The Surgical Residency Interview: A Candidate-Centered, Working Approach

2012 APDS SPRING MEETING

The Surgical Residency Interview: A Candidate-Centered, Working Approach Heather Seabott, BA,* Ryan K. Smith, BA,† Adnan Alseidi, MD,ⴱ,† and Richard C. Thirlby, MD,ⴱ,† Departments of *Graduate Medical Education; and †Surgery, Virginia Mason Medical Center, Seattle, Washington PURPOSE: The interview process is a pivotal, differentiating

component of the residency match. Our bias is toward a working interview, producing better fulfillment of the needs of both parties, and a more informed match selection for the candidates and program. METHODS: We describe a “candidate-centered” approach for

integrating applicant interviews into our daily work schedule. Applicants are informed upon accepting the interview of the working interview model. Our program offers 33 interview days over a 12-week period. A maximum of 5 applicants are hosted per day. Applicants are assigned to 1 of our general, thoracic, vascular, or plastic surgery teams. The interview day begins with the applicant changing into scrubs, attending a morning conference, and taking part in a program overview by a Chief Resident. Applicants join their host team where 4-8 hours are spent observing the operative team, on rounds and sharing lunch. The faculty and senior residents are responsible for interviewing and evaluating applicants though the Electronic Residency Application Service. RESULTS: A total of 13 surgeons are involved in the interview process resulting in broad-based evaluations. Each surgeon interviewed between 3 and 12 applicants. Faculty rate this interview approach highly because it allows them to maintain a rigorous operative schedule while interacting with applicants. Current residents are engaged in welcoming applicants to view the program. Faculty and residents believe cooperating in a real world manner aids their assessment of the applicant. Applicants routinely provide positive feedback, relaying this approach is informative, transparent, and should be the “standard.” Applicants believe they are presented a realistic view of the program. Ultimately, this candidate-centered process may be attributable to our resident cohort who exhibit high satisfaction, excellent resident morale, and very low dropout rate. CONCLUSIONS: We present a candidate-centered, working interview approach used in the selection of general surgery res-

Correspondence: Inquiries to Adnan Alseidi, MD, Virginia Mason Medical Center, 1100 Ninth Ave., Mailstop C6-GS, Seattle, WA 98101; fax: 206-341-1908; e-mail: [email protected]

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idents. While it may require more resources than the traditional approach, it harbors advantages for the applicant and the program. (J Surg 69:802-806. © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: applicant interview, attrition, resident selec-

tion, program assessment COMPETENCIES: Professionalism, Interpersonal and Com-

munication Skills, Practice Based Learning and Improvement

INTRODUCTION General surgery residency is, at least, a 5-year partnership between training programs and residents. Creating the most compatible fit between program and a prospective resident is a mutual goal. Consensus surveys of general surgery residency programs throughout the country show that programs consider the interview to be the most important factor when considering an applicant’s ranking.1 Because there is no objective method to assess important personal characteristics of the candidates (overall attitude, motivation, integrity, problem-solving, and interpersonal skills) subjective methods are regularly employed. Identifying useful predictors of resident success using the current interviewing method has been inconsistent.2 Consequently, a quarter of all residents matched into surgical programs in the United States will not finish because of probation, resignations, or dismissal.1 Therefore, a more robust model of residency interviewing is required to meet the needs of residency programs and their candidates. During program selection, demonstrable disparities exist between the factors considered by programs and those considered by candidates.3,4 Most consider resident ranking based heavily on cognitive factors (United States Medical Licensing Examination, grades); however, a paucity of vital noncognitive abilities are the most significant contributor to residents’ failure.5 Meeting the needs of candidates during the interview process is not a routine consideration of the traditional interview approach. Candidates find difficulty assessing the program’s educational environment, curriculum, faculty, residents, staff, and location, and largely base decisions on interview day impres-

Journal of Surgical Education • © 2012 Association of Program Directors in Surgery 1931-7204/$30.00 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2012.06.004

sions.3 Misinformation, miscommunication, and the inability to identify vital elements can lead to poor fits for the candidate or program.6 Our institution offers a novel, “candidatecentered” alternative to the traditional interview style. Applicants are invited to spend the day with our program in an observer capacity where they are allowed into the operating rooms (ORs), interact with faculty and residents, and share in an informal interview session. The bias is toward allowing “full disclosure” between the candidate and the program which facilitates a well-informed match selection process.

