This anonymous online survey received responses from the majority of Canadian OHNS residency programs and represents an overview of clinical electives in OHNS in Canada prior to visiting electives being cancelled in 2020 due to the COVID-19 pandemic. Worldwide, the COVID-19 pandemic affected medical student education, particularly student electives, with some being cancelled altogether, some at a student’s home institution, and some electives became virtual [6]. However, the full long-term impact these changes have had on medical student education remains unclear [6]. In addition, these changes have affected students' transition from medical school to residency in terms of feelings of preparedness and confidence [7].

Even before the COVID-19 pandemic, this survey demonstrated that electives are quite variable from one institution to another, and there is a lack of consistency in the structure of electives across Canada, which is a common theme amongst surgical clerkship rotations across Canada [8]. This study provides insights into the value of visiting OHNS electives and its effects on the CaRMS process.

Our survey demonstrated a variable amount of didactic learning, evaluation, procedural skills, and call expectations from one institution to another. This variation further contributes to the lack of consistency in the OHNS curriculum across Canada. This was depicted by the different amounts of time with various preceptors and areas of OHNS that elective students can partake in with variation in types of learning activities offered to the students. The majority of programs offered 2-week rotations for students and assigned students to spend most of their time in structured clinical activities (OR and clinic) compared with non-structured activities such as ward/inpatient responsibilities. With the similarities in their structure, it allows for the possibility of creating a more standardized structure for electives. When a standardized curriculum was implemented at a single institution in urology, it demonstrated that students were more likely to achieve core learning objectives [9].

Generally, when the format of fourth year electives was designed, their goal was to remain loosely structured to allow students to explore various careers pathways [10]. Providing structure to an elective enables students to put a greater focus on career selection, increasing clinical responsibilities expanding on clinical knowledge and skills, and decompressing from their core clerkship experiences [11]. Furthermore, there has been discussion about reforming electives in the USA to have a greater focus on student mentoring and career advising while on rotations [10]. With the current flexibility of the curriculum, it can allow students to focus on gaps in their knowledge and clinical skills, but this approach requires adequate guidance and support from the faculty at the elective site [10].

However, having a standardized rotation time would be beneficial for creating a tailored curriculum for elective students. This was demonstrated by the lack of consistency between elective sites can create barriers to student learning; this includes unknown expectations and the possibility of repetitive curriculum [12]. Additionally, this variation is an added barrier for students who are unable to do electives away from their home institution, as their elective experience will differ from their peers across the country. We feel it is also important to note that although performing inpatient and ward duties are important and can impart crucial knowledge, having time in the OR and clinic likely provides more educational opportunities and a chance for the students to be observed and receive feedback.

However, there is an advantage for a student having a variation in their elective experiences allows them to broaden their perspective of OHNS as a specialty. Additionally, being exposed to new learning environments can be beneficial for a student when deciding which institution best suits their learning needs when submitting their CaRMS rank order list. The differences in student experiences will likely not significantly affect the student by the end of their five-year surgical residency program.

Electives are important for students to address knowledge gaps and learning goals as only 75% of Canadian medical schools teach OHNS-related lectures in pre-clerkship years, and the average Canadian medical student clerk will have 4.6 days of mandatory clinical clerkship experience within OHNS [13]. These knowledge gaps are not unique to OHNS and are common in other niche areas of medicine, such as ophthalmology, further highlighting the need for electives to help students develop their skills and knowledge in the field before postgraduate training [14]. However, beyond the clinical knowledge that will be further developed in residency, fourth-year electives offer the opportunity to teach students skills they will need in residency, including self-reflection, organizational skills, and professionalism from a variety of perspectives and experiences [15].

The majority of teaching sessions were designed for residents, so the value to medical students is debatable. Having educational content delivered specially for elective students would possibly help fill knowledge gaps. As responders appeared to be willing to provide more teaching to elective students, this may not be much of a challenge to convince the attending surgeons to implement these learning objectives in the elective curriculum. However, exposure to the types of learning offered to residents can be beneficial for students to assess the teaching styles offered at various institutions.

