LAUSR

To the Editor: During the interview season, fourth-year medical students eagerly await invitations to residency interviews. It is an anxietyladen process for both applicants and residency programs; however, an unnecessary amount of that anxiety is due to the process itself. In as early as September, residency programs begin to send interview invitations, doing so at varied and unpredictable times throughout the day, evening, and weekend. If an applicant fails to respond to an invitation quickly enough (sometimes within a few minutes), they may end up on a waitlist or find themselves left with options for interview dates they cannot attend. As a result, fourth-year medical students have strong incentives to check their emails constantly throughout the day. In our experience, this system detracts from learning, could jeopardize patient care, and is unkind to the applicants that residency programs are hoping to recruit. Medical students understand the importance of being able to check their emails during this time. As a result, students are incentivized to avoid labor-intensive clinical rotations for a significant percentage of their fourth year (including subinternships and many procedural rotations). When medical students do have clinical rotations during the fall of their fourth year, their attention is split between caring for their patients and frequently checking their email. Research has shown that multitasking can lead to errors [1], and task switching is cognitively expensive [2]. By penalizing students for focusing on patient care, the current system encourages work patterns that are worse for patient care. From a behavioral psychology perspective, applicants receive an intermittent reward at unpredictable intervals [3]; they face a steep penalty for failing to respond (i.e., missing an email alert) and minimal penalty for overresponding, apart from wasted time. It would be difficult to design a system that would more effectively cause hypervigilance. In short, this process trains residency applicants to be jumpy and anxious. Moreover, as these applicants are the very people that residency programs wish to recruit, it should concern us that this process may negatively affect the relationship between the interviewees and the interviewers. Formal data on the residency and applicant behaviors during the interview process would be valuable; however, even informal information suggests that random invite schedules are sufficiently prevalent to motivate frequent checking behaviors. Anecdotal evidence also suggests that at least some programs over-invite, meaning that they send invitations to more applicants than they have spots. In such cases, an early response is crucial. Perhaps more important, programs do not commonly disclose their process. For example, in informal discussions with program directors, we found that some programs do have a practice of sending out invitations at consistent times; however, they do not reveal these times. In the face of uncertainty, the default will be to check for invites frequently and respond quickly. Additionally, an informal survey of current psychiatry residents revealed the perception that most programs penalize delayed responses, either explicitly or implicitly. The AAMC’s comment on this trend (AAMC, email communication “Planning for Residency Interviews,” Sept 14, 2017) suggests that this is a prevalent practice. We found support for this when we adopted an electronic scheduling system, which logs when an applicant responds to an invitation. With this system, we found that some applicants manage to respond within the first minute of our invite, even though we did not announce when we would send it. Approximately 20% of applicants responded within 10 min of our invitation, and 95% responded by the end of the business day. This response pattern is only possible if applicants are frequently checking and some nearly constantly. One alternative would be for residency programs to send interview invitations during a set window (e.g., between 12 pm and 1 pm Eastern Time). This practice limits the email checking to 1 hour a day but allows programs the flexibility to * Natalie Feldman [email protected]