Familiarize yourself with residency interview structures

/Familiarize yourself with residency interview structures

Familiarize yourself with residency interview structures

by Pedram Mizani, MD, MHSA, family physician and chief clinical officer of the AmeriClerkships Medical Society

Published in Residency Program Alert* on January 2018.

Research has shown that interviews are filled with bias and that interviewers on average reach a final decision about applicants within four minutes of a 30-minute interview (Judge, Higgins, & Cable, 2000). Given the high level of variability in how medical residency programs structure and conduct their residency interviews, this article will explore some of the most commonly encountered structures, as well as emerging structures, employed during the annual Main Match.

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Published with permission from HCPro/Residency Program Alert. Also published on HCPro.

* About Residency Program Alert: Residency program managers in all specialties are challenged to effectively manage their programs as accrediting agencies focus on outcome measures, the core competencies, proper documentation, resident supervision, and program, faculty, and resident evaluation. Add to those responsibilities the challenge to prepare for site visits, develop budgets for your program, and mitigate legal risks. Residency Program Alert is the source you need to confidently meet these challenges. This monthly resource provides residency managers with essential tips, tools, and best practices from the most well-respected, in-the-trenches experts. Dr. Pedram Mizani, the AmeriClerkships’ Chief Clinical Officer, is a writer and contributors to Residency Program Alert.

Research has shown that interviews are filled with bias and that interviewers on average reach a final decision about applicants within four minutes of a 30-minute interview (Judge, Higgins, & Cable, 2000). Given the high level of variability in how medical residency programs structure and conduct their residency interviews, this article will explore some of the most commonly encountered structures, as well as emerging structures, employed during the annual Main Match.

Medical residency programs have a limited number of annual interview slots, yet must choose from hundreds (if not thousands) of impressive applications that are growing in number each year. This increased number of applicants poses secondary challenges for residency candidates, who must positively differentiate themselves from the rest of the first-year residency applicants, especially if they have multiple United States Medical Licensing Examination (USMLE) attempts, have below-average scores for their specialty, or may be viewed as veteran medical graduates (i.e., those who graduated five or more years prior). Residency programs also face challenges with effectively recruiting their next set of first-year residents who will fit in and complete the program.

These are all exciting residency recruitment challenges to solve, and now with the Association of American Medical Colleges’ (AAMC) launch of the operational pilot project Standardized Video Interview (SVI) in the 2018 Match, residency programs may be able to invite candidates to interview in a much more standardized fashion.

Effectively recruiting medical residents is an amazing process, filled with duties and responsibilities that can have global impacts. Various forms of this recruitment process have been adopted by medical residency programs, but each, within limits, has been customized to highlight a program’s unique characteristics, organizational mission, vision, and values. The recruitment process is most customized in the following stages:

Prequalification: Correctly and systematically deciphering the information provided by candidates from all across the world. See my previous article about spotting markers of problematic residency application for more information. 

Interview: Making the time and financial commitment to invite the most potentially suitable candidates to interview, and providing an interview structure and experience that is not only positive for both parties but also enables each party to evaluate if the other is a good fit.

Post-interview: Using ethical techniques to follow up with and maintain the interest of some or every candidate (though one can argue the latter is unethical) whom the program interviewed until rank order lists are submitted. Both parties must then do their best to rank and be ranked by one another so they match without finding themselves in violation of National Resident Matching Program policies.

Residency interview structures

Residency interviews fall in one of two categories: screening or selection. Screening residency interviews, which prequalify candidates based on direct communication, are significantly underused by residency programs. Those that fall into the selection category can be conducted in one of two main styles:

Unstructured: This style can also be referred to as traditional interviewing or a “search for negative evidence” (Rowe, 1989). It features ad-libbed interview questions based on a candidate’s academic criteria, USMLE performance, content of recommendation letters, or other components of a residency application package presented to the interviewer, with no predetermined questions. This interview style creates a more personalized interview experience at the expense of bias and a reliance on the interviewer’s “gut feeling,” which allows the interviewer to give more weight to negative data than positive.

