Learning Resource: The Flipped EM Classroom

Many educators feel that the future of didactic instruction is the "flipped classroom" model.  Students review materials at home before coming to class, sometimes watching on-line lectures/videos.  In the classroom they do their "homework", working through problems and concepts while the teacher(s) circulate and help the learners.  Many Emergency Medicine Residency Programs are adopting, or at least experimenting, with these concepts.

One benefit to all is that a lot of on-line resources are being produced.  A great example is that work of The Flipped EM Classroom.   The foundation for the content covered is the Clerkship Directors in Emergency Medicine (CDEM) Curriculum for medical students, so it makes a strong foundation of knowledge.  Think of this like a souped-up, FOAMed, multi-media version of the "First Aid for the EM Clerkship"-type books.

There are small, easily-digested, modules on "Approach to..." a variety of common ED complaints like:  Abdominal Pain, Poisoning, Trauma, etc.

There are also Disease Specific reviews grouped by organ system.  For example, in the Cardiovascular group there are Abdominal Aortic Aneurysm, Acute Heart Failure, Pulmonary Embolism, and more.

For third years soon to start EM rotations: this is the knowledge base and approach that your supervisors are going to be looking for.  Get a jump on understanding this information from an EM perspective.

For fourth years going into EM.  Your program is going to be expecting you to have this foundation of knowledge when you show up.  If you don't, you will get feedback like, "knowledge base is behind that of peers".  Any you don't want that.

Enjoy!

The big DO decision

We just added a guide for the osteopathic student interested in training in an allopathic EM residency.  The advice is a little late for anyone applying on this application cycle.  However, there is a dilemma facing many of the DO students who have interviews at both allopathic and osteopathic residencies.  What do you do about the DO match?

EM is competitive, very competitive.  Goal number one is to match into a training spot, even if it is not the perfect location.  You need to make rationale decisions based on what is going to give you the best chance to match.  That being said, you can predict whether you have drawn enough interest from the allopathic programs to safely withdraw from the osteopathic match in January.

Most students are going to fall into one of three groups.  For two of these, the decision is easy:

1. Has only 1 or 2 allopathic interviews.  If you find yourself in this group, you should stay in the osteopathic match.  The chances of being left without a spot are too great.
2. Has 10 or more allopathic interviews.  This group can withdraw from the osteopathic match, if their top programs are allopathic.  These programs are going to rank you on their list.  The odds are excellent (>95%) that if you rank 8 or more programs, one of them is going to rank you high enough that you match there.  
3. Has 3 - 9 allopathic interviews.  This group has the toughest decisions to make.  You are going to have to decide on whether to gamble on the allopathic match.  The safe play is to rank several DO programs and stay in that match, moving only to the allopathic match if you do not get one of those.  If you have greater risk tolerance, you can take a chance and withdraw from the DO match.  All it takes is one program ranking you high enough to match there.  There is no one size fits all answer.  The best way to figure out what is right for you is to look at your individual situation with a trusted advisor.

Effective Interviews - Part 2: What's Hot?

In part 1 of "Effective Interviews" we covered the basics of how to get the most out of your interview days.  In part 2 we are going to raise your interview game with a discussion of what topics are "hot" in Emergency Medicine in the fall of 2013.

While on the interview trail you are discovering the "hot topics" to talk about from your fellow applicants.  This is the default topic.  The one you go to when you are out of other questions or because everyone says you should ask about it.  For a long time this was Trauma, as in: "What is your Trauma experience like?"  For a few years now Ultrasound has usurped this spot.  This year, another shift is likely upon us: "What role does Social Media have in your education program?".  The most mainstream of EM publications, the Annals of Emergency Medicine, just published an article about Twitter.

Twitter is a great window into what is being discussed and debated in EM.  All you have to do is follow a few of the disseminators of #FOAMed (@emlitofnote, @njoshi8, @emcrit, @CriticalCareNow, @srrezaie, @precordialthump, @LWestafer, just to name a few) and you will quickly be caught up on the discussion.

But if none of the preceding paragraph made any sense to you, here are some of the big topics under discussion in 2013:

• Social Media in Education - you should probably have an opinion or stance on this.  Many of your interviewers will.   Though you shoudl be ready for otherwise wonderful and enthusiastic educators to be very skeptical of the whole concept.  They may also be more interested in your understanding of professionalism as it relates to Facebook/Twitter/Snapchat/etc.
• Thrombolysis for Acute Ischemic Stroke - this is being debated vigorously in EM with ACEP releasing a policy statement that has led to much consternation from many practicing Emergency Physicians.  This has recently been discussed really well on the ERCast podcast.  The LITFL blog also did a good discussion to review as well.
• Video vs. Direct Laryngoscopy - This is being hotly debated in EM right now with very knowledgable people on both sides of the "Is direct laryngoscopy dead?" debate.  As someone about to begin your training, knowing the programs philosophy on airway management is going to be really important to your education.  What do they do?  What do they teach?  This is way more important to your eventual career than how they get Trauma experience (A comes before T, after all).

Other topics of recent discussion also include:

Transexamic Acid (TXA) in Bleeding Trauma Patients - Review by Napolitano et al.

Novel anti-coagulants and newly approved treatments - Dabigatran, Rivaroxaban, Prothrombin Complex Concentrates

And just this past week, the value of Therapeutic Hypothermia (aka Targeted Temperature Management [TTM]) in Cardiac Arrest came under renewed scrutiny.

So much to know.  Maybe you should get that Twitter handle after all...

Effective Interviews - Part 1: The Basics

The interview process is a huge expenditure of precious resources on both sides.  If you are going to go to the trouble and expense of interviewing at a residency program, you owe it to yourself to come prepared.

The Program Director will almost invariably give you some kind of overview of the program or "sales pitch".  This may even include perceived weaknesses and plans for improvement.  Even if their presentation seems balanced, they are still emphasizing the programs strengths, just as you did with your application.  You will have an opportunity to talk individually with the Program Director and other members of the residency and you owe it to yourself to dig deeper.

