Medical student advising during virtual residency recruitment: results of a national survey of internal medicine clerkship and sub-internship directors

ABSTRACT Introduction The residency application process is a critical time for medical students. The COVID-19 pandemic prompted changes to the residency recruitment procedures with the conversion of interviews to a virtual format. For medical school advisors guiding students on an all-virtual residency application process brought uncertainty to their advising practices. Thus, this study aimed to identify advising practices during the 2021 virtual application cycle. Methods We administered an IRB-exempt national survey through the Clerkship Directors in Internal Medicine to 186 internal medicine core/co-/associate/assistant clerkship directors and sub-internship directors representing 140 Liaison Committee on Medical Education-accredited U.S./U.S.-territory-based medical schools in spring 2021. The 23-question survey was designed and pilot-tested by faculty-educators and leaders with expertise in undergraduate medical education. Data analysis included paired t- and z-tests and thematic analysis of open-ended questions. Results The institutional response rate was 67% (93/140) and individual rate 55% (103/186). Half of the respondents felt prepared/very prepared (40% and 13% respectively) for their advising roles. Compared to pre-pandemic cycles, respondents advised a typical student in the middle-third of their class at their institution to apply to more residency programs (mean 24 programs vs 20, p < 0.001) and accept more interviews (mean 14 interviews vs 12, p < 0.001). Sixty-three percent (64/101) of respondents spent more time on student advising; 51% (51/101) reported more students asked them for informal advice. Fifty-nine percent (60/101) of respondents reported their advisees were able to assess a residency program ‘somewhat well;’ 31% (31/101) expressed that residency recruitment should remain entirely virtual in the future. Conclusion The transition to virtual residency recruitment due to COVID-19 prompted advising practices that may have contributed to application inflation and increased advising workload. Future studies should explore longitudinal outcomes of virtual interviews on student success to guide best practices in how to advise students during residency recruitment.


Introduction
The residency application process is a stressful time for medical students. Advising can help students navigate the process and maximize their success in the Match [1,2]. The COVID-19 pandemic prompted changes in the residency recruitment processes with the conversion of interviews to a virtual format. These changes raised concerns about the impact of virtual interviews on residency application inflation [3,4], and match success rates [5], and questioned best student advising practices in virtual residency recruitment. Thus, the purpose of this study was to identify advising practices during the 2021 virtual application cycle through a national survey administered by the Clerkship Directors in Internal Medicine (CDIM) and offer a potential reference for medical student advisors.

Methods
From March to May 2021, we administered an online survey about the virtual IM residency application process to 186 IM core and co-/associate/assistant CDs, and sub-internship directors representing 140 Liaison Committee on Medical Education fullyaccredited U.S./U.S.-territory-based medical schools. The 23-question survey was designed, revised after multiple iterations, and pilot-tested by CDIM facultyeducators and leaders with expertise in undergraduate medical education. Eleven of the survey questions focused on student advising for residency (Appendix 1). Data analysis was conducted in Stata 16.1 and included paired t-and z-tests to compare application cycle outcomes between the pre-2020-21 and the 2020-21 application cycles. For open-ended questions, thematic analysis was conducted following an iterative approach. The study was deemed exempt by Pearl IRB (U.S. DHHS OHRP #IRB00007772).
Compared to pre-pandemicIM residency application cycles, respondents advised a typical student in the middle-third of their class at their institution to apply to more residency programs (mean 24 programs vs 20, p < 0.001) and accept more interviews (mean14 vs 12, p < 0.001); spent more time advising students (63%, 64/101); and received more requests from students (37%, 31/84) and other individuals (19%, 15/79) to contact residency programs and advocate for students. Half of respondents (51%, 51/ 101) reported that more students asked for informal advice during the 2020-21 cycle (Table 1).
Fifty-nine percent of respondents (60/101)reported that their advisees could assess a residency program during the virtual interview day 'somewhat well,'and 9% (9/101) 'very well.' From free text responses to a question about challenges their advisees experienced due to virtual residency interviews, 81% (61/ 75) of respondents felt the virtual interview format made it difficult for students to 'get a good feel' of a residency program and its culture, the hospital, and the location. Additionally, 31% (31/101) of respondents expressed that residency recruitment should remain entirely virtual.

