provide faculty and resident narratives regarding subspecialty and research opportunities, as well as specific values unique to the program. These narratives may come in the form of additional website information or perhaps from a preapplication virtual residency fair and could allow applicants to apply more thoughtfully, based on their individual attributes and future aspirations.

  • Improve the quality of information programs receive

    • When determining which applicants to interview, program directors highly prioritize information regarding an applicant’s integrity, reliability and dependability, motivation, initiative, teamwork, and professionalism, yet they express relatively low satisfaction with currently available tools to assess these factors.7 Previous recommendations to standardize the Medical School Performance Evaluation (MSPE) could be further modified to systematically address these domains and include thoughtful assessments of an applicant’s strengths and areas for development. To provide an incentive for meaningful evaluation, program directors could deprioritize applications from institutions with MSPE letters that are not formatted according to consensus guidelines.

  • Temporarily make exceptions to the NRMP all-in policy

    • The all-in policy requires that residency programs participating in the match offer all of the program’s residency spots through the NRMP match. To help programs manage the large number of applications and help certain applicants avoid overapplying, the NRMP could consider making exceptions for programs to accept some students outside of the match. Each year, many graduating students choose to remain at their home institution or affiliated hospitals. In some specialties, it has been reported that more than 20% of residents had attended the program affiliated with their medical school.8 Allowing these applicants to contract outside the match could relieve some stress for students and programs. These exceptions could be limited to the average number of residents in the program from the institution or affiliated medical school. The potential benefits of such a change must be weighed against the risk that applicants will be pressured to accept offers outside of the match. Additionally, such a policy may be perceived as reducing opportunities for students from schools without affiliated residency programs.

  • Cap the number of interviews a student can accept

    • Data from the NRMP indicate that seniors at US medical schools who submit more than 4 to 12 contiguous ranks have a greater than 90% chance of successfully matching in almost every specialty, with diminishing returns thereafter.6 Imposing caps on the number of interview offers a student can accept could potentially prevent well-qualified applicants from overinterviewing and limiting the number of interview spots available for others. The specific cap and how it would be implemented and monitored could be a student-driven process.

  • Implement preference-signaling mechanisms

    • Some of the inefficiency in the residency selection process occurs because programs and applicants cannot discern the true level of interest they may have in each other. Allowing applicants to designate preferred programs could improve the process. For instance, some job markets, such as for new PhD graduates in economics, allow applicants to send an expression of special interest to as many as 2 employers prior to interviews, which helps with securing interviews and facilitating matches.9 Computer modeling suggests a similar approach could be useful in residency selection.10

Amidst the devastating effects of COVID-19 on the global health system and economy, health care leaders have pointed out the missed opportunities to prevent or attenuate some of the harms once the risk of the virus is known. Some potential consequences of COVID-19 that may affect the residency selection process could be anticipated. With leadership and thoughtful action, these harms could potentially be mitigated, and the residency application and selection process could be improved both for applicants and residency programs.

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Article Information

Corresponding Author: Maya M. Hammoud, MD, MBA, Department of Obstetrics and Gynecology, University of Michigan Medical School, 1500 E Medical Center Dr, L4000 Von Voigtlander Women's Hospital, Ann Arbor, MI 48109 (immaya@umich.edu).

Published Online: June 3, 2020. doi:10.1001/jama.2020.8911

Conflict of Interest Disclosures: None reported.

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3 Comments for this article
IMGs needing visa will be impacted more
Rajkumar Doshi, MD MPH | University of Nevada Reno School of Medicine
I read with great interest the article by Hammoud et al. I agree that the residency application process needs to be changed. The COVID-19 pandemic will affect International Medical Graduates (IMG) who need visas more. I note a few more points here:

1. When the pandemic started in January, a few IMGs had already taken their USMLE step 2 CS exams and received their results. The rest will not be able to take the exam since they have cancelled it for the next 12-18 months. NRMP should stop reporting for USMLE step 2 CS exam to programs. Otherwise, I
suspect this will result in a biased selection of candidates.

2. This pandemic will hopefully help those IMGs more who did not match last match cycle and who have a complete ERAS application. Since they have applied last year, most of them will have enough United Stated Clinical Experience (USCE), letter of recommendations from the previous year, and an ECFMG certificate, which is required by the most programs.

