Reimagining Residency Selection: Part 1—A Practical Guide to Recruitment in the Post-COVID-19 Era

The COVID-19 pandemic has dramatically and rapidly changed the status quo for nearly every aspect of medical education, including resident and fellow recruitment.¹ Several organizations, including the Association of American Medical Colleges and the Canadian Resident Matching Service, have issued statements encouraging or mandating virtual-only interview processes for the upcoming recruitment season.^2–4 Further, institutions have placed restrictions on visiting student clinical rotations.⁵ Traditionally, visiting student rotations have functioned as “audition rotations,” whereby applicants and residency programs can assess mutual compatibility.⁶ The loss of these opportunities limits applicants' ability to experience programs in person, assess program culture, and obtain external letters of recommendation.

In this article we will review the recruitment process and provide guidance for overarching conceptual changes as well as practical, evidence-based recommendations for virtual residency recruitment.

Revisiting Recruitment

Every application cycle, residency programs devote an immense amount of time, effort, and resources to recruit residents who will be successful in their programs. Recruitment costs to programs include development of promotional materials and websites, interview day meals, transportation between clinical sites, and staff and faculty time dedicated to organizing and conducting interview days.^7,8 Although the cost to residency programs varies, the mean cost of recruiting a single postgraduate year 1 position is estimated at $9,899.⁹

Recruitment must be conducted thoughtfully in order to maximize the return on investment for applicants and programs. Effective recruitment requires an understanding of what applicants value in residency programs and which applicants are most likely to succeed in the program's particular clinical learning environment. The 2019 National Resident Matching Program (NRMP) Applicant Survey identified the top factors influencing applicants' application and ranking decisions as perceived fit, program reputation, academic medical center program, quality of residents in the program, and the interview day experience.¹⁰ A 2015 study evaluating applicants' priorities in selecting residency programs identified these top factors: the program's ability to prepare residents for future training or position, resident morale, faculty availability and involvement in teaching, depth and breadth of faculty, and variety of patients and clinical resources.¹¹

Traditionally, program recruitment strategies have involved creating program branding,¹² fostering a national reputation,¹³ participating in residency and fellowship fairs at large specialty conferences, developing a program website,¹⁴ and having a social media presence.^12,15 Additionally, many programs have recruited internal candidates through participation in mentorship, teaching activities, and medical school specialty interest groups.^16–20 Clerkships have traditionally served as one of the most powerful recruitment tools for both internal and visiting students, offering more prolonged, repeated contact between applicant and program.^6,21–24

Reimagining Recruitment

The COVID-19 pandemic has shifted recruitment toward digital media.⁵ This changing landscape provides potential advantages for residency programs that seize this opportunity for innovation. Looking to remote and digital companies may provide inspiration. For residency programs, factors such as geographical region, city, program size, or hospital affiliation are not modifiable. However, key virtual recruitment interventions may specifically highlight program and location strengths. We propose 4 key metrics in a residency program's digital presence: marketing, content quality, accessibility, and technology.²⁵

Marketing to Expand Reach

Within the realm of marketing, social media provides an increasingly important source of information for applicants to residency programs.¹² Information sharing via social media may facilitate the residency program application process for applicants and programs. Social media platforms such as Twitter, Instagram, and LinkedIn can give applicants a more intimate look at a program's culture by featuring events, current faculty and trainees, and content reflective of the program's mission, vision, and values.¹²

In addition to disseminating content via social media platforms for passive consumption, residency programs can harness opportunities for bidirectional communication with applicants. Examples of bidirectional communication platforms include Reddit, an online network of communities based on personal interests. Reddit users can host an “Ask Me Anything” (AMA) session, whereby representatives of a residency program allow potential applicants to ask any questions anonymously.²⁶ The AMA format offers a unique opportunity to experiment with an online bidirectional dialogue with participants and to extrapolate from these experiences to determine best practices for the future.²⁷ These AMA opportunities should be considered not only with residency directors, but also with current residents, alumni, faculty, and departmental leadership.

Conveying Your “Brand” via Quality Content

In addition to marketing through social media, residency programs should enhance their digital presence through website content development and curation. Even before COVID-19, residency websites often influenced applicants' first impression of the program and have been cited as a critically important factor in applicants' decisions.²⁸ Residency programs can envision their websites as a first point of contact for general applicant communication and education.²⁹ While social media is essential for raising public awareness and excitement about a program, a website gives programs a home base for applicants to explore and find details about the program.

