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To the Point: advising students applying to Obstetrics and Gynecology residency in 2020 and beyond

This article, from the “To the Point” series by the Undergraduate Medical Education Committee of the Association of Professors of Gynecology and Obstetrics, is a guide for advising medical students applying to Obstetrics and Gynecology residency programs. The residency application process is changing rapidly in response to an increasingly complex and competitive atmosphere, with a wider recognition of the stress, expense, and difficulty of matching into graduate training programs. The coronavirus disease 2019 pandemic and societal upheaval make this application cycle more challenging than ever before. Medical students need reliable, accurate, and honest advising from the faculty in their field of choice to apply successfully to residency. The authors outline a model for faculty career advisors, distinct from mentors or general academic advisors. The faculty career advisor has detailed knowledge about the field, an in-depth understanding of the application process, and what constitutes a strong application. The faculty career advisor provides accurate information regarding residency programs within the specialty, helping students to strategically apply to programs where the student is likely to match, decreasing anxiety, expense, and overapplication. Faculty career advisor teams advise students throughout the application process with periodic review of student portfolios and are available for support and advice throughout the process. The authors provide a guide for the faculty career advisor in Obstetrics and Gynecology, including faculty development and quality improvement.


Introduction
Medical students often cite career advising as an area of unmet need, and rank guidance from faculty career advisors (FCAs) in their chosen specialty as the most helpful resource in the residency application process. 1e4 General advisors without an in-depth knowledge of the specialty may provide inaccurate counseling, whereas clerkship directors (CDs) and residency program directors (PDs) may not have time, resources, or training to excel at career advising. 5 The rapid changes in the 2020e2021 application cycle owing to coronavirus disease 2019 (COVID-19) demonstrate the need for FCAs with both specialty-specific knowledge and an overall understanding of the application process. 6 This article, one in the faculty development series "To The Point" by the Undergraduate Medical Education Committee of the Association of Professors of Gynecology and Obstetrics (APGO), is intended as a guide to advising medical students applying for Obstetrics and Gynecology (OBGYN) residency programs through the main residency Match of the National Residency Matching Program (NRMP).

Faculty Career Advisor's Role and Responsibilities
The FCA fills a unique advising role, distinct from academic advisors, mentors, or coaches. FCAs are knowledgeable about the specialty, application process, and residency programs. 7,8 Despite up to 90% of faculty performing some career advising, the role is often considered low status. 9,10 Although the FCA role is often considered part of CD duties, FCAs should receive institutional recognition as advisors for the residency application process and should receive protected time to meet with and advise students commensurate with the number of advisees. 9,11,12 There are no guidelines for the ideal student-toadvisor ratio, and in some specialties, FCAs advise more than 20 students annually. 13 FCAs should frequently review the online resources published by the NRMP, Association of American Medical Colleges (AAMC), and other national organizations (Table 1). These websites are updated at least annually and provide a comprehensive view of the application process and updates on current conditions. The APGO OBGYN Residency Directory (https://www.apgo.org/ students/) provides a concise listing and comparison of residency programs, which is a vital resource for students and advisors. Medical schools should provide FCAs with an access to the AAMC Careers in Medicine (CiM) website. 14 Students can access CiM for career choice guidance. FCAs should also be aware of student-led websites that may be less reliable than those of professional organizations. 15 Specialty FCA teams should meet regularly to review recent changes in the application process, ensuring equitable, accurate advice for all students. Successful teams work together to maximize outcomes for all students.
Medical students often have a limited understanding of the residency application process. 4 Women and first-generation and underrepresented minority students may be less likely to use networking or have mentors. 8,16,17 FCAs can help achieve opportunity equity by providing specialty-specific information about competitiveness and factors considered in granting interviews and ranking candidates. 4,13 Early Career Advising Advising preclerkship students includes mentorship, networking, and informational meetings. 4 FCAs can help clarify career goals and identify research, extracurricular, and leadership opportunities. 4,13,18,19 Certainty and compatibility Once a student decides to pursue OBGYN, the FCA should assess a student's motivation and ensure understanding of residency training commitments. 19 Discussing career goals, plans for fellowship, research, advocacy, and topics such as abortion and assisted reproduction helps the FCA guide students' program choices. 13

