AAIM Recommendations for the 2020-2021 Internal Medicine Residency Application Cycle in Response to the COVID-19 Pandemic (2024)

Abstract

This statement was released in June 2020 by the Alliance for Academic Internal Medicine to provide guidance for the 2020-2021 residency application cycle in light of the COVID-19 pandemic. While many of the recommendations are specific to this cycle, others, such as the Department Summary Letter of Evaluation, are meant to be an enduring change to the internal medicine residency application process. AAIM realizes that some schools may not yet have the tools or resources to implement the template fully this cycle and look toward collaboration within the internal medicine education community to facilitate adoption in the cycles to come.

Keywords: COVID-19 pandemic, Graduate medical education, Residency application cycle, Student advising, Undergraduate medical education

Introduction

The Alliance for Academic Internal Medicine (AAIM) empowers academic internal medicine professionals and enhances health care through professional development, research, and advocacy. Through the Administrators of Internal Medicine, the Association of Program Directors (APDIM), the Association of Professors of Medicine, the Association of Specialty Professors, and Clerkship Directors in Internal Medicine (CDIM), the Alliance includes more than 11,000 faculty and staff in departments of internal medicine at medical schools and teaching hospitals, representing the entire continuum of medical education from medical student to practicing physician. As such, AAIM has a stake in enhancing and fortifying the medical education continuum. A work group of CDIM (undergraduate education) and APDIM (residency education) leaders collaborated to develop this document to address key issues affecting applicants and training programs during the 2020-2021 application cycle. In these challenging times of coronavirus disease 2019 (COVID-19), we offer specific recommendations to guide the internal medicine education community of students, faculty advisors, and clerkship and program directors during the upcoming interview season.

Given the recent recommendations by the Association of American Medical Colleges (AAMC), the National Resident Matching Program (NRMP), and the Coalition of Physician Accountability, we recognize the urgent need to provide guidance for the upcoming recruitment cycle. Thus, we developed the recommendations below, incorporating key principles of our mission as medical educators in internal medicine:

• 1)

  We value the health and safety of our learners and programs as well as of the patients and communities they serve.

• 2)

  We aim to create an equitable application process for students and programs, recognizing the unique circ*mstances in internal medicine that make this challenging. Our community is diverse, and balancing the individual needs of students, along with varied program characteristics, is complex.

• 3)

  We selected areas that are within our scope of control and focus on providing guidance and highlighting flexibility within the current official policy developed by the Electronic Residency Application Service (ERAS; AAMC), NRMP, the Educational Commission for Foreign Medical Graduates, and other regulatory agencies.

We share the same goals as the overall medical education community: reducing unwarranted confusion, stress, and inequity for our students, our programs, and their directors and teams, while ensuring a successful internal medicine match despite the expected impacts of COVID-19. We realize there are no perfect solutions and no process will address all stakeholders’ needs. As such, AAIM developed these consensus recommendations to best represent the professional values of our internal medicine community. This document provides guidance based on currently available information.

Away Rotations

Due to the COVID-19 pandemic, it is necessary to support public health principles of avoiding unnecessary travel. In addition, medical schools are facing challenges in accommodating their learners’ needs to complete their clinical requirements for graduation. However, AAIM acknowledges that a few schools require away (extramural) rotations to meet graduation and accreditation requirements. In addition, there may be unique factors for some residency programs that warrant special considerations (for example, hosting international medical students).

Virtual Interviews

Public health and medical experts predict the COVID-19 outbreak to continue through the fall and winter, with geographic hotspots or a national resurgence compounded by coincident influenza. If there are geographic outbreaks with stay-at-home orders and limitations on traveling, holding in-person interviews with some, but not all, applicants creates disparities. Accordingly, internal and external (local and distant) candidates should be treated the same. Although virtual interviews are suboptimal for both the applicant and the program, the recruitment process should be as equitable as possible. In addition, if there is a second wave of the pandemic later in the year and adjustments must be made mid-season, the disruption would be challenging for both applicants and programs. A smooth and consistent process is key to a successful recruitment season for applicants and programs.

A secondary consideration is that virtual interviews offer a more cost-conscious option in a time when pandemic-induced financial hardships may make traveling and hosting prohibitive. Especially during this uncertain time, virtual interviews also allow for more flexibility in accommodating students’, program directors’, and faculties’ schedules.