Since you are reading a blog about getting into EM, you have likely encountered lists of "must ask" questions.  I think there is no such thing as the "right questions" to ask.  I would much rather discuss topics that the applicant has a genuine interest in.  Answering the same questions over and over again is not enjoyable for either side.  Instead, ask about what really matters to you.  Find out if this is a place that is going to meet those needs.  If you have made it this far without deciding what really matters to you in your future training program, now is a great time to start thinking about it.

The questions you ask should be thoughtful enough that you cannot just answer them from going on the programs website for 5 minutes.  Though this is a great way to find things to discuss.  Make your question a level deeper than the website goes.  For example:  Don't ask, "What kind of rotations do the interns do?".  That is invariably on the website.  But you can ask what the experience is like on specific rotations, and if they have any concerns about the objectives being reached.

If you are going to put all this effort into coming up with good questions, you should feel comfortable asking the same questions of all of your interviewers.  You may get different answers depending on who you ask.  For example:  the Program Director and the Pedi EM Fellowship director may have very different perceptions of the EM residents pediatric experience.  You will have to decide whose opinion to put more stock in, but this information can be incredibly valuable.

One particularly important area to explore, that will not be addressed by the website is the stability of the program.  If there are changes to the size of the residency, the curriculum, the physical plant, or the program director or chairman, find out how these came about and what impact these are expected to have.  Change is often a good thing, but abrupt change is often not.  Particularly when there is not a cohesive forward-thinking plan for the future.

A few other general interview tips.  These may seem obvious, but a remarkable number of students break these "rules", usually to the detriment of their chance to match:

1. Go to whatever they have the night before.  This is essential to getting a feel for the culture of the program. 
2. Be on time for the interview.  In fact, be early.  Leave yourself enough time that even if you get lost, you will still have plenty of time.  Inability to plan ahead is not a sought after trait in Emergency Physicians.
3. Dress professionally.  You do not need to wear your black or funeral-gray suit, however you also should not look like you are going tailgating or clubbing right after the interview.
4. Be respectful to everyone, especially the coordinators.  Especially the coordinators!
5. Be yourself.  The professional version of yourself.

AAEM 2014 Med Student Track

The American Academy of Emergency Medicine has their annual meeting coming up in February.  It will be at the Midtown Hilton in New York City February 11 - 15, 2014.

They are going to have a whole track just for medical students on February 12:

Wednesday, February 12, 2014

7:30am-8:00am	Networking breakfast
8:00am-9:00am	Pearls & Pitfalls of Emergency Medicine
9:30am-10:00am	Finding your Match: Types of Residency Programs
10:00am-11:00am	Program Director Panel
11:00am-11:15am	Break
11:15am-11:45am	Career Paths in Emergency Medicine
11:45am-12:15pm	Ultrasound in the Emergency Department

This is a great opportunity to learn more about the specialty and about navigating the application process.

Blogs are fun and all but getting to interact with actual people is even better.

Where are the interviews?!?

This is an anxiety provoking time of year.  Interviews start soon and right now you fall into one of two groups:

Group A - You have too many interviews (more than 10 - 12) and you are not sure which ones you are going to actually do.

Group B - You don't have enough interviews (less than 10-12) and you are in a panic over having to scramble to another specialty.

Let's deal with Group A first, as they are easy.  Unless you have special circumstances, like a difficult couples match (EM-ortho, EM-EM, EM-Derm), you already have all the interviews you will need.  And as programs start to get into their Wait Lists, you are going to get more offers.  In your Personal Statement you talked about what a great team player you are, now is your chance to prove it.  Politely decline some of those interview offers. Throw them back.  As programs higher on your list contact you with an opening, let another one go.  Most people do not want to do more than 10 - 12 interviews.  No one has stayed sane doing more than 15.  You will match 99% of the time if you rank more than 8 programs.

If you are in Group B, you are nodding vigorously right now.  You are waiting for interview offers because your colleagues are holding on to all of the spots right now.  They will start to give them back.  More spots will become available.  What you need to do right now is make sure that when those spots open up, you get consideration for them.

Make sure your application is complete.  If a letter was not uploaded, many programs will not have even reviewed your application before giving out all of their interview spots.  If your application was completed late for any reason, send a polite email to the coordinators of your most important programs.  Showing a little extra interest, courteously, can make the difference in who on the Wait List gets offered an interview.  This is the most useful thing you can do to increase your interview chances.

What you are thinking about doing is applying to more programs.  The programs will know that you just applied to them.  Most EM programs have the luxury of being picky about who they interview.  They are not going to be interested in looking at the application of someone who only recently became interested in them.  Not when they already had hundreds of more enthusiastic applicants.

Polite interaction with programs that already have your application is your best bet.  Be available on short notice.  Be courteous with whoever you get in touch with.  Be ready to bring your A-game on the interviews you get.  It only takes one program to rank you competitively to get you into EM.

Link: ALiEM Interview Tips

Nikita Joshi (@njoshi8) over at the incomparable Academic Life in Emergency Medicine site recently posted some great tips for the residency interview process.

This is a great list of recommendations.  I would add particular emphasis to "Being interested".  You should have questions ready to go for anyone you talk to.  The benefits are both for you and the program.  You get as much information as possible and impress upon the program how interested you are.  An applicant without any questions is presumed disinterested.  Even if the Residency Director answered every question you had during the "sales pitch", you should still ask about the things that matter to you.  You may even get different answers from a different source.

Another point that deserves a little more emphasis is "Remember that you are interviewing the program as well".  Once you have cleared the hurdle of getting an interview they want to like you.  You have met their academic standards and something about your application drew their attention. No one will sour on you for asking insightful questions.  Ask about the factors that matter most to you, from an educational perspective.  Both sides benefit from you making sure that this is going to be a good fit.