Review portfolio
The FCA should review the student's curriculum vitae (CV) using the standardized AAMC CV or a school's recommended style. 14,20 The student should accurately describe activities and research, taking credit for work done, but not overstating achievements. If a student participated in research without a resulting publication, the FCA can recommend poster or abstract presentation opportunities or suggest writing a manuscript with the research mentor.
The CV should highlight activities highly valued by residency programs including leadership, advocacy, teaching, honors and awards, such as the Gold Humanism Honor Society and Alpha Omega Alpha. Student membership in professional societies such as the American College of Obstetricians and Gynecologists (ACOG) demonstrates commitment to the field.
The FCA should review potential weaknesses, including illness or adversities that affected academic achievement. A low grade or score can be an opportunity to demonstrate resilience.
For students with a lapse in professionalism, legal action, or criminal conviction, the FCA can coach the student through an honest appraisal of the episode to provide a path to a successful match.
The FCA should also assess interpersonal skills and offer communications or public speaking training if needed. 21,22 FCAs must understand the school's grading rubric and the Medical Student Performance Evaluation (MSPE), which is the standardized narrative summarizing the student's achievements, grades, evaluations, and class rank. 23 Many schools invite students to highlight achievements for the MSPE. FCAs can advise students to list attributes based on personal knowledge of the student and of factors valued by residency programs.

Postclerkship Planning
FCAs advise students on postclerkship electives, research, and extracurricular activities to promote professional development and build a competitive portfolio. 18 Away electives Because of COVID-19, in 2020e2021, the AAMC recommended limiting away rotations to students whose medical schools do not offer equivalent clinical experiences. 6,24 FCAs can reassure students there seems to be no association between completing away electives and matching at an institution, whereas a poor performance hurts a student's chances. 25e32

Postclerkship curriculum
FCAs should recommend electives to broaden medical knowledge, such as cardiology, infectious disease, emergency medicine, dermatology, critical care, or neonatology. 13,25,33e35 Students should plan flexible schedules during interviews and complete an elective with direct patient care in the months before graduation and, if available, a Transition-to-Residency course. 34,36e38 A "Step Up to Residency" program is offered at the annual ACOG meeting. 34,39 Some students take a fifth year; for less academically competitive students, ajog.org Expert Reviews research, publications, or a second degree may bolster their portfolio. The FCA should maintain regular contact with students during time away. At a minimum, hold a midyear conversation to confirm career plans and assure student well-being.

Networking
The FCA should ensure students meet with the Chair to discuss the departmental letter of recommendation (LOR). 40 The Chair may delegate writing the LOR, but personal knowledge of the applicant is desirable. The student should send the CV and personal statement (PS) for review before the meeting, bring extra copies to the meeting, and be prepared to discuss their application. Meeting with the department Chair helps build student confidence for interviews. With current travel limitations, FCA teams can maximize networking through introductions to faculty at desired programs with similar clinical or research interests.

Assembling the Application Holistic review
The FCA and student should review the Electronic Residency Application Service (ERAS) application, including the United States Medical Licensing Examination (USMLE) or Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) scores, grades, research, teaching, volunteer and work experience, publications, and extracurricular activities. Preferences for program size, type, location, and whether the student is couples matching should be discussed. The FCA can then suggest programs where the student is likely to receive interviews.

Letters of recommendation
Students applying in OBGYN should submit at least 3 LORs including a letter from the department Chair. 40 Because of the pandemic, the Council on Resident Education in Obstetrics and Gynecology (CREOG) and others recommend programs require fewer LORs for the 2020e2021 cycle. 6,41 FCAs should advise choosing faculty, research mentors, or project supervisors who know the student personally and who can comment on strengths and fitness for residency. 40 Authors from other specialties may be considered. Students should request a LOR at the time they work with the author and meet to review their portfolio. Students should be mindful of the time required to write LORs and request letters early enough to meet deadlines.

