Virtual Interviews and Their Effect on Cognitive Load for Graduate Medical Education Applicants and Programs

Abstract

The impact of coronavirus disease (COVID-19) has dramatically affected virtually all aspects of health care use, including patient care, research, and education. Among the groups affected were prospective applicants to graduate medical education training programs. To ensure a safe and equitable process for residency and fellowship application, multiple accrediting bodies strongly recommended that training programs conduct fellowship and residency interviews in a virtual format. With little experience in virtual interviewing, most programs, including ours, were compelled to make substantial changes to the traditional interview format. We present some of the unanticipated challenges we experienced with virtual interviewing in the context of cognitive load theory. We use cognitive load theory to highlight why the challenges existed. We also offer practical tips to minimize the cognitive load experienced with virtual interviewing so that trainees and programs alike derive maximal benefit when using virtual communication platforms.

The impact of coronavirus disease (COVID-19) on medical institutions and providers is well documented, even as the pandemic continues to unfold. Besides the clinical adaptations to this novel disease, other facets of academic medicine have been profoundly affected, including research and education. Trainees in graduate medical education (GME) training programs experienced various new forms of strain as they were redeployed to help care for patients with COVID-19, in some cases taking them away from important experiences in their specialty training. As the pandemic continued, the disruption extended into the 2020–2021 recruitment cycle for both residency and fellowship programs.

On May 11, 2020, multiple educational accrediting bodies, including the Accrediting Council for GME and the National Residency Matching Program, issued a joint statement regarding transitions from medical school to residency as well as from residency to fellowship in the approaching 2020–2021 interview season (1), strongly advising all GME programs to adopt a virtual interviewing format. On May 15, 2020, the Association of Pulmonary and Critical Care Medicine Program Directors (2) endorsed this recommendation. The rationale for virtual interviewing was twofold: 1) to provide equity in access to interviews because regional COVID-19 outbreaks could prohibit applicants or programs from conducting in-person interviews because of government travel restrictions, quarantine requirements, or hospital operational needs; and 2) to protect applicants and interviewing program personnel from infection.

Complying with this recommendation meant major changes for our pulmonary/critical care medicine and critical care medicine fellowship programs as we adjusted our recruitment process to offer an informative and meaningful experience for applicants interviewing virtually. After implementing many changes to our interview process, it was apparent that virtual interviewing presented some new and often unanticipated challenges.

The Concept of Cognitive Load

To analyze the challenges of virtual interviews, we applied the theory of cognitive load (3–6). Cognitive load is a psychological construct, initially described by Sweller in 1988 (7). It is based on evidence that sensory information is processed by the brain’s “working memory” into bundles of information to be stored in the brain’s long-term memory. Although the brain’s ability to store information in long-term memory is substantial, its working memory can be overwhelmed. Sweller’s theory of cognitive load described three elements of working memory that participate in the transformation of sensory input into long-term memory: intrinsic load, extraneous load, and germane load.

• •Intrinsic load is the mental energy demanded by learning something new, or the amount of working memory needed to complete the task. If the task is complex or the learner is new to the task, the intrinsic load is greater. Overly complex tasks can overwhelm the working memory by imposing too much intrinsic load, which limits long-term learning. On the other hand, mundane or previously learned tasks may carry an insufficient intrinsic load to create new long-term memories. New memories are formed best when the intrinsic load is optimized.
• •Extraneous load is the mental energy required to filter out distractions while processing the intrinsic load. Any energy devoted to extraneous load is unavailable to manage the intrinsic load.
• •Germane load is the mental energy needed to use learned cognitive processes that facilitate learning, such as connecting new information to previously stored memory, organizing information into a useful framework, or linking data to possible applications. Germane load is energy unavailable for managing intrinsic load, but it activates mental tools that reduce the amount of intrinsic load involved in a given task. It requires mental energy but makes learning more efficient.

Table 1 highlights examples of each type of load as they apply to the interviewing process. According to cognitive load theory, for learning to be effective, the intrinsic load must be optimized, extraneous load minimized, and adequate mental resources allocated to germane load. When viewing the challenges specific to virtual interviewing through the lens of cognitive load, the extraneous load factors unique to virtual communication deserve special consideration.

Table 1.

