Navigating the New World of Applying to Emergency Medicine

 If you have spent any time looking around the pages of this site you already know that a lot of the advice is quite outdated. We used to have some hard data on the Emergency Medicine Match, and where we lacked that there was expert consensus opinion from groups like the CORD-EM Advising Students Committee and the Emergency Medicine Residency Associate (EMRA). They even published a book together. There is still a lot of useful advice to found on topics like choosing EM and preparing for rotations. But the actual Match process has been turned upside down in the last few years.  In this post I am going to try to connect you with the best resources we have to help you navigate this new world.  

The CORD ASC-EM MyERAS Guide

This exceptional document takes you through all the changes to the ERAS application and includes balanced recommendations with transparency on where there is controversy or data is lacking. A must read for anyone applying to EM.  

The CORD ASC-EM Resources page

A compilation of various special population advising guides, virtual interview advice, student planners and much more. These guides do get updated annually, though the pace of change in the match has been hard to keep up with. 

EMRA Hangouts

This series of recorded discussions covers the changes to the EM application process for this application cycle. 

EMRA Match

The premiere residency (and clerkship) navigator program. The information is not perfect but the data provided is what previous applicants have asked for.  

ALiEM Match Advice Series

This podcast series is a great place to understand how the match has changed, how program directors look at these events, and to get additional insights on the updated ERAS process. 

Understanding the SLOE

EM has unique Standardized Letters of Evaluation (SLOE) that will be one of the most important parts of your application. This information page from CORD should help you better understand them. 

I hope you find these resources helpful.  

- Adam

Preference Signaling for Emergency Medicine - How to Use Your Program Signal Tokens well

Preference Signaling is Here

One of the biggest challenges for applying to Emergency Medicine residencies is conveying genuine interest. Just applying to a program is not sufficient as many students apply to programs they have no desire to train at. Over-application is a completely rational response to a system where it is difficult to assess personal competitiveness and where the consequences of not getting enough interviews can be not matching in your desired specialty. This still leaves programs attempting to sift the “serious” applicants out of the pool of those who apply. We use surrogate markers like geographic ties, applicant interests and experiences that align with program strengths, or recent experience with applicants from that school.  

In response a common practice developed of applicants also sending an emailed “letter of interest” outside ERAS. This is more work for the students and disliked by many Program Directors, especially when the letter did not add anything not already in the application they just received. If Program Director’s assume that applicants send these letters to all of the programs they applied to, they have no meaning.  

Enter the idea of “preference signaling” by applicants to programs. The applicant does not have to write an additional letter and the program knows this signal has value as each applicant is limited to 5. How this came to be is covered really well in the Council of Residency Directors in Emergency Medicine (CORD-EM) Preference/Program Signaling Supplemental Guide. What I want to discuss here is how to approach using your 5 precious signals. 

The goal is to positively influence Program Directors at places you have genuine interest and  who would not have offered you an interview if there was no signal. Right now we don’t know for sure how programs will respond to a signal, but we can make some educated assumptions. Based on surveys, discussion forums, and data from other specialties, it is likely that a signal will make most programs more likely to interview you. However, the big exception will be among programs who receive an overwhelming number of signals. They will either make a signal a requirement for them to consider an application or ignore the signals entirely. This choice will depend on their assumptions around how applicants will use the signals. 

Let's Talk Strategy

So how should you strategize using your signals? Here are a few general “rules” that apply to most applicants:

1. Use your signals on program you are genuinely interested in 

2. Don’t signal programs you are rotating at unless they explicitly tell you that you need to

3. Signals are best used on programs where you might get an interview, but are not definitely getting one

1. Don’t waste them on programs where the signal is unlikely to convince them to interview you

2. Don’t waste them on programs that are highly likely to interview you anyway

4. Use your signals on program you are genuinely interested in 

1. This is in here twice because there is real potential to over-game this system - don’t lose sight of the goal is to go somewhere you want

Even following those rules you can still come up with very different strategies for how to use your signals. Your training and career goals, self-assessment of your competitiveness as an applicant (aided by an experienced advisor) and your risk tolerance should all factor into your personal strategy.

