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4 Articles in this Series
Introduction
Complex Regional Pain Syndrome (CRPS): A Screening & Treatment Update
Facial Pain: Recognizing & Treating Trigeminal Neuralgia, Temporomandibular Disorders
Multiple Mini Interviews: The New Approach to Pain Fellow Recruitment
Neuropathic Pain: An Update on Practical Management Including Neurostimulation and Mechanism-Based Pharmacotherapy

Multiple Mini Interviews: The New Approach to Pain Fellow Recruitment

An AAPM 2021 Meeting Highlight with Ravi Prasad, PhD, Charles De Mesa, DO, and Scott G. Pritzlaff, MD  

Finding the best fellows for a pain medicine fellowship program has always been a challenge; it's even more so with the COVID pandemic. At the AAPM 2021 virtual annual meeting, a trio of experts from the University of California Davis presented detailed information on an innovative approach to pain medicine fellow recruitment: multiple mini interviews or MMIs.

The pain medicine fellowship is an intensive year, as Ravi Prasad, PhD, clinical professor of anesthesiology and pain medicine and director of behavioral health at UC Davis, told listeners. Both the candidates and those choosing the candidates face challenges.

There are 106 total pain fellowship programs in North America, and 103 of them participating in the match. It's a highly competitive field. ''As clinicians, we have to provide training to clinicians who come from a wide variety of backgrounds," said Dr. Prasad. With that range of skills coming in, he noted, there is a need to provide comprehensive training to all.

Needless to say, the pandemic has added to the stress, with travel restrictions and other challenges. Lack of live interviews means not being able to pick up on nuances, as one has been used to, he said. At the same time, without travel expenses, applicants can apply to more programs, leading to a rise in competition.

This environment has led to some shifts in recruiting ideal candidates: the MMI. But how does it work? Below are the highlights.

Traditional Recruiting Practices for Pain Medicine Fellowships

Among the components of a traditional fellowship recruitment process, according to Dr. Prasad:

  • Board scores and academic preparedness
  • Letters of recommendation
  • Personal statement
  • Experience such as research
  • Interview performance

While these traditional measures do supply valuable information, they come with limitations. For instance, recommendation letters might actually be written by the applicant and signed by the recommending professional. Or, a letter writer might be the supervisor, but they may not be adept at communicating thoughts that truly capture the candidate. Interview performance, based on one traditional interview, does not always capture the true skills and personality of the candidate.

Alternative Model: Multiple Mini Interviews (MMIs)

At UC Davis, the pain medicine fellowship administrators have transitioned to an MMI approach. Basically, this is a series of mini interviews or "encounters," closely timed and lasting under an hour total. The approach is not new – MMIs began at McMaster University in Canada nearly 20 years ago and have become popular in other countries, and other professional fields in the US including other areas of medicine – but they have not taken shape consistently in pain fellowships, noted Dr. Prasad.

Among the benefits: MMIs minimizes bias, maximize fairness, and are based on science and research. Plus, they can be conducted virtually, in person, or both. For applicants, having multiple interviews with multiple raters (ie, interviewers) provides an opportunity to save grace, so to speak; if they fall short on one interview, they can work to make up for it in the next.

Multiple Mini Interviews: The Evidence

Are multiple mini interviews effective? Yes, according to Charles DeMesa, DO, associate professor of pain medicine at UC Davis. However, training for faculty and staff who will be conducting the short encounters is crucial (more on this below). Also, it’s important to recognize that MMIs still must be supplemented by other information, such as applicants’ board scores, academic preparedness, experience, and community service.

The UC Davis experts say there is a correlation between the composite MMI score and academic indicators. In a survey of 103 candidates, over three recruiting seasons (two before COVID, one during)  at UC Davis, the majority reported being satisfied with their MMI interview day. The candidates shared that felt listened to and had great interactions with faculty. In another study of 24 candidates who had virtual MMIs, there was also great satisfaction, with no one rating the experience as neutral, unsatisfied, or very unsatisfied.

The Multiple Mini Interview (MMI): The How-Tos

At UC Davis, for the pain medicine fellowship, applicants have 6 encounters, all blinded, that last 8 minutes each. Except for the program director, the raters do not know the candidate's name or other information. In each mini interview, the candidate takes 2 minutes to read a scenario (see below) and 6 minutes to discuss the situation with the rater. There is a circuit of stations.

Scott Pritzlaff, MD, director of the UC Davis pain medicine fellowship program, presented a sample MMI scenario, from McMaster: If you were in charge of a committee to decide whether to mandate a flu vaccine for healthcare workers [in a specific location], what information would you collect first?

The rater must assess analytic skills used, whether the candidate considered the issue from multiple perspectives, and judge whether the candidate understands the points related to the issue, among other judgments. The interviewer usually asks a series of 3 questions, but gives no feedback on answers. When scoring, there are no right or wrong answers on the score sheet. It is a continuum, from ''unsuitable" to "outstanding."

Several aspects are important to keep this type of assessment effective, said Dr. Pritzlaff. It's important to discuss the ground rules, such as telling the candidate about timing and how they will be presented with a scenario. In addition, he advises that raters score in real time. "In a busy day, with 6 to 8 candidates, you don't want to lose the fidelity of that encounter."

Most important, he said, is that the rater not provide any feedback to the candidate. "That introduces an element of bias," Dr. Pritzlaff said. The encounters are blinded to reduce bias.

When doing MMIs all virtually, program directors need to explain ahead of time to the candidates how the virtual sessions work, have technical support on hand in case of glitches, and send a confidentiality agreement in advance to all participating applicants.

Additional Tactics

After the session, Dr. DeMesa told PPM that he would urge those involved in fellowship recruiting who want to try MMIs to check around at their own institution. "They may be doing it already in [other programs,” he noted. At UC Davis, for instance, his team received guidance from the university's veterinary school, which had already launched MMIs.

As for those hesitant to make the leap from traditional interviewing to multiple mini interviews, “This can be done incrementally," Dr. Pritzlaff told PPM. A hybrid approach is one, using both traditional and MMI approaches where possible to get started.

At the end of the day, Dr. Prasad reinforced that ''consistency is critical" when using an MMI approach, such as in the timing of each MMI and in reminding the rater to be consistent.

The UC Davis speakers published a summary of their approach.

In Other News: Pandemic Impact on Pain Fellowship Education, Mentoring

In a related but separate session at AAPM’s 2021 annual meeting, Lynn Kohan, MD, director of the pain fellowship program at the University of Virginia, talked about how pandemic policies have impacted fellowship education and mentoring. She cited input from the Accreditation Committee on Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS).

In a survey to gauge how fellowship programs across the country have adapted during the pandemic, Dr. Kohan sent a questionnaire to directors of  just over 100 fellowship programs; she got 70 responses. Of those, most reported a decreased workload on directors and fellows, with more than half saying their fellows were sent to provide non-pain care. Despite the necessary restrictions on in-person interactions, with a shift to telemedicine, she found some pandemic-related silver linings, such as an increase in inter-institutional sessions and webinars to supplement education.

 

Disclosures: Dr. Pritzlaff is a consultant for SPR Therapeutics, EBT Medical and Nalu Medical and is on the board of World Academy of Pain Medicine United, Pacific /Spine and Pain Society. Drs. Kohan, DeMesa, and Prasad reported no disclosures.

Next summary: Neuropathic Pain: An Update on Practical Management Including Neurostimulation and Mechanism-Based Pharmacotherapy
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