Saturday, March 28, 2015

A Fourth Years Perspective: Applications and Interviews

Elizabeth Karr is a 4th year medical student in the 2015 EM Match.  This post is the second in a series - a 4th years perspective. Part 1 was on what a third year students needs to know right now. This post tackles the next steps in planning your application year.

Now, what about residency applications, interviews, and traveling? Start looking at programs during the spring/summer of your third year to decide where you want to apply.  Think about what is important to you in a program; the level of trauma, opportunities for fellowship training, experience in sports medicine/pediatrics/critical care/aeromedicine, specific off service rotations, vacation time, work-life balance. Consider whether you are looking for a three-year program or a four-year program; do you want an extra year of experience, and what does that extra year do to add to your learning. Also think about geographic location that you would like to be in, as this is the place you will be living for the next three to four years. Come up with a list of criteria that are important to you and find the programs that fit them.   

I think the biggest part of the application process is making sure you submit your application as soon as possible after the ERAS system opens (mid-September). It doesn’t have to be submitted on the day the application cycle opens, but within the first week is best.  Also, the application doesn’t have to be 100% complete when you submit it: You can always add more SLOE’s or general letters of recommendation,  and you can also add on programs.

After submission, patience becomes a virtue that you will learn, as it won’t be until mid-October or early-November when programs start contacting you regarding interviews.  Of note, many programs utilize an electronic system for scheduling interviews and you need to sign up within an hour of getting the e-mail from a program or the interview spots they offer will already be full. So, if the opportunity is there, check your e-mails regularly. I am not someone to constantly be on my smart phone, but during the fall, my phone was set to fetch my e-mails every 15 minutes during the day.

I do wish someone had suggested I take a month off from rotations to do interviews.  This process takes time, and sometimes you have no choice as to when to schedule an interview.  It is recommended you rank at least ten programs to ensure a match. This means ten residency dinners and ten interview day. That is 20 days right there.  Then if you have a long way to travel, you may need another day to drive or fly. It is time consuming. I personally took two weeks off and then was also able to schedule 2-3 interviews each month during rotations.  Most rotations know you are interviewing and they can be flexible with your schedule and give you two days off.  However, it is not acceptable to miss an entire week of your four week rotation.

When you are accepted to an interview, you should do everything in your power to go to the interview dinner.  It is an opportunity to get to know what the residents are like outside of the program.  They will be your colleagues, but they will also be the people you will be with for the next three to four years.  Most residencies tend to have like minded people, and you need to find the program in which you feel that you fit in.  The dinner is also an opportunity to ask candid questions and learn more about the program.  They are usually casual and last for anywhere from two to four hours. If your travel gets delayed, most of the time it is okay to show up late. If this is the case, try to notify the resident contact that you are still trying to attend.

After an interview, it is a great idea to write down your initial thoughts.  How you felt about the program. How you fit in with the other residents, staff, ect.  What you liked about the program, or what you didn’t like.  The NRMP has a “Prism” app that can be downloaded to your phone to rank different categories and compare programs side-by-side.  It was something that I found very helpful, and all in all aligned with my opinions of the programs. In the end though, it is important to know what your gut feeling is about a place, and how you think you fit in with the program itself and the people in the program.  

After interview season is done, you have a few weeks to think about your rank order list.  Don’t over think it.  There is likely to be 1-3 programs that are at the forefront in your mind.  Followed by several programs in the middle of the list in which all seem equivocal.  Lastly, there is the bottom of the list; the programs that did not impress you, but would be better than not matching into EM at all.  Talk about it with your significant other, family, friends, etc.  Then you have to go with your gut and submit your rank list.  Once it is submitted, you can rest easy and wait until match day!  Also, statistics indicate that 50% of applicants will match to their top choice, and 75% will match to one of their top three choices.  It seems the odds are in our favor, so best of luck.  Lastly, have some easy rotations planned for the end of the year, because after the excitement of interview season, everyone will be ready for a break!

Look for Elizabeth's next post, An Osteopaths Perspective on Interview Season, coming soon...

Friday, March 13, 2015

So you did not match...

This is an update of our advice for the student who finds themself in the unfortunate position of having NOT matched in Emergency Medicine. There are some changes from last years post on the same topic. As always the advice that follows is based on the experiences of applicants who did not match in recent years and the compilation of recommendations from the members of the Clerkship Directors in Emergency Medicine (CDEM) and Council of Residency Directors in EM (CORD EM). 

First step: take a breath, your life is not over. Your goal of training in Emergency Medicine is still alive. While it is difficult to see now, the hurdles, trips, and falls teach us more than our successes. You will grow and learn from this and become a better care giver for having struggled through this. 

You are now faced with a huge decision:  Do you SOAP (scramble) into something else with the plan to train in that specialty? Or are you still intent on EM even if it is not this year?

The advice that follows will be useful to those not willing to give up on EM.  One key thing to remember when deciding which group you are in: not matching this year does not mean you would not be an outstanding Emergency Physician. There are many great unmatched candidates out there who would have a spot if it were not for late applications, poor advising, a bad test score, or just bad luck.   