Assessing Competitiveness - Part 2

In Part 1 we introduced how to assess your own competitiveness.

An even more difficult task is determining competitiveness of the programs you are considering spending your application dollars on.

The most important thing to remember about assessing programs is that "perceived competitiveness" has little to do with how good your training experience is going to be at that program.  "Perceived competitiveness" determines how hard it is to get an interview at the program.  Your experience training at the program is going to be determined by the educators, the clinical environment, your class mates, etc, etc. (as addressed in "Where to Apply").

What follows are some characteristics that may help you predict which programs have a high degree of "perceived competitiveness" = "harder to get an interview."

In descending order:

1.  Is the program in a region that is highly desirable and where there are not many other programs?  For example: many people in their 20's prefer big cities to small ones.  Another example: there are many more programs on the East Coast than on the West Coast, so West is even more sought after. (Last note both the Northeast and West Coast want letters and rotations from their own coast, if you did not rotate in their region this will be a hale mary for you.)

2.  Does the program have "EM-famous" faculty?  Prominent figures in the world of EM, particularly those who would be visible to students (i.e. #FOAMed > past-presidents of ACEP).
Is there a popular blog or, podcast out of this program. Were you dying to hear a lecture by an attending? Is one of the attendings an author of a book you keep handy?

3.  Academic affiliation with a University that sounds impressive?  If your mom would be impressed with the affiliation, that counts.

4.  Age of program?  Older, very well established programs are often more competitive than their newer neighbors, especially if they played prominent roles in the history of EM.

5.  A multitude of fellowships, especially the ACGME approved ones (Toxicology, Pedi EM, EMS, Sports Medicine, Hyperbaric)? More fellows can be a surrogate for more academic stuff going on.

The mistake often made by applicants is to only apply to programs with high degrees of "perceived competitiveness".  If you are an average or below average applicant, you should be applying to programs across the spectrum.  This will ensure that you get enough interviews to not be a sweaty mess on Match Day.


You need to do the math:

The number of interviews you will get is a product of your competitiveness times the perceived competitiveness of the programs you apply to:

Above average candidate X Uber only = some interviews :|

Average candidate X Full Spectrum = Uber interviews :)

Average candidate X Uber only = few interviews :(

Below Average candidate X Uber only = no interviews :((


Lastly remember this is advise so you can maximize your application and interviews. There is nothing wrong with applying to a program you have always dreamed of joining, even if you are not an above average candidate, just realize the interview may not come.

Assessing Competitiveness - Part 1

Step 1 is to figure out how competitive a candidate your are.  Your advisor's should be able to help you sort yourself into one of three "buckets":  the average candidate, the above average candidate, and the below average candidate.

Above average candidates have:

• Honors in everything clinical
• Board scores that are above average (>240)

Above average candidates have little to worry about and should not be reading blog entry's on how to get a residency. Make a list of spots you like and would like to train (15-20).

An average candidate is going to match in EM if they make a reasonable list of programs to apply to.

The average applicant has:

• Board scores that are in the neighborhood of average (~220  >220).
• EM grades and letters that sum up as: going to do well in EM (Honors or High Pass with a supportive letter, & hopefully followed by Honors on the second rotation).
• No red flags.

Goal is a diverse list in different regions of the country (25-40).

If you fall short on any of those criteria you should consider yourself to be a below average candidate and plan appropriately.  This means applying to lots of programs (40-50), not wasting money on the most competitive programs, and having a back-up plan for not matching in EM.

This is additionally complicated if you are an Osteopathic or Foreign Medical Graduate looking to join an Allopathic EM program.  Only some programs (68%) will even consider your application.  The programs open to you have their pick of candidates and they are looking for the cream of the crop.  If your not at least an average candidate AND you are from an Osteopathic or non-U.S. school, your chances are slim and you need a back-up residency plan like IM or Family Medicine.

Fortunately, the receptive programs are easy to find by going to their website.  Look at their "residents" pages and see where their residents came from.  If you see residents who are D.O.'s or are from your country/med school, they will probably give your application a fair review.

Now that you have a sense how competitive you are, you can try to figure out the programs...

Communication Breakdown: Zebras, not Unicorns

In my last post I discussed the role of presentations in determining how a student is perceived by their evaluators.  Today I want to hone in on one particular part of the presentation:  the Differential Diagnosis.

The usual advice given to students on how to construct an "EM appropriate" differential is to go "worst first".  This means that the first diseases you discuss are those most likely to result in morbidity and mortality for the patient.  This is important in the ED as this is the place where all the sickest patients get funneled to.  In most out-patient settings acutely ill patients are a terrifying rarity.  In the ED they are the routine.  If you do not think of a life-threatening diagnosis, your chances of lucking into it are low.  "Worst first" is a safety net for us and our patients.

Every student has probably heard the truism, "When you hear hoof beats, think horses, not zebras."  The problem with this clever turn of phrase is that zebras are real.  If you have ever been to a zoo, or the Serengeti, you have seen them.  Positioned as we are, at the bottom of the medical pathology funnel, the ED is the Serengeti of medicine:  the place where zebras roam.  Or at least the zoo of medicine.

Not all uncommon diseases (zebras) are dangerous.  The uncommon and bad ones, like aortic dissection (~200 times less common than MI) are the ones we must be vigilant against and belong on our differentials when we "hear hoofbeats" (i.e. "chest pain").  Zebras that are not particularly dangerous do not need to appear on your differentials.

There are still diagnoses we should ignore, diseases that do not belong in an ED differential.  These are the ones that are neither common nor dangerous.  These are the ones we will only find in text books.  For EM, the truism should be changed to, "When you hear hoofbeats, do not think of Unicorns".

