American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Dog, Old Tricks: Mitigating Implicit Bias in the Virtual Interview Space

Alaina D. Geary, MDJad M. Abdelsattar, MDTania K. Arora MD, FACSKari M. Rosenkranz, MD, FACS

Peter Yoo, MD, FACSValentine N. Nfonsam, MD, MS, FACSLilah F. Morris-Wiseman, MD, FACS

Introduction

Facing the Coronavirus Disease 2019 (COVID-19) global pandemic, residency and fellowship programs must transition from in-person to virtual recruitment. Though virtual interviews have been trialed previously in other specialties,1 most surgical programs are in uncharted territory. Early experiences can offer guidance for both programs and applicants on best practices.2,3 However, as programs adjust to virtual interview settings, we must be cognizant to reduce potential bias against applicants, particularly applicants from groups underrepresented in medicine (URM).

Implicit or unconscious bias refers to stereotypes that all people form without realizing it. While the term "bias" may seem pejorative, it is critical that members of your interview team recognize that every person possesses unconscious bias related to their own experiences. 

Programs can start by highlighting diversity on websites and promoting virtually their institutional commitment to inclusivity and equity. Simultaneously, changes in the application screening process may be necessary to ensure that a diverse pool of candidates is invited to interview. Both programs and candidates may have additional opportunities given reduced time and cost associated with virtual interviews.1 Programs can celebrate their diversity by presenting a representative panel of speakers and interviewers who consistently demonstrate respect for, and acceptance of, individual differences.4 Consider developing a dedicated and diverse recruitment team of faculty and residents to review applications and interview and rank applicants. Team members should be formally prepared to ensure understanding of the program's goals and objectives. Programs should also train faculty and residents to recognize and mitigate implicit bias that can unintentionally alienate URM applicants.4 

Types of Unconscious Bias

Some of the most common types of unconscious bias in business hiring5 are also common in residency interviews, as follows:

  • Education bias: "He went to a top-rated medical school; he must be smart."
  • Enthusiasm bias: "She's so excited about being in the OR. She will hit the ground running."
  • "Like me" bias: "I see a lot of myself in her. She must be amazing."

Tools to Mitigate Unconscious Bias

Implicit bias training should be done without targeting individuals but through development of program-level practices that support equity and inclusion using validated guides such as the Racial Equity Readiness Assessment Tool.6,7 Specific tools to help mitigate unconscious bias in the virtual interview space are detailed below.

Curate your program's message in virtual spaces. Display unique aspects of your program in a "virtual tour," potentially highlighting sites not normally visited during in-person interviews. Early introduction to the rich culture of your program may attract a broader group of applicants and may set them at ease.

Invite applicants to "meet" program faculty and residents from your trained, core recruitment team. This group should be especially versed in the use of inclusive language devoid of invalidations and assumptions.  For example: "You mentioned your fiancé will be moving with you, what do they do?" If heteronormative language is used, an LGBTQ+ applicant will feel uncomfortable because the message transmitted is not an inclusive one. Another approach might be to ask panelists to be more thoughtful about how questions are asked. For example, the phrase "Where are you from?" might alienate a non-white applicant who does not want to be "othered." Instead, a subtly different phrase such as "Tell me about where you grew up," could be used to build rapport.

Use standardized interview questions and assessments. The best evidence for meaningfully reducing bias in interviews recommends using structured interview questions paired with behaviorally anchored rating scales.8 The Association of American Medical Colleges (AAMC) recommends using pre-selected questions asked of all applicants that are job-related and reveal whether the applicant's and program's goals and needs align.9 Specifically, programs should use pre-defined rating scales with clear criteria, multiple trained interviewers, and formulas to create interview scores.9 Virtual interviews offer the potential to record and review interviews with a diverse team whose unconscious biases are different. This method attempts to avoid the subjective, potentially biased, and unhelpful assessment of applicants based on relationships, for example: "We had a terrific conversation. We really connected."

In video-based interactions, subtle interpersonal cues may be lost8 and as a result, applicants may be perceived as less likeable and it may be more difficult to ascertain cultural fit.10 While some may be concerned that structured interviews limit rapport building, there is also evidence that these questions provide meaningful information regarding whether a candidate will handle situations in-line with expectations at a given institution.8

Consider carefully the virtual environment you set. One must be conscious of objects or pictures visible in the background. Many institutions have worked to standardize their backgrounds, thereby mitigating bias or unintended exclusivity and further promoting their mission and culture.

Recognize the limitations of virtual interviews. Speak slowly and clearly. Know there may be delays in the audio that can result in longer time for the candidate to respond to questions. Furthermore, institutions should recognize the possibility that some medical students lack a professional space from which to interview. One way to circumvent this is to offer applicants an opportunity to test their virtual interview set-up and get feedback prior to interview day. Departments can provide designated offices to their own students with high quality lighting, a camera, and a reliable Wi-Fi network to avoid connectivity issues that invariably result in lost interview time that is difficult to reschedule and could reflect poorly upon the applicant. 

Further Considerations

The unexpected transition from in-person interactions to a cyber interview space has introduced many unknowns. Marginalized applicants may, unfortunately, feel the brunt of this if programs are not open-minded and intentional in their recruiting processes. In the past, the non-white, LGBTQ+, or intersectional applicant relied on exploration of space and observation of the diversity of people around campus in order to fully assess their comfort and inclusion in a program. The virtual setting negates these cues, compromising the candidate's ability to judge institutional culture and perceived future success.

Ultimately, thoughtful consideration is needed to mitigate bias as we enter this new landscape. But we need not start from scratch. We can use the tools already available to us, particularly structured interviews, to continue to develop a more diverse, equitable, and inclusive surgical workforce. We must continue to highlight the importance of diversity and equity so all programs will work to recruit and retain URM regardless of the interview platform.

About the Authors

Alaina D. Geary, MD, is a general surgery resident currently in research at Boston Medical Center.

Jad M. Abdelsattar, MD, is a chief resident in general surgery at West Virginia University School of Medicine.

Tania K. Arora MD, FACS, is an associate professor and program director of the general surgery residency at Augusta University at the Medical College of Georgia.

Kari M. Rosenkranz, MD, FACS, is an associate professor of surgery and program director of the general surgery residency at the Geisel School of Medicine at Dartmouth.

Peter Yoo, MD, FACS, is an associate professor of surgery and program director of the general surgery residency at Yale School of Medicine.

Valentine N. Nfonsam, MD, MS, FACS, is a professor of surgery, interim chief of the division of surgical oncology, and program director of the general surgery residency at the University of Arizona College of Medicine Tucson.

Lilah F. Morris-Wiseman, MD, FACS, is an assistant professor and associate program director of general surgery residency at the University of Arizona College of Medicine Tucson.

All authors are members of the Association of Program Directors in Surgery Diversity and Inclusion Committee.