In the Canadian curriculum, most instructional OHNS content outside of elective time did not contain opportunities for formal evaluation [16]. On the other hand, we found that the majority of our responders did provide an opportunity for evaluation, most commonly in a post-elective meeting (74%), and most responders evaluate students through a formal evaluation from (70%). These conversations can help set expectations for the student to focus their learning and for the program to evaluate how the student’s knowledge and abilities change over the elective. Pre-elective meetings are helpful for students to establish expectations with program directors, highlight learning goals, and ensure the program is aware of their baseline knowledge [17]. In addition, feedback can be helpful for students to discover areas of improvement and receive feedback on things they are doing well and helps the student become an active participant in their learning process [17, 18]. Interestingly, when a formal evaluation was used, it was most commonly the elective student's home evaluation form that was used. Having multiple different feedback forms used to evaluate students can lead to ambiguity when trying to compare students during CaRMS ranking. A standardized form used by all programs could be one method to decrease this variability.

Program directors tend to focus more on interpersonal skills and teamwork than academic excellence and technical skills. For example, in a study from the United States of America (USA), electives were seen as a valuable tool for programs to assess candidates, and they were seen as an audition to show the department a student’s interpersonal skills [19]. However, the program directors placed a higher value on knowledge and the interview process when asked to select the most important traits of a potential candidate [19]. Interpersonal skills are challenging to evaluate through any other format than an elective, as interviews may not represent a candidate's ability to collaborate or demonstrate an ability to work in team settings.

Prior to the pandemic, most Canadian residency programs placed a higher weight on performance during electives, letters of reference, and the interview process [20]. This survey depicted that most residents (77.4%) had done an elective at the institution in which they matched. Many programs found that electives are essential for determining if someone will match over interviews alone. Electives may be especially advantageous for a student without a home program as it helps them gain exposure, build connections, and confirm their career choice [21]. From the student perspective, electives are beneficial for students to determine which programs align best with their career goals, geographic preferences, and characteristics of the learning environment [20]. This may also demonstrate the importance of students without a home OHNS program having the opportunity to perform electives outside their institution to obtain a residency position. In a study from the USA, 78.8% of students without a program at their home institution felt like they were more disadvantaged in their chances of obtaining an OHNS residency compared to their colleagues from schools with a program [22]. With the current suspension of travelling electives, it poses challenges for students without OHNS programs at their home institutions to acquire meaningful letters of recommendation to comment on their abilities as a student [6].

These challenges have led both programs and students alike to find creative solutions to be able to mimic the traditional CaRMS experience as closely as possible given the virtual format [23]. One of the new ways to build relationships and allow students to meet the residents and the faculty has been the introduction of Zoom open houses, Zoom resident-only mixers, and more regular updates to program websites [23, 24]. As 31.7% of the survey respondents stated that there will be changes to the CaRMS process, it poses the question of how might these changes be made? In countries like the USA, even prior to the pandemic, the U.S Medical Licensing Exams (USMLE) scores and letters of recommendation were the two most important factors for a candidate to obtain a spot in a residency program [20]. While, in Canada, with the absence of objective measures of grades and scores, it is postulated that programs will begin to rely more heavily on other factors including, research, volunteerism, clerkship performance, and the virtual interview process, as a lack of travelling electives makes it difficult for programs to accurately assess a student’s clinical performance [20, 25].

There are several limitations to this study as it was a qualitative study. Not every Canadian OHNS program responded to this survey, and these results may not reflect the opinions of all programs. This may be especially true for provinces with only one to two programs, as candidate selection may vary from one province to another. There may have also been some response bias as some programs filled out this survey as they would have prior to the COVID-19 pandemic, while others completed the survey with the cancellation of electives in mind.