Once a student is able to reliably think of the dangerous zebras, the life threats, I encourage them to order their list by probability.  When first getting used to EM it is okay for your differential for a 25 year old man with pleuritic, reproducible chest pain and normal vitals to be "AMI, dissection, PE, pneumothorax, and espophageal rupture".  You have included the bad stuff.  But you have not given weight to prevalence of disease or your own clinical impression.  This is not what your supervisors are actually doing.

Instead, once you are reliably thinking of all the bad diagnoses, you can start presenting your differential the way the residents do.  Start with what you think the patient actually has, and why.  And that can be a common and less dangerous diagnosis.  You need to follow that "horse" with the less likely but more concerning differentials (the zebras), why you do not think the patient has them, and how far you want to go in tracking them down.   You can even tack a unicorn on at the end, so long as you do not want to actually pursue that mythical beast.

Happy hunting!

The Secret to Honors- Presentation Presentation Presentation

Now that Dr Kellogg has told why you need great communication, including presentations, here are some hints for how to be a rock star. Giving a superb presentation is a sure fire way to get honors in your EM clerkship. While it may seem each supervisor wants something different, there are some common features wanted by all. If you can master these basic aspects of the presentation and then tailor the finishing touches to your supervisor, you will succeed. 

Make sure to read The 3 Minute EM Presentation. It is a road map for success. 

First you must give an ordered, structured presentation: Don’t jump around or be too casual this is interpreted as lack of interest or knowledge.

Begin with the chief complaint - Set The Stage

“This is a 65yo male with h/o cad presenting with 1 hour of precordial chest pain.”

Follow with the history of present illness - Paint The Picture

Put the pieces you have gathered in the history together but make sure you have a reason for what you say.

Focus on the chief complaint, with the seven cardinal descriptors, followed by pertinent positives and negatives.

“The chest pain began 1 hr ago, while he was mowing the lawn, he describes it as a pressure over his central chest, radiating to the left jaw, associated with nausea, diaphoresis and shortness of breath. It increased with walking and decreased with rest and abated on arrival to the er. He had similar symptoms last year when he underwent catheterization with 2 stents.

He denies radiation to back, paraesthesia, pleuritic pain, change with position, or calf symptoms.”

Next you will review pertinent past medical history, medications, allergies, social history, and review of systems - Fill In The Background

Keep the focus on what relates to the chief complaint, not everything you learned.

“The patient has a history of hypertension, hyperlipidemia, CAD, Cath with stent x2 1 yr ago. He takes metoprolol last dose this morning, Aspirin 81mg last dose this am, and statin. He has NKDA. He does not smoke, drink alcohol or use cocaine, he does not use medications for erectile dysfunction.”

While you may know all about this patient’s h/o appendicitis at age 12 it does not relate to the complaint so leave it out.

Then relay the physical exam -

Again focus on what is important for the chief complaint. 

“vital signs stable, pt appears in no distress conversant, lungs CTAB, CV s1s2 RRR without m/g/h/t/ with full equal distal pulses no JVD, abd soft nd nt bs normoactive, ext no c/c/e symmetric calves”

Now you summarize the patient - Grab Your Audience 

This is your opportunity to pull your supervisor back in and show how you can interpret, assess, and plan. Your supervisor is likely being pulled in 5 different directions, you need to command their attention. 

“In summary this is a 65yo with h/o CAD presenting with exertional chest pain concerning for ACS.”

next move quickly to your differential and plan: Don’t get run over by your supervisor and never get the chance to show what you know and think.

“While ACS seems most likely we must consider dangerous causes of similar presentations including dissection, pulmonary emboli, esophageal rupture, and common mimickers of precordial chest pa in such as gerd, pneumonia, musculoskeletal pain and bronchitis.”

“My plan is to intervene with medication for pain, while supplying 02 as needed, and keep the patient on the cardiac monitor. To investigate his sx I would like an EKG, chest xray and laboratory studies to include cardiac enzymes.”

Remember to address: 

Interventions-what you do for the patient 

Investigations-what you do to investigate the chief complaint and differential

EM presentations are succinct, directed toward the chief complaint, focused on both dangerous and probable causes of the symptoms, and above all convey a clear picture of the patient and context for concern.  Remember to set the stage, paint the picture, fill in the background, and grab your audience. This is skill it takes concentration, practice and fortitude. Listen to the verbal and non-verbal feedback you are getting and tailor your presentation to your audience.

Communication Breakdown: Presentable Presentations

If you want to be a better clinician the most important area to improve your skills is communication.

Really.

Of course you need medical knowledge, but that takes a while to build.  And you need procedural proficiency but that also takes time and opportunities.  And you need to learn to function in different clinical environments, each with it's own set of processes, rules, and traditions.  That also takes time and  you start over with each new place.

But communication.  That is something you already have experience with and does not require a prolonged investment of time.  What it takes is the desire to actually communicate better.  With patients, with staff, with other services, and with your supervisors.

Not coincidentally, communication is also the skill that can most dramatically improve your evaluations during your EM rotations.  We will tackle the other areas of communication later.  Today we are diving into the art of presentations.

A really good, focussed, well organized presentation to your supervisor is the most effective way to convince them of your skills.  You will be evaluated in many areas.  Knowledge base, focussed history taking and exam skills, ability to form a differential, and ability to make a plan all being fairly typical of what your supervisors will be assessing you on.  To know exactly what they are asked to assess you on in writing you a "letter" take a look at the SLOE.

You will sometimes be directly observed to see how well you relate to patients and gather info from them.  However, in most rotations these skills will more often be assessed when you present to your supervisor.  More direct observation would be better, and as we will discuss below, more fair.  The pace of most ED's and a common belief that watching you will change your behavior (The Hawthorne Effect) prevents direct observation from happening more often.

If your presentations are going to be this important to the perception of your abilities then it is critically important that you make them good.  Relay only the pertinent HPI details and exam findings and you will appear able to distill information and focus.  Describe an appropriate DDx, giving weight to life threats and common problems, and they will believe you have a strong and well-organized knowledge base.  Share a plan that includes tests and treatment, and that is practical in the ED setting, and they will believe you understand EM practice.

