Betting on Safety First

Asynchronous lectures. Zoom meetings. Digitally proctored exams. Or instead, in-person classes, testing, contact tracing and isolation protocols. These are choices that college and university leaders are facing across the country for the forthcoming academic year. Should we open in the fall?

For senior medical students like myself, the unprecedented challenges presented by the pandemic have led to much ambiguity, confusion and even despair. Before COVID-19, we found the last year of medical school to be the most enjoyable -- it offered some stress but mostly more freedom than the first three years, perhaps rotations abroad, and a nice vacation before officially starting residency. But now few things are sure when it comes to what our academic year will look like. Most of us must still decide on a specialty, meet competencies through medical licensing exams and important rotations, and apply to residency. Yet even those mundane aspects are now permeated with as much uncertainty as everything else.

I took a year between the traditional third and fourth years of medical school to conduct research after completing key senior rotations. Fortunately, I also got all my required licensing exams out of the way. That was not the case for many of my peers. Medical students across the country were held in limbo during the spring, as testing centers canceled and rescheduled their test dates at the last minute.

Meanwhile, clinical rotations were on hold for at least two months at most medical schools, causing a significant delay in meeting graduation requirements. And while most students have now returned to the wards, those who are interested in competitive specialties, such as orthopedic surgery and emergency medicine, are in a bind. In normal times, beyond a core rotation at their home institutions, they would complete additional ones at other institutions as auditions or a chance to receive a letter of recommendation from outside faculty. It is a tremendous opportunity to shine and impress programs. With the pandemic, visiting rotations are limited to students who do not have such access at their home institutions.

The current patchy state of the pandemic makes it unclear whether and how a potential resurgence of cases will affect our rotations. For those going into surgical specialties, it’s unclear whether the volume of operations will be back to a reasonable level to help make that decision: Can you really see yourself practicing medicine without ever stepping foot back into the operating room after graduation? The dreaded second wave might upend it all, and we have yet to truly solve the PPE shortage nationally.

See, being a senior medical student now is almost like being in purgatory. We are students but also almost doctors, so how much risk should we assume in the middle of a pandemic? What about when we leave the hospital? Are we going to be worried that we may take the virus home? I share an apartment with friends. How anxious will they be about living with someone working in the hospital? Sadly, some landlords have reportedly asked nurses to find other accommodations because of the new risk. Would it be better to live with other medical students or alone?

Career Challenges

The biggest change when it comes to our careers is that residency interviews will most likely be virtual. In the past, my friends have described a gut feeling that helped them rank programs based on their experience at a pre-interview dinner or by observing how residents interacted with each other. Are they welcoming? Do they seem to enjoy being around each other outside work? Does someone have one too many drinks and say something racist? Then how do the rest respond? But it’s unclear how palpable these soft aspects would be over videoconferencing.

Certainly, I appreciate saving what I would otherwise spend on flights and hotels to interview across the country. For example, the average cost of interviews among orthopedic surgery applicants is nearly $4,000. For urology applicants, the average is $7,000, and two-thirds among them do not receive any financial aid. Plus, the public health implications of 30,000 medical students flying across the country and touring hospitals during flu season in pre-vaccine COVID-19 times are serious. It may be for the best that we will interview from home.

Yet that said, will introducing videoconferencing lend more bias to the process? For instance, a 2018 study showed that video interviews may favor job candidates with better internet connections and that being aware of this bias does not make it go away. For those like myself who are darker skinned, we know about cameras distorting Black skin. What does that mean if we’re trying to be memorable?

And will the money we get to save truly make the process more equitable? Or now that traveling is no longer a limitation, will a few applicants with high board scores hoard the majority of interviews? In regular times, for instance, about 12 percent of internal medicine applicants consume 50 percent of interviews. Surely phone or video interviews are not that uncommon in other fields.

The anxiety for us, however, is about committing three to seven years of 80-hour weeks to a program without having crucial in-person interactions with future colleagues, knowing that switching is near impossible. Bumping into the same person at a few interviews can lead to organic friendships, trading notes and even plotting to become co-residents. Will the Zoom connections and Reddit gossip from previous years suffice?

There are more questions. The end of med school as we knew it is no longer. The days of traveling for interviews, rotations abroad and nice vacations after match day are gone. The uncertainty we are dealt with as future doctors is similar to what university administrators are facing: making important decisions with little or ambiguous data because of an unprecedented moment.

So far, the recommendations made by medical education leaders regarding this residency application have prioritized public safety and did not hedge on the safest possible scenarios. That, too, should be the first guiding principle as colleges and universities decide, “Should we reopen?” Among colleges that are planning to bring a proportion of or all of their students back on campus, a great many assumptions are being made to determine how to prevent an outbreak. A recent study suggests that testing students every two days is what it will take to prevent an outbreak. But that assumes that college students will adhere to behavioral guidelines -- not a given. And what about how many resources this will drain from the communities in which these colleges are located?

This level of uncertainly alone might explain why some colleges, such as Princeton University, Howard University and Johns Hopkins University, chose the absolute safest option, just like those leading the medical residency selection process. Betting on community health over young adults adhering to behavioral guidelines will come at some cost to the college experience, just as my colleagues and I will lose out on the gems of our interview season and final year in medical school. But it is the safest thing to do.