3. As appropriately mentioned by the authors, most IMGs will not be able to complete required USCE and will not have a complete application for this match cycle. Criteria need to be adjusted by the programs for better selection process.

4. Most IMGs will not be able to take USMLE step 2 CK as well. I suspect there is a huge backlog of applicants who are waiting to take their exam. Delaying the application will of course help them but not all the candidates will be able to take their exam on time.

Indeed, a better tool than USMLE exams and USCE is required for the residency selection process.
Limiting the Number of Applications Based on Strength of the Applicant
Sandy M, MS |
I agree that if the intent is to holistically review students applications', then it is essential to put in place some restrictions so that faculty have enough time to review thoroughly each application (as opposed to eliminating applications based on scores). However, I believe limiting residency applications, rather than limiting interviews, is a better solution that would benefit both students and faculty (less expenditure in the application process, more time to evaluate applications respectively). Most importantly, in order to truly level the playing field among applicants it is necessary to limit the number of applications based on the strength of a student's application (the higher Step scores, outstanding clerkships grades, ranking, etc, the most robust the application). Below-average students, students who have encountered exceptional difficulties (taking an extended leave of absence) and couples applying together should have the right to apply to at least twice as many more programs than the above-average students. As a numerical example only (I understand the number of applications is much higher) if an above average-student applies to 10 programs, most likely he/she will be invited to 8-10 interviews. If a below-average student were to apply to 20 programs, there is a 50% chance of being interviewed by 10 programs, but since it's known that we have many more applicants per positions available and that there will be programs who will continue to use specific scores as a cut-off value, then the possible number of interviews for a below-average student would look more like 2-3 (conservative stats).
COVID-19 Pandemic and Its Impact on the 2021 US Main Residency Match
Faran Ahmad, MBBS | Creighton University Medical Center, Nebraska
One of the major consequences of the pandemic-associated turmoil was suspension of the USMLE Step 2 Clinical Skills (CS) examination for the next 12-18 months. Many USMLE applicants had to face cancellations of their other scheduled tests as well as unexpected delay in the ECFMG certification. This resulted in considerable distress in US medical students and international medical graduates(IMGs) who were preparing their application for the 2021 main residency match. To address the issue, applicants who wished to enter an ACGME-accredited residency program for the 2021-2022 academic year and were unable to take Step 2 CS due to the suspension were advised to meet the clinical skills requirement for ECFMG certification through one of five pathways specified by ECFMG. Two considerable requirements in these pathways are proof of home country permanent medical license and passing occupational english test (OET). Both requirements have their own limiting factors.

Also, the US clinical experience has been the key factor in determining the competency of an applicant for the residency spot. Unfortunately, many clinical sites which were offering hands-on clinical experience to these potential IMGs cancelled their externship and observer-ship rotations due to COVID-19. Moreover, due to travel restrictions, many applicants could not travel to the US to join their scheduled elective clinical rotations. Hence, most of these applicants will have relatively weaker applications as compared to prior years due to limited number of faculty evaluations and letters of recommendations.

To assess the impact of these changes on the upcoming 2021 main residency match, I conducted a brief online survey including 50 IMGs from Pakistan who were planning to apply for the match. It revealed that 89% of these potential applicants had their USMLE Step 2 Clinical Skills examination postponed and only 8 applicants were able to secure alternate exam dates so far. Only 65% had a permanent medical license from their home country. 94% of the potential applicants are still seeking “pathway 1” for the ECFMG certification which requires that the applicant must have a full, unrestricted license or registration to practice medicine in any country at any time on or after January 1, 2015. Due to unexpected cancellations, overall 23% of the applicants were dissatisfied by the Prometric center, the global USMLE testing services provider.

Now, considering the impact of the pandemic, it is important to highlight that many residency programs are planning to conduct online interviews of the applicants. Keeping in view these complex limitations, the upcoming residency match will be a tough one for many applicants including IMGs. While ACGME-accredited residency programs attempt their best to select the impressive pool of residents, it is equally important to make sure that process remains standardized.