Here are some examples that are a little more concrete: 

Maximum Value - For the applicant worried about their competitiveness for interviews. Use your signals on programs you are interested in BUT that you expect to NOT get a lot of signals (less popular locations, less well-known, newer, or other evidence of being a less competitive program). The less signals a program gets the greater value each signal has. 

Shooting for the Stars - For the applicant who is above average on paper and in the eyes of an experienced EM advisor. Use your signals on programs that are likely to get lots of signals. You will get many other interviews regardless and it may be necessary to signal the more “popular” programs to have a chance at an interview. 

Balanced - For most applicants who don’t want to overthink this. Use three signals on programs that you are genuinely interested in and that are realistic for you (nothing about the program is telling you that this should be a hard interview to get). Use one signal on a program you are really interested in but where you suspect you don’t have a realistic chance at an interview. Use one on an acceptable program you expect to not get a lot of signals. 

There is no evidence on what a “winning” strategy is for using Preference Signaling this year. If you have other ideas on how to approach this, put them in the comments below and we can talk them out.  

Most important take home:  Use your signals, and use them at places you are interested in. 

Adam Kellogg has not done a very good job keeping this site updated during the pandemic. That has been fixed now with most of the Advising “pages” updated for 2022. 

URiM Opportunities are Abound

What's available for URiM Applicants

If you are looking to secure your away rotation in Emergency Medicine(EM) have you considered looking into Underrepresented in Medicine(URiM) scholarships within EM? There are many programs currently offering scholarships to assist you with the expenses related to externship. Programs are looking for ways to actively attract a wide variety of applicants including those currently underrepresented in EM. Check out EMRA Match Clerkship, SAEM, and AAEM's RSA for the myriad of scholarship options. 

Looking for more advice, CORD ASC EM has a dedicated Applying Guide for URiM that is well worth a read even if you already secured your rotations. Also check out the American Medical Student Association’s Race, Ethnicity, and Culture in Health Action Committee(AMSA-REACH) tremendous list of resources, the American Medical Association-Minority Affairs Section(AMA-MAS) is free for all students, regardless of AMA membership and offers many scholarship programs and awards. If you are looking for a mentor consider the Society for Academic Emergency Medicine’s Academy for Diversity and Inclusion in Emergency Medicine(SAEM-ADIEM).

At UMMS Baystate we have additional scholarships available this year and open spots this fall for away rotators. We are committed to serving a diverse population within the Springfield, MA area. Our goal as an emergency department is to recruit a diverse workforce that reflects the diversity of patients we see in Hampden county, to provide caring and equitable care to all who walk through our doors. 

The diversity and equity division was created within our emergency department to create initiatives focused upon increasing awareness of health inequities. Doctors Vanna Albert and Nadia Villarroel are two emergency medicine faculty members at UMMS Baystate who are leading and working with members of the emergency department to help enhance the medical education around health inequities. Some of our initiatives include providing scholarships for underrepresented students for our emergency medicine clerkship. We also aim to discuss health equity topics in a longitudinal fashion throughout the academic year within our health equity fellowship, journal club and residency didactics. Apply for an AI rotation through the Visiting Student Learning Opportunities (VSLO, previously known as VSAS).

This application process includes submission of a CV and letter of interest in EM

- Submission of a Supplemental Scholarship Application (500 words or less):

• Describe how your experience as an under-represented student in medicine has shaped your path to pursue a career in emergency medicine

• Email this supplemental scholarship application to: baystateemdiversityinclusion@gmail.com

Take this opportunity to explore all the options for support and involvement within URiM & EM.

Lucienne Lutfy-Clayton is an Associate Residency Director, past Chair of the ASC-EM, and avid supporter of URiM especially the really short.

Consensus Statement on 2021-22 EM Match - Implications for Applicants

 The COVID-19 pandemic is anticipated to impact the 2021-22 Residency Application cycle, though in different ways than this past year.  The Coalition for Physician Accountability (CoPA) released guidelines for Away rotations in general and all of the Emergency Medicine stakeholder organizations put together a detailed Consensus Statement that you can read here.  

