The Career Medical Interview: solid selector or just ‘impression management’? Ray F Swann*, Damien M Bolton* and Nathan Lawrentschuk*† *Department of Surgery, Austin Hospital, University of Melbourne, and †Division of Cancer Surgery, Olivia Newton-John Cancer Research Institute, Austin Hospital and Peter MacCallum Cancer Centre, Melbourne, Vic., Australia
Introduction Interviews remain the discriminator for selection to surgical training schemes. This is due to normalising issues with the other two main components, being referee scores (often averaging out across candidates) and curriculum vitae scores (capped thus rarely allowing for ‘stand out candidates’). However the interview as a selection tool may suffer from a number of systemic issues due to potential variables such as the ‘halo effect’ (where one key attribute from a candidate might influence the interviewer in another of his/her attributes), first impression, and contrast bias (where candidates may be compared to each other rather than strictly to the criterion). Recent modifications have attempted to counter such perceptions, including a folio based approach to interviews whereby different sub-interviews, vignettes and even role plays make up the ‘whole interview’. Further, the continued development and evolution of the MMI (multiple mini interview), along with further research into inter-rater reliability have refined the process. Interviews aim to measure many desirable cognitive and noncognitive attributes. Career medical interviews are unique by rating both the ability to learn as well as assessing established qualities desired in a urologist. What remains unknown is the strength of an interview to have predicative validity for a candidate as they move through surgical training. Do current candidates ‘over prepare’ or rote learn responses as an effective means of ‘impression management’? Might this also be distorting the selection scale, and ultimately leading to the wrong candidates being selected? Are candidates being ‘ratedout’ as they are not able to prepare properly?
Further Tensions on the Interview Process for Applicants Recently published figures demonstrate that growth in trainee applicants is outpacing growth in training positions [1]. Whilst this in part validates candidate selection in terms of supply/demand, there is increasing pressure on the aspirational surgeon. In short, there is huge pressure to get a position, more competition and the selection process is mostly a closely guarded secret. Training bodies rarely publicise what they expect in an interview, and it is in their
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interest to protect such data to mitigate against prepared answers. So how is the aspiring trainee best advised to prepare for the selection interview? Published selection criteria only refer back to global concepts of what is expected of a well trained doctor such as the Canadian CanMEDS criteria (www.royalcollege.ca) or the RACS ‘attributes of a surgeon’ (www.surgeons.org). An analysis of freely available preparation strategies using free online access medical education (FOAMed) tools provides few answers. Of the FOAMed resources for a search of ‘interview preparation’ there were 21 items, but only one related to how to actually prepare for an interview- ‘to be one’s self.’ Whilst not specific, it is consistent with Rosenfeld’s mantra for an interview being to ‘look in the mirror’ to see what sort of person you are [2]. There remains a disconnect between wanting to prepare for a surgical selection interview, knowing how to properly prepare and manage factors that distort the measurement instrument, and clear logical advice as to how to prepare.
Problems with Preparation and Process Persist With the lack of course specific and readily available material, it is not surprising that many applicants engage in impression management (IM) strategies to improve their chances of success and to minimize anxiety. IM is defined as the conscious attempt to control portrayal in social interactions [3]. The key area is the reduction and/or management of anxiety in regards to an interview performance, which is often difficult to manage for many candidates. In an interview, candidates suffering interview anxiety may experience a range of symptoms potentially impacting on their performance [4]. Yet these perceived weaknesses in the interview may not actually be consistent with their ability to competently treat patients. In other words, they may not be ‘good at interviews’ but may be excellent sympathetic communicators and doctors, and able to easily manage other forms of stress and anxiety. It could be argued too that there are some candidates who may perform well in an interview, yet not communicate as well to a patient or manage the rigours and high stakes involved in a surgical career.
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Impression Management in Surgical Interviews Little is known about impression management in urology interviews. IM literature states that impression management is very common in career interviews, with nearly all candidates engaging in some form of IM [3]. IM starts with appearance and body language but in this context it is manipulating carefully what one actually says in response to questions. The overall aim is to leave the interviewers with a favourable impression, but perhaps more calculated and crafted than the well meaning concept of ‘leaving a good impression’. At best, this might include strategies such as ingratiation (a form of assertive IM) [5] or possibly taking more credit than due in a story illustrating a feature of their persona. At worst it may include fabrication and deceit. In a recent survey of successful urology training scheme applicants, 14% admitted that if they did not know the answer to an interview question that they would ‘make one up’ [6]. It has been found in career interviews that likelihood of a successful interview outcome rises significantly if extensive image creation was used in the context of the interview to influence the interview rater. It has also been argued that ‘faking’ can actually lower anxiety in an interview, thus becoming a desirable strategy for some. Thus interview performance may be enhanced by IM but are the right applicants selected? A lack of quality control by training bodies exists in this area as there is no published research correlating interview scores with how candidates perform over their training period or when completed. One may speculate on other metrics as to how well candidates are matched into careers. One example may be the medico-legal literature that constantly reminds us that difficulties arising in the health system can be attributed to poor communication the one attribute that theoretically should be assessed in an interview. Harder data on training assessments matched against selection interviews, rather than extrapolating from troublesome doctors, would be far more accurate but is
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lacking. Furthermore, a systematic analysis of successful candidates and their performance outcomes in urology training matched against interview scores and items would help to better understand if the present system of measurement was effective, or whether impression management was potentially an issue.
Summary There are a number of factors that need to be considered to answer the question of whether the present interview is a solid selector or is influenced by impression management tactics. To this end, clinical benefit may ensue from further clarifying the selection criteria within the career medical interview, and demystifying this process. Further research into developing models of training that provide a logical and systematic approach for candidates would be valuable to ensure that the results of the interview selection instrument remain closely correlated with good clinical outcomes for successful candidates.
References 1 Joyce CM. The medical workforce in 2025: what’s in the numbers? Med J Aust 2012; 1: 6–9 2 Millar E. Let’s all play doctor. Maclean’s. 2009; 122: 50–1 3 Schlenker BR. Impression Management: The Self Concept, Social Identity, and Interpersonal Relations. Monterey, CA: Brooks/Cole; 1980. 4 McCarthy J, Goffin R. Measuring job interview anxiety: beyond weak knees and sweaty palms. Pers Psychol 2004; 57: 607–37 5 Tedeschi JT, Melburg V. Impression management and influence in the organization. Res Sociol of Organ 1984; 3: 31–58 6 Swann RF, Lawrentschuk NL, Bolton DM. Set trainees and the career medical interview: what they think and how they prepared. BJU Int 2013; 111: 90
Correspondence: Ray Swann, Suite 5, 210 Burgundy St, Heidelberg, Vic. 3084, Australia. e-mail:
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