Let's take two hypothetical students:  Student A and Student B, and put them on a hypothetical rotation together.  Student A is well read, with great board scores, and spends a lot of time with his patients getting their history and explaining their care.  Student A gives long, very detailed presentations, and does not suggest a DDX or plan because he does not feel confident that he knows enough to create a good one.  Student B prefers to learn by doing, has mediocre scores, and moves fast, talks fast, and is all over the department.  Student B gives short, focussed presentations and is willing to throw out a DDx and plan even though they are often wrong and get changed.  Student A may turn out to be the better physician but Student B is usually going to do much better on her ED rotation.  If you empathize with Student A this should seem patently unfair.  And that is because it is unfair.  Most emergency physicians are high energy, decisive, and direct people and they usually value those attributes in others.

This is not to say that the ideal is Student B.  Those who incorporate the best qualities of both Student A and Student B are those most likely to experience long term success.  Student B is just going to have an easier time getting in to EM.

If you believe your presentations need work, a good road map to get you started is The 3 Minute EM Presentation.

Good luck!

The New SLOE is Revealed

The SLOR has been revamped to emphasize its true utility as a letter of evaluation. The new SLOE, retains many of the previous features to define each candidates fit, commitment and abilities in EM, while striving to be both standardized and accurate. 

Departmental SLOEs are often composed by the clerkship director, with input from the program director, and faculty that worked with you. Personal SLOEs can be written by any faculty member with whom you have had extended clinical contact. You should strive to have two departmental SLOEs done by October.  A personal SLOE can act as an additional letter of evaluation.

The SLOE continues to relate the author's credentials, provides a global assessment of each candidate, allows for peer to peer comparison, and for personal written comments about each student. 

The SLOE begins with background information including the type of SLOE, author, length of your and the author’s relationship, nature of your contact, the grade during your rotation, how many EM rotations you’ve completed, and last years grade distribution for the clerkship. In the new SLOE there is an added space to distinguish required and elective rotations. This will allow programs to view the grade scale in context of the rotators, and continue to discourage grade inflation.

The new SLOE also defines the author's relationship to the residency program. Since SLOE's are not solely used by the program administrators, this better defines how closely the author influences and understands the ranking process.

Next the SLOE establishes the students qualifications for EM, in comparison to other applicants. Your commitment to EM, work ethic, differentials and treatment plans are each compared with your peers, and categorized as “Above Peers,” “At level of peers,” and “Below Peers.” In the new SLOE the descriptors of candidates now emphasizes team work, and ability to communicate a caring nature to patients. These two essential characteristics of the EM candidate have replaced the personality questions on the previous SLOR, to shift focus from personality traits to skills.

The predicted amount of guidance each student will need is now defined in comparison to peers.  Students are ranked as needing, “Less than peers,” “The same amount as peers,” or “More than peers.” Given this guidance the author predicts your success as “Outstanding,” “Excellent,” or “Good.” 

Next the Global Assessment of each candidate with ranking compared to other EM candidates recommended in the last academic year, as “Top 10%,” “Top 1/3,” “Middle 1/3,” and “Lower 1/3.” The number of applicants recommended in each category last year, and the number of letters written last year are listed, to allow for both context and comparison. Finally the expected placement of each student on the programs rank list as “Top 10%,” “Top 1/3,” “Middle 1/3,” and “Lower 1/3,”  or “Unlikely to be on our rank list.” 

After each applicant is compared to peers there is a comments section with the emphasis clearly on addressing areas of concern and strength. Detailed information about the rotation itself, the residency program and grading system, are now separated onto the program demographics form easily accessed at the cord website, or it can be attached to each letter. This allows all programs to define their theory and unique approach, without adding bulk to the evaluation itself.

This new streamlined SLOE's name may be quirky but it's aim is true: to create concise accurate and useful evaluations, to maximize students matching at the program best suited to their abilities and needs.

Communication Breakdown: Get 'em booked

One of the most intimidating tasks for a student in the ED is getting patients admitted.  You want the responsibility.  You want the sense of ownership.  You want to prove that you can be persuasive and get things done.  Successfully booking an admission accomplishes all of these things. I am more impressed with a student who can complete a tough admission than if they can close a complex laceration.  

Conversely, should the admitting conversation not go well, you may feel embarrassed or inadequate.  If your supervisor has to take over, their evaluation of your performance may go down.  

There is no surefire, guaranteed, approach that will sell even the obstructionist medicine resident.  But there are some things you can do to keep your admission call from going down in flames.

Walk a mile in their clogs

Understand the perspective of the person on the other end of the phone.  This may be easier as a student, having recently been on these other services,  than a couple years from now when you are firmly entrenched in the ways of the ED.  

Dig up those detailed IM presentation skills and give them a deluge of data.  Often times they do not want you to tell them what you think is wrong with the patient, they want you to give them the information so that they arrive at the same conclusion you did.  This is, of course, the exact opposite of what we are looking for in the ED - for you to make an assessment and come up with a plan.  

But if you are talking to a surgeon, you need to give them a very specific reason for why the patient should be admitted to them.  Not, “because they have belly pain”, instead, “we believe they have appendicitis”.  

Use the hammer

The hammer is the point that cannot be argued, that no physician behaving in a remotely professional manner can ignore:  “the best interest of the patient”.  This is a powerful tool.  You will encounter many objections from people you have contacted asking them to do work.  You have added to their task list.  They may be thinking in terms of what your request means for their day/night/weekend.  By judiciously using “the best interest of the patient” you can wear down almost anyone.  

In the same vein, you will often encounter pushback on “social admits”.  These are patients who cannot go home, but not for a strictly medical reason.  These patients are very frustrating for in-patient doctors and so they will often work hard to convince you that they do not need to take them in the first place.  But if a patient is unsafe, or can’t walk, or can’t control their pain at home, going back to “the best interest of the patient” is a hard thing to argue effectively.  