Personal statement
The FCA plays a critical role in reviewing the PS. 42 Although the PS is the only place in the application where the student's voice is heard, students often struggle with writing. 42e44 A reflection exercise to identify strengths, weaknesses, career goals, and desired program characteristics leads to a well-organized, effective PS. 42 The PS should focus on the student's goals and what the student seeks in and brings to residency, rather than a patient or family story or why the student chose medicine. 45,46 The tone should be Expert Reviews ajog.org professional and positive, avoiding criticism of the field, particular institutions, or individuals. Weaknesses should be addressed in a psychologically safe manner, with an emphasis on growth from adversity. 42,47 The FCA should proofread and suggest edits, but refrain from revision. The PS should be the student's own work; a recent report found a 2.6% incidence of plagiarism in the PS. 48 Social media Modern professionalism includes cultivation of an online social media presence. 49 More than half of PDs report screening applicants' social media for unprofessional behavior. 50e54 Reassuringly, a recent study of 87 OBGYN applicants found no unprofessional postings. 55 Social media is also an opportunity for student networking with the medical community through education, research, and commentary. 56e58 Assessing competitiveness The FCA can help students assess their competitiveness in comparison with classmates and with the entire applicant field. 26 To ensure adequate interviews for all students, FCAs should advise students to apply strategically based on attributes valued at different programs, because residency programs often interview only a few candidates per school. This requires FCA teams to work collaboratively, equitably advising all applicants, while maintaining confidentiality.

Recent changes
National efforts are underway to simplify the application process. 60 In 2019, OBGYN became the first specialty to recommend residency programs limit the number of invitations extended to only the number of interviews available, standardize invitation dates, and give a realistic response time to accept invitations. 60 Figure 1 provides an overview of the advising timeline including adjustments made in the current year in response to the COVID-19 pandemic. In 2019, the National Board of Medical Examiners announced Step 1 will become pass/fail 62 ; the effects of this change are uncertain, but may prompt the use of holistic reviews and may change recommendations for the number of applications to submit. 6 Attributes considered in ranking When ranking applicants to match, PDs consistently cite interpersonal interactions and communication skills as the most important attribute. 61 Although academic excellence is often required to receive interviews, interpersonal skills are the deciding factor in ranking candidates. In 2020, all interviews will be virtual. Although concerns exist that this will adversely affect perceptions of communication skills, 63 a pilot study in anesthesiology comparing virtual and face-toface interviews reported no difference in matching results. 64 The Application Process Applying to residency programs: which ones and how many? Applying for residency is expensive and time consuming. For OBGYN in 2019, students submitted a mean of 61.3 applications, whereas programs received an average of 438.1 total applications. 61,65 Students frequently overapply out of concerns for not matching. 7 FCAs can guide students to limit the number of programs at which they apply through a strategic approach including student interests, plans, and academic record.
In deciding where to apply, students consider clinical interests, academic competitiveness, geography, couples matching, and finances. 13 Research and advocacy opportunities, patient population, and diversity are additional factors. FCAs can help students limit the overall number of applications by considering other aspects of their planned career paths in selecting programs at which to apply. For example, students interested in a nonacademic career may consider community hospital programs over academic medical center programs, whereas students planning to subspecialize may wish to apply to programs with associated fellowships. Students should apply to their home institution's programs, unless they are certain they will not stay for residency.
In determining the number of applications, the AAMC "point of diminishing returns" (PDR) tool uses Step 1 scores to predict the number of programs needed to apply to match successfully. 14 In OBGYN, applicants with a score of 230 needed to apply to 14 programs (confidence interval [CI], 13e15) to reach the highest likelihood of matching successfully: adding more applications did not increase the chances of a successful match. For scores of 214 to 229, the PDR was 21 programs (CI, 19e23), with an 82% likelihood of matching. For scores of <213, the PDR was 28 programs (CI, 26e30) with a 76% likelihood of matching. Approximately 90% of OBGYN applicants ranking 10 programs matched; more than 99% of applicants ranking 20 programs matched. 14 Because of the ajog.org Expert Reviews decreased expenses associated with virtual interviews, students may consider overapplying during the 2020 application cycle. FCAs can use the PDR to encourage limiting the number of applications. In this fluid, competitive environment, less academically competitive students may need to apply to up to 30 programs to receive interviews (and thus rank sufficient programs), whereas highly competitive students may need to only apply to 10 to 14 programs. 5,7 The process of deciding which programs at which to apply may become simplified with proposed changes resulting from the pandemic, including more transparent communication from programs regarding program values and desired applicant characteristics. 6 Interview preparation and reflection The FCA can assist students with mock interviews and review recent graduates' experiences. 21,22 Because few students have experience with online interviews, FCA teams should offer specific training and mock virtual interviews for the 2020 application cycle. 63 Results from a prepandemic online interview pilot demonstrating equivalence of outcome with in-person interviews may reassure students. 64 Students should explore program websites and attend online social events if offered to understand programs' values, mission, and desired candidate qualities. 6 During the interview season, FCAs should contact advisees regularly to review interview invitations and reflect on impressions and rank programs as they complete interviews. 66

