EM Scramble Advice

Match day is almost upon us.  With your rank list submitted and your “top programs” notified, you may feel like there is nothing more you need to do between now and March 14th.  This is true for the vast majority of students applying into Emergency Medicine.  Unfortunately, on the monday before the match, some applicants will receive an email telling them that they are now part of the scramble (now called the SOAP).  As future Emergency Physicians you will create back-up plans as a matter of course.  This situation is no different.  

If you are of a paranoid disposition, just skip this paragraph and go to the part about what you can do now.  If you are still reading -  you must want to assess whether there is a realistic chance you are not going to match.  The best marker is how many interviews you went on and how many programs you ranked.  If you rank eight to ten programs, or more, the likelihood you are not going to match is very, very small.  Conversely, if you did interviews only at places you rotated, you are at significantly greater risk.  Also, reassuring is the feedback you received from programs.  They would not be telling you how much they liked you if you bombed the interview.  And if you interviewed well at one program, you were probably on your game most days.  The opposite should be worrisome: if no one reached out to you, you could have cause for concern.  

So now that I have you adequately worried - what can you do?  

You need a plan.  And your plan needs a back-up plan.  

First, now is the time to decide if all of this will truly be worth the effort in the end.  How bad do you want to be an Emergency Physician?  There was no scramble last year in all of EM, and very little the years before that.  Scrambling to an EM program for a July 1, 2013 position is not a viable plan.  You are going to have to do something else for at least a year while you reapply.  

Once you decide that you are willing to do something else for at least a year before starting your EM training, you need to decide what to do with that time.  The best thing you can do with that time is gain clinical experience.  There are other options but none will enhance your application.  Doing a year of research, a popular idea, will not help you gain the kind of clinical skills that will make you an asset to a Residency Program.  

Clinical experience is the most reliable way to bolster the inadequacies in your application.  Your reapplication needs to address these inadequacies and you are going to have to look better on paper than those applying for the first time. That missing ingredient(s) that gets you the interview could be many different things, and should be discussed with an individual adviser.  The most common are boards score, clinical grades, and letters.  You are stuck with your grades and scores (unless your step 2 did not make your application).  Where you have a real opportunity to improve your application is in your letters.  

The next six months should include the pursuit of better letters of recommendations as both a student and intern.  As a student you may be able to do another away EM rotation.  Preferably at a program that is realistic for your reapplication.  

In addition to maximizing the value you get from med student experiences you should choose what you are looking for in the scramble with the same goal of making you a more attractive EM candidate next year.  

The absolute best position you can get is one that allows you to rotate early in the ED as an intern, at a hospital with an EM Residency Program.  And you need to perform as good or better than the interns who did match there.  And you want to get a letter or two from their faculty, so that other programs get to see how good you are.  

What kind of position you take is the subject of much debate among program directors.  Here are a few of their best points, pro and con:

Transitional pre-lim. year - Diverse exposure that is very applicable to EM.  These are becoming less available and probably need to be found in the Match, not the Scramble.

Categorical IM or FP (guaranteed PG2 and 3 spots) - Offers a safe landing if you don’t match on the second try.  However, these are less rigorous and generally less impressive to EM Program Directors.  

Surgical prelim year - Rigorous and impressive to Program Directors.  However, you get treated like a surgical intern for a year and may have trouble getting an early ED rotation, depending on the program.  

For all of these, the early ED rotation as an intern, should be part of the negotiation and your decision process.  

There are many opinions on which is best but here is mine:  being at a hospital with an EM Residency trumps all other considerations.  After that, the more clinically challenging, the better.  This is your chance to get a leg up on the competition, and build  skills that will lead people to say, “I cannot believe that _______ did not match the first time.”

The Match is an imperfect system.  Every year, good candidates who will one day be great Emergency Physicians, do not match for a variety of reasons.  Not matching does not mean you are not good enough to be an Emergency Physician.  It just means you are going to have to work harder to get there.