Structured: In this style, an interviewer uses a predetermined set of questions established by his or her residency selection committee. The exact same questions are then presented to every candidate to establish a more standardized, residency-relevant post-interview scoring and evaluation process. This comes at the expense of an interview experience that has the potential of being impersonal at best.

The following are residency interview structures I have witnessed. They can be used as stand-alone structures or conducted in any combination imaginable.

Pre-interview questionnaire. This is used as an effective screening tool by programs with unique characteristics (e.g., rural or Seventh-Day Adventist) but it can be used by any program. With a pre-interview questionnaire, a residency program acknowledges a candidate’s application by presenting him or her with a structured set of questions specific to that program in an effort to align interests between the two parties prior to committing to an expensive interview process. This can be done either live (less commonly by phone or video) or by requesting written responses to the questions. Residency programs have been slow to unanimously adopt live-screening protocols, even though this is the normal process by which companies conduct their vetting of potential candidates.

Informational. This is an unofficial meeting between a candidate and a program faculty member, a resident, or even an influential community attending physician, in which the candidate asks questions about the program and seeks the advice of the individual close to the program. Informational meetings happen all the time, and although they are not typically considered an interview, they can certainly leave a great (or horrible) first impression for either party.

Courtesy. A courtesy interview is often extended to friends and families of well-liked residents or faculty. The candidate may have been officially invited along with other naturally selected interviewees or asked to meet the program director prior to being extended a full interview offer. This is often the one and only opportunity to interview such candidates.

Serial. A candidate is subjected to multiple back-to-back interviews, with different interviewers, during the one- or two-day interview timespan. Interviewers summarize a candidate’s responses along with their comments on post-interview comment forms (which may also contain predetermined questions), then share the information with the rest of the team during the ranking process. Even though this is the most expensive and time-consuming structure, serial interviews are by far the most commonly implemented interview method within the U.S. GME community.

One-on-one. These can be divided into two categories:

Serial: Other than duplicating “what has worked for years,” a multiple one-on-one structure may be favored so a candidate is allowed to speak more freely and perhaps answer similar questions asked by different interviewers, letting the interviewers later evaluate the candidate’s consistency and genuineness. The documented challenge with this structure is that on average, an interviewer reaches a decision about a candidate within four minutes of the interview, after which point the interview may lose its effectiveness (Judge, Higgins, & Cable, 2000).

Single: This is one interviewer conducting a single interview, which may be a courtesy interview. I cannot think of a scenario in which a resident is better off not working in a team; therefore, the residency interview and selection process must also be a team project. There are a couple of exceptions. One is during a follow-up interview when the candidate has already gone through the formal interview process. The other is when a few candidates each year manage to secure one-on-one meetings with program directors or associate residency faculty in hopes of being ranked. If not re-invited for an official interview with the rest of the residency team, then that one-on-one meeting was most likely not a genuine invitation to begin with.   

Tag-team. This residency interview structure can be divided into four types, each with pros and cons:

Group interviews: By increasing the number of applicants invited to interview each day, a program may save on resources and even cut down the total number of interview days. Group interviews are a great way to assess interpersonal and communication skills and even group members’ “fit” for one another. However, it takes a seasoned interviewer to keep the group balanced. Also, group Q&As are not always fluid, definitely are not as personal, and may not provide some interviewees a chance to respond. A group interview typically consists of three or fewer interviewees simultaneously meeting with one interviewer, but I’ve seen up to 20 interviewees being interviewed simultaneously at Emory University while touring the 953-bed Grady Memorial Hospital in Atlanta.

Panels: The candidate appears before a committee or a panel with typically two or three interviewers. This is typically done to save interviewers time, but it can be intimidating and overwhelming for the interviewee.

Grand rounds: I’ve only seen two variations of this type. In one, a subintern was asked to present during morning rounds, and the program director considered the four-week rotation and the subintern’s final day presentation as his official interview. In the other, a child neurology candidate was asked to present a topic during morning rounds, then questioned by everyone, and that was the end of the interview. In a way, this format can feel like a giant panel interview, but both candidates reported that they enjoyed it.

