Each year, a growing number of ophthalmologists seeks fellowship subspecialization in order to obtain new skills and to provide better and more specialized care to patients.1 Recent surveys have found that most graduating ophthalmology residents in the United States and Canada (65% and 63%, respectively) plan to pursue a fellowship—double the numbers from the early 2000s.2-4

As the number of fellowship applicants continues to grow, the application process is rising in competitiveness. One of the most important aspects of the application process, according to fellowship program directors, is the interview.4 Studies have highlighted the strengths and weaknesses of the current standard application process and, in the case of the ophthalmology residency match, have found that applicants desire improvements in the interview scheduling process, including the possibility to conduct videoconference interviews (VCIs).5

With the emergence of SARS-CoV-2, widespread changes are occurring in ophthalmology. Ophthalmologists are moving toward offering more telehealth medicine, surgical cases are being delayed or cancelled for the well-being of patients and providers, and the American Board of Ophthalmology is moving to a Virtual Oral Examination for 2020.

Such changes are not confined to ophthalmology. All of society is performing social distancing that will likely be required for years.6 Although the virus may necessitate a temporary move toward more use of VCIs, the emergence of this option presents an opportunity for permanent, meaningful improvements to be made to the application process.

MAKING IT WORK

During the COVID-19 era, the most apparent need for change in the application process is social distancing. To avoid the requirement for cross-country travel and face-to-face contact, use of VCIs will likely play an important role in the 2020-2021 application cycle.

At least for residency programs, the use of VCIs does not appear to affect the ability of the program to evaluate a candidate.7,8 Learners seem to perform just as well whether they were selected by VCI or in-person interview,9 although the applicant’s perception of his or her subjective fit into a program is an important factor in decision-making.5,7

With a VCI, there is a loss of opportunity to gather subjective impressions of a program. Participants can’t tour the program’s facilities, observe the attending-fellows dynamic, or explore the city where they will potentially live and work.

When designing a virtual interview day, programs must strive to mimic the process of an in-person interview as closely as possible.8 Some elements of the socialization that takes place during a standard in-person interview day may be able to be digitized. Between interviews, for example, applicants could be invited to video chat rooms where they could speak with other applicants and with current fellows and attendings. This would give the applicants opportunities to ask important questions that might not have come up during the interview itself.

Programs could also provide applicants with answers to frequently asked questions (FAQs), including descriptions of fellowship structure and expectations, surgical numbers, didactic and research opportunities, call responsibilities, and city life.

Additionally, lectures that are normally delivered as part of an interview day could be digitized and made available on the program’s website. In fact, if these lectures and FAQs were made available on the program’s website year-round, applicants would be able to use this information when choosing programs. In turn, applicants might be more selective when sending applications, and this might help to relieve some of the administrative burden that programs may incur because of these changes.5

A move toward VCIs could also ease the financial burden on applicants. Interview-related travel—including cross-country flights, hotel stays, food, and other expenses—make up a large portion of overall match-related expenses.5 By offering VCIs that can be completed in one’s home, institutions could largely eliminate these travel expenses. Applicants would not be faced with inflated last-minute airline ticket costs or change fees when an interview itinerary must be modified.

LOGISTICAL ISSUES

Use of VCIs could also lead to improvements in interview logistics. In residency matches, one of the most significant barriers to attending an interview has been navigating issues with dates and locations.5 Instead of being forced to take a red-eye flight to interviews on opposite sides of the country on back-to-back days, with VCIs, an applicant could perform both interviews from the same location. He or she could therefore be well-rested and functioning closer to top form.

Interview timing could also be made more flexible for applicants with scheduling conflicts. Although it would be impossible to attend in-person interviews on the East and West Coasts of the United States on the same day, use of VCIs could allow interviews to be arranged at nontraditional times (eg, in the evening) to leave time for interviews with other programs or professional obligations during the day.

DOWNSIDES?

Despite the relative ease of interviewing and the significant financial and logistical benefits for some applicants with VCIs, the process may not be without downsides.

In the current system, applicants are often forced to cancel one or more interviews due to any number of reasons. This newly freed interview slot is then generally offered to another applicant for a second-round invitation. With VCI attendance less restricted by travel, applicants may be less likely to require cancellation of an interview appointment. Also, because the marginal cost of attending an additional VCI (ie, the applicant’s time) is lower than for an in-person interview (ie, the applicant’s time plus the costs of lodging and transportation), applicants may aim to attend more interviews than they could previously. Therefore, if interview appointments are no longer being cancelled and offered to other applicants, this new system may hurt less-competitive applicants, and the process could become even more competitive.

To combat this, it is possible that fellowship programs will interview a larger number of applicants, although this would increase administrative costs. With FAQ information available on programs’ websites, applicants may be able to be more selective regarding programs to which they apply,5 but changes to match guidelines may be required as these trends are uncovered.

A VOLUNTARY OPTION

Because an applicant’s sense of subjective fit is important in decision-making,5,7 programs may wish to offer in-person interviews or tours during the current era with health-protective measures in place. If an applicant attends an in-person tour, the financial benefit of a VCI is virtually eliminated.10 Therefore, during the COVID-19 era, when attending an in-person session means incurring risks to the health of the applicant and to those in the program, it will be important to ensure that attending an in-person session is completely voluntary.

Applicants should be evaluated similarly regardless of the type of interview they choose. In-person tours should not be perceived as more favorable, but rather as a voluntary opportunity for applicants to learn information for use in their decision. One way to ensure this would be to require earlier rank list finalization from programs than from applicants, and to hold these second-look tours in the interim.

CONCLUSION

Although no one is sure exactly what shape the fellowship interview trail will ultimately take, changes will surely be required for 2020-21 and likely beyond. From crisis can come opportunity. By preparing early, we may be able to convert temporary social distancing measures into permanent improvements in the application process.

1. Gedde SJ, Budenz DL, Haft P, et al. Factors influencing career choices among graduating ophthalmology residents. Ophthalmology. 2005;112(7):1247-1254.

2. Noble J, Schendel S, Daniel S, Baerlocher MO. Motivations and future trends: a survey of Canadian ophthalmology residents. Can J Ophthalmol. 2007;42(6):821-825.

3. Parke III D. In the pursuit of fellowship. AAO Young Ophthalmologists. May 14, 2015.

4. Venincasa MJ, Hubschman S, Kuriyan AE, et al. Perceptions of vitreoretinal surgical fellowship training in the United States. Ophthalmol Retina. 2019;3(9):802-804.

5. Venincasa MJ, Cai LZ, Gedde SJ, Uhler T, Sridhar J. Current applicant perceptions of the ophthalmology residency match. JAMA Ophthalmol. 2020;138(5):1-7.

6. Kissler SM, Tedijanto C, Goldstein E, Grad YH, Lipsitch M. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science. 2020;368(6493):860-868.

7. Lewis J, Dubosh N, Rosen C, et al. Interview day environment may influence applicant selection of emergency medicine residency programs. West J Emerg Med. 2017;18(1):142-145.

8. Pourmand A, Lee H, Fair M, et al. Feasibility and usability of tele-interview for medical residency interview. West J Emerg Med. 2018;19(1):80-86.

9. Stephenson-Famy A, Houmard BS, Oberoi S, et al. Use of the interview in resident candidate selection: a review of the literature. J Grad Med Educ. 2015;7(4):539-548.

10. Pasadhika S, Altenbernd T, Ober RR, Harvey EM, Miller JM. Residency interview video conferencing. Ophthalmology. 2012;119(2):426.e5.