Including links to synchronous communication opportunities, such as Google Hangouts sessions that are open to any potential applicant, gives applicants opportunities to ask questions and can improve transparency.³⁰ Links to asynchronous hangout locations such as open Slack spaces can allow medical students to ask questions and interact with residents at their convenience.³¹ Links to blogs that allow for bidirectional communication permits indexing, inclusivity, and transparency that single closed sessions do not allow.³² Additionally, offering recordings of faculty lectures on the residency program's website can deliver asynchronous learning opportunities for residents while simultaneously improving the visibility of program faculty.³³

In addition to synchronous and asynchronous communication forums and educational content, the residency program website creates a window into the program's facilities and life in the area—which can be used pre-interview and also around the time of interviews and afterward.⁸ The limited opportunity for on-site visits makes this component critically important. Programs can harness technology to offer virtual tours of facilities and surrounding areas.^34,35 A low-cost video of a walking tour, filmed on a mobile device by a current trainee, can show the location in a way that feels authentic and personal. Note that care must be taken to maintain compliance with HIPAA regulations when filming patient care areas.

Beyond the residency program's digital presence, additional opportunities for pre-interview day interaction with applicants include remote electives or “virtual away rotations”. Several specialties have adopted virtual rotation experiences, including emergency medicine,³⁶ neurological surgery,³⁷ and otolaryngology.³⁸ Social enterprise networks such as Slack have been previously used to provide asynchronous curricula for medical students³⁹ and residents,⁴⁰ and could also be opened to potential applicants.³¹

Programs can consider strategies to connect with applicants who are selected for interviews prior to the actual interview. For instance, programs can implement a “buddy system” to link applicants with one or more residents across a variety of training years as points of contact. This may foster longitudinal interactions that give applicants and programs enhanced insights into program-applicant compatibility. Additionally, programs may consider sending applicants a “virtual care package,” with institution- or program-branded promotional items or personalized written messages from the program's trainees and/or faculty.

Accessibility and Technological Usability

Accessibility refers to a website's ability to appeal to a broad audience across varying literacy levels, technical aptitudes, and disabilities.⁴¹ This includes a webpage's meta description, readability, and the overall layout of the website. Technological usability refers to factors such as technological design, performance user experience, back-end coding infrastructure, and server management.⁴¹ Although the detailed aspects of accessibility and technology are beyond the scope of this article, we recommend that residency programs seek external reviews of these metrics because previous website evaluations have noted significant gaps in these areas.⁴¹ The table displays the methods for increasing digital visibility for recruitment of potential trainees prior to interview day. The box provides ideas for using digital tools for residency recruitment.

table Methods for Increasing Digital Visibility for Recruitment Prior to Interview Day

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Acknowledging Limitations of Virtual Recruitment

While digital platforms offer many solutions to the restrictions necessary during the COVID-19 pandemic, limitations exist. The first limitation involves the actual creation of the digital media and materials for promoting the residency program.⁴² Creating and updating a program's website and promotional materials requires knowledge, money, and personal investment by program leaders. However, this can be a great opportunity for a junior faculty member, who has not yet carved out an academic niche. Involving residents who may have interest or prior experience in graphic and digital design can distribute the work and increase the relevance of the content to applicants.

Another limitation involves the program's use of technology, including the buy-in, effort, and knowledge to use different media. The goal is to create ways to interact with potential candidates to provide a polished yet authentic sense of the program, the people, and the overall culture. This engagement is critical and requires active and motivated faculty, residents, and others to reach out and promote the program and be available to interact and answer questions. Achieving the right balance of digital presence is a challenge.

The most important limitation is that real-life interactions, city and site visits, and personal experiences cannot be fully replicated using technology. Social interactions are reported to be extremely influential on an applicant's decision-making process and are difficult to replicate with an online format.³⁵ In addition to social experiences, immersion in a program and community through a visiting rotation is hard to recreate. Regardless of how well and creatively technology is used, it is unlikely to supplant actual in-person experiences entirely.³⁵

Conclusions

The transition to virtual recruitment strategies in the 2020–2021 NRMP Match cycle has begot new challenges and opportunities for residency program leadership. Special attention should be paid to 4 key factors: marketing via social media, website content quality, accessibility, and technological usability. Navigating a program's creation and use of recruitment-focused technology can be resource-intensive and requires achieving a balance between providing both a polished and authentic representation of the program. Although a program's digital presence cannot fully replace the power of in-person social interactions, virtual recruitment can differentiate a program among applicants when implemented with an evidence-based and innovative approach.

In these tumultuous times, it is our hope that this introduction to virtual recruitment strategies may inspire graduate medical education leaders to not just translate their current processes into the digital world, but rather use this opportunity to truly rethink their recruitment and selection processes going forward. Now is the time to pause before repeating the same old processes, examine the best evidence available, and make our recruitment processes better.