Discussion
The transition to virtual residency recruitment due to the COVID-19 pandemic brought uncertainty and questioned best advising practices. Although, many organizations (e.g., Alliance for Academic Internal Medicine) offered resources for virtual interview preparation for students, advisors, and programs [6,7], our results showed that only half of the respondents felt very prepared/prepared for their roles as student advisors.
During the 2021 virtual residency recruitment, respondents advised a typical student in the middlethird of their class to apply to and interview at a higher number of IM programs which may have contributed to application inflation [3,8,9]. Their advice misaligned with data from the National Residency Matching Program [10] showing that 99% of students would match to IM when their rank list includes 12 or less programs, and that 8-10 interviews would suffice. It is possible that lack of familiarity with these recommendations and uncertainty about the impact of virtual interviews on student candidacy may have been responsible for these findings.
Moreover, advisors received more requests from students and other individuals to contact residency programs, and were asked for informal advice by an increased number of students. One possible explanation may be the ambiguity and angst among students and educators about the virtual residency recruitment process. However, these requests increased advising workload for clerkship leaders raising concerns about burnout [11,12]. Our results underscore the need for institutional support and faculty development interventions to better prepare educators for their advising roles [13].
This study had limitations. Although our respondents were broadly representative of IM clerkships' advising practices, our findings represent a single specialty and may not be generalizable to other specialties or disciplines. Our survey focused only on advising practices for middle-third ranked students, and variability in student ranking systems among IM clerkships might explain differing responses. Additionally, responses were self-reported which could be subject to perception bias.
In summary, the transition to virtual residency recruitment during COVID-19 prompted advising practices that may have contributed to higher application numbers and increased advising workload. Future studies should explore longitudinal outcomes of virtual interviews.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This work was supported in part by the University of Chicago Bucksbaum Institute for Clinical Excellence article.

Data availability statement
The data that support the findings of this study are openly

Ethical approval
The study was deemed exempt by Pearl IRB (U.S. DHHS OHRP #IRB00007772).

CDIM Spring Survey on the Virtual Residency Application Process
The purpose of this survey is to 1. understand the perspectives of internal medicine (IM) clerkship and sub-internship directors (as student advisors) about the 2020-21 residency application cycle when interviews were conducted virtually; 2. identify perceptions of how your advising might have changed; and 3. gather data essential for providing medical schools and residency programs with recommendations about the virtual application process.
The survey results will be compared to the 2021 APDIM Spring Survey of Residency Program Directors on Virtual Interviewing, to provide medical educators with more holistic information. Summary results from both surveys will be available at IM.org in the months after survey closure. Upon completing this survey, you will receive your responses by email.
The survey should take approximately 15 minutes to complete. At any point, you may exit and return without losing your data. Please use the unique survey link in your email invitation; you will be returned to where you left off. The survey software will alert you of any unanswered questions but you may skip any that you do not wish to answer.
This study (#21-AAIM-118) is exempt by Pearl IRB (U.S. DHHS OHRP #IRB00007772) under FDA 21 CFR 56.104 and 45 CFR46.104(b) (2). You are invited to participate as an IM core clerkship or sub-internship director whose institution is a CDIM member: co-/associate/assistant clerkship directors are included. Participation is voluntary; refusal to participate will not affect your/your institution's membership. Upon survey closure, all personal and institutional identifiers will be removed by Alliance for Academic Internal Medicine Surveys staff, who manage data collection. 2. This survey is compatible with most tablet devices but if you encounter technical problems please check that your device's operating system is updated. Smartphones use is discouraged, due to programming that might cause unexpected survey navigation problems. Further technical support FAQ's may be viewed here (a separate browser window/tab will open).