COVID-19 is Moving the Goalposts: Program Director and Prospective Residency Applicant Sentiment towards Sub-internships and the Match

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In the current COVID-19 pandemic environment, neurosurgery program directors (PDs) and prospective residency applicants will face novel challenges in the upcoming 2020-2021 match cycle. Sub-internships have historically provided an opportunity for students and programs to familiarize with one another and assess a potential cultural fit. Given the public health crisis, the Society for Neurological Surgeons (SNS) provided recommendations for students to perform eight weeks of a home rotation without exdternal sub internships in an attempt to prioritize safety and provide a robust fourth-year neurosurgery experience to students. Before these guidelines were issued, we surveyed PD and applicant perspectives regarding the upcoming match process during the pandemic.

Although the survey was undertaken before the official SNS announcement, we asked questions related to a potential desire for other experiences should sub-internships get canceled, as well as elucidating any upcoming changes for the application cycle due to COVID-19. The survey results reinforced the impression that there is substantial uncertainty from both PDs and students regarding the forthcoming period. Without sub-internships, PD expressed concern rin regards to qualitative assessment of the applicant pool. Multiple PDs noted the role of the sub-internship in applicants’ securing of letters of recommendation from neurosurgeons. One concern was limited institutional diversity among applicant’s letters of recommendation, as home programs tend to write more supportive letters. Another PD identified the importance of inter-institutional faculty conversations in regards to specific applicants.

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Medical students expressed concerns about the absence of subinternships and its impact on their applications. Seventy-one percent of students felt this situation and the letters of recommendation will be less reflective of their true potential as a resident (Figure 1). While many students explained the benefit of sub-internships as providing opportunities for improving clinical skills, assessing program culture, and networking, some students indicated they would not find enough value in sub-internships if they were not expected, cost being  a primary concern. Financial savings do not need to come at the expense of sub-internships; eighteen percent of students were agreeable to a nontraditional experience such as a virtual sub-internship. Exploring unconventional methods for students and programs to connect prior to interviews, such as virtual sub-internships, could benefit all parties tremendously.

While it is impossible to predict how the upcoming match cycle will unfold, it is this uncertain environment that will allow for equitable and creative solutions; hopefully this will ultimately prove beneficial to the neurosurgery match.  Continuing conversations at the national level with consideration to program and student perspectives may ease the burden of uncertainty we all carry.

Figure 1. Prospective neurosurgery residency applicants were asked “Do you think an evaluation without sub-internships would be more reflective, or less reflective of your potential?” Thirty students indicated less reflective, two said more reflective, and ten said the evaluation would be the same.
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