Factors within the interview experience that affect cognitive load

Intrinsic Load Factors	Extraneous Load Factors	Germane Load Factors
•Understanding the program’s curriculum, expectations, and unique opportunities for training •Visualizing how the physical campus and resources will facilitate learning or make it more difficult •Sensing the morale and culture of the program, especially of the trainees already in the program •Gathering information about the city, cost of living, weather, traffic, housing, etc.	•The screen as a monotonous single environment •Background noise on both sides of the virtual connection •Internet connection issues such as inability to connect easily, dropped connection, audio or video cutting out, audiovisual lag, and pauses between connections and breakouts •Time zone differences between program and applicants •Lack of nonverbal cues, including difficulties with eye contact •Lack of group visualization	•Experience with prior program interviews •Having read a guide to residency interviewing •Having participated in a mock interview with feedback •Creating a system for evaluating and comparing the characteristics of different programs

• 1.Prolonged monotony: In-person interview days allow for breaks and frequent changes in the environment, allowing for varied sensory stimulation and better engagement throughout the day. Physical movement between venues allows for mental resets to occur and improves the assimilation of information (8). With virtual interviews, all participants are usually confined to a single sedentary location and are on the same computer screen for the entire experience. Lack of variation within virtual platforms and competing activity on the screen (e-mail, text notifications, etc.) can distract both applicants and interviewing faculty. Although we provided break times, few people elected to use these early on in the interview season. We eventually prompted participants to stop and stretch during breaks with the intention to create distinct moments in which participants could refresh.
• 2.Internet connectivity: Many of our applicants and interviewers preferred to interview from home. Rising residential internet use has created connectivity headaches for many (9). Most people have experienced a frozen screen, voice or video dyssynchrony, or even being dropped entirely from the virtual platform. Beyond the awkward apologies that often follow technical glitches, we found that the flow of conversation was often disrupted or cut short. Data are limited on the effect technical challenges have on the applicant–interviewer relationship, but in one experiment, delays of 1,200 ms in telephone connectivity caused participants to perceive the other caller as less friendly, attentive, and active (10). Among our interviewers, there was no perception that applicants who experienced technical issues were ultimately ranked lower on the program match list, but these issues increased stress among both faculty and applicants and thus may have affected interview impressions.
• 3.Time zone differences: These challenges usually fall on the applicant to deal with. We are in the Eastern U.S. time zone. We had applicants this year from the Central and Pacific time zones as well as from Hawaii and Australia. Interview day start and finish times can affect daily routines and lead to sleep disruption. Sleep deprivation impacts cognition and working memory (11). Whether virtual interviews across multiple time zones impacts cognitive load more or less than in-person travel (which also commonly affects daily routines and sleep) is not known.
• 4.Background activity: Background noise, busy background effects, poor webcam placement, and bright backlighting that obscures facial features all represent factors that increase the extraneous cognitive load (12). These can draw an interviewer’s focus away from the applicant or vice versa. Background objects or pictures may distract but may also provide opportunities to discuss interests and unique qualities. In fact, some experts have recommended driving the interview narrative by intentionally selecting specific décor before an interview (13). Unanticipated intrusions can similarly disrupt the focus of a conversation, creating unforeseen stress and an increase in extraneous load. These disruptions can cause memories of the disruption itself to displace impressions about the applicant or program as a whole.
• 5.Diminished nonverbal cues: In the virtual space, loss of nonverbal cues increases intrinsic load (14) rather than extraneous load. A significant proportion of human communication occurs nonverbally (15–17). In video and phone interactions, decreased nonverbal cues fundamentally change how we communicate compared with in-person interactions and alter judgments of character and effectiveness (18, 19). Personal composure, hand motions, physical features, eye contact, and tone of voice provide subconscious feedback that affects the perceptions of an individual. Emoticons and interactive widgets (20) currently available on virtual platforms are limited in their ability to replace nonverbal cues (21). Although one may assume that virtual interviewing could benefit recruitment efforts by minimizing the potential bias related to nonverbal cues, it is not clear that this improves recruitment of qualified persons or increases recruitment diversity. For example, one study evaluated the impact of using avatars in lieu of a person’s real face during virtual interviews (22). In the study, researchers identified that the perceived attractiveness of the avatar significantly affected how interviewees were rated.
• 6.Loss of group visualization: In group settings, we naturally maintain eye contact with others. Virtual platforms usually display participants as square tiles in a grid. This format organizes the participants, but it increases extraneous load as well. The number of tiles that appear on a single screen is usually limited. Not seeing the entire group at once reduces visual feedback cues that may be helpful. A program director speaking to applicants receives less feedback about their engagement than in a live setting. This leads to fatigue and hampers the speaker’s ability to interact with the audience (23, 24). Not seeing the entire group can lead to interruptions, awkward pauses, and disparity among participants with regard to opportunities to speak or ask questions. Like with emoticons, virtual platforms have created innovative workarounds. Display options exist that assimilate participants more naturally and may be less fatiguing. But some argue the extraneous load is just as high with these features, as users may be more apt to focus on their own image rather than on learning (25).