MATERIALS AND METHODS

Medical Student Perspective

The working approach to interviewing was adopted in our general surgery residency in the late 1970s. This method was developed to help faculty continue with their day-to-day activities, encourage candidates to experience the professional environment, and provide a forum for evaluating candidate’s knowledge and interpersonal skills in a fair way. Because the length of time this interview method has been employed it is not possible for us to draw comparisons within our institution between the traditional and working approaches; national standards have been substituted when available. Candidate and resident data on the working approach has been retained for our residency over the past 12 years. Applications are screened through the Electronic Residency Application Service (ERAS). Interview invitations are sent via the ERAS post office. The invitation letter lists the available interview dates (33 in total) spanning October to January. The invitation letter introduces the applicant to our working interview model. Applicants respond via e-mail listing their top 3 interview dates in order of preference. When scheduled, the Program Coordinator sends individual applicants a confirmation letter containing interview details (date, arrival time, parking instructions, interview schedule, and where to report). Applicants are informed of their schedule, reminded they will be changing into scrubs upon arrival, told to bring medical school identification, and are advised to wear comfortable shoes. The interview schedule (Table 1) includes attending morning SurTABLE 1. Applicant Working-Interview Daily Schedule Time 6:30–6:45 AM 6:45–7:30 AM 7:30–7:45 AM 7:45 AM–12:00 PM 12:00–1:00 PM 1:00–4:00 PM

4:00

PM

gical Conference, ward rounds, joining a team in the OR, and a sit-down interview with either the Program Director or Associate Program Director. A formal presentation regarding the program details is also given to all applicants by a senior resident, and applicants have an informal lunch with junior residents. Pursuant to institutional and federal policy, the candidates are briefed on the Information Privacy and Security Policy and HIPAA regulations, and sign a confidentiality agreement. The candidate’s role as strictly an observer is clearly defined, and candidates are hosted at all times by faculty and/or residents, who accompany them to, from, and within the OR suites.

Activity Check in (change into scrubs) Attend Morning Conference Overview of Program with Chief Resident OR Time with host team Lunch with interns (1) Rejoin OR host team (either in OR/ward) (2) Twenty-minute sit-down interview with PD/APD Wrap-up with resident host

APD, Associate Progam Director; OR, operating room, PD, Program Director.

On the day of the interview, candidates arrive at 6.40 AM and are greeted by the Program Coordinator. They are instructed to change into scrubs and provided a packet of information, including the daily interview itinerary (Table 1). Candidates are also provided a voluntary postinterview questionnaire which they are asked to fill out and return anonymously in a drop box at the end of their interview day. As part of our full disclosure policy, candidates receive a packet that includes important program details: benefits, case mix, case numbers, didactic schedules, resident participation in meetings, resident publications, and board pass rates. These are also reviewed in the senior resident’s presentation and are on our web site. Faculty and Resident Perspective Faculty and chief residents receive an interview schedule a week ahead of time, including the name of their assigned applicant and their medical school. Faculty members are expected to review the candidate’s application (through ERAS) before the interview. Faculty and senior residents are given a standard scoring sheet of how to score the applicants within ERAS. Program Coordinator, Program Director, and Associate Program Director Perspective The Program Coordinator has access to all faculty schedules and calendars. This includes scheduled time away, operating room block schedules, clinic time, and administrative time. Using these materials, the Program Coordinator creates a weekly schedule of the candidates coming in the following week and distributes it via e-mail to the OR host team, the afternoon interviewing surgeon, and the support staff of the surgeons involved. Scheduling is adjusted according to physician availability. In addition, at least 1 member of the program’s leadership (Program Director or Associate Director) is scheduled to have a sit-down interview with each applicant. Literature Search Methods To allow a comparison between our candidate-centered interview process and the traditional method, a literature search was performed. A Medline search was conducted for years 1990 to current

