Associations Between Family Medicine Residency Applicants’ Debt Concern and Their Perception of Virtual Residency Interviews

Following recommendations from the Association of American Medical Colleges (AAMC) during the COVID-19 pandemic, graduate medical education (GME) residency programs transitioned to virtual interviews for the 2020-2021 application cycle.¹ Since then, studies have highlighted benefits including time efficiency and cost savings, alongside barriers such as technological access.^2,3 Given the high cost of American medical education, interview expenses are a significant challenge for applicants.^4,5 Although traditional interview costs vary, digital formats have helped reduce some financial burdens.^6-10 Nonetheless, there are limited data linking medical students’ debt concern with their experiences of interview formats. We hypothesized students with higher debt concerns would favor virtual interview offers and recommend them for future cycles.

The American Academy of Family Physicians (AAFP) Institutional Review Board determined this study to be exempt from review. Using quantitative and qualitative responses from the AAFP 2023 Medical Student Education Survey, we explored associations between applicants’ debt concern and perception of digital residency interviews.¹¹ The AAFP medical education team compiled a 50-item survey through an inductive process with the goals of (1) examining students’ perspectives on family medicine and the AAFP, and (2) identifying ways to better help applicants navigate the residency Match process. The survey was emailed to all 2023 AAFP student members with valid email addresses. If there was no response, two follow-up reminders were sent via a modified Dillman method.¹² In addition to demographic questions, the survey covered several topics: Family Medicine Attitudes Questionnaire (FMAQ), AAFP membership and resources, specialty choice, student debt, the match process, and student needs. We focused our study sample on those who applied to match in 2023 and answered questions relating to personal debt and virtual interviews, as recategorized in Table 1. We compared our study sample to the demographics of overall 2023 ERAS applicants using χ² goodness-of-fit test. We analyzed relationships between applicants’ debt concern and perception of virtual interview formats using descriptive bivariate analysis. Through rapid cycle thematic evaluation, one reviewer examined each open-ended response and categorized them based on evolving themes related to financial barriers and interview formats. Two to three rounds of review ensured consistency and alignment with these themes.

The survey was emailed to 20,585 AAFP student members with a 6.0% response rate, resulting in 1,225 replies. Of the total respondents, 294 participated in the 2023 match. After omitting 32 “not applicable or no student debt” responses for Question I. and 20 “do not know or not applicable” responses for Question II, our final sample size of 239 only included those that answered the study’s questions of interest. When comparing our study population to the demographics of the 42,908 overall ERAS applicants in 2023, our sample had a smaller proportion of male applicants (31.4% vs 48.9%, P=.051), smaller proportion of Hispanic applicants (0.9% vs 11.3%, P=0.003), greater proportion of applicants who prefer to self-describe their ethnicity (10.4% vs. 2.1%, P=.019), and greater representation from urban areas (48.1% vs 28.3%, P=.023, Table 2).¹³ A majority of our study sample (86%) had some level of debt concern (Question I categorized as slightly, somewhat, or moderately impacts), and most (88.8%) also noted that a majority of their interviews were virtual.

Contrary to expectations, there was no association between debt concern and digital interview preference. Most candidates preferred the virtual format. Regardless of debt concern, most students (87.4%) accepted virtual interview offers that they may not have otherwise due to time and expenses (Figure 1). Additionally, 87.1% recommended a virtual component to future residency interviews. Covariates of sex (P=.006) and MD/DO degree (P=.031) were associated interview format preferences, while race (P=.443) was not. While most accepted virtual interviews, 64.8% also highlighted the importance of visiting programs of interest in-person. Several applicants provided free-response narrative feedback related to debt impacts on career considerations (Table 3). Students described the financial burdens of medical training and how it limited their ability to apply and interview widely. Some appreciated how digital residency interviews reduced financial barriers and noted that in-person second look events were also helpful. 

Irrespective of debt concern, virtual residency interview formats are important to students and offer more flexibility within an already expensive and time-consuming process.^14-18 This study suggests that factors beyond medical school debt alone may influence applicants’ preference for and recommendation of virtual interviews.

Existing literature supports our study’s narrative feedback, citing cost alleviation, time efficiency, accessibility, and equity as benefits of virtual interviews.^19-26 The pervasive fear of not matching also likely plays a role, as online formats offer more feasibility, leading to increased applications.^27-30 However, despite reduced costs and application inflation with digital interviews, our data highlight that the financial burden of medical education still limits how broadly applicants apply and interview.

Programs have enhanced virtual interview days with more social engagement, but applicants do still value in-person second look days before finalizing their rank lists. This suggests that students are cognizant of program fit and find in-person days beneficial for decision-making.^31-32 However, unless residency programs standardize this process, expand financial accessibility, and ensure that attendance will not impact rank orders, inequity remains.^33-37 

Our study has limitations, including a low survey response rate resulting in an underwhelming sample size, with some significant demographic differences compared to overall ERAS applicants. Although varied, most email survey response rates are about 25%, possibly influenced by factors such as survey length and postpandemic survey fatigue.^38-40 AAFP membership trends also help contextualize this sample. Although many students obtain AAFP membership for a variety of resources, internal tracking show that 11%-17% of student members go on to become resident members. Additionally, debt concern may not accurately reflect financial stressors and does not account for actual debt burden. Variations in debt levels, generational and cultural wealth, and first-generation medical student status, may influence debt perception and residency decisions.^41-44 

Future studies should better quantify debt burden and incorporate more narrative feedback to understand interview preferences. Residency program directors should weigh applicants’ concerns and preferences in an overburdened application process, while prioritizing equity throughout.