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This COVID-19 Practice: Changes in Testing, Travel Restrictions, and COVID-19 Create New Challenges for Recruiting Neurology Residents

On May 26, the United States Medical Licensing Examination (USME) program announced that it was suspending its Step 2 Clinical Skills testing for at least 12 to 18 months. The suspension came just three months after the USMLE announced that it would change its Step 1 test from graded to pass/fail, no earlier than January 2022.

The cancellation, combined with travel restrictions caused by COVID-19 concerns, left residency directors nationwide suddenly scrambling to readjust their interview protocols and determine new ways to promote their program to medical school candidates.

Some said they hoped that the Step 2 Clinical Skills step would be canceled altogether, saying that its high pass rates (typically 94 percent for medical schools)  make the test mostly meaningless, except to confirm English skills. They said the cost of flying to one of the testing sites was both time- and financially prohibitive, particularly for foreign students and those from lower-income backgrounds.

Too Many Changes at Once

Karen L. Roos, MD, FAAN, the neurology residency program director at the Indiana University School of Medicine in Indianapolis, said that it's been a struggle to address so many changes at once. The school typically accepts eight neurology residents a year.

"Grades at many medical schools have become pass/fail, then step 1 became pass/fail, and we don't have step 2—you don't have anything to compare students,"  Dr. Roos said. "Now we're doing virtual interviewing and that's a completely new experience."

She said that they had some practice with virtual interviewing when the school interviewed for a new chair, first in person in February before COVID-19 shut things down, and then virtually in May. 

Most people did better in person, and she wonders what this will mean for neurology candidates.

"It's become more of a writing test, because we're really looking at their personal statements and we want them to be genuine, and a lot of them put what they think we want to hear," she said.

Where residents would usually meet with new candidates and share their input, this year the school is going to have a virtual dinner with food being delivered to all of the residents at the same time (hopefully!). During interview day, they will have breakout rooms where residents and applicants can have a chance to talk, Dr. Roos said.

Foreign students have it particularly hard, she said, because they used to be able to emphasize their Step 1 and Step 2 scores.

"Now I have nothing. I can't meet them, I can't interview them in person, and we have no data on them," she said.  "It's going to be a very hard road ahead, and honestly, it's unfair to foreign medical students—they'd like to come over and do rotations, and that's not possible. It's so overwhelming for everyone, because we're doing everything differently all at once."

Rafael H. Llinas, MD, FAAN, professor and chair of the department of neurology at Johns Hopkins Bayview Medical Center and director of the neurology residency program, said he was much less concerned by the cancellation of Step 2 Clinical Skills than the change in Step 1.  He said because of the high pass rates, if someone failed Step 2 but had done well in Step 1, it was often chalked up to a bad day.

The biggest concern, he said, was the elimination of outside rotating medical students, who usually apply to spend a month or five weeks at the hospital to see if it's a good fit before applying for a residency. The program plans to interview more students than usual, and they are putting together a video of interviews with faculty and students, trying not to make it seem like an infomercial, he said.

"For us it's particularly useful for people to visit in person because, like it or not, Baltimore has a certain reputation, whether you've see it on a show like The Wire or on the news," said Dr. Llinas. "If you can't visit, you don't realize what the city is actually like, and Baltimore is really nice."

"So students may just choose based on what they think the location is like, and places like Minnesota and San Francisco and Philadelphia, where they are having problems, may suffer, and that's not really a good way to decide whether you like a city."

The suspension of Step 2 Clinical Skills might be a good move toward canceling the exam altogether, said Christiana A. Wilson, MD, PhD, FAAN, residency program director, associate chair of education and the interim chief of the vascular neurology division at the University of Florida College of Medicine in Gainesville.

"It does raise questions about the big picture for residents: Is it necessary to take both portions of Step 2 to sit for Step 3 and take the boards?" said Dr. Wilson. "It's one of those things that's intensive for students in terms of time and finances but it's low yield for us in terms of giving us information about how well they would do as a doctor."

Like all the other schools,  Dr. Wilson said they planned to do virtual interviews, and more of them. But she thought it might bring some unexpected positives—mainly that it might open the door to students who wouldn't otherwise be able to afford to travel for multiple interviews.

"Now that we've removed that financial barrier, I think we're going to see students applying for a lot more programs," she said.  On the other hand, there might be a lot more students casually applying and not seeing themselves as serious applicants, and students won't really get a feel for the program in the same way as if they came to campus.

She worried that because it is getting harder to screen people based on their grades and USMLE scores that students from the better-known medical schools will receive even more of an advantage, simply because it's inferred that they will be strong clinicians.

It's not just next year's foreign medical students who may be impacted. Rebecca Fasano, MD, program director of the neurology residency training program at Emory University School of Medicine, said she's concerned that one of her incoming 2020 residents may not make it because of visa issues.

She worries that next year's foreign medical school applicants will be affected by the change in Step 1 and the suspension of Step 2.

"I look at Step 2 as evidence that international medical graduates have adequate communication skills and without that, the only judgment I'll have is interviewing them, and that will be virtually," she said.

Dr. Fasano, like all the other directors, was worried not only about the students the program would be attracting, but about making themselves attractive to students.

"I feel like Grady Hospital is amazing and you have to see it to understand," said Dr. Fasano. "Our program's strengths are intangible; the atmosphere here is all about kindness and the residents have great personalities–they are all interesting, fun, wonderful people, and I am concerned about how we are going to show that. We can make some videos, but it's not the same.

"I worry about this next class. How am I going to recruit? How will I know if the applicants seem like a good fit for us? It's hard to know over Zoom."