Applying - What is a "Red Flag"?

Updated August 2016

"Red Flag" is a term common in medicine, like the "Red Flags" for spinal cord compression in back pain.  It indicates warning signs for more serious disease and it has been adopted by application reviewers to refer to signs in an application that raise concerns about the qualities of an applicant. 

Knowing if you are an applicant that will raise "Red Flags" in the mind of a Program Director is really important for planning your application strategy.  You will need to do everything you can to make these "flags" as small as possible.


What are common "Red Flags"?

Failing a step of the Boards.  A great fear for program director's is that their graduates will not pass the boards when they finish.  Not passing the USMLE or COMLEX is a strong predictor of struggling to pass later exams.  Most advisors will recommend addressing any mitigating circumstances that led to failing the boards in your Personal Statement.  Even low scores, borderline for passing, can scare off some programs. 

Repeating a preclinical course or year.  Another sign of academic struggle. Also needs to be addressed.

Repeating a clerkship.  Failing a clinical experience will almost always be interpreted as a result of professionalism deficiencies. These are deal breakers to most Program Directors and need to be explained.

Academic misconduct.  Get caught cheating and you are in a lot of trouble. For your school to still graduate you, you must have convinced them that it was a misunderstanding or that you have been rehabilitated. In a competitive specialty like EM, there is little reason for a Program Director to bother taking the chance.

Unexplained gaps in your career. Big unaccounted for chunks of time are concerning. There can be really good reasons that these happen. But if left unexplained, application reviewers may just assume you were in prison or rehab.


What do I do if I have a "Red Flags"?

There are two approachesthat most applicants use:
  1. Hope they go unnoticed or that some reviewers of your application will not be dissuaded. This is often wishful thinking, depending on how visible the "Red Flag" is in your application.
  2. Get in front of them - Use your Personal Statement to explain mitigating circumstances and how you emerged from this better prepared for a career in EM. This is almost always a better way to go. Things happen, life is complicated, and reviewers can understand this. If you give them the chance.  

32 comments:

  1. I just found out I failed Step2CS. I am an average applicant. How much of trouble am I in for the upcoming cycle?

    ReplyDelete
  2. While probably not as bad as failing the clinical knowledge portions, this is going to be a problem. Programs that don't know you are going to be concerned about your ability to connect with patients and work with staff.

    You need to retake and pass ASAP to prove that it was a fluke. You should also start working on a back-up plan should you not get enough EM interviews. If you need to match this year, you may want to consider an additional specialty to apply in. If extending med school is an option for you, that would allow you to retake CS and to complete more rotations that will show up in next years application - more data that better describes your actual communication skills. Have a look at: http://emadvisor.blogspot.com/2015/03/so-you-did-not-match.html

    For this years application - this needs to be discussed in your Personal Statement: http://emadvisor.blogspot.com/p/applying-personal-statement.html That is the first place most application reviewers will go looking for an explanation.

    ReplyDelete
  3. Happy thanksgiving Adam!
    In spite of a redflag that I am worried about, I currently have a total of 9 interviews and waitlisted at a couple of places. I am however still very concerned about not matching. I have a feeling a lot of programs did not offer me an interview because I was filtered out. The truth is, even if I have 20 interviews, a part of me would still be concerned about not matching.
    Do programs go back and re-analyze applications before final rankings or are rankings based solely on how you interviewed? .i.e. is it always true that once you get an interview, you are on a level playing field with everyone else being interviewed at that program?
    How comfortable should I feel about matching with only 9 interviews?

    ReplyDelete
  4. I think you are in a pretty safe position to match. Programs where you rotated could have given you a courtesy interview, or not be worried because they feel they know you. But, any program that invited you solely on the strength of your application is not that worried about your Red Flag. Each program is looking for different qualities in an applicant and believe in different predictors of success. So it is not surprising that something that scares off one program won't matter to another.

    As for danger of not matching: 9 interviews is great at this point, and you will probably get a few more. The match rate with 9 last year was well over 90%. There is no number of interviews that get's you to a match rate of 100%. There will always be a few people who have great applications that get them lots of interviews but who really struggle at those interviews. There are no guarantees, and having a back-up plan is always a good idea, but based on having 9 interviews already you should be okay.