Practice makes perfect

If possible, run your admitting presentation by one of your supervisors.  If that is not time practical, at least make sure that the reasons for the admission are clear.  Make sure that you understand why the patient will benefit from being in the hospital.  If you do not know or if you are struggling to put the rationale into words, this is probably not a good admit for you to attempt because you are likely to fail.  

It is important to remember that even if you do everything right, sometimes you will have to call in your supervisor because the person on the other end of the phone is not being reasonable.  This has happened to everyone.  Making your calls within earshot of your supervisor helps them realize when it is not you that is the problem.  

If you want additional tools for getting others in medicine to do what you want, have a listen to an EMRAP Educators Edition podcast with Dr. Chad Kessler on communicating with consultants.  

Good luck!

Scoring Procedures

One of the goals most students have for an EM rotation is to get some procedural exposure and experience.  There are some procedures that that the residents will happily give to you, like ABG's, NG tubes, suturing, and anything involving pus.

However, the procedures you are really hoping for are the ones with greater complexity, like intubation, central venous access, and lumbar puncture.  These are usually much harder to get.  You may even be in competition with an intern for these, especially in July and August.

Here are some tips that can result in more complex procedural opportunities:

1. Be involved - Your supervisors will be much more interested in finding cool stuff for you to do if you are engaged and participating in what the team does.  
2. Be ready - You need to have background knowledge on indications, contraindications, landmarks, and technique for any procedures you would hope to get the chance to do.  Your supervisors may use screening for this knowledge to decide if you get the chance to do the procedure.  Also, take any chance you get to practice on a simulator before trying this on a real person.  
3. Be proactive - It does not hurt to ask for the opportunity.  The worst thing that happens is they say, "no".
4. Be honest - Actually, the worst thing that can happen is that you claim to have experience you do not have, get found out, and then get demolished in your evaluation and letter.  Lack of experience won't keep you from some opportunities but lack of honesty will  

What in the world is FOAM... and where can I get some???

The new education trend sweeping Emergency Medicine is FOAM (Free Open Access Medical-education), also known as #FOAMed.

Offering medical knowledge free to the world is a break from the pay-to-learn model that has existed in medicine (buy a textbook, subscribe to a newsletter, pay for CD's, etc. etc.).  But information wants to be free and educators are finally embracing that it is more satisfying to expose a larger audience to what you have to teach.

Everything a student of Emergency Medicine could want to know is now out there for free. The challenge has become:  how do you find what you want to know.

As a student just getting started in this specialty you are faced with a daunting mountain of resources.  And many of these sites, blogs, and twitter feeds are not targeted to the early EM learner.  So where should you begin?

Well, two of the best sites for students recently posted some great content on getting the most out of this  wonderful new world:
Academic Life in Emergency Medicine 
iTeachEM

Enjoy!

Should I do combined EM/IM residency?

If you ask most people who trained in just Emergency Medicine they will tell you that EM/IM training is not necessary.  They may even look at you funny for voluntarily doing more ward medicine months.

As an advisor, my best "pro" for dual training was that it left open the option for Board Certification in Medical Critical Care.  With that pathway now open to those who train solely in EM prior to Critical Care Fellowship, I have had to reevaluate who I recommend EM/IM too.

But instead of listening to me, take a look at what Dr. Matt Astin had to say about his own experience over at Academic Life in Emergency Medicine.  

Stuff for Students: EM Basic

EM Basic is a podcast and blog by Dr. Steve Caroll.  The sub-heading on his home page reads: "Your Boot Camp Guide to Emergency Medicine".  That about sums it up.

Listening to this podcast will give you a solid foundation in clinical Emergency Medicine.  He started with approaches to common clinical complaints like chest pain, abdominal pain, etc., and progressed to reviewing essential evidence and discussing elements of EM practice like trauma resuscitation, procedural sedation, and much more.

You can find EM Basic on iTunes or download the files from his website.

Enjoy!

Stuff for Students: ALiEM and Patwari Academy videos

Academic Life in Emergency Medicine (ALiEM) is a wonderful blog started by Dr. Michelle Lin for Emergency Medicine enthusiasts.  There is now a stable of authors providing useful content for anyone interested in EM.

Particularly helpful for students and early residents are the Patwari Academy videos they post every Sunday.  These are short videos, Kahn Academy style, of an expert breaking down an EM topic on a "whiteboard".  Here is a link to the most recent on Salter Harris Fracture classification.  Other recent topics include Early Goal Directed Therapy, Approach to Altered Mental Status, and a series on Chest Trauma.

To get caught up you can go to the ALiEM blog and go back through the posts, OR search the blog for all "patwari" posts.

Enjoy!

Stuff for Students: SAEM Website

SAEM is the Society for Academic Emergency Medicine.  A natural part of their mission is to provide resources for medical students, especially those with an interest in a career in academics.  They recently revised their website to make it more functional.  There are still a few bugs and misplaced links, but there is also a ton of resources for students.

Follow the "Membership" tab to the "Medical Students" page and have a look around.  What follows are a few of the most useful resources.  You do not need to be a member to use any of these, but membership does confer additional benefits, though at a not insubstantial price.

Full disclosure:  I am a member of an SAEM committee whose mission is to find ways to better serve  medical student's and resident's.  I do not think this creates any conflicts of interest.

The most invaluable resource SAEM provides are their Directories, including their Clerkship Directory and their Residency Directory.  These are interactive maps of the U.S. with links to information on most of the EM rotations and all of the Allopathic EM residencies.  This is a great place to start researching the programs you may want to apply to.  The information here is very helpful.  A word of warning: not all of the details are right (I found several errors on my home institutions page).  A residencies actual website, usually linked to in the profile, should be considered a more definitive source of information.

