Implications of COVID-19 on the General Surgery Match.

SURGICAL PERSPECTIVE Implications of COVID-19 on the General Surgery Match Naomi M. Sell, MD, MHS,  Motaz Qadan, MD, PhD,  Keith A. Delman, MD,y Kevin K. Roggin, MD,z David A. Spain, MD,§ Roy Phitayakorn, MD, MHPE,  Keith D. Lillemoe, MD,  and John T. Mullen, MD  Y Keywords: COVID-19, general surgery, general surgery education, general surgery residency, medical student education, surgical education, the match (Ann Surg 2020;272:e155–e156) T he COVID-19 pandemic will have lasting implications that span the breadth of healthcare in the years to come. As a byproduct of multiple factors, including supply chain preservation, potential for asymptomatic spread, and a desire to minimize risk to individuals not required for care provision, medical students have largely been sidelined during this crisis. Although medical educators continue to develop virtual solutions to adapt the medical school curriculum, 1 concern that arises is how the COVID-19 pandemic will affect the process of medical student career planning, especially recruitment into surgery. In this article, we discuss some of the foreseeable challenges related to medical student careers and propose solutions to mitigate its impact. THE PROBLEM Limited Exposure to Surgery In accordance with Association of American Medical Colleges guidelines, most medical students are currently being kept out of hospitals across the country.1 This strategy was implemented to protect students from exposure and to preserve limited personal protective equipment. For medical students, this is occurring during a time when they would otherwise be immersed within the hospital on core clerkships, including general surgery. Although creation of a ‘‘virtual’’ surgical curriculum would be beneficial,2,3 the exposure to actual surgery cannot be replicated with any available virtual surrogate and as such, surgical disciplines are disproportionally affected by the inability to experience the hospital setting firsthand. Strategies to account for these missed opportunities must be developed given the critical importance that core clerkships ultimately have on medical students’ decision-making in choosing career specialties. Numerous studies have demonstrated the impact that a surgical clerkship rotation has on inspiring career choices for medical students.4 Exposure to the operating room environment, in particular, remains critical to fully appreciate a surgical career, and with current tools it is impossible to completely replicate it virtually. From the Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; yDepartment of Surgery, Emory University School of Medicine, Atlanta, Georgia; zDepartment of Surgery, University of Chicago Medicine, Chicago, Illinois; and §Department of Surgery, Stanford University Medical Center, Palo Alto, California. . NMS was supported by the NIH T32 Research Training in Aging grant 5T32AG023480-14. The NIH had no involvement in study design; collection, analysis or interpretation of data; writing of the report; or decision to submit the article for publication. The author declares no conflicts of interest. Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/20/27202-e155 DOI: 10.1097/SLA.0000000000004032 Annals of Surgery  Volume 272, Number 2, August 2020 With limited exposure to a hands-on surgical clerkship, medical students may not be as confident or well-informed in their decision to pursue a 5–7 year residency in surgery, with repercussions for students entering the match in general surgery for the next 1–2 years after the height of the COVID-19 pandemic. Impact on Sub-internships (sub-Is) In addition to the impact on core clerkship rotations, there is a simultaneous effect on students with an expressed interest in surgery with planned sub-Is. These rotations provide critical experiences during which students gain a deeper appreciation for the field of surgery to learn if it is an appropriate ‘‘fit’’ for them as a career choice.5 Sub-I’s also provide many students foundational knowledge to help prepare them for surgical training. Furthermore, the added exposure a student gains to their home department can prove critical in their quest to identify advisors, mentors, and advocates to help them navigate their future professional endeavors. Reciprocally, these rotations provide an opportunity for faculty to evaluate students’ performance, offer them guide advice as to ideal characteristics of residency programs, and generate the content of letters of recommendation (LOR). Many students undertake multiple sub-Is within their desired specialty, which start as soon as April, to maximize opportunities before submitting their applications. Because many surgery residency programs use a rolling residency application deadline, students often feel obligated to submit their applications as soon as the electronic residency application service (ERAS) site opens. Unfortunately, the current pandemic has placed a halt on sub-Is, which has considerable implications for the downstream application components. The questions that therefore, arise are how can the educational system compensate for these losses and will the value of a LOR be diminished as a result? More importantly, how will the students gather an acceptable portfolio of information about specific disciplines to make informed choices about their optimal career? Decreased Availability of Away Rotations The decreased availability of sub-I rotations also adversely affects ‘‘away’’ rotations, which are likely to be difficult to arrange even after core clerkship rotations have resumed due to ongoing travel restrictions. For most students, the away rotation is an opportunity to audition at specific programs of interest or to demonstrate their interest in a particular geographic location, and it provides an exploration of ‘‘fit’’ in otherwise unknown programs.6 This added obstacle will further exacerbate the challenges evolving in students’ decision making as access to data about outside programs erodes even further. Similarly, for residency programs that utilize these rotations to evaluate prospective applicants from around the country, programs will have to create new opportunities to recruit the best students from across the country and abroad. PROPOSED SOLUTIONS Given the above highlighted challenges that may have a substantial impact on downstream resident recruitment for years to come, we propose the following potential solutions: www.annalsofsurgery.com | e155 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Annals of Surgery  Volume 272, Number 2, August 2020 Sell et al Modify Core Clerkship Schedules Adapt the Residency Interview Process Serious consideration should be given to shortening the duration of each core clerkship and/or enabling students to tailor their clerkship schedule to their clinical interests. For example, a student interested in surgery may wish to spend m (...truncated)