Every year our pathology department decides who we will invite for an interview for a spot in our residency program. Deciding who to interview is difficult because there are so many applicants and we have limited information about the applicants. It is especially challenging when we evaluate international medical graduates (IMGs), because we often don't know what their accomplishments mean. This initial screening decision will have a big impact on the individual applicant and our program. The decision on how to rank applicants is also an impactful one, but it is one we only reach after screening for an interview.
We feel honored but also frustrated participating in this initial screening process. The goal seems straightforward: choose the applicants who will most likely successfully complete and thrive in our program and make our department better. Many factors go into this decision, some articulated and acknowledged, others less so. One big problem is that there are too many applicants to thoroughly evaluate every person. The average number of applications per program in 2021 was 492. We had 526 applications for 3 positions. This is a recognized problem. Commentators have proposed a number of remedies, including a cap on the number of applications per applicant, or on the number of interviews an applicant can accept.1
A second part of the problem is that we have to make our decisions about whom to invite for an interview based on relatively limited information about the applicants and their institutions, just like the applicants have to make their decisions based on relatively limited information about our departments and our programs. This problem has been accentuated during COVID-19, when interviews and tours are virtual. A virtual tour does not allow the applicants to visit the programs and communities at which they will spend their residency years, and it doesn't give programs the opportunity to see and talk to applicants in person. Importantly, however, a virtual interview is cheaper for applicants and makes it easier for them to visit and interview at even more programs.
Within these limitations, how can we identify and attract the people we want to interview? How can we improve our applicant screening in our post–COVID-19 world and in our political and cultural place of heightened awareness about issues of diversity, equity, and inclusion? And how can our screening process account for and address structural racism?
One way is to celebrate and improve how we evaluate IMGs. For many years we have worried about a shortage of pathologists and have lamented the low numbers of US medical graduates (UMGs) choosing pathology for their careers.2 Changes in medical school education have decreased exposure of medical students to pathology, and it is possible that a pass/fail US Medical Licensing Examination (USMLE) Step 1 will further de-emphasize pathology and lead to even fewer UMGs choosing pathology.3 This is not a new issue for pathology; for years pathology has depended on IMGs to fill residency slots and to provide pathology services in our country. In recent years the percentage of IMGs has been generally in the low 40% range. In 2021, non-US IMGs represented about 40% of total filled residency positions, which is a higher percentage than other medical specialties.4 IMG residents and practicing pathologists who graduated from medical schools outside the United States have increased pathology's diversity; they have brought new perspectives and provided new skills. IMGs have promoted equity without pathology having to rely on the pipeline provided by US medical schools. Nonetheless, evaluating IMGs during the initial screening remains difficult even if we know the value of bringing IMG applicants to pathology. The struggle when evaluating IMGs in the interview screening process is the lack of standardization and often not understanding the context of the applicant's experience and education.
The objective for residency programs is the same for UMGs and IMGs: identify and attract residents who will thrive and complete the residency and benefit the program and our profession. But it is often more difficult to screen IMGs because there are more unknown variables than when screening UMGs. It is often difficult to gauge the quality of the IMG applicant's medical school, to know what the applicant's grades mean, to understand the more subtle aspects of letters of recommendation, to evaluate the applicant's resilience and privilege, and other aspects of their application. Many IMGs have time gaps since medical school graduation, often because they are pursuing research activities or additional education either in the United States or elsewhere to bolster their applications. However, we often have difficulty evaluating these positions and accomplishments since graduation. It can be too easy to simply dismiss things we don't know about because we are risk averse, perhaps biased, and don't want to hire a resident who ends up struggling.
Ironically, IMGs' life stories are often more detailed and provide more information than those of many UMGs and thereby should allow for a more holistic evaluation. The holistic approach, endorsed by the Association of American Medical Colleges (AAMC) and others, warns against overreliance on USMLE scores and ranking of both student and medical school. Holistic review focuses on the “whole” person; an Ivy league education is nice, but there is more to a person. AAMC explains that holistic review “is a flexible and individualized way of assessing an applicant's capabilities, by which individualized balanced consideration is given to experiences, attributes, competencies, and academic or scholarly metrics (EACM) and when considered in combination, how the individual might contribute value to the institution's mission.”5
A holistic review for screening residents for interview invitations is a worthwhile first step and makes sense, but at least 2 problems persist, especially when evaluating IMGs. First, often experiences and accomplishments can be difficult to judge when they are in an unfamiliar context. One proposed solution is to increase standardization. A 2021 scoping review1 in the Journal of Graduate Medical Education discussed many of the obstacles to holistic evaluations for UMGs, including the lack of standardization across institutions for clerkship grading, for Medical Student Performance Evaluations, and letters of recommendation. The article also noted that IMGs, couples, and osteopathic graduates “face additional barriers.” Standardization may help, but would be difficult to coordinate for IMGs given the large numbers of institutions and countries, and would not help us evaluate many of the work and volunteer activities of our IMGs. Interestingly, our post–COVID-19 world will likely continue to rely on more virtual observerships, which has the potential for allowing IMGs and UMGs to participate together in observerships and perhaps allow for some efforts at standardization. In combined virtual observerships, IMGs and UMGs might be directly compared, and residency directors can become familiar with the quality of particular US virtual observerships and evaluations. A second problem not wholly addressed by holistic review is identified by Truglio et al,6 when they write that holistic review “does not explicitly address the institutional racism at the heart of racial inequities in health care.” The authors go on to describe their antiracist review process in which power and privilege are explicitly discussed when making “program design and recruitment decisions.” They see their approach as building on the holistic review to better address issues of systemic racism. For example, they blinded their selection committees to Alpha Omega Alpha status and did not use USMLE scores for their initial reviews because both favor the privileged and highly resourced applicants.6 It becomes difficult, however, to know which criteria should replace our previous “objective criteria” like USMLE scores. Beginning some time after January 2022, every program will see only a pass/fail score for Step 1 USMLE scores, which—when combined with many medical schools using pass/fail for their preclinical coursework—significantly reduces the amount of information available for each applicant. Inevitably, other data points will take up the slack, but exactly how this will play out remains uncertain, and there is concern that the increase in uncertainty for students and programs will lead to an even greater increase in the numbers of applications per applicant.3,7,8
What alternatives do we have to our current screening process? Many medical schools and businesses have changed how they interview candidates by standardizing their interviews and emphasizing skills and assessments, but this is not possible at the screening stage. Some commentators suggest capping the number of applications each applicant can submit or the number of interviews each applicant can accept.1 The Dutch have used and will again implement a lottery system for entry into medical school, a process that acknowledges the randomness of selecting among qualified applicants. With only limited criteria and criteria that don't necessarily correlate well with competencies that really matter, a lottery could make sense.9 This doesn't mean that our resident selection process should become a lottery, but it does focus on how some criteria may be spurious and how important it is for us to develop the right criteria for choosing our pathology residents.
In summary, IMGs offer many benefits to pathology residency programs and our profession, including increasing our specialty's ethnic, cultural, and economic diversity. Many but certainly not all IMGs lack the wealth and privileges enjoyed by many UMGs, but it can be difficult to ferret out these factors, and issues surrounding the quality of their education and experiences, in the information supplied by the Electronic Residency Application Service (ERAS). The United States will continue to rely on IMGs to provide pathology services, and we are grateful to the IMGs who come to our residency programs. How we screen our IMG resident applicants is important and could be improved. It is time for a conversation on how we can do this and what changes we can make to continue to attract the best residents, both UMGs and IMGs.
The authors have no relevant financial interest in the products or companies described in this article.