Thursday, September 3, 2015

Applying Wisely - Quality over Quantity

This is a long post with many links to other materials.  The goal was to make a one stop guide to submitting your application on September 15th.

Application season is about to begin in full force for students applying for allopathic (ACGME) residencies in Emergency Medicine (EM).  As an advisor the most common question I am hearing is “How many programs should I apply to?”.  This is a great question.  This is a timely question (applications open in less than two weeks and you need your part of the application done ASAP!).  This also may be the wrong question to be asking.  

In this post I am going to recommend that you approach choosing which programs to apply to with the goal of making a high quality, high yield application list specific to you.  This is an alternative to the “shotgun” approach that you may be hearing recommended - “apply to 50 or more programs”.  

The Goal
You need to get sufficient interviews.  The magic number of interviews complete to assure matching is 10-12 (95-99% chance of matching in EM).  And because the match is student weighted the majority of applicants get into one of their top 3 programs with many getting their #1.  If you have 10 - 12 interviews you are going to match (unless you bomb all of them).  For a much deeper dive into match data and what it means, take a look at this article from EM Resident: Diagnosing the Match.  You can also have a look at the data from NRMP for yourself.

So why not just apply to 50 or more programs when ERAS makes it so easy?  This is your future, what is a few more hundreds of dollars?  The problem is that even if you shotgun out 50 applications you may still not get 10-12 interviews if you choose those programs poorly.  So even if you are determined to go shock and awe with your applications, you are still going to need to be smart about which programs to apply to.  

Applying Wisely
In order to build a quality list of programs to apply to, you need to answer these four question for yourself:
  1. Where you need to be?  
  2. How do you want to train?
  3. How competitive are the programs you are looking at?
  4. How competitive are you?

Location, Location, Location
There are ~170 allopathic EM programs.  Applying to all of them is crazy (and not effective).  Most applicants have a regional preference (ie - northeast, west coast, Texas, etc).  Others have a type of area they want/need to live in (ie -urban with public transport, or rural so they can raise chickens, or suburban with access to a large enough city to support an EM program).  You should choose an area, or type of area, that interests you and let that narrow your focus.  Within these areas will be a variety of programs that are likely to be looking for different things in their applicants and to have different levels of competitiveness.  That variety will be really important in keeping your application balanced.   

Program Characteristics
Every program in EM is held to rigorous standards by the ACGME and RRC to ensure you emerge as a competent Emergency Physician (EP).  How they get you there can be quite variable.  These characteristics can help you sort the programs and to start determining which ones are going to be a better fit for how you want to train.  

Some common examples of easy to determine characteristics are how many years the training is (3 years vs. 4 years), the types of off-service rotations they do, the patient population, the sites they rotate at, the structure of their didactics, the fellowships available, their research emphasis, etc.  For a little more depth on these consideration have a look at this page:  Choosing where to Apply.  To start figuring this out have a look at the EMRA Match tool.

You should use these characteristics to help you pre-screen programs.  However, your eventual decision on how to rank them will be strongly influenced by factors that are hard to assess from reviewing a programs web site:  their culture of wellness, their education and adult learner philosophy, the residents happiness and satisfaction, and whether you feel like you would fit in.  This is why we still do interviews.  

Program Competitiveness
In the last couple years some private companies have attempted to help students applying to EM rank the EM Residency Programs.  Lacking access to actual program data they relied upon alumni rankings of the programs.  I have no idea if this actually resulted in a list of which programs provide the best training (though I have my doubts).  I am certain that their lists did not address the most meaningful measure of program competitiveness from the standpoint of the applicant:  How many people applied to the program?  That is not publically available information.  

You can estimate which programs get the most applications, as we outline in this post we did on Assessing PROGRAM Cometitiveness.  
To sum up, the more of these characteristics a program meets, the more applications they are likely to receive:
  1. Is the program in a highly desirable place to live?
  2. Does the program have “name brand” recognition that would look impressive on your CV?
  3. Is the program “EM famous” for their faculty or their longevity within the specialty?

The programs that receive the most applications can fill all their interview slots with above average applicants.  So how do you know if you are above average?

Your Competitiveness
While determining program competitiveness is an inexact science (to put it charitably), assessing your own competitiveness is somewhat easier to do.  This is a guide to Assessing YOUR Competitiveness that we previously wrote.  
To sum up - the applicant field breaks up into three broad categories:
  1. Above average and have it made
  2. Average and will match
  3. Below average and at risk

Where you fall is based mostly on your board scores and the EM rotation grades and the SLOE’s that came from those rotations.  These are the characteristics that all programs will give some weight to.  The other characteristics of your application (clinical grades, work and service experiences, scholarship and research) can all have an impact on how programs rate your application and whether they offer you interviews.  This will not be consistent from program to program, or reviewer to reviewer.  Thus you need to get your application in front of a variety of reviewers at realistic programs.  

To sanely navigate the match process: gauge your competitiveness and build a list of programs to apply to that has a foundation of realistic programs, with appealing characteristics, that are in areas that work for you and your family.  You can apply outside of this group, because you never know what might catch a reviewers eye, but you cannot consider those applications to be a realistic part of your foundation.
If you are an above average candidate you have the option to be a sniper.  Choose 20-25 programs that highly interest you and get all the interviews you need.  

If you are an average candidate, you are going to match.  Choose 20-25 programs that appear realistic and add another 10 or so that may be a stretch.

If you are at risk, or in an applicant group that many programs will not seriously consider (Osteopathic students, those training Internationally), you should apply to ~40 realistic programs.  Any program that does not seem realistic does not count towards your 40.  
For more detailed perspective for Osteopathic applicants have a look at this page of Advice for Osteopaths.  International Applicants should read this post by Max Hockstein, MD.

You also need to get some personalized advice.  These recommendations are a good place to start but are too generic to use as your sole source of advice.  EMRA has a great mentorship service you should use.  Feel free to contact us with specific questions in the comments or via email.  EMRA also maintains a page of other resources for medical students that can connect you with more opinions and advice.

Good luck and get those applications in!

Adam Kellogg is an Associate Residency Director and a former Clerkship Director. He is the Chair of the CORD Student Advising Task Force whose mission is to improve the quality of the advising students receive who are applying to Emergency Medicine.