    ReplyDelete
  5. Hi,

    I have a question regarding application for EM. I am an Osteopathic student who ran into a few issues when trying to take my Comlex and USMLE Step 1. Basically family and personal health problems and was recovering from Surgery. I took the comlex but did poorly not because of my lack of knowledge but rather my inadequate testing skills. I passed by the skin of my teeth, however because I passed I cannot retake it. I also canceled my Step 1 because I was afraid failing it or doing really poorly would look worse.
    I am now realizing into my fourth year that I should have taken it anyways. So I am trying to apply to both AOA and ACGME programs however, I have a terrible comlex score looming over my head and I intend to do much much better on Comlex 2 and Step 2 towards the beginning of August so that my scores are released by early September. My question is, how will my late SLORS and late score submissions by the AOA application's standards affect my overall application and chances of interviews. If it does affect me, how badly do you think that would be and what can I do to really improve my application for the AOA match? I am trying to get some additional research on my CV and I have rejoined the fire department, because I also love being a firefighter/EMT. Your advice is truly appreciated.

    ReplyDelete
    Replies
    1. Having a low comlex/step 1 score is difficult to overcome. The best action you can take is exactly what you are doing: take step 2 early. Your score should be with plenty of time for ACGME programs to use it as part of their decision whether to offer an interview or not.
      The AOA application process starts so early that there is going to be less you can do. You should certainly address your low score in your Personal Statement. When your COMLEX 2 posts, that will be a good time to politely update AOA programs on the additional information in your application. Hopefully that will help you secure a few late interviews (and they all count).
      A low step 1 is going to rule you out for some progams. However, most look at you as a whole applicant and recognize that test scores are not the most important determinant of your success as an EM resident. Excelling on your EM rotations (and getting good SLOE's) will make programs want to ignore a low step 1.
      Good luck!

      Delete
  6. Hello,

    I want to take your opinion about a critical issue in my plan. I am an intern(the final year med student) in Turkey. I am currently studying for Step1. I will take the test in September, I suppose. But I am going to graduate soon. Nowadays I am considering the idea of taking a time out (leave of absence) from my faculty just before my graduation, so I will be able to search and apply for an elective as a student. Some people around me say it worths, some say it doesn't.

    I heard that Hands-On USCE is positive and the gaps during the medical education is negative. So I am trying to calculate the net effect of the two opposite impacts of these two factors on my future residency applications.

    Okay, let's say somehow I will be able to start my two months long clerkship just two months after Step1. In that scenario, I will be extending my faculty 8 months for 2 months of electives.

    I wonder your point of view. Is this a wise strategy or an absurd idea?
    Looking forward to hear your advice.

    ReplyDelete
    Replies
    1. Thank you for the question. I don't have enough knowledge of the system for EM training in Turkey, so I am going to try to answer based on the ASSUMPTION that you are planning to try to get a residency in the United States.
      This is going to be hard as an International Student, but not impossible. You need to do rotations in a hospital with an EM residency in the United States. If you cannot get those clinical experiences you will not be able to match directly to EM. You may need to match into another specialty and then reapply for EM once you have clinical experience as a resident physician.
      I don't entirely follow what your options are as you have laid them out - but the one you need to pursue is the one that gives you the best chance to rotate in a U.S. ED with a residency.
      I hope that helps.

      Delete
  7. Hello,

    I have some red flag issues I need to address. I was convicted of a misdemeanor reckless driving charge prior to medical school. I drank and drove and was pulled over on my way home. I take ownership for what I did and acknowledge my mistake. It has been almost 5 years since the incident. Otherwise, I am a competitive applicant (250+ Step 1, several honors). How do I approach this red flag on ERAS and my personal statement? What are my chances of matching?
    Thank you

    ReplyDelete
    Replies
    1. Your chances of matching are very good. This will hurt you with some programs, particularly those in states where it is difficult to get a medical license with a DUI/OUI. That can be a hard thing to predict so you will want to make sure you apply to multiple states (a necessity anyway, except in NY).

      There is a field in the ERAS application that gives you a chance to explain any legal troubles. This is where you will want to explain this episode and what you have done to remediate this. You should not need to further explain elsewhere in your application unless you feel that this was a particularly formative experience on your road to EM.

      I hope that helps.

      Delete
  8. Now that ERAS is upon us 2018ers I desperately need some advice. I'm a DO student who did well on my COMLEX but only got a 189 on my USMLE step 1. I passed the COMLEX Level 2 PE and I'm taking the Level 2 CE in August. Besides board scores I have decent grades/class rank, leadership positions in interest group school organizations, etc. I had hoped to be able to devote myself to just the AOA match but with the single accreditation there are fewer EM programs participating in AOA in 2018, and there are some ACGME programs I love with all my heart. Can I go with just my COMLEX score, or do I absolutely have to submit both scores if I do the ACGME match? Should I try to take the USMLE Step 2? What are my chances of matching in the ACGME match and what do you think I should do?

