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Clinical Scenario
You’re chairing the faculty committee for your otolaryngology-head and neck surgery department. The committee is tasked with planning the forthcoming 2020-2021 otolaryngology match process at your institution. Owing to the pandemic crisis, new challenges are anticipated for this year’s match, and your committee is determined to plan a process that’s not only successful, but also ethical for all participants. You believe that, while significant obstacles need to be overcome, opportunities also exist to review the elements of your program’s approach that could emphasize and enhance integrity and professionalism, as well as demonstrate a commitment to ethical conduct.
Concurrently, the medical students at your institution who are planning to enter the otolaryngology match are anxious for faculty guidance and information that will be helpful to their preparation. As usual, these students have excellent grades, top standardized test scores, and have been actively engaged clinically and in research with department faculty. Still, the pandemic has affected medical education over the past quarter of a year, and they’re unsure how the match process will proceed. They feel “ungrounded” with respect to the potential changes in the application and interview process, and seek reassurance from your committee, the resident cadre, and their faculty advisors.
You and your committee are trying to assimilate all of the available information on formal and informal processes for the forthcoming match. Above all, you want to ensure, as much as possible, that the process will be fair and equitable, for the applicants and the program, and will reflect the ethical conduct and professionalism that’s expected of the profession. Fundamental to these goals is the identification of just what the ethical conduct of this residency match process should embody.
How can you navigate ethical challenges and student expectations in creating a match experience that’s fair for everyone?
Discussion
Over the past 70 years or so, the National Resident Matching Program process has undergone a significant series of changes and improvements, perhaps most notably with the advent of computer-based matching algorithms. When this author applied to various residency programs for selection, otolaryngology did not have a well-developed matching process, and a handshake was used to “seal the deal,” often on the initial interview visit. Later, as the otolaryngology match process began to take shape, it started as an “opt in/opt out” format, with some programs participating and others not. Violations weren’t uncommon in the transition to full participation, but in the end, appropriate regulations and rules prevailed and were followed. The modern otolaryngology match has been a helpful process for both applicants and programs.
However, it’s no wonder that, for the forthcoming 2020-2021 match cycle, there is considerable anxiety about how the process will play out. There’s no doubt that programs are sincerely working to identify the most effective, efficient, safe, and supportive process for applicants under the pandemic restrictions. Yet, the nature of this uncertainty raises the issue of how to ensure that the process will be both ethical and professional in its conduct. How programs manage the match could provide a model for integrity that shouldn’t be lost on applicants, who are the future practitioners of otolaryngology. If the process is equitable, ethical, and professional, it will be a win for all of us.
Otolaryngologists strive to utilize the ethical decision-making process in the clinical care of their patients. The same ethical principles of autonomy, beneficence, nonmaleficence, and social justice can clearly be applied to the conduct of the residency match and of the participants. The proper mechanics of the application, interview, and selection processes are quite important for the integrity of the match, but so also are the ethical and professionalism implications inherent to this important lifeline of the specialty. Our care of patients involves shared decision-making, an amalgamation of the ethical principles—the resident selection process also involves shared decision-making and should be undertaken with an expectation for integrity and veracity.
How do the four ethical principles fit into the equation for developing a match process whose usual form has been compromised by the COVID-19 pandemic?
Autonomy. First, regarding the issue of autonomy: Can both the applicant and the training program make an informed decision that’s based on an adequate exchange of information and knowledge of what would be the best fits for both? Both the applicant and the training program, under the computer matching system, have their own, distinct autonomy of decision. The ultimate shared decision occurring at the match date may not be salutary unless each has the opportunity to learn as much as possible about the other with respect to the ultimate goal of a “best fit” match. Just like clinical informed consent discussions, the training program must be forthcoming in its communication regarding the personality of the program and the formal and informal characteristics of its graduate medical education. Similarly, applicants must be able to provide sufficient information about themselves to properly project their capabilities, personalities, accomplishments, and potential for making informed decisions on behalf of the training program. The process required for this match cycle needs to be carefully planned and managed to achieve that goal—it must be transparent and maintain integrity throughout the entire process.
This forthcoming resident match process must be designed and conducted in a manner that emphasizes ethics and professionalism, not only to secure the integrity of the process, but also as a reflection of the responsibility to model the best traits and virtues for those who will become the future of our specialty.
Fairness. Second, will the pandemic-altered match process be one that’s beneficial for all of the stakeholders, including the applicant, the training program, the current and future resident cadre, the faculty, and the institution? Every training program in otolaryngology over the years has likely experienced a situation where the fit between a matched applicant and the training program hasn’t worked out beneficially. This can occur even without the limitations of a pandemic, but the forthcoming match cycle may present challenges that increase the risk of unsatisfactory matches. A poor fit between an applicant and a training program can have a long-term impact on both, with multiple ramifications for all of the stakeholders. Therefore, mitigation of risks is both an ethical and a professional obligation, one that is primarily placed on the training programs, because they hold the balance of power and are in charge of the mechanics of the match.
Mitigation. The third ethical principle is that of nonmaleficence. As in clinical situations, we have an obligation to not allow harm to any of the stakeholders, especially the applicants, through a faulty process. How could harm be done? Foremost, applicants might not have the opportunity to fully describe and present their personal attributes and professional capabilities during a limiting virtual interview process. One of the most important aspects of the previous in-person interviews has been the ability for a “connection” to occur among applicants, residents, and faculty. Informal discussions can often be revealing, not only in determining interpersonal compatibility, but also in finding common interests upon which relationships can be built. In the absence of the informal discussions of the past, it will be harder to get to know each other in a manner that could provide the applicant and program with the sense that this could be a good fit for each. This potential harm must be considered in the course of development of the format for virtual interviews, as well as any potential “signaling” process and post-interview communications. Additionally, if the program decides to utilize asynchronous questions for video response, the opportunity to determine the applicant’s ability to spontaneously consider and respond to a question during a discussion is lost. In contradistinction to facilitating sufficient information exchange during salient discussions, limiting the ability of applicants to tell the story of who they are could be detrimental to making the best decisions. Body language observations and inferences may not be possible. Technical difficulties with virtual interviews are always potential concerns and can place applicants at a disadvantage. This compromises nonmaleficence.
Of no less importance is the principle of social justice, wherein equity must be achieved throughout the entire match process. Programs must internally consider whether any applicants might be disadvantaged with the processes during the pandemic-altered match—on any basis. While virtual interviews may level the field financially across the applicant pool, other equity concerns might exist, including access to high-speed internet, clarity of computer cameras, risks that the applicant’s living quarters might not be as well appointed as others, that children or roommates in the home might interfere with the focus of the interview, and the availability of in-person visits to some applicants (external to the program’s institution) but not to others. Ex parte schemes that offer access to programs for a fee must be scrutinized for equity and ethical compromise. Every applicant must have similar access to programs without any type of discrimination acting as an impediment.
Advice to this author from an otolaryngology chief resident and a medical student who will participate in the match has also revealed cogent concerns from their perspectives. Unfortunately, there may be an increased emphasis this year on applicants’ objective data, causing a lost opportunity for them to get a feel for the program, its personality, and the faculty and residents with whom the matched applicant might be working in the near future. Social media information and blog sites may or may not be helpful for the applicant, but they will undoubtedly play a role in this match cycle, so validity must be verified. Selecting an applicant for the top rankings by the department, and likewise the applicants’ final rank list, are normally a combination of synthesized information gleaned from research and interviews amalgamated with a gut feeling of compatibility or reservations about a fit. Not always a primary consideration for the programs, but often quite important to the applicants and resident cadre, is whether there’s a sense that they will be able to work together as a functional and positive team to provide patient care and share responsibilities. Not having a formal opportunity for an applicant to get to know the resident cadre in a given program, and vice versa, can raise anxiety and may lead to inaccurate perceptions that could adversely affect the decision-making process.
This forthcoming resident match process must be designed and conducted in a manner that emphasizes ethics and professionalism, not only to secure the integrity of the process, but also as a reflection of the responsibility to model the best traits and virtues for those who will become the future of our specialty. You and your fellow faculty will need to provide as much assistance and information to your medical students as is allowed, and help them navigate the uncertainties and anxieties that have arisen. This is part of the faculty’s responsibility for teaching professionalism. Additionally, it’s possible that salutary improvements in future match cycles could result from thoughtful considerations and outcomes of this year’s unique match situation, especially in the context of ensuring ethical conduct and professionalism. Otolaryngology–head and neck surgery is a specialty highly regarded by the profession of medicine, and this is another opportunity to earn that respect.
With appreciation to Ben Hunter, MD, chief resident, and Max Feng, senior medical student, at the University of Texas Health Science Center at San Antonio for their helpful perspectives.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.