I have often found myself wondering about the point of submitting letters of recommendation during the trainee selection process. Maybe we should just do away with letters of recommendation in general. I mean, who asks someone to write a letter unless they know they will get a good letter?

Then there are grades. Everyone is in the same ballpark for the most part.

The personal statement can be fun when not bland. You can get an insight into what candidates value about themselves and what their journey has been. But it is still very tedious to read 80 of them to select 40 candidates to interview for one or two positions. Most are just more of the same.

Then, after this grueling first round, we finally choose a select handful to come perform. Everyone puts on a good show — from the candidates to program faculty to the trainees themselves. Anyone can look good on paper and then act reasonably normal and happy for a few hours. However, the problem is that people who are not a good “fit” still slip through the process and after those few hours, the mistake becomes apparent.

I can’t imagine that a foolproof system such as ours wouldn’t prevent that! I’ve often half-joked that the interview process would likely select better candidates if the interviews were performed by the spouses and significant others of the faculty and house staff. This is probably not that far from an accurate statement.

Many programs have turned their interview process upside down to address the issue. There are several interesting approaches:

• Candidates at Virginia Mason Medical Center in Seattle spend a day with one of the services in a type of working interview. This allows more transparency and potentially a more contextualized evaluation through taking a trial-by-fire approach.
• Many medical schools are shifting to the scenario-based Rapid Multiple Mini Interviews developed by McMaster University. These are designed to decrease the impact of any single interviewer and allow for increased and more reliable assessments of the candidates.
• Some programs may use personality inventory testing to better identify candidates that would be a good fit. This approach has been criticized, but it is something that people are doing to find the best match.

I recently participated in a faculty development program targeted to teach the writing (and deciphering) of letters of recommendation. While I thought I knew how to read them, I apparently knew nothing. The nuances and subtleties of word choice as it related to the level of recommendation and the fitness of the candidate for training was eye-opening for me. While I would love to discuss my revelations in detail here, I cannot divulge all the secrets!

It still remains that we need a better way to identify candidates. More importantly, candidates need a better way to identify programs. Attrition rates from general surgery training programs are around 18% according to a study published in JAMA Surgery. Of those who leave, the study found that 20% go to another general surgery program and 13% switch to anesthesia. (Although, plastic surgery, radiology, and family medicine were other common specialties that attracted general surgery residents.) While some general surgery residents are leaving to take positions in subspecialty surgery (integrated plastic or vascular surgery for example), this is clearly the minority. A fifth of the emigrants simply take the same job somewhere else!

There is clearly a clinician shortage coming, including specialists, according to the Association of American Medical Colleges. Attrition is not simply a morale problem, but it is a key component of potentially addressing the looming clinician shortage. Ensuring better program to resident pairing and harmony can not only help ensure adequate numbers of graduates, but the quality and satisfaction of these graduates can be optimized. Maybe this can help with burnout too.

All in all, we need to rethink our approach and better identify the disconnect so that we may resolve the problem. Maybe it involves rapid remote interviews via video chat applications prior to an in-person probationary evaluation. Maybe we should do trust falls and other team-building activities. (We should be doing these kinds of activities after we hire them regardless). Maybe we get someone else to do it. Why not? We already have FCVS and ERAS collating the documents, so maybe they can select our trainees too.

If you think our trainee selection process is outdated, how would you change it?

Dr. Issam Koleilat is a vascular surgeon at Montefiore Medical Center/Albert Einstein College of Medicine in Bronx, NY. He is also the proud father of a wonderfully curious five-year-old daughter and bright-eyed five-month-old son, and the husband of a breast cancer genetic epidemiologist. He enjoys traveling with his family, and as the kids get older he hopes they will hike, ride horses, and go rock climbing more.

Dr. Koleilat is a 2018–2019 Doximity Author.