key: cord-1014443-hm2z2h15
authors: Nelson, David B.; White, Peter T.; Rajaram, Ravi; Antonoff, Mara B.
title: Showcasing Your Cardiothoracic Training Program in the Virtual Era
date: 2021-01-23
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2021.01.022
sha: e5ef2ff3bb74c1fb01cad0e333f42ca6f9fe581a
doc_id: 1014443
cord_uid: hm2z2h15

As part of the response to the coronavirus disease 2019 (COVID-19) pandemic, cardiothoracic training programs quickly transitioned midinterview season toward a virtual format. This monumental and rapid undertaking led to the adoption of novel virtual interviewing techniques, many of which have been developed and partially rolled out by other specialties for years. The COVID-19 pandemic is still here, and when the end will be in sight is unclear. However, most, if not all, of the novel interview techniques that were rapidly adopted by cardiothoracic training programs during the 2020 interview season will continue to be relevant even after the pandemic and need for social distancing subsides. In this literature review, we highlight techniques that can be used by cardiothoracic training programs to virtually showcase their attributes and strengths to give applicants as realistic of a view of the program as possible. Such efforts include developing and emphasizing a social media presence, expanding information within training program websites, broadcasting virtual educational content, and creating virtual tours. In addition, we will review approaches toward structuring a virtual interview day to provide candidates with a deeper glimpse into the inner workings of the program. We can use this opportunity provided by the COVID-19 pandemic to develop innovative methods of conducting fellowship interviews that may persist long into the future, as we consider limitations historically caused by finances, scheduling, clinical responsibilities, and family needs.

novel virtual interviewing techniques, many of which have been developed and partially rolled out by other specialties for years. The COVID-19 pandemic is still here, and when the end will be in sight is unclear. However, most, if not all, of the novel interview techniques that were rapidly adopted by cardiothoracic training programs during the 2020 interview season will continue to be relevant even after the pandemic and need for social distancing subsides. In this literature review, we highlight techniques that can be used by cardiothoracic training programs to virtually showcase their attributes and strengths to give applicants as realistic of a view of the program as possible. Such efforts include developing and emphasizing a social media presence, expanding information within training program websites, broadcasting virtual educational content, and creating virtual tours. In addition, we will review approaches toward structuring a virtual interview day to provide candidates with a deeper glimpse into the inner workings of the program. We can use this opportunity provided by the COVID-19 pandemic to develop innovative methods of conducting fellowship interviews that may persist long into the future, as we consider limitations historically caused by finances, scheduling, clinical responsibilities, and family needs. Program (NRMP). In addition, we will highlight approaches that can be used to showcase fellowship programs in the virtual era. The fellowship recruitment process has been significantly disrupted by the ongoing pandemic for both applicants and programs. Although the loss of in-person interaction is unfortunate, we can find an opportunity during this crisis to modernize, improve, and strengthen our fellowship recruitment methods in ways that can be used for many years to come.

A literature search was performed of PubMed and MEDLINE using the Medical Subject Heading search terms "virtual interview." In addition, PubMed and MEDLINE were searched using the abstract/title search terms "virtual interview residency" and "virtual interview fellowship." A snowballing strategy of searching citations within selected articles was used. 

The NRMP is a private, nonprofit organization that provides an orderly and fair mechanism for matching applicants to United States residency positions. The NRMP does not formally oversee or regulate the interview process that precedes the match. However, the NRMP released a policy statement on May 13, 2020, recommending that programs conduct virtual interviews in the upcoming match season, a policy stance by which most programs have abided. 1 The NRMP has additionally given additional guidance on other changes that would arise as recruitment transitions to a virtual format. These include the use of token gifts (such as pens, tote bags, etc), which are recommended to be of equitable value among applicants. In addition, expectations regarding the use of video recording during interviews should be clearly stated before the interview and may be subject to local and state laws. 1 The TSDA was established in 1978 as a membership organization for cardiothoracic surgery residency program directors and provides resources and networking opportunities for program directors and residents to support cardiothoracic training. The TSDA held a virtual session on September 26, 2020, to address the needs for an upcoming virtual interview season. 2 With regard to integrated residency applications, the TSDA has stated that all visiting medical student rotations for the 2020-2021 academic year should be discouraged, with the only potential exceptions to be considered when an applicant's home institution does not have a cardiothoracic surgery program. 3 In accordance, given restrictions in visiting rotations, letters of recommendation from noncardiothoracic surgeons should be given greater weight than would be customarily afforded. The TSDA is enacting efforts to implement a standardized recommendation letter to assist this process. Lastly, policies regarding mandating virtual interviews should be applied to all applicants, including local residents, to promote equality and fairness during the interview process.