DOM Summary Letter of Evaluation

In 2013, APDIM and CDIM updated their joint guidelines for the Department of Medicine (DOM) Summary Letter. However, wide variations still exist as to how these guidelines are incorporated, and many program directors remain unsatisfied with the lack of a standardized format, redundancy in the Medical Student Performance Evaluation, the lack of graphical data on grade and objective assessment distributions, including National Board of Medical Examiners Internal Medicine Subject Examination scores, and missing descriptions of the roles and responsibilities of students on core clerkships and acting internships.

Given the truncated time to review applications in this upcoming recruitment cycle, it is essential that program directors receive objective data presented in a standardized format. If no additional objective data to guide decisions is available, residency programs are left to rely only on available data, such as US Medical License Examination (USMLE) scores. Unfortunately, data such as USMLE scores and class quartiles have limitations and will be more difficult to interpret this year. DOM Summary Letters should provide additional standardized, objective student data to facilitate holistic review. In particular, program directors desire information about a student's accountability and commitment to growth, as well as teamwork and communication skills. All stakeholders want students to attain a match that will facilitate success during residency.

Letters of Recommendation (LORs)

With the COVID-19 pandemic, students have had truncated or revised clinical experiences, including sub-internships. These changes may limit the ability for some students to obtain a clinical LOR from their Internal Medicine clerkship. This may be especially true for preliminary Internal Medicine applicants who may complete sub-internships in their primary specialty. In addition, Internal Medicine faculty are being stretched personally and professionally due to the pandemic and may have limited time to write letters.

Program directors aspire to perform a holistic review of applicants and value quality letters of recommendation over quantity. Currently, program directors receive thousands of applications and are unable to comprehensively review each application despite the best of intentions. A provision of fewer but higher-quality LORs would be of benefit. Guidelines and best practices on completing letters of recommendations have been shared at previous AAIM workshops.

Current recommendation for most categorical programs is 2 LORs (with at least one representing a clinical internal medicine experience) and one DOM Summary Letter. Some programs have exceptions, such as asking for an additional LOR.

Current recommendations for preliminary programs differ across programs; usually 3 LORs, with some preferring a DOM Summary Letter. Internal medicine departments vary on whether they provide DOM Summary Letters for preliminary applicants.

Fourth-Year Medical Student Experiences

As the pandemic has significantly impacted the ability of many medical students to complete clinical experiences in internal medicine, including reduced availability of sub-internships (acting internships) and scheduling delays, AAIM recommends flexibility in program requirements at the time of application review. In addition, AAIM recognizes the ongoing challenges in securing USMLE testing slots for Step 2 Clinical Knowledge (CK) and the suspension of Step 2 Clinical Skills (CS) testing.

Number of Applications Per Candidate

Several factors are likely to contribute to a more stressful and potentially less holistic application review process this cycle, including:

• •

  A compressed application review period for program directors due to delays in the ERAS timeline

• •

  Competing demands of managing residency programs through a predicted resurgence of COVID-19 cases

• •

  Increased application submissions due to heightened uncertainty (including changes to clinical skills assessments, visa delays, or other COVID-related factors)

• •

  Increased application submissions due to the perceived ease of virtual interviews

It is essential that our community take steps to prevent application inflation. Although limiting the number of programs a student can apply to through ERAS has been proposed in the literature and on various discussion boards, there are few data and little consensus to guide equitable imposition of limits given the heterogeneity of applicants and residency training programs. AAIM recognizes the diverse requisites of stakeholders, which adds layers of complexity to producing solutions for the application inflation conundrum. As such, exploring creative options during this period should be considered in order to improve the application cycle in the years to come.

Footnotes

APPENDIX A. Department of Medicine Summary Letter of Evaluation Template

APPENDIX B. Department of Medicine Summary Letter of Evaluation Mock-Up

This letter of evaluation was prepared upon request of the student in support of an application to your residency program. The student has waived their right to review this letter under the Family Educational Rights and Privacy Act (FERPA). The letter was written in accordance with the 2013 APDIM-CDIM Guidelines for Department of Medicine Summary Letters,1 composed by the student's primary advisor. The content of the letter is derived from clinical evaluations and comments from faculty and residents from the student's Internal Medicine rotations (including the Internal Medicine Core Clerkship and MS4 Internal Medicine Sub-Internship or sub-specialty electives if available), their performance on the NBME Medicine Subject Examination, and personal interactions with and assessment of this student. The letter is reviewed by the co-chairs of the Residency Advising Committee, Drs. Reeni Abraham and Stephanie Brinker, and the Chair of Medicine, Dr. Thomas Wang.

Reference