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with relevant keywords: “surgery, residency, interview, candidate, application, attrition.” All resultant abstracts were reviewed by 1 of the authors and reports deemed related were obtained. To our knowledge, our approach to applicant selection has never been described. The review revealed a plethora of methods attempting to identify residents with the highest success or lowest potential. These methods proved to be widely subjective depending on the program resources and time invested.

RESULTS Our program’s match statistics for the last 3 years are presented in Table 2. We annually fill 5 categorical and 5 preliminary positions. All applications are processed through ERAS. Applications are screened based on program-specific criteria. As shown, our program maintains an approximate 15% increase annually in the number of applicants. In the 2011-2012 interview season, the number of invited candidates increased by nearly 30% by adding 8 interview days to our normal schedule. Qualitative feedback obtained in our annual program evaluations indicated both faculty and current residents are highly satisfied with the program and interview process. Specific aspects of the program that were repeatedly positive through the evaluations included the apprenticeship model, the teaching opportunity, and the collegial atmosphere both in and out of the OR. These features of our program are clearly articulated to applicants through our interview process. Our residency attrition rate for the past 12 years is 12% (6/50 residents); to our knowledge, the lowest published rate. Of those residents who withdrew from the program, 4 residents left to pursue anesthesiology, 1 for emergency medicine, and 1 went into research (nonclinical). None of the residents who decided to withdraw were on academic remediation, their American Board of Surgery in Training examination scores were within standard range, nor were they pressured to select another specialty before their withdrawal. Timing of withdrawal occurred between the postgraduate year (PGY)-1 and PGY-3 (2 PGY-1; 1 PGY-2; 2 PGY-2/3 Research; 1 PGY-3) which is typical of attrition in surgical residents.7,8 Noteworthy, 83% of the residents (5/6) that withdrew from the program stayed within the same institution, and pursued neither general surgery nor a surgery subspecialty training program. This is suggestive that the motives for discontinuation were not because of the compatibility with the program or institution but rather that surgery is not what they want to purse as a lifelong career. Attrition rate is multifactorial, and the

TABLE 3. Postinterview Anonymous Survey: Applicant Comments Strengths • Great day and a better interview style than most places • Strong and well run, —seems like a good educational experience • Unique experience, —more interviews should be like this • Best interview day yet • No changes please! —It was an excellent experience • Good resident–faculty interactions • Exciting/interesting interview day format • Having the chance to attend OR with residents and attendings was a fantastic experience. —Best staff–resident interactions I have seen • Interview day options were awesome and made scheduling extremely convenient. • Best interview day experience so far! Areas of Improvement • • • •

Dinner the night before More interviews Could include a tour More interactions with other residents besides the few on the hosting team • I would have liked to prepare for the case I scrubbed in on • Scheduled time to meet with Program director • Schedule on an index card, —to take with during interview day OR, operating room.

interview process cannot be solely identified as the singular origin of our low rate of resident withdrawal. Forty-four percent of the candidates choose to offer feedback by filling out the postinterview anonymous survey. This was overwhelmingly positive. Table 3 lists representative candidate feedback received. Feedback from faculty and residents was also sought, and they report satisfaction with our interviewing style specifically because it allows them to assess the applicant in more a naturalistic fashion with minimal interference with their operative schedule. Faculty comments regarding candidate focus on overall personality and fit, the ability to ask informed questions, and overall communication skills. They further assess the candidates’ compatibility and comfort in an OR setting; noting their level of confidence and attention during a case. Resident’s comments are centered on the candidate’s helpfulness, engagement, insight, sincerity, and overall compatibility with the program. Residents enjoy being a part of the interview process and ranking session.