Audition: This is an extended form of an on-the-job interview, where a candidate’s potential as a resident at that institution is witnessed firsthand during a two- or four-week clinical elective or subinternship with the residency program. An audition residency interview must allow candidates to fairly demonstrate their ability to exercise the six ACGME core competencies in an insured environment with direct patient contact. Therefore, I discourage programs from using clinical observerships, which by definition are uninsured and limited to shadowing, as a form of auditions.

Sequential. Candidates meet with interviewers over a course of several meetings. This is not commonly seen in U.S. GME, unless a candidate has already been prescreened by a program director or faculty member, and that person recommends the candidate for an official interview. 

Multiple mini (also referred to as MMI). Always structured in style, MMIs include a timed circuit of stations to assess skills, including interpersonal communication, professionalism, and ethics. We often see MMIs being used by medical school admission committees, yet some residency programs in Alberta and Ontario, Canada, have exclusively used MMIs as their interview structure.

Clinical or non-clinical vignette (also referred to as situational or performance interviews, using single or multiple cases). Interviewers are asked to evaluate a candidate’s skill sets in handling hypothetical clinical and nonclinical scenarios and the candidate’s depth of insight with regard to accessing reasonably available resources to handle any situation if hired as a first-year resident. There have been reports of a program in New York whose entire interview structure consisted of answering a single clinical vignette question.

Stress. These interviews are generally intended to put interviewees under various pressures to assess their response during highly challenging, emotionally charged, and possibly unethical scenarios. Due to the nature of medical residency, stress interviews may be appropriate if conducted by a trained interviewer. During my nearly two decades of hosting mock interviews, I’ve learned that all interviewees regardless of profession expect at least one question having to deal with a stressful scenario, but residency candidates in particular enjoy the challenge. If the scenario is coached carefully, this structure can help identify candidates who will remain professional while using their multidisciplinary skills to effectively resolve the stressful scenario. After all, this is medicine, and anything can happen.

Behavioral (also referred to as accomplishment interviews). In these interviews, candidates are asked to describe past residency-relevant experiences or undergo assessment testing—personality, aptitude, or interest inventories—in an effort to ascertain characteristics desirable to the residency program.

The main difference between a behavioral and a stress interview is that a behavioral interviewer seems to be in constant agreement with the candidate and typically makes the candidate believe that he or she is doing amazingly well and providing the perfect answers. I’ve often seen skilled interviewers layer behavioral with non-behavioral questions or comfort interviewees so much that they begin to reveal more information than they perhaps intended to.

Mealtime. A mealtime interview is typically enjoyed by both parties and can tell a program how candidates handle themselves outside of medicine in a new community/society. This gauges the social skills of a candidate, typically over dinner. A program may even strongly suggest that a candidate be accompanied by his or her spouse.

Although residency candidates are clever enough to know that they should be on their best behavior during any interaction with their potential future employer, holding a seemingly casual meeting over a meal tends to display how a candidate may treat guests or even non-medical professionals (e.g., ignoring or being over-demanding of a server, or leaving the dinner table in a mess).

A mealtime interview is especially successful when an interviewer is able to witness the combined effects of a spouse who joins the interview, especially if an interviewer decides to bring a friend instead of a spouse, or if the two have never been in a semiformal setting where the spouse (who is not being interviewed) is fully aware that his or her actions can dictate the outcome of that interview.

Before any interviewee brings a spouse, I typically recommend that the interviewee ask and treat an attending physician and his or her spouse to dinner for some incognito practice.

Combination. Combination interviews employ any of the previously mentioned structures in the same or follow-up interview.

Emerging interview structures

Interview structures are not limited to those I have discussed thus far. There are a number of emerging structures you should be aware of.

Standardized video. As I mentioned, the AAMC launched SVI in the 2018 Match as a direct response to the increasing number of residency program applications.

Between May and July 2017, all emergency medicine (EM) residency candidates were required to record their responses to six questions using the video interview software HireVue, focusing on two ACGME core competencies: professionalism and interpersonal and communication skills.