    Thank-you so much in advance for your thoughts!

    ReplyDelete
    Replies
    1. You should be able to go with just your COMLEX. Programs that give serious consideration to DO applicants, especially those that were recently AOA, will be find with a COMLEX. What you lose by not having a USMLE is the traditional ACGME programs with tepid interest in DO applicants. And most of them would likely be scared off by your USMLE score.

      Delete
  9. Hi I'm a u.s. citizen IMG and just found out that i failed step2 cs...obviously devestated...I scored ok on step1 224 and am expecting around a 240 on ck. I really want to match EM but idk if this will be possible now and now I'm afraid i won't match at all even IM or FM. Any advice for me?

    ReplyDelete
    Replies
    1. You need to retake CS as soon as possible so that a pass shows up in your application this year. EM was going to be difficult as an IMG and this does make it more unlikely. Your best chance of EM residency would be to match into IM or FM and attempt to reapply as you build some clinical experience. So long as you pass CS as quickly as possible, IM or FM should be possible.

      Delete
  10. Hi! Hoping for some advice on a tricky situation. I got back my COMLEX step 2 and did worse than my COMLEX Step 1 ( 538 -> 496). I have good clerkship grades and good LOR/SLOEs (at least I've been told they are good). Are my chances pretty much shot as a potential EM candidate or should I still think about applying? Thank you.

    ReplyDelete
    Replies
    1. Your scores are still comfortably above the pass threshhold. While going down a little from step 1 to step 2 isn't that common it is certainly not the death of your application. All programs look at board scores but very few prioritize them above SLOE's and other clinical performance. If EM is what you want you should still apply. You do have the option to also apply to something else to have a back-up in place should your application not turn out to be as otherwise strong as you hope it is.

      Delete
  11. Hi Dr. Kellogg,

    Thank you for your blog. I have questions related to Board Scores, red flags, and "getting ahead of it." I finished my M2 year and pushed back my first rotation to take more time to study for Step. My score is still improving as I think I have finally realized how to study properly for this exam. I am thinking of pushing back my second rotation also; however, this would put me a off-cycle, graduating with my year but applying to residency with the next. I also would then have a Leave of Absence on transcript if I do so. Already taking off one rotation subtracts one away I can do (we don not have an EM program). A couple of sources told me pushing the second rotation would be fine while another told me it would be better to get a 210 or so and not have a "LOA flag" on my transcript while be off-cycle for away rotations. I guess my questions are 1) What is your perspective? 2) Is a summer LOA a red/yellow flag? I know different programs have different scoring techniques, but generally, would I be more likely to get cut from the pool for a low score or a LOA? 3) If not, is it legitimate to explain that I was studying for Step and (not in jail) or is that unacceptable as my classmates did not need the extra time? 4) What else should I (not) be considering?

    Thank you ahead for your insight.

    ReplyDelete
    Replies
    1. I think you are considering the right factors. An LOA can be a concern, depending on the reason. If you took that extra time to study and didn't do average or above on step 1 that would be more concerning than a below average score with a typical time to prepare.
      On the other hand, if that delay in applying results in more opportunities to complete away EM rotations (with no home program) then it is probably worth it.
      EM rotations where you do well are more important than step scores. You need to clear a bar of test performance to get considered but the decision on who to interview is much more heavily influenced by SLOE's.

      Delete
    2. Hi Dr Kellogg,

      I delaying step 1 in my 2nd year of medical school, and ended up taking it last October and received a slightly above average score. My practice exam scores put me at risk for failure so I used a few more weeks to change my study methods and focused more on questions which really helped improve my score. I took the additional time off after step to do research, and started 3rd year rotations this July. Assuming I do well in my rotations, step 2, and receive good SLOEs, will this gap in my education be a major hindrance to landing a residency in EM? or should I look to less competitive fields that also interest me?

      Thanks for taking the time to answer our questions!

      Delete
    3. A gap in your application is not a deal-breaker for getting into EM, just something that needs to be explained. This is not the kind of gap that will typically create enough concern in a reviewer to disqualify you from interviewing. That could be different, depending on the reviewing program, if there is significant academic struggle documented in your transcript/MSPE.

      Delete
  12. Hi, I got a Step 1 of 200, and am pending CK, which comes out in a few weeks. Passed CS. Got my 2 SLOE's and pretty certain they are above average, both programs I rotated at said people loved me. Got H in IM and EM, and likely to get 2nd highest "category ranking" on my deans letter. What are my chances of getting interviews this year considering EM has gotten so competitive? Obviously a high Step 2 CK will help, but assuming thats average ~220-230. Thanks for helping answer questions for us!