Postinterview communications
Students are often unsure about communicating with programs after interviews. Programs generally welcome notification of new publications or awards. Students should not falsely promise to rank a program first but may wish to inform a program of specific reasons they are ranking a program first, such as a spouse at the same institution. Communication from a program does not necessarily indicate a student will be ranked highly. Both candidates and programs are governed in behavior and communication by the NRMP Code of Conduct that prohibits programs from mandating second interviews and audition rotations or asking how the candidate will rank the program. 61 Final step: rank order list Before submission, the FCA should review students' rank list. Students should rank programs in their preferred order. By ranking a program, the student is agreeing to employment at that program. Students should not rank a program they do not wish to attend. The NRMP recommends submitting the list before the deadline, because internet or website failures have occurred. 61

Couples Matching
FCAs should understand the special concerns of couples matching, described in detail at the NRMP website (http:// www.nrmp.org/couples-in-the-match/). For couples, each student must rank the same number of programs or options, up to a total of 300 combinations of residency programs, including "no match" options. 61 The couple will match to the most preferred pair of programs All dates adjusted for the 2020e2021 cycle. Royce. Advising students applying to OBGYN residency 2020. Am J Obstet Gynecol 2021.
Expert Reviews ajog.org on the rank order lists where each partner has been offered a position (or a "no match" option is listed). A frank appraisal of each student's competitiveness in their specialty is essential to ensuring the best match for both students. In general, both students will need to apply to more programs than an individual student. 61  In the immediate postmatch time frame, the FCA can offer support for the unmatched student, because this is often emotionally stressful. 68 Bumsted et al 68 provide an overview of SOAP and alternatives for achieving a residency position. After the closure of SOAP, the NRMP releases a list of unfilled programs. The FCA can assist the applicant in identifying programs because FCAs may learn of open positions in the specialty before general advisors. 68 If an applicant does not match through the traditional match but obtains a preliminary position, the FCA should maintain contact and offer to review a second application. 68,69 Effects of Coronavirus Disease 2019 In response to the pandemic, most American medical schools suspended educational and research activities in March 2020, resulting in decreased opportunities for students to prepare for residency. Changes in the application cycle were instituted by the AAMC, whereas APGO/CREOG recommended OBGYN-specific changes (Table 2). 6,70,71 As Ferrell and Ryan 72 noted in April 2020, "The panic in the community is palpable, and many are confused by how to proceed in the wake of COVID-19" because the normal methods for demonstrating achievement are severely limited. Students may face added stress from societal upheaval, family illness, financial stress, and rising inequities. In light of the pandemic, virtual mentor relationships such as FCAs remain the educational intervention most desired by students. 73 The APGO/CREOG specifically recommend students work with an FCA during this application cycle. 41,74 FCAs should review the recent general and OBGYN-specific changes to the application process to accurately advise students. 6,60 New FCA roles in 2020 include virtual interview preparation and electronic networking. 63 Improving Advising: Continuous Quality Improvement Resources FCA teams should update local student resources regularly. Medical schools should provide current data, including programs where students have recently matched. FCA groups may conduct informal surveys or focus groups of graduates to elicit hard-to-capture data regarding student experiences.

Faculty development
The FCA is a novel role evolving to meet the needs of students during the residency application process. The pool of faculty serving as FCAs may vary from school to school, including subspecialists. Although no formal training programs exist, APGO and other specialty societies have published resources to assist faculty members as they develop the skills needed to successfully serve as FCAs. 18e22, 26,42 Online resources are listed in Table 1. FCA teams can improve advising through standardized programs, sharing best practices, case-based critical review of recent student experiences, and reflection on their own experiences to inform advising style and substance. 75 Continuous quality improvement FCA teams should meet annually after the match, to debrief, inviting administrative staff who often have a different perspective on student experiences. Recently, evaluation tools for undergraduate medical education programs have been published and may be used to identify and adopt best practices. 76,77 Conclusion Effective FCAs possess a deep understanding of the application process and residency programs and use holistic review techniques of student compatibility to maximize students' success in matching into a desired residency. As the postpandemic medical education landscape evolves, the application process will undoubtably change, and specialtyspecific FCA guidance will remain invaluable. -