Historically, the fellowship interview process has primarily been a single-day experience consisting of "wining and dining" the applicant, while trying to showcase the salient features of the program to the extent that can be done in a single day. This process has been developed and refined to work quite well, with many applicants stating that the interview day was the most important way to get to know a program, 4 and with programs' rank lists of applicants being formulated with significant weight on impressions after the interview. 5 Although the traditional interview process is effective, unfortunately, it is also quite burdensome in financial costs and clinical time off. A recent survey found general surgery residents applying to fellowships often miss 7 or more days of clinical training to attend interviews, which leads to clinical burdens requiring shifts to be covered by other residents and lost training time. 6 In addition, 62% of the surveyed residents spent more than $4000 on interviews. All together, most residents favored changing the interview process. Among more competitive specialties, the financial and clinical burden can be even more substantial than these stated numbers. 7, 8 In response to the concerns of the financial and clinical burden from traditional interviews, attempts have been made in the past to transition the interview process to a virtual format. In 2010, applicants to a urology program at the University of New Mexico were randomized to conduct virtual interviews, with those randomized to virtual interviews receiving subsequent inperson invitations. Applicants perceived the virtual interviews as being less effective than the traditional onsite interview, although many still favored continuing the virtual program as an adjunct to on-site interviews due reduced cost and improved convenience. 9 Similarly, in 2017 a pediatric surgery program at Johns Hopkins All Children's Hospital attempted an initial virtual screen for the interview season. 7 In a postinterview survey, 75% of their applicants stated that the virtual interview screen was helpful; however, 80% preferred that the virtual interview would not be substituted for an on-site interview. Specifically, applicants raised concerns that it was challenging to determine whether the program was the correct "fit" using the virtual format alone. Based on these results, the authors concluded that virtual interviews may be able to best function as a screening tool before an on-site interview.

Linda University Health reviewed their results after offering virtual or in-person interviews to applicants and found that their admission rate was not statistically different among those completing in-person vs virtual interviews. 10 This finding suggested that programs were not significantly lowering the rank of applicants who completed a virtual interview. In this situation, applicants stated that they chose virtual interviews in lieu of in-person interviews due to interview date conflicts, travel concerns, or financial limitations. Similarly, an ophthalmology program at the University of Arizona offered virtual or in-person interviews to their ophthalmology applicants, and they found that there was no difference in the rate of being ranked among the top 25 applicants when comparing those who completed a virtual interview with those who interviewed face-to-face. 11 

A very reasonable concern from applicants may be that a virtual interview might not allow them to identify the best fit in a program as was possible through the process of an in-person visit and interview. One approach to address these concerns is to increase the exposure of the applicant to the program, potentially over a much longer (Table 1) . [12] [13] [14] [15] EXPANDED TRAINING PROGRAM WEBSITES. Applicants place great importance on program websites, with their value undoubtedly heightened this interview season as trainees will be unable to visit programs in person. These websites present an opportunity for fellowship programs to describe not only the "nuts and bolts" of their program but also the overarching training style and educational philosophy embedded within their institution.

Consequently, training program websites have a significant impact in informing applicants of not only which programs to apply to but also their decision to interview. 6, 16 Unfortunately, many program websites are underdeveloped and in need of revision. 17, 18 In a survey study of fellowship interviewees at MD Anderson Cancer Center, respondents indicated that the most important information they sought on program's website included faculty profiles, rotation schedules, and profiles of current and former fellows. 13 However, a recent national analysis of 89 cardiothoracic residency and fellowship programs websites found most lack this information and fall woefully short in several other content domains important to applicants. 12 Moreover, website accessibility from traditional educational platforms, such as the TSDA, Electronic Residency Application Service, and Accreditation Council for Graduate Medical Education, was deemed suboptimal due to sites lacking links or containing nonfunctioning links that redirected users to other sites. 12 Clearly, there is opportunity for improvement broadly. Now is the time for fellowship programs to revamp their websites, with attention paid to aesthetic criteria, including design, layout, and ease of navigation for an increasingly technologically savvy generation of trainees. Regarding content, in addition to including the aforementioned criteria, programs should strive to include operative case logs, research opportunities, hospital descriptions, training program history, ancillary benefits, housing information, and interview day details. 13 Accessibility issues should be addressed, with program websites containing hyperlinks that are active and in working order. Moreover, programs would be well-served by taking a proactive approach to ensure links from other educational sites are functional.

The COVID-19 pandemic has compelled institutions to move swiftly as they seek to offer digital solutions for traditional formats. Similar to multidisciplinary tumor boards or heart failure conferences that have been moved online in the form of video teleconferencing, so too is it necessary to respond to the current crisis with web-based solutions for prospective trainees. Certainly, institutions will have to consider the costs of upgrading departmental websites. However, these changes will provide long-lasting benefits that will far surpass the duration of the pandemic. An online externship, in lieu of a visiting rotation, has also been proposed as a novel means for applicants to better understand the training environment of a program and to benefit from the support and advocacy of a mentor. 15 The TSDA has proposed that online externships be used in a structured manner, with virtual participation in conferences, journal clubs, and any non- Among a survey for the urology match, 64% of respondents stated that interactions with residents were the most important part of the interview day, and most expressed concerns regarding replicating resident interactions virtually. 44 In addition, respondents generally agreed that city visits could not be accomplished virtually. Encouragingly, 80% of applicants stated that they believed that faculty interactions could be well replicated virtually. These details may help guide our efforts for upcoming interview seasons to improve virtual resident interaction and provide the means for applicants to better understand the environment of a program.

Adjusting to the coronavirus pandemic has shown the incredible nature of applicants and programs across the country to be flexible and to adapt to changing needs.

The improvements in fellowship recruiting will surely provide long-lasting benefits that will persistent long after the pandemic has subsided, making the upfront costs more than worth it. Careful attention will need to be exercised to consider applicants that may be disad- These challenges offer a wonderful opportunity for us to support our future colleagues and to ensure an equitable recruitment process. Moreover, while these lessons will be vital in the current pandemic, they also provide insight about how we can accommodate candidates in the future, allowing transparent and informative recruitment processes to occur with potentially limited financial burdens, lessened scheduling challenges, and fewer absences from clinical and personal commitments.

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