Another incredibly useful service provided is the E-Advisor program.  This is a great way to get advising on a different region of the country from where you go to school.  This is also a great way to connect with an adviser if you do not have a local EM program.

One more to highlight is their collection of Student Resources.  Included are a variety of documents answering common questions and providing advice on numerous issues facing students applying to EM.

There is a lot more as well including award and grant opportunities, and information on the Annual SAEM meeting (next week in Atlanta).  Enjoy!

Acing your EM Clerkship

Acing your EM Clerkship

Here are five things you can do to shine during your rotation

1. You are on stage all month: present yourself well at every opportunity. Residents, nurses, and secretaries notice how you act, and will make their thoughts known. Be polite, be agreeable, be willing to bend as needed. Be WHERE you are expected WHEN you are expected: be eager from minute one, until you leave. 
2. Yes, but... At some point you will be asked to do something you have never done before. Accept the challenge but explain your limitations. This way your supervisor knows where you are starting from. When asked if you would like to suture a child's face answer "yes, but this will be my first experience suturing a child’s face. Can you walk me through it."
3. Anticipate the next step: Students who interpret are noticed. If you sent a urine to check for infection, decide what antibiotic you want to use if it is positive. Be flexible, plans will change, patient's status will worsen, exams will change- don't be too invested in any one direction, flow with the needs of those around you.
4. Presentations present you: Be concise, succinct, and focused. Take a moment after seeing the patient to put your thoughts together and practice your presentation. Focus on the complaint and the differential, and let them guide your presentation of the history, exam, differential, and plan. The following is a great article on EM presentations: The 3-minute emergency medicine medical student presentation: a variation on a theme. Davenport C, Honigman B, Druck J.Acad Emerg Med. 2008 Jul;15(7):683-7.
5. Demand timely, useful feedback: at the end of the shift residents and attendings are rushing to finish. Rather than asking how you did at the end, give your supervisor an area to concentrate on right from the start. As you begin a shift let them know the area you want to work on. "Today I'd really like to work on my presentations, can you help me with that." Now your supervisor has a focus, and you've enlisted them to be your ally.

Applying Pages

Several new resource pages have been added to this blog that should be of help to those applying for the 2014 match.  All the "pages" can be found in the right hand column.

An Intro to the Application should get you started with some basic over-view of what you need to know now.

The pages below then elaborate on the five main components of your application:

The ERAS Application
The Personal Statement
The Dean's Letter and Transcript
The Boards
Letters of Recommendation

 Now is a great time to find out what you are going to need to do.

Spring To Do List for Fourth Years

To Do List:

1. OWN OCCUPATION Disability insurance-  As you finish up medical school you have an opportunity to get disability insurance that will cover you within your specialty of choice EM, at a steep discount. ON OC covers you if you can no longer practice in your specialty. This is imperative as many policies will stop covering if you can practice in another area of medicine. 
2. COBRA Health insurance - this is health insurance through your medical school to cover any gap from your coverage during school and your coverage at your residency hospital. Check your paperwork for coverage dates and ensure you are covered. Accidents happen, please think ahead and protect yourself.
3. PAPERWORK- Whether electronic or in paper the stack is huge. Your residency and hospital have a lot for you to fill in. While it may seem pointless and often redundant, you have an obligation to get them done and done quickly. You will be working with your residency coordinator for three to four years- don’t make her life harder by needing nagging to meet your obligation.
4. CAPSTONE- if your school doesn’t have a capstone course to get you in gear for residency then make your own. See our section on designing your own  https://www.blogger.com/blogger.g?blogID=5950597211152538922#editor/target=post;postID=5649412330569209983;onPublishedMenu=allposts;onClosedMenu=allposts;postNum=5;src=postname
5. TAKE SOME TIME - you have an opportunity to use your time this spring to explore, travel and renew yourself. Residency will be exhilarating but the hardest work of your life. Don’t waste the time you have, enjoy it.

Away Rotations - Keeping Bridges Unburned

After working so hard, and stressing so much, over securing the Away Rotations that are going to make your application for EM perfect, it can be really hard to let those rotations go.  What is the harm in hanging onto that spot until the last minute, just in case?

Please do not do this.  Once you know you will not be completing a rotation, politely withdraw.  Three groups are hurt if you wait to the last minute to vacate that spot:

1.  You - that program that you were recently interested in enough to rotate at will now treat you like persona-non-grata.  Drop them at the last minute and you should not bother wasting money on an application.  The repercussions could be even broader than burning bridges at one program.  All the Clerkship Directors know each other.  

2.  The Clerkship and Program left with an empty spot - they are trying to get as many students an opportunity to rotate as they possibly can.  Canceling at the last minute just makes their job harder.  Clerkship Directors, as a rule, are really nice people.  Generous with their time and very much invested in helping students navigate the path to an EM Residency.  They are a difficult group to make angry.  Leaving them with a last minute unfilled spot in the rotation they pour so much of their personal and professional time into, is a very reliable way to make them angry.   

3.  The other students in the applicant pool - somebody else would have really liked that rotation opportunity that it may now be too late to fill.  Emergency Medicine is a team sport and cut-throat, self-serving behavior has no place in it.  If you even occasionally suffer from these "qualities", now is the time to remove them from your character.  

While I cannot guarantee that Groups 2 and 3 matter to you, I am pretty sure that Group 1 does.

No rationale person, including Clerkship Directors, will be angry if a student withdraws more than a month before their start date.  They may not even notice, and they certainly will not put you on a list of students whose careers they must crush.  No one has that kind of time.

Withdraw at the last minute, or no show, and that Clerkship Director may decide to make the time.  

Tricks of the Trade: Rotations

Tricks of the Trade

Rotations

When you get the rotation you wanted you have preparation to get done:

Read the paperwork from the program carefully, and complete it in a timely manner. There is no second chance for a first impression. You don't want to arrive, and not be able to rotate because of paperwork. Health requirements vary at different institutions. Check with the undergraduate medical education office or health services, at the hospital you are going to. They should relay what you need in detail. This is the time to jump through the hoop and get it done.

