Recruiting gastroenterology and hepatology fellows virtually - Should we continue after the pandemic?
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02/27/2023
, from the standpoint of the program director (Dr. Clark) and the associate program director (Dr. Dakhoul) of the fellowship program at the University of Florida in Gainesville. We have conducted our fellowship interviews for the academic year 2022-2023 completely virtually over multiple half-day sessions and fully matched all four positions. At the time of the interviews, we extended a general invitation to all candidates for an in-person visit for the purpose of touring the facilities and our community. Out of the 37 applicants interviewed, 2 made an in-person visit later.
After we concluded the interview season, we conducted a brief, anonymous survey to assess the overall experience of the interviewees with their virtual interviews. (See end of this article.) The survey contained a combination of single-choice questions and open-ended questions. The response rate was 35%. Most responders (92.3%) thought that they had a great understanding of the program from the information provided to them, and 84.6% were quite satisfied with their virtual interview experience. Regarding the likelihood of accepting the interview if it were offered in person, only one person answered that he/she would not have accepted the invitation. A total of 31% of participants might have changed the ranking of the program if they’d had an in-person interview instead.
When asked to choose between an invitation for an in-person vs. a virtual interview, the majority (77%) chose the virtual option. The stated pros of being interviewed virtually included convenience (not having to find coverage, etc.), time and cost savings, and a less stressful experience. Cons were focused mostly on not being able to see the hospital or the geographical area in person, as well as limited exposure to the facility and work environment for subjective assessment of “fitting” into the program. Additional comments included mostly positive feedback about the whole experience specific to the program. Finally, 77% of respondents recommended that the program should continue to conduct its interviews virtually.
It seems that the general feedback from our survey was positive. Certainly, limitations exist, including but not limited to the response rate, the geographic locations of the invited candidates, the design of the interview day, and familiarity with the fellowship program and the surrounding area. Several studies have been published on the topic with variable results across centers and among specialties, but most of them reported an encouraging overall experience.4-9
While the virtual recruitment experience seems to be most appealing to candidates, fellowships program directors and faculty who are part of the selection committee do not seem to be completely satisfied with the process and/or the outcome. Although virtual recruitment was shown to reduce financial costs and use of institutional resources,6 the major drawbacks were a lack of perception of the communication skills of the candidates as well as an inability to properly assess the interpersonal interactions with fellows and other applicants, both major keys to ranking decisions.10
Furthermore, the number of candidates who applied to our program has been steadily on the rise since the virtual platform was introduced. This has been the case nationwide and in other specialties as well.11 Applicants invited for an interview rarely decline or cancel the invitation due to the convenience of the virtual setting.6 These factors can affect the choice of candidates and subsequently the results of the match, especially for smaller programs. These observations create a new dilemma of whether fellowship programs need to consider increasing the number of their interviewees to ascertain a full match. Although the number of gastroenterology fellowship positions is steadily increasing with new program openings every year, it might not match the speed of the up-trending number of applicants. This certainly creates concern for fairness and equity in the selection process in this very competitive subspecialty.
As most gastroenterology programs continue to recruit their fellows virtually, it is important to keep in mind a few key elements to enhance the virtual experience. These include: a) familiarity of the interviewers and interviewees with video conference software to avoid technical problems, b) inclusion of up-to-date information about the program on the institutional website as well as videos or live-stream tours to show the physical aspect of the training sites (mainly the endoscopy areas) as alternatives to in-person tours,12 and c) timing of the interview, taking into consideration the different time zones of the invited applicants. Despite optimizing the virtual experience, some interviewees might still choose to visit in person. While this decision is solely voluntary and remains optional (at least in our program), it does allow program directors to indirectly evaluate candidates with a strong interest in the program.
In conclusion, there is no clear-cut answer to whether conducting interviews virtually is the best way to continue to recruit gastroenterology and hepatology fellows beyond the pandemic. While our perspective might be somewhat biased by the positive experience we had in the past few years recruiting our fellows virtually, this should be an individualized decision for every program. It is highly dependent on the location and size of each fellowship program, faculty engagement in the interview process, and the historical matching rates of the program. On a positive note, the individualized approach by each fellowship program should highlight the best features of the program and have a positive impact on recruitment at the local level. We have to bear in mind that a nonstandardized approach to fellow recruitment may have disadvantages to both programs and applicants with fewer resources to successfully compete and may introduce another element of uncertainty to an already stressful process for applicants and programs alike. As we continue to understand the implications of using the virtual platform and to reflect on the previous match results through the performance and satisfaction of the fellows recruited virtually, this option does not seem to have completely replaced in-person meetings. Further follow-up to evaluate the impact of virtual interviews should be done by surveying program directors nationally on the impact of match results before and after implementation of virtual interviews.
Survey
A. Do you think you had a good understanding of the UF GI Fellowship program from the information provided to you during your virtual interview?
1. I was provided with all the information I needed to know, and I had a great understanding of the program
2. I was provided with some information, and I had a fair understanding of the program
3. I was not provided with enough information, and I don’t think I understand the program well
B. How likely were you to accept this interview if this had been an in-person interview?
1. I would have still accepted the invitation regardless
2. I would have thought about possibly not accepting the invitation
3. I wouldn’t have accepted the invitation
C. Do you think an in-person interview would have changed your program ranking?
1. Yes
2. Maybe, I am not sure
3. No
D. If you had a choice between conducting this interview virtually vs. in-person, which one would you have chosen?
1. Virtual
2. In-person
E. Overall, how satisfied were you with your virtual GI Fellowship interview experience at UF?
1. Quite satisfied
2. Somewhat satisfied
3. Not at all satisfied
F. If you chose “somewhat satisfied” or “not at all satisfied” in the previous question, please tell us why, and what are the things that we could have done better:G. Do you think the UF GI Fellowship program should continue to conduct its interviews virtually (regardless of COVID)?
1. Yes
2. No
H. Please list some of the pros and cons of being interviewed virtually, in your opinion:
I. Additional comments:
Dr. Dakhoul, Ms. Rhoden, and Dr. Clark are with the division of gastroenterology and hepatology, University of Florida, Gainesville. They have no disclosures or conflicts.
Summary content
7 Key Takeaways
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Developed a paper-based colorimetric sensor array for chemical threat detection.
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Can detect 12 chemical agents, including industrial toxins.
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Production cost is under 20 cents per chip.
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Utilizes dye-loaded silica particles on self-adhesive paper.
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Provides rapid, simultaneous identification through image analysis.
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Inspired by the mammalian olfactory system for pattern recognition.
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Future developments include a machine learning-enabled reader device.
The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?
Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.
Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?
Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).
Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?
Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.
The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?
Dr. Staller: I define “refractory” with three anchors.
1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).
2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.
3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).
What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?
Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.
The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?
Dr. Staller: I see three major areas.
1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).
2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.
3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.
Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.
Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.