COVID-19 and the Urology Match: Perspectives and a Call to Action

On March 11, 2020 the World Health Organization declared COVID-19, the disease caused by the novel coronavirus SARS-Cov-2, a global pandemic.¹ As COVID-19 continues to spread, governments have imposed increasingly aggressive measures including travel bans and even statewide shelters-in-place.¹ These actions have demonstrated benefits in reducing the spread of the virus and minimizing the impact that cases have on local health care systems.¹ However, in the wake of these changes, medical student education has been brought to a standstill.

For third-year medical students, spring is a critical period for making final decisions on their future medical specialty, often relying on home urology rotations to confirm final decisions. Spring is also when visiting student learning opportunities (VSLO or away rotations) are organized and a plan is created for completing required licensing examinations, notably the United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK) and Clinical Skills (CS).

Urology is a unique field in that many students will have no or minimal experience in the specialty during core rotations, with students relying heavily on home sub-internships and VSLO for exposure and confirmation that urology is their desired field. However, a large number of academic urology departments across the nation have appropriately either suspended or canceled medical student rotations as well as away rotations while uncertainty regarding the trajectory of the COVID-19 pandemic looms. Although this decision is paramount to protect learners, there may be long-term ramifications for the upcoming urology match.

Could students who do not have substantial exposure to urology instead apply to other specialties due to the lack of experience in our great field? Elective rotations in urology are essential for recruitment as only 5% of medical schools have a mandatory urology rotation.² When medical schools do reinstitute medical student rotations, it is likely that mandatory rotations required for graduation will be emphasized over electives, further curtailing potential urology residency recruitment.

Another key opportunity for exposure to urology is through away rotations. Away rotations serve as a critical component of medical student evaluation and function in addition to providing a rich educational experience. Studies have demonstrated consensus among program directors that performing an away rotation at their program is one of the most important factors for considering an applicant.³ The loss of this experience limits an applicant’s ability to evaluate diverse working environments (academic vs clinical focus, traditional vs mentorship model, 5 vs 6-year training, Veteran Affairs exposure, small vs large hospital footprint), and precludes opportunities to demonstrate a strong work ethic, amicability and cohesiveness with existing residents and faculty.⁴ Away rotations also allow an applicant to demonstrate interest in a particular geographic region. As such, another potential consequence of limited VSLO in the 2021 match cycle is a geographical clustering of applicants matching in regions near where students attended medical school.

Studies have found that letters of recommendation (LORs) are among the most essential components of the urology residency application. In a survey of urology program directors LORs from urologists were the single most important factor in assessing applicants.³ With the potential loss of LORs, the diversity of insight that urology programs can garner regarding a given applicant’s aptitude for a career in urology may be attenuated. Furthermore, if students are unable to complete home clinical rotations prior to application deadlines, LOR writers may be unable to comment on a student’s clinical and interpersonal aptitude which is an essential data point to any program director.

With restrictions on VSLO and a resulting decrease in LOR opportunities, there is a loss of subjective measures that can be incorporated into the applicant evaluation process. As such, there may be an increasing push among applicants to replace the loss of subjective measures with an additional objective measure, such as the USMLE Step 2 CK exam. Given the National Board of Medical Examiner’s recent decision to eliminate 3-digit scoring of USMLE Step 1, it is likely that there will be greater emphasis placed on USMLE Step 2 CK. This decision may be apropos given findings that Step 2 CK, rather than Step 1, is an independent predictor of excellent performance as a urology resident.⁵ So, what are some potential methods of mitigating these challenges?

An important first step may require delaying the date at which urology match applications open and, therefore, modifying interview dates to maximize student opportunities to complete a urology rotation at their home institution as well as at least 1 away rotation. Traditionally applications open in mid-September, shortly after which application data are pulled from the online servers to be used to assess candidacy for interview. By delaying the opening date for applications to November, applicants will have additional time to attend away rotations and obtain these much needed letters. This would require moving interview dates, rank list due dates and match day. We would propose that rank list due dates and match day coincide with the National Resident Matching Program dates. Urology stands unique among all specialties in that we control our own match, giving us the ability to be agile and adjust to this once-in-a-lifetime event.

Moreover, it may be worthwhile to foster greater adoption of a standardized letter template with consistent metrics and language such as the one designed by Penson cited by Filippou et al ⁶ to better evaluate applicants on a more level playing field. Finally, if letter writers are unable to comment on clinical and interpersonal aptitude, perhaps recommending students submit a letter from another surgical clerkship in which their clinical interactions were observed may be an appropriate surrogate.

If away rotations are completed this year, it is also important that programs prioritize applicants without home urology programs to allow them the opportunity to gain exposure to the field and acquire vital LORs. Those without a home urology program may be disproportionately affected by a loss of VSLO, and loss of this group of prospective applicants may perpetuate the ongoing decline in the urology applicant pool. When away rotations are allowed their availability will likely be limited. The American Urological Association should consider recommending that medical students applying in this upcoming cycle only participate in 1 away rotation, thus enabling fair distribution of these limited opportunities. Just as COVID-19 has caused an increased reliance on online means of connecting with colleagues and patients, there should be a push for improved online open access urology resources that appeal to medical students.

Finally, medical students are encouraged to take advantage of whatever time was set aside for away rotations (but may no longer be able to capitalize on) to bolster other elements of their application, including finalizing research activities, studying for Step 2 CK and engaging in urology educational activities (ie remote grand rounds).

Ultimately the COVID-19 pandemic will create challenges for the upcoming urology match. Successful applicants will not only need to demonstrate proficiency in their academic metrics, but exhibit fortitude during what will surely be a dynamic and constantly changing application cycle. However, the time to make changes is now, and consider moving back the application process and setting clear application requirements for the upcoming urology match to encourage and not dissuade applicants from pursuing a career in urology.