    ReplyDelete
    Replies
    1. You will still get interviews but should focus on programs that do not filter out applicants with lower Step 1 scores. EMRA Match can help you find these programs. The advantage to having the SLOE (though it does provoke some anxiety by forcing "ranking" of students") is that EM can emphasize board scores less when considering applicants.

      EM is more competitive because each applicant is applying to more programs. The overall pool of applicants has not changed in size relative to the number of training spots (both are steadily increasing). Programs are adjusting how they evaluate applicants to account for the growing number of applicants who apply to them without being particularly interested in that program.

      Delete
    2. Hi Adam, thanks again for all of your valuable advice!

      My step 2 CK score came back, 228.
      Now, with all the pieces from above and now step 2, should I be looking into applying for a preliminary spot? Or is it likely I'll get 10+ interviews with my stats (I know, a little hard to tell, but just based off whats been given).

      Also, for those programs that screen low step 1 scores, if I am interested in the program, am I able to reach out to them and ask if they can review my application as a whole?

      Thank you!

      Delete
    3. Based on the info provided there is nothing to make me think you won't match unless you apply mostly to programs that emphasize high board scores. Unless there is a red flag not mentioned you shouldn't need to apply to a back-up specialty.

      I would not recommend contacting programs that volunteer that they screen scores to ask them to look at your application anyway. They are sharing that information to save you money by NOT applying to them in the first place. Spend your money elsewhere.

      This is different than contacting a program later in interview season to let them know about your interest in them that may not have come across in your application. With Board Scores, they already have the info they are looking for.

      Delete
  13. Dr. Kellogg,

    How do programs view student applicants with previous substance abuse issues that have completed treatment?

    ReplyDelete
    Replies
    1. That is a tough question to answer as I think this will vary a lot by program. Some will have had bad experiences with residents in recovery and will be more reluctant to interview students with that history. Particularly if there were legal problems related to this. Obtaining state licensure can become even more complicated than it already is.

      However, many programs will be appropriately concerned BUT will still consider the student if their is evidence that they have been successful in their recovery. The personal statement is the common place this is addressed, though there is also a spot for legal disclosure in the ERAS application. The MSPE may also address this if med school work was affected.

      Delete
  14. Hello Dr. Kellogg,'
    DO student here.
    I went from 242 (step 1) -> 226 (step 2). Believe i got a middle 1/3 on my first SLOE. I applied 60+ programs. Should I be concerned about matching EM? thanks!

    ReplyDelete
    Replies
    1. It is not common to drop step 1 to step 2 but your scores were not bad.
      Unfortunately I cannot accurately answer your question based on the information available. What I can say is that IF you had a reasonable application strategy (more than half of those programs are welcoming to DO students) and your letter is a supportive middle 1/3 letter, and there is nothing else about your application that is going to hurt you, THEN you should be competitive for interviews and have a good chance to match.

      Delete
  15. Hi,I posted earlier regarding my drop in score.I’m sorry but I didn’t notice this is for EM.I am applying to IM.Any idea how good my chances will be?

    ReplyDelete
    Replies
    1. Based on my understanding of the competitiveness of IM programs, you should be fine.

      Delete
  16. Hello Dr Kellogg

    I am in my last year of Medical School in Brazil.
    Everybody knows gaps are red flags most of the times and I got stuck in a bad place considering my personal life because my husband is 48 and waiting to have our kids after at least 8 years from now considering I'll be finished the Residency at that time is not really an option.
    I've been studying the past 6 months for the Step 1 aiming 250+ (scheduled for next March) and take all the other Steps in 1 year range in order to get over with this, get pregnant twice and then apply for my Residency, because I don't want to impair my training process neither to harm my future residencymates with any absense of mine. This scenario would give me around 3 years of gap between my Step 1 and my application for the Residency and 2 years between the last test taken. Is it too bad approaching this way or will be better if I start the process later to have my Scores "fresher".

    ReplyDelete
    Replies
    1. My first caveat is that I do not know anything about the intricacies of training in EM in Brazil.

      If your plan is to come to the United States you will need to take the USMLE. Timing for step 1 is less important than for step 2, which you will want to take closer to when you are actually applying.

      More importantly, to have a reasonable chance of matching into EM in the United States you need to gain clinical experience in an ED with a residency that has a history of taking students who trained internationally. This will be difficult to accomplish if your school does not have a relationship with a US hospital. After graduation, when no longer a student, doing clinical rotations will be impossible because of malpractice insurance. "Observerships" are not adequate experiences.

      Delete