Between June and September 2017, interviews were reviewed and scored in a standardized process by a third party. EM programs then had access to candidate scores and videos for the 2018 Match season.

What distinguishes SVI from traditional video responses to interview questions is its proprietary scoring system, which is supposed to provide program directors a consistent and bias-free interview score that can be rapidly incorporated into their interview selection process. Follow-up studies are pending.

Videoconference (or a simple telephone call). How programs use this interview structure will depend on when it is employed:

During Match Week: Although primarily seen during Match Week’s Supplemental Offer and Acceptance Program, some programs attempt to gain a more complete picture by speaking with (and seeing) candidates who seem qualified on paper. This process may be structured or unstructured, and may be conducted through a third party (e.g., HireVue) or by a residency program staff/faculty member.

During the regular Match interview season: Nearly every employer I know has screened at least one candidate for a job; however, for reasons unbeknownst to me, residency program gatekeepers often skip the extremely valuable screening interview by way of videoconferencing (costing only the screener’s time, since the videoconferencing tools are commonly free) and instead leap into inviting a candidate to the coveted medical residency interview, which can cost a program several thousands of dollars and an interview slot.

Follow-up (or a second interview). Interview season is exhausting and expensive. Just imagine the hourly cost of everyone involved to set up a one-hour meeting ($150–$400+/hour for a program director, plus all administrative support personnel costs). Residency programs often look forward to the interview season winding down and do not typically offer follow-up or second interviews. However, they are often open to granting a high-performing candidate the opportunity to have a brief, informal one-on-one with the program director or to join the rest of the team during a grand round, noon report, or even subinternship, depending on program, hospital, or state regulations—this excludes observerships because the program is unable to truly assess a candidate’s familiarity with ACGME core competencies if there is no insured patient interaction. The structure of this second interview is variable, but follow-up interviews are generally granted if a candidate is seen as a potentially good fit.

My recommendations

I’m an advocate of screening residency candidates via directly observing their patient interactions during clinical rotations. If that’s not possible, then I recommend group videoconference sessions, a simple one- or two-minute unannounced phone call, or AAMC’s SVI pilot project, which I have great hopes in.

I was delighted over lunch recently when a former program director of one of the most prestigious emergency medicine programs in Southern California said, “I think [AAMC] finally nailed it with SVI scoring.” However, until the kinks of SVIs are worked out and this system is extended to all specialties, I recommend that residency program gatekeepers get a head start and begin screening candidates by videoconferencing. Nearly everyone has used video with voice tools, such as Apple’s FaceTime, Facebook’s Messenger, WhatsApp, Viber, Google’s Hangouts, or Skype.

The most common complaint I hear is the time needed for coordinating a screening interview. I assure you, the costs—financially and in lost time—of inviting an unsuitable candidate are far greater. Additionally, videoconferencing can be combined with a group structure where multiple prequalified candidates are invited to register in predetermined virtual meeting time slots.

If you’re still not convinced, then maybe an unannounced phone call can help you gauge a candidate’s interest in your program. To identify those not committed to a single specialty, ask which specialty a candidate applied to. Or ask candidates to tell you about themselves as a means of assessing their English fluency and communication skills.

A residency interview structure is only as good as its interviewers and interviewees. By carefully planning and tightly integrating the prequalification and screening interview process, you will preserve resources, lessen your exposure to possible labor law violations, improve residency morale, and lower the chances of residents having to be terminated due to mismatches that could have been identified by a trained individual.

References

Judge, T. A., Higgins, C. A., & Cable, D. M. (2000). The employment interview: A review of recent research and recommendations for future research. Human Resource Management Review, 10(4), 383–406. Retrieved from http://www.sciencedirect.com/science/article/pii/S1053482200000334

Rowe, P. M. (1989). Unfavorable information and interview decisions. In R. W. Eder & G. R. Ferris (Eds.), The employment interview: Theory, research, and practice (pp. 77–89). Newbury Park, CA: Sage.

2018-05-10T14:45:20+00:00