The EMStud Podcast

I recently became aware of a new resource that every medical student interested in Emergency Medicine should check out: the EMStud podcast.

Started this fall by Dr. N8 (@emstudpodcast), they are hitting on key topics of importance to students applying to EM. They have covered The 7 P's of RSI (Really Stellar Interviewing), had a 2 part Q&A on Interviewing (part 1 and part 2), and most recently got the rank list discussion started with 100 Days to Match Day.

These short (well under 20 minutes!) podcasts hit the key points that students need to know. He also provides links to longer form advice for those seeking more. EMStud is a welcome addition to the growing collection of resources for students interested in EM.

Enjoy!

Interview Etiquette: The No Show

A comprehensive collection of Interview Resources is coming soon, just in time for phase 2 of the interview season (the time when interview spots really start to open up). There is one topic, not previously covered in detail, that I wanted to give more attention to: the Interview Day No Show.

The short version... This is a terrible idea and reflects badly on you, your advisors, and your school. 

The longer version... First a qualifier: a true Interview Day No Show is when an applicant who has scheduled an interview does not show up without notifying the program in a meaningful way. Programs understand weather-related travel delays and family emergencies. They don't mind you canceling your interview - there are plenty of other applicants who actually are interested in the program to take that spot. The program director will actually appreciate you giving someone else the opportunity. That reflects well on you.

However, you create an entirely different perception of your character if you cancel with so little notice that finding a replacement is impossible. Or, even worse, if you just do not show up at all with no attempt to contact the program and explain your circumstances.

Many reading this are horrified that anyone would have such an egregious lapse in professionalism. Though there are likely a few who are thinking, "well, I did not want to train at the program anyway, so what is the big deal?"

Here is a list of who the aggrieved program director will likely be notify of your No Show:

1. Your dean
2. The residency director at your home institution
3. Anyone who wrote a SLOE or a LOR
4. Your mom (okay, probably not your mom... unless she wrote one of your letters)

You may not care about the program you just No Showed. However, your home program director, and those at any away rotation that provided you with a letter, are going to care. Inferences will be made about your sense of responsibility, duty to your patients, and overall professionalism. This is a huge professionalism Red Flag. All it takes is one Red Flag to sink your chances.

Adam Kellogg is an Associate Residency Director and former Emergency Medicine Clerkship Director.  He has never personally hunted down a "No Show" to give them a piece of his mind. Yet.

Diagnosing the Match

We are in the heart of EM residency interview season here in the United States. This has been an anxiety provoking year for all involved.

Applicants and their advisors are worried because they do not have as many interviews as they expected.

Residency programs have unprecedented numbers of applications this year and are worried they are not interviewing enough candidates.

The Council of Residency Directors (CORD) Student Advising Task Force and the Emergency Medicine Residency Association (EMRA) worked together to try to shed some light on these events. The result of this collaboration, written by Zