Dis CORD? Pandemic Advising–Round 2

On January 25, 2021, the Coalition for Physician Accountability, an organization whose members include the American Medical Association, the Association of American Medical Colleges, the Liaison Committee on Medical Education, the American Osteopathic Association, and the Accreditation Council for Graduate Medical Education—and a host of other national oversight organizations—released updated recommendations on away rotations that will mainly affect the 2021-22 academic year.

The updates provided were to COPA’s May 2020 statement addressing the 2021 application cycle, released as it became clear the COVID-19 pandemic would detonate the entire process.  That communication recommended that away rotations be discouraged for any student except those without access to a home rotation in their desired specialty, or for whom an away rotation was required for graduation or accreditation.  COPA simultaneously recommended that all residency interviews be administered virtually, and that the ERAS application cycle be delayed to compensate for the educational and administrative delays caused by the public health crisis.  

It’s worth mentioning that, while most agree the May COPA guidance was generally followed, no one now knows where it led.  There has been much discussion on  whether removing the barrier of travel led to interview hoarding (at least this take on preliminary data says it didn’t), and plenty of programs despaired of differentiating themselves without the benefit of tours, socials, unmediated swag sweeteners.  Candidates and programs alike lamented the lost second SLOE to counter or reinforce the home take. But the pudding our proof will be in is the Match—until we can dig into that data, we are nibbling at potential proxies. 

It’s also worth a brief review of the divers drivers that—long before COVID came along—made the topic of away rotations so vexing. Program directors love having away rotators—it’s basically a month-long interview-cum-tryout where red flags will be hard to hide, and the entire application process serves as advertising to a willing—slavering—audience.  Students generally love a chance to see the true colors of a residency, and to fly their own. 

A third category of players with chips in on the away rotation game is advisors. The problem with advisors is that we do not all hold the same stakes.  Some are program directors, some are clerkship directors—for whom the labor-to-benefit ratio for visiting students may skew higher than for PD’s—and some have positions in their school’s leadership and administration, where any unmatched—or even unhappy—student will be perceived and dealt with as a professional failure on the advisor’s part.  

And then there is the sea we swim in: the wildly differing—and practically unmeasurable—“competitiveness” of both candidates and programs, and the stark—and practically irremediable—resource imbalances on both sides. And the saving graces: an honest hunger for rigorous training on the part of the candidates, and a genuine desire for equity on the part of program directors.  But it is only that last—plus the limitations of the space-time continuum as we currently experience it—that have incentivized minimizing the number of away rotations per student, or creating a system in which more away rotations is not generally (perceived as) better for all stakeholders.

The novel coronavirus exploded the traditional residency application process and—depending on how things go in March—the path laid out by COPA’s original recommendations may demonstrate that it’s at least possible to do things differently than they have traditionally been done. 

And so: the January 2021 COPA statement.  It reaffirms the value of away rotations to both students and programs, and acknowledges that the current shambled state of our nation—vaccinations developed but potentially limited, new viral strains with unclear impacts, differing state and institution-specific travel regulations, a new federal administration—may not be sorted before the end of the summer.  But the statement doesn’t address the issues pre-dating the pandemic, other than to recognize that if away rotations begin later in the year, it will create a worse-than-usual shortage, and to suggest what has long been suggested but never quite implemented in our specialty: limiting each student to a single away rotation. 

This statement recommended that no away rotations be offered before the first of August, but didn’t weigh in on an ERAS deadline timeline and—if read closely—acknowledges that the proposed August start may be wishful thinking.  The group promises another update on April 15, which would be post-Match and—tellingly—would fall before their recommended May 1 start-date for processing away rotation applications. 

COPA did not clarify exactly what is meant by either “rotation” or “away,” leaving certain questions open—Does a two-week rotation count the same as a four-weeker? And if so, could a school with three affiliates potentially game the system by creating a six-week rotation with a separate SLOE from each clinical site? 

Given all the foregoing, there are those who feel it would be a missed opportunity if we simply return to how things were, without identifying and amplifying the benefits forced on us by the radically different 2021 application cycle—of which, arguably, simplicity was foremost. 

Meanwhile, the EM-bound students who will participate in the 2022 Match are beginning to come forward, to seek out advice on their academic schedules, rotation strategies, how to stand out from the crowd.  That they will be anxious is very nearly the only certainty available. It will likely be helpful to students if their advisors are familiar with their school’s policies on travel, with the original COPA statement and updates, and with the dates on which more information is likely to surface.  Crystal clarity on our known unknowns may be, for a while, the only peace we have to offer.

Shannon Moffett, MD @BrickCityEM and Ronnie Ren, MD @RonnieKuoRen in conjunction with CORD ASC-EM (advising students committee in emergency medicine)

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