Despite this attempt to provide clarity, there are still a lot of questions as to what this really means for students, especially those without a traditional "home" rotation available.  

Below is some Q&A on common questions that have come up in response to these guidelines.

When can students complete "away" rotations?  These are not supposed to be available before August 1, 2021.  However, this restriction does not apply to students without a "home" rotation.  Those students can take the first available opportunity at an institution that is open to "away" rotators.  

How many rotations can students complete?  The recommendation is one or two rotations at Residency Programs (usually called something like "Sub-Internship" or "Advanced Elective").  If two rotations, then either one "home" and one "away" or two "away" rotations.  Other EM rotations do not count towards this total, including sub-specialty rotations (like Ultrasound or Pedi-EM) that take place at a Residency Program.  

What if I have two separate "home" sites available to me?  While this is not available for many students, you can do both, but you should then NOT do an away rotation.  If you are looking to be considered outside of the region where your medical school is you are likely to be better off doing only one of the "home" sites and doing an "away" rotation somewhere else you are interested in going to.  

How many SLOE's should I have this year?  The recommendation is two SLOE's from Residency Program Leadership (Residency SLOE).  The other letters in your application can be from the other types of SLOE's, but two Residency SLOE's should always take precedence in planning your application.  However, having just one of these letters is NOT going to be disqualifying.  Having three or four Residency SLOE's is strongly discouraged and will likely result in some application reviewers down-rating your application.  

Do I need to do an "away"?  Only having one Residency SLOE will not hurt your application.  However, there is added value in having two separate residencies evaluate your performance and candidacy for EM.  If one letter is not particularly strong the other letter can compensate for that, especially if growth is shown from one rotation to the next.  This is why EM has always preferred that students do two rotations.  The lack of a second SLOE may have hurt some applicants in the 2021 Match who would not have faced similar challenges getting interviews in a previous year when a second letter would have been available to provide reassurance.  

There is still a lot we don't know about what the 2021-22 Application cycle will look like, including whether interviews will be in-person, virtual, or a hybrid of the two.  

If you have other questions, or want some additional clarification, please submit those in the comments section below.

New Program outside Philadelphia and in the 2021 Match!

There is another new Emergency Medicine residency program that has been approved to recruit for this 2021 match.  The Pottstown/Phoenixville EM Residency in suburban Philadelphia will be in ERAS soon.  The Program Director, Ernest Leber, would like to hear from interested students through the email at the end of the message below:

I have been approved for a new EM program with Tower Health at Pottstown and Phoenixville Hospitals. Our program will  be a 3-year community EM program here in suburban Philly. We will have rotations at Pottstown, Phoenixville and Reading Hospitals. We have an excellent and enthusiastic group of physicians ready to train residents/learners.

We are recruiting for a July 2021 start. The process of getting listed in ERAS takes time but should be completed within the next couple of days which does not leave us much time for students to forward us their app and for us to interview. Please pass my email address on to any students you think may be interested in my program. They can email me directly to set up an interview before we get listed on ERAS.

Ernest.Leber@towerhealth.org

Thanks everyone
~Ernie

EM Application Uncertainty - What do we know?

There is a lot of concern on both sides of the Emergency Medicine residency application process.  Some programs have reported dramatic increases in the number of applications they have received.  Many students are worried by how few interviews they have been offered.  Has something fundamentally changed in the application process that can explain what is going on?  The answer is that yes, there has been a change, but there is not more competition for residency spots than in previous years.  

Below is a dive into the preliminary ERAS data for 2021 taken from the ERAS Statistics page at AAMC.org.  The data shows that applicants have not (or at least not yet) applied to substantially more programs than in previous years.

The answer to what is going on, unfortunately, does not have data to back it up.  Anecdotally, many EM residency programs are reporting that their interview acceptance rates are way up this year.  Applicants who get offered interviews are reportedly saying “yes” to almost all of them and are rarely cancelling.  This is different from previous years and is depriving other applicants of the chance to interview.  

Every year we see the applicants with the best on paper applications get the majority of the interview offers in the early stages.  As their schedule fills up they decline interviews which are then offered to other applicants.  So far this year, that is not happening.  With travel not being a barrier the “haves” are able to hoard interviews without repercussions. 