So what are your options if you are still intent on EM?
Most people come up with one or more of the following plans:

  1. SOAP into an open EM spot at a program they had not previously applied to.
  2. Take a year off and do research or pursue a graduate degree like an MPH to improve your CV.
  3. Extend your med school training to a fifth year and improve your application for next year.
  4. SOAP into another discipline with the intention of reapplying next year.

Let's address each of these options:

1.  Using the SOAP to get into an open categorical PG1 EM spot is almost impossible.  There were just 2 spots in 2013, with 686 US seniors without a match in EM. The chance of getting one of those 2 spots is 0.2%.  To put it another way 99.8% of US seniors who did not match in EM did not get a SOAP spot in EM. In 2014 there were 14 unfilled positions in the match, which is still not very many (family med had 142 and surgery prelim had 449). There is no reason that you cannot try to SOAP into EM but you need a back-up plan in place.

2.  There is near universal agreement that taking a year off for research will hurt you more than it helps you. Program Directors just do not care that much, especially about the kind of research you can set up and complete in one year (just not rigorous/impressive enough).  Many Program Directors are happy to interview re-applicants who have gained some clinical experience, but often do not bother if an applicant did research for the year.  There is significantly less agreement about what a degree like an MPH would do for you - which means that some people will be interested and others will not. 

3.  Extending medical school may be the best option for some students, if your school will allow you to do that. The clear downside is cost, which is likely huge. If the price or rules of your school (ask your dean) are not deal-breakers you can build an extra-year of experiences that will make you a better qualified candidate for next years match. This is a particularly good option for solid candidates whose applications suffered from being late to EM or being complete late in the application cycle. If more opportunities to interview were all you needed to get your 10 to 12 interviews, then extending will let you do that. This option also leaves you available to fill a last minute opening that comes up after the match (though you cannot count on that kind of luck). 

4.  Lastly, is the most common back-up plan: doing a year of something else. The clinical experience will certainly better prepare you for your EM training and can make you a stronger candidate. Putting yourself through the application process again can only enhance the perception of your commitment to EM. Many applicants have been successful using this pathway to eventually match to EM. If you choose this option there are two primary considerations in this decision:  What kind of year to do?  Where to do it?

If I want to reapply to EM, what specialty should I SOAP into?

There is significant disagreement among CDEM and CORD about what kind of prelim PG1 year is best, or if you should go for a categorical program (contract for full course of training) instead.  Here are the options and some explanation:

Transitional prelim year - thought of by the majority of Program Directors to be the best option for a re-applicant. You split the year between surgery and medicine and get to do many of the things you would be doing as an EM1. It is more rigorous and impressive than a year of IM and your future EM program may be able to give you credit for some of the months. The downside is finding a suitable one that fits your other needs (see below).  There is also possible lack of flexibility for doing EM months and interviewing, and at the end of it you are left without a job if you do not match into something else. In recent years these have become increasingly difficult to find in the SOAP as less are available. The best way to have a Transitional year as back-up is to apply and interview for it, not to scramble (too late).

Surgery prelim year - students choose to do this but few Program Directors think it is necessary, or even more helpful than a Transition or IM year. That being said, there are some who think the more rigorous/abusive Surgery year is more impressive. Again, you are left without a job after one year.

Medicine prelim year - often provides greater flexibility for getting EM elective time early (when you can get a new letter) and for interviewing. And you will usually be treated better. Some Program Directors are less impressed because it is not as rigorous, AND at the end you don’t have a job. However, finding a categorical IM program that will let you start as a PG2 should be an option if matching into EM does not work.  

Medicine or Family categorical spot - same benefits and downsides as a one year Medicine spot but with the advantage that you still have a training position should you be unable to jump to EM. There is an additional downside of needing to break a contract should you match in EM. This rarely is a problem so long as you are open and upfront with your IM Program Director. Re-application is hard, and they know they have a good chance of keeping you, so being supportive of your plans keeps you happy with them.  After a Transition year this is the second most recommended option by EM Program Directors because you have a fallback position if you do not match in EM.

Where you do your year is MORE important than what kind of year you do.

The ideal position is one where you will have the opportunity to do an EM elective early (August, September) in an ED that has a residency program you are interested in joining.  This gives you access to new letters from people in an EM residency. Most EM Program Directors agree that these letters will be the most important part of your re-application. You are better off doing a conditional Medicine year at a hospital with an EM residency than doing a Transitional year at a hospital without an EM residency. You need access to EM faculty who teach EM residents, and the EM Program Director at your hospital can be your best advisor in getting a spot in their program, or another.  

What do you do if you find out at noon on Monday, March 16th, that you did not match?

  1. Call your dean and find out what your options are.
  2. Call your EM advisor for a personalized recommendation on what you should do. You can also contact us by email or in the comments.
  3. Schedule as many clinical EM rotations as you can for the rest of the year. Get SLOE's from all of these rotations so that you can include better letters than you had this year and so that you can meet as many people within EM who can advise and advocate for you. 
Best of luck!

Adam Kellogg is an Associate Residency Director and formerly an Emergency Medicine Clerkship Director.  He is a member of the CORD EM Student Advising Task Force and of the SAEM Resident and Student Advisory Committee. Some of his favorite Emergency Physicians did not match on their first try.