TABLE 2. Program Application Statistics for 2009 –2012 Year

Type of Applicant

Total Applications

Invited Applicants

Interviewed

Withdrew

Ranked

2011–2012

Categorical Preliminary Categorical Preliminary Categorical

423 33 371 60 324

129 27 99 41 84

103 17 65 15 73

26 2 34 4 11

55 12 58 12 61

2010–2011 2009–2010 804

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DISCUSSION Faculty have found dissatisfaction with traditional residency interview approaches for decades.9 A possible consequence of the imperfect process of identifying the best candidates is the high attrition rate in general surgery residencies nationwide (14%-32%).8 Currently, the great majority of the power in residency selection has been placed in the hands of faculty members. The working interview approach described here is a multivenue opportunity based on full disclosure and focused on the candidate’s experience. Applicants become part of the social, clinical, and surgical settings over the span of 7-10 hours. Using our candidate-centered approach to the interview process, our program has been successful in matching residents who are highly compatible with our institution which may be further linked to achieving our low attrition rate. Matching compatible and satisfied residents is the primary objective of the candidate-centered, working interview. Using the traditional interview method, resident satisfaction is inherently a secondary goal of the process,10 and the factors residents consider important do not coincide with faculty and program goals.4 In our experience, the working interview approach encourages an exchange of information regarding an institution’s educational opportunities, working environment, and location, which elicits further noncognitive (soft skills) information from the candidates. The results of our survey indicate candidates are able to evaluate significant factors which influence their ranking selection decisions: house staff satisfaction, diversity in training, program size, research, gender distribution, conference/teaching program, and friendliness.3,4 Providing candidates with the opportunity for mutual evaluation assures assessment takes place in critical arenas. For the interviewer, the candidates’ involvement in the daily activity provides firsthand access to their thought processes and work ethic. The candidate is equally offered time to interview the program, observe faculty–resident interactions, and ask more discerning questions regarding specific topics. Nevertheless, matching poorly fit residents will always be a risk despite the breadth of information which they receive. However, our bias toward full disclosure disinclines incompatible candidates from ranking our program highly, thereby self-selecting out of the applicant pool. Evaluating compatibility is inherently subjective for candidates and faculty alike. This subjectivity is beneficial when used in a manner that can shed light on the characteristics that otherwise are difficult to ascertain.1,10,11 Taking into account the candidate’s needs during the interview (compatibility with institution/residents/faculty/program) has contributed to our success in resident retention compared with the national average. We assert that through recognizing the breadth of candidates’ needs and how the interview process can better serve them, the program and the applicant alike will become better informed. The quality of residents is not sacrificed but rather strengthened as well-matched candidates are more likely to be high performing resident surgeons. Advantageously, the work-

ing interview approach allows surgeons to continue with their daily routine while becoming better informed on candidate’s personalities and characteristics. Time in the OR, clinic, or wards provides a more comfortable environment for the attending surgeon to assess medical knowledge, soft skills, work ethic, team mentality, and patient care skills of the applicant: tasks that cannot be realistically assessed in formal, sit-down interviews. There has been much effort put forth to create ways of identifying the “ideal” candidates.1,6,11,12 Our experience suggests that faculty and programs should encourage full disclosure with candidates which aids in matching residents who are highly compatible and more satisfied. A philosophy of openness during the interview aids in determining those candidates who are the best fit for a particular institution. Each program has its own unique culture,12 and individual programs are encouraged to explore that culture and share it with candidates. There should be an understanding that a candidate, as an individual, has the most at stake during the interview process. By exposing the programmatic nuances to the candidates, both parties are well-served and ranking residents inherently becomes a wellinformed process.

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