A US MD Senior guarding their collection of Emergency Medicine interview offers.

If you have more than 12-15 interviews:  it’s time to let some go.  Making decisions is a core skill in EM.  Each program offering you an interview already wants to match you.  You can narrow your list and cancel or decline the ones that are not in your top 15.

If you don’t have very many interviews: hang in there.  More are coming.  Either when your peers start to drop them or when programs add interview slots as they recognize that many of the applicants interviewing with them early in the process are not genuinely interested in their program. 

And now the data deep dive...

Looking at this data can help answer some questions about this unprecedented match year for Emergency Medicine.  First is the data followed by some analysis.

The total number of applicants to EM has been trending up steadily.  Folks do not appear to have been scared away by the front-line nature of EM. Instead, the steady growth in applicants has continued.  It is important to note that this increase has been accompanied by a steady increase in the number of residency spots available, both from new EM Residencies opening and existing residencies increasing their class sizes.

In addition, the data in this table make it look like DO applicants have just discovered the wonders of EM, but that is not what is really going on.  Instead this data just reflects the move to a single-accreditation system under the ACGME.  All DO applicants to EM are now shown here, not just those who applied to ACGME residencies (by 2021 all residencies are under the ACGME).  

The Bottom Line: The number of applicants to EM has NOT gone up in a way that will affect your chances of matching.   

According to this data, which is preliminary, the number of applications per applicant has actually leveled off for the last few years for both US MD and DO applicants.  That big climb in DO applications is deceptive as it did not include the applications to osteopath-only programs before the merger.  IMG applicants have steadily increased their numbers of applications.  

What we don’t see here is the expected increase in applications due to uncertainty.  If this holds it may reflect improved dissemination and uptake of application advice.  Or there could be another wave of applications coming as applicants panic over not getting sufficient interviews.  We shall see. 

Bottom Line:  So far, there has not been an increase in the number of applications per applicant, despite anecdotal reports by residency programs of significantly increased application numbers.  

This table argues against a generalized increase in the number of applications programs are receiving. Some programs may be seeing a significant surge in applications, but there does not appear to be a dramatic increase for most programs.  One possibility is that there has been a real increase in the number of applicants at programs that were prohibitively expensive for applicants to apply to.  This could be programs in areas that required most applicants to fly to.  For example, a student on the east coast (where there is a heavy concentration of medical schools) faced a significant cost to interview on the west coast.  That financial barrier is gone. 

Conversely, if some programs have seen a significant increase in the number of applications they have received, but the overall average number has barely changed (+33 from 2019), then there would have to be a group of programs that have seen their number of applications decrease.  

The Bottom Line:  There will be more competition for interviews at some programs, but not at all.   

If you have questions, comments, or other interpretations of this data, please share them in the comments and we will try to figure this out together.

Where are the Emergency Medicine interviews? Asking for a friend...

On October 21 at 8 am EST your meticulously crafted ERAS applications were sent to your chosen EM Residency Programs.  Now you are waiting to hear who wants to meet you in a virtual interview.  And waiting.  It's been 5 days?!?  Where are the interviews?!?!

(I know you don't really feel this way.  You get that to do proper application review takes time. But it is human nature to worry and to self-doubt, so I wanted to share some concrete information that may help in a year when there is a pronounced lack of solid information to go on.)

This year the County Program Unified Release Date is November 2* at 12 pm EST.  

This means that any program that is part of this agreement will not offer their interview spots until then.  Most of the self-identified "county" EM residencies participate, as do many other EM programs for whom this date makes sense.  This year it is reasonable to expect that the majority of the first wave of interview offers will go out around November 2.  

Therefore, there is no reason to panic right now.  Even if you don't have 12 interviews by November 4, it is still NOT time to panic.  After this first wave of offers there will be more.  Many programs do not release all their interview spots right away and all programs will have openings as applicants rearrange their schedules as higher priority interviews become available.  Every year this process takes a while to sort itself out.  

Have a look at this reference page on on the mechanics of interview season and submit your questions in the comments below.  

*A previous version of this post listed the Unified Release Date as November 3rd.