How many is too many?

There are no perfect number of clerkship applications. Get help from your advisor to review your application to determine your competitiveness. Look at where you want to go, and how competitive a market it is for clerkship. For most student 4 applications will suffice. If you are a weaker applicant or looking at a more competitive market- consider 6. If you get a clerkship and still have applications outstanding that you will decline, call and let them know you appreciate their time but have accepted another opportunity. This is better than waiting and declining the spot. This proactive stance will win you points with the clerkship director and the coordinator. If at all possible do not accept a rotation and then back out of it. This sends the message you are not interested and inconsiderate- not a good impression.

To Research or not to Research?

Research is less likely to enhance your application than great letters and rotations, but can be another opportunity to get experience, get to know an EM attending, and be on the front lines. Discuss with the attendings at your home institution or contact the Research Director at a program you are interested in. They can help connect you with ongoing projects that you can assist in. Many EM attendings have great ideas and simply need man-power to make them reality. If you get involved, list the project on your ERAS application. Be prepared, this will be a topic of interest in your interviews.


Who is successful?

Students who succeed in EM are proactive, flexible, and enthusiastic. Be a "tigger1." Show up to every shift with a smile, ready to do and be anything needed. Have a positive outlook, and energize those around you. Put your hands on patients, and FOLLOW THROUGH. Know the labs, update your supervisor on how each intervention has worked, and ask to make consultant and admission calls. When you don't know something, look it up. Find articles, case reports, or guidelines and show your supervisors. Be honest, if you didn't ask, or didn't do it, say so. I trust a student who say, "I didn't...."

1. Amal Mattu. Becoming the Leader That Others Follow: ACEP Teaching Fellowship, March 9, 2013.

What can we learn from the 2013 NRMP match experience?

If you go to the NRMP website you can read their preliminary report on the 2013 match.  This is usually followed by a more detailed analysis of each specialty and program, but I think there is some useful information here.

For 2013 there were 165 EM Residency Programs offering1,744 training spots.  Only 3 of these spots went unfilled in the match.  Scrambling to an EM spot is not a reasonable back-up plan.

1,428 of those 1,744 spots (~82%) went to U.S. Seniors.  There were another 212 of these U.S. Seniors who applied for EM, but did not successfully match.  So 87% of senior medical students at Allopathic schools successfully matched to EM.  Most U.S. Seniors will not need a back-up plan.

313 non-U.S. Seniors (i.e.  everybody else in the applicant pool) also matched to EM out of a non-U.S. Senior applicant pool of 790.  So if you were a DO applicant, a re-applicant, or a foreign trained student, you had a ~40% chance of matching.  Knowing you face these odds should factor into your strategy.  

The number of EM spots has been growing.  1,744 this year.  1,668 in 2012.  1,607 in 2011.  Whether this yearly growth will continue is debatable given the current discussions about cutting funding for resident training.   

EM is growing in size and continues to ascend in popularity among medical students.  What these numbers tell you is that most U.S. allopathic seniors will match so long as they make reasonable application decisions.  Applying to dozens of programs is not reasonable.  It just makes more money for the ERAS service.  Better to be realistic in choosing the programs you apply to.  Your individual advisor should be able to give you a good idea of what programs you should specifically target.

Non-U.S. Seniors can absolutely match in EM, but they need to be even more realistic in their choice of programs to apply to.  Again, it is not about the number you apply to but choosing ones that will be interested in you as an applicant.

Do not be dissuaded by these numbers.  They are just another part of your application strategy that needs to be managed.

SAIL SENIOR SAIL

Preparation is the key to success. As you embark on fourth year, this is a great time to do your research, and set yourself up for success by planning your EM clerkship rotations. Here are jumping off points to get you started:

You need one HOME, and one AWAY, between May and September.

For most HOME will be your medical schools academic EM rotation.
Rotate early and get FEEDBACK.

AWAY offers a myriad of options:

 Decide WHAT you want and WHERE you want it.

Location, Location, Location - want to relocate, or try someplace new?
Your away rotation is your chance to try someplace out.

There Is No Place Like Home - 
Your away rotation is your chance to try a new setting:

If home is urban, try suburban.

           If home is a "community" ED try an "academic", or "county" ED.

Think about your home program’s attributes and look for something different. These rotations will help you learn what you like and dislike. As you interview, you can discriminate what is important for you.

Mirror Mirror - Review a program’s curent and recent residents on their website - look for residents similar to you in interests, experience, and education.  

Like minds, attitudes and interests, tend to flock together. If no one seems like you, it may not be a good fit.

 Dream A Little Dream - Go where you hope to be. 
Your away month is the best interview you will give. 
Consider taking a chance.

 Game Time - On your rotation:  Be prepared.  Be proactive.  Be positive.  
Be willing to change and grow.

Take the feedback you get at home and sail on.

Now that you are thinking, go ahead and read through the full details on the rotation application process and preparation.

Who can I trust...

In my opinion, the greatest challenge facing a medical student who is interested in Emergency Medicine is where to get trustworthy advice on the applying process.

There are numerous sources of information and it is difficult to know what you can trust.

This may sound ridiculous coming from a blog, but the best stuff is probably not available on social media and the internet.

There is no replacement for finding an advisor at your school or affiliated hospital.  Someone you can sit down with, face-to-face, and discuss your situation.  They can give you advice specific to your particular circumstances in a way that a blog like this one cannot.

This is not to say that the web does not provide useful resources.  Just be careful to not trust any single resource.

If you are interested in Emergency Medicine, but do not have any local advisor you can turn to for some personal advice, SAEM (Society for Academic Emergency Medicine) may be able to help with their e-Advising program.  These are Academic Emergency Physicians throughout the United States, willing to provide guidance, particularly on their region.