The Effect of Cognitive Load on Heuristic Biases

Video interviewing can affect cognitive load in many ways, but does this affect the ability of candidates and programs to assess each other? The reason cognitive load matters is that when it gets too high, the value of the interview experience is diminished, and participants fall back on preconceived notions rather than using newly acquired information in making decisions. Although the issue applies broadly, this issue may be cause for concern for some underrepresented minorities, as underrepresented minorities disproportionately experience disparities with respect to the traditional metrics used to rate applicants outside of an interview (26). Typically, before interviews, faculty will review the applications of prospective trainees, and applicants seek program-related information from peers, mentors, internet sites, and other resources. Preinterview data necessarily contribute to a preliminary opinion on both sides, which interviews can and should substantially confirm or refute. During the interview experience, as cognitive load increases, the ability of the working memory to assimilate new information becomes more challenged (19). When this occurs, participants increasingly resort to the impressions they had previously, without necessarily integrating the information they were seeking from the interview. In a 2008 study, the effect of cognitive load on medical professionals learning via video lectures versus in-person lectures was evaluated. The study showed that video learning methods increased cognitive load and that audience perception of the lecture’s quality was based more on their opinion of the lecturer’s reputation or likeability and less on the merits of the lecture itself. The opposite was true for in-person lectures (6).

Although we may not ever eliminate completely the extraneous load associated with video interviewing, there are several tips to minimize it and decrease reliance on preconceptions in the assessment of an applicant or program.

Tips for Improving Cognitive Load during Virtual Interviews

• 1.Keep it short: We limited our interviews to the essential elements: an introductory review of the program, a 10-minute welcome from our department chair, and the interviews themselves. Other elements that we would otherwise include in a traditional interview visit were prerecorded in short segments and linked to a webpage. The webpage was sent to all applicants ahead of their scheduled interview. Applicants were able to view conferences, hospital tours, and other vignettes about our program at their leisure, on their own schedule. The ability for applicants to have this information in-hand shortened the interview experience, thus decreasing extraneous load during the virtual interviews themselves. We also believe it gave applicants a better opportunity to focus on the interviews themselves because they already had information sufficient to make some preinterview impressions about our program beyond those traditionally available.

  During the actual interview day, we also provided frequent breaks, during which we asked everyone to turn off their camera and move around so no one felt compelled to remain at the computer. Other programs have addressed this issue by offering asynchronous interview scheduling options. We believed that the maximum time that should be allocated to a virtual interview day was 5 hours.

• 2.Simplify visual aesthetics: Visual aesthetics include lighting, camera position, clothing choice, and environmental background. With respect to lighting, it is essential to ensure that your face is properly illuminated. This can be achieved by placing a light source directly in front of your face (27) and avoiding windows or other bright lights directly behind you.

  Placing the camera at eye level gives the viewer the impression that they are sitting at a table across from you and not looking up from under you. Seeing nostrils or the ceiling is distracting. If your camera is embedded into your laptop, consider placing books underneath to raise it up. Sit at a distance where your face, shoulders, and midtorso are captured but not distorted by the wide-angle camera on most devices.

  When selecting where to put your camera, ensure that you as the subject are the focus. Avoid complex, messy, or overstimulating backgrounds. Virtual backgrounds are widely available and can be applied on most virtual platforms, but many are distracting and may cast you in a way that increases cognitive load rather than reducing it. Experts suggest a soft, plain background with a few aesthetic objects (28). Whatever you use, it is best to test it and consider how you look before the interview.

  Busy outfits can also increase the cognitive load for a viewer. On a virtual platform, consider plain colored outfits rather than complex, striped, or patterned clothing. White and black have a tendency to lose contextual form on video and thus may not appear as a sharply defined shirt or blouse (29).

• 3.Make eye contact: Eye contact is essential for establishing an emotional connection. When users focus attention on the computer screen, it looks like they are focused on something other than the conversation at hand. Looking directly at the camera can feel unnatural and interferes with looking at other users on the screen. We advised our interviewers to decrease the size of their video window and position it on the monitor directly under the camera. One person in our group placed their camera on a stand in front of the monitor and placed the video window directly behind the camera. Many ways have been proposed to coax users to look directly at the camera, including taping interview questions directly above the camera or even taping the image of a face around the camera (30).
• 4.Know your platform: Most virtual platforms have a similar set of tools for use. Despite general familiarity with the common platforms, applicants and interviewers may have limited experience with the specific platform used. As a host, provide simple instructions about the functions of the platform, either ahead of the interview in writing or at the start of the interview experience. Interviewees should review web instructions for any platform they are not familiar with and consider a practice session on the platform with a colleague ahead of the actual interview if possible.
• 5.Optimize your voice: Sound quality can be a major issue when you are in a noisy environment or have a suboptimal microphone. Sometimes, sound can be improved by using earphones with a built-in microphone (31).

Conclusions

Cognitive load theory provides a useful framework for analyzing the challenges experienced by both training programs and applicants in this first-ever, all-virtual interview year. We hope our experience and the suggestions we have offered will help to overcome these challenges and establish virtual interviewing as a consistent and reliable way to assess trainees and programs during the GME recruitment process.