Comparison of current recruitment process for specialty or residency training in UK and USA

KEYWORDS:

• Comparison
• recruitment
• interview
• UK and USA

In the USA, medical residency and fellowship applications follow a national recruitment process which starts off with applications from candidates through an online portal (ERAS) to various programs. A common application form is generated to all applications made by an individual regardless of the specialty. It is human nature to have choices and apply to more than one specialty as a backup. In contrast to the common application, personal statements and letters of recommendation can be attached to individual applications depending upon the specialty and program requirements/preferences. Often, these are carefully looked at during the shortlisting and selection of candidates. Personal statements and letter of recommendations help program directors make important decisions for predicting candidates’ true interests and actual priorities toward one specialty and their program. Interviews are carefully conducted before final selection of candidates in the matching process of National Residency Matching Program (NRMP) [1]. These interviews are structured to judge individual interests, strengths, weaknesses, and future aims. Interviews are mostly similar in assessing candidates, but could vary slightly depending upon the type of program (University based, University affiliated community based or Community based) and other program characteristics. Clinical based questions are becoming outdated in interviews based on the fact that knowledge has already been assessed through multiple exams before the stage of interview. Many times a pre-interview dinner is offered as an opportunity for existing residents to mingle with job applicants and foresee if they have a similar temperament to work together in their residency or fellowship program. This process of job applications and interview attendance can often cost a fortune to applicants, yet leaving many candidates jobless.

The process of recruiting medical graduates into residency/specialty training in the UK has similarities as well as differences to the system in the USA. Similar to the USA, exams like PLAB and MRCP are a requirement for applying into specialty training. These exams have more than one part as does the USMLE exams and test clinical knowledge as well as clinical skills including communication and patient ethics. In the UK, applications for specialty training are made through a universal application portal (ORIEL) as in the USA, however, these applications are individually submitted to each specialty and there is no ‘common application form’. This benefits the candidates who could adapt several parts of the application like highlighting particular training courses while omitting irrelevant courses to show ‘commitment’ to each applied specialty. On the other hand, it makes it more difficult for the recruiting panel to short list and select suitable candidates.

The interview stage in the UK is very different than in the USA. In the UK, the interviews are conducted on a National level where central bodies (Deaneries) paneled by a handful of consultants select candidates to start working all across the UK, Scotland and Wales. The interviews are structured and graded to achieve uniformity in assessment, but often resemble an exam situation. A standard interview is composed of three 10-min stations, testing clinical knowledge, clinical governance, acquaintances with ethics and similar dilemmas [2]. Onyon et al. in 2009 analyzed the reliability of the interview process and concluded poor reliability for recruitment, suggesting the need for up to 26 interview stations to achieve reliable results [3]. Needless to say, this would not be without several constraints for time as well as resources. Additionally, Roberts et al. in 2014 found that multiple mini interviews needed to be sufficiently long to be adequately reliable in selecting candidates for general practice training in Australia. Limited number of questions or stations could decrease the reliability and hence make the whole process full of flaws [4].

The advantages and disadvantages of the current recruitment systems in the UK and the USA are summarized in Table 1. The current style of interviews in the UK could benefit several changes. First, single interviews for nationwide jobs could result in bad mentorship. Effective mentee-mentor relationship requires a matching of personality. Since trainees do not meet their supervisors or his team until after starting their tenure, it gets difficult to find the right mentor. Furthermore, specialty training in the UK is rotational, whereby trainees rotate through different hospitals in their geographic region on an annual basis. Although this is beneficial in exposing the trainees to both secondary and tertiary care, it makes finding compatible mentors even more difficult. Contrastingly, programs in the USA are based in the same hospital throughout the training. Second, the structure and environment of interviews in the UK resemble an exam scenario and finds it hard to judge an individual’s nature outside the medical books, as judged by the USA experts. Third, many times the interview deviates further from the original definition of an interview, i.e. a one-to-one conversation. This happens when one of the interview stations requires candidates to speak on an interesting medical topic (presentation), while the interviewers sit idle and listens. Fourth, in the current interview format, the number of stations are limited and can cause poor reliability. Last, the interviews are not without bias. Candidates who have worked as juniors under one or more of the interviewers are subconsciously looked upon as differently to those who do not have this privilege.

Table 1. Advantages and disadvantages of current recruitment process for specialty training in the UK and the USA.

Recruitment Process in the UK
Advantages	Disadvantages
Single structured nationwide interviews aim to standardize the selection process	Nationwide interviews could result in poor mentorship
It is free to apply for training positions and traveling expenses incurred for attending the interview are reimbursed by the training boards	Limited number of interview stations (usually three) could result in poor reliability and require improvement by increasing the number of stations
	Testing clinical knowledge in an interview station gives it an exam environment, which have already been tested previously through formal exams. Additionally, it wastes resources when the number of interview stations are already limited.
Recruitment Process in the USA
Advantages	Disadvantages
Each program conducts own interviews looking for best suited candidates as per program specifics (for example, University based programs are usually more interested in an Academic career centered candidates, whereas Community based programs equally like candidates with purely clinical interests)	Job applications and traveling for interviews is costly to candidates.
There is a potential for better mentorship
Having a ‘common application’ limits the potential for candidates to ‘trick’ programs in showing commitment and helps select the best candidates
Pre-interview dinners are good activities to mingle and informally judge applicants

Proposed solutions

1. A common application form to all specialties could improve short listing for interviews in the UK.

2. Interviews should be restructured to judge the characteristics of candidates outside the medical book and an exam environment.

3. In the UK, interviews could be conducted individually by each program rather than nationally, to improve the chances of better mentorship. Alternatively, the current national interviews could be used for benchmarking followed by another selection interview conducted locally by the region/hospital.

4. In the USA, standardizing the interview questions could be beneficial but may not be entirely practical since the interviews are not conducted nationally and could naturally vary from one program to another.

5. Generating funding to support applicants through the interview process in the USA could save money for the candidates.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial relationships to disclose.

Additional information

Funding

None.