Digital eye strain during the virtual interviews: evidence-based strategies for medical students

Summary

The 2020–2021 residency interview season was the first in which interviews were entirely virtual, and residency interviews may continue to be offered in this format. Digital eye strain can negatively affect applicants’ interview experience. We provide an overview of the virtual residency interview experience with a view to providing applicants with solutions that minimize eye strain. Symptoms, contributing factors, and evidence-based interventions for digital eye strain are discussed.

Interviews and Eye Strain

The coronavirus disease 2019 (COVID-19) pandemic has affected medical education and the residency application process, with almost all residency programs adopting the virtual interview for the National Residency Matching Program (NRMP) and the San Francisco Match. The 2020–2021 residency interview season was the first exclusively virtual interview season for medical students applying to residency and remained virtual for the 2021–2022 application cycle. Because the pandemic continues to limit travel and in-person interviews, virtual interviews may continue beyond the 2021–2022 residency application cycle. With the pandemic, there has been a significant increase in digital device use, with associated digital eye strain in the general population and in students who have transitioned to virtual platforms.1,2 Although this has not yet been reported in medical students participating in virtual interviews, the prevalence of eye strain is higher among students in virtual classes compared with the general population.2 Compared to traditional virtual classes, the virtual interview experience further requires a focus on presentation and lighting, with uninterrupted intervals in front of a screen as applicants use the full allotted interview time to interact with programs virtually. As applicants prepare to present themselves best to residency programs during this competitive process, they may neglect measures to minimize eye strain.

The Virtual Interview

Matched US MD and DO seniors reported that they attended an average of 14 interviews in their preferred specialty during the 2020–2021 cycle.3 The average number of invitations to interview for matched individuals applying for ophthalmology during the 2020–2021 cycle was 12.4 This number is unchanged from the 2018–2019 and 2019–2020 ophthalmology application seasons despite the transition to virtual platforms.4 With persistence of the COVID-19 pandemic, virtual interviews may remain a staple of the residency application process, offering cost savings and decreased travel-related stress.5 Notably, virtual interviews have been offered in past years by some residency programs, with Pasadkika et al6 reporting that between in-person and virtual groups, there was no statistical difference in percentage of candidates who were ranked in the top 25. In this study, candidates who did virtual interviews reported that this method made it possible for them to complete more interviews. Although the 2021 NRMP Applicant and Program Director survey found that over half of respondents preferred the in-person interview experience, more than 50% also indicated the reduced travel costs and the increased ability to attend more interviews afforded by the virtual environment were important drivers of their interview experience.7 The number of interviews and related virtual events concentrated during the application season underscores the importance of identifying methods to reduce eye strain in applicants.

The virtual interview set-up, with intense artificial lighting and popular ring lights to optimize visualization and prolonged hours presenting in front of a screen for virtual interaction may contribute to digital eye strain in medical students because of the sheer volume and concentration of interviews. Medical students have indicated that the virtual interview process supports attending more interviews with additional virtual opportunities to interact with residency programs. Students applying for ophthalmology residencies have been limited to accept a maximum of 18 interviews beginning in the 2021–2022 season. Other specialties did not cap the number of interviews applicants can accept in the previous virtual interview seasons. While both applicants and residency programs are interacting throughout the virtual interview, students interviewing from their homes are frequently advised to invest in lighting and equipment to optimize their interview performance.8 Additionally, virtual interviews are variable in length, with applicants navigating unique formats dependent on each residency program department preferences. Applicants can control various elements in preparation for successful virtual interviews and should not neglect aspects that may exacerbate eye strain.

Symptoms

A significant increase in digital eye strain symptoms, also referred to as computer vision syndrome, has been reported in the general population and by students transitioning to virtual platforms.2 Recognizing the symptoms of digital eye strain that are attributable to interview lighting and prolonged screen intervals will prompt steps to mitigate contributing factors in the future. These symptoms include blurred vision, difficulty in refocusing from one distance to another, eye burning and irritation, dry eyes, headache, and sensitivity to bright lights (Table 1). Digital eye strain can significantly affect quality of life.9

Table 1.

Symptoms of digital eye strain9

Contributing Factors

Factors contributing to eye strain and interventions have been reported with tested survey measures in the published literature on computer use and digital eye strain.9,10 Table 2 summarizes factors contributing to digital eye strain that may be associated with virtual interviews, based on shared applicant experiences and avoidance strategies recommended by medical education platforms. Screen positioning above the horizontal gaze and closer than 20 inches increases the exposed surface of the eye and increases tear evaporation. Extended screen duration with limited breaks contributes to reduced blinking and incomplete blinking, disrupting the supportive tear film, causing dry eye.12 Monitors set at maximum brightness, with reflective glare from direct lighting on the screen and smudges can further affect eye strain. Recommendations on the Association of University Professors of Ophthalmology website and previous literature for optimizing video quality for virtual residency interviews include utilizing ring lights for quality visualizations.13 However, side effects of light in direct gaze, including eye strain, headaches, and irritability, have been consistently reported in studies of high luminance bright light therapy and lower luminance placebo groups evaluating this treatment modality for psychiatric use.14 Environmental factors, such as high-flow heating and air conditioning, can reduce humidity, which worsens dry eye symptoms and contributes to eye strain.

Table 2.

Summary of contributing factors and possible interventions for medical students to confront digital eye strain during the virtual interview cycle

Underlying ocular issues in applicants may result in further eye strain, because uncorrected refractive errors lead to squinting and poor visualization. However, using contact lenses disrupts the normal surface tear film and causes discomfort. Lack of awareness regarding interventions to reduce digital eye strain is likely another contributing factor relating to eye strain during the interview season.

Recommendations

Applicants can take steps to optimize the virtual interview experience while minimizing eye strain, although the published literature with virtual residency interview recommendations does not adequately address this aspect of the digital interview.3,8 Evidence-based recommendations to mitigate digital eye strain are summarized in Table 2. Screen positioning at or below viewing gaze and distanced 20–24 inches from eye level is recommended.15,16 Breaks should be implemented according to the 20/20/20 rule; that is, every 20 minutes the gaze should be redirected to an object 20 feet away for 20 seconds, allowing the eyes to rest. Intentional, complete blinking is also helpful; many individuals blink less often and less completely when sitting in front of a computer screen. Optimal lighting is important for visualization, and screen brightness should be adjusted to match the ambient environment; a clean screen will also minimize glare.17 Selecting a soft white light and removing high luminance lighting from direct gaze may allow for a well-lit setting that does not contribute to eye strain. Other environmental factors include using a humidifier to support a healthy tear film while avoiding high-flow heat and fans.18 Applicants with an underlying ocular issue, such as chronic dry eye disease and uncorrected refractive error, should have an eye examination to prevent unintentionally exacerbating the condition, because squinting contributes to eye strain.19 Wearing glasses instead of contact lenses is recommended to reduce symptoms of digital eye strain.20 Supplementing with omega-3 fatty acids and artificial tears may also promote eye health and prevent aggravating eye strain symptoms.21

Conclusions

Increasing awareness of evidence-based interventions may allow applicants to minimize digital eye strain experienced in virtual interviews. The virtual residency interview, with its emphasis on bright lighting and uninterrupted intervals in front of a screen, may contribute to eye strain, particularly when applicants feel compelled to undertake many interviews over a short period of time. Increasing awareness of symptoms, contributing factors, and interventions among applicants and interviewers may help to decrease digital eye strain as applicants prepare for the process. Medical students can control various aspects of their environment to support better eye health and allow for a more comfortable virtual experience, potentially improving the current process and mitigating the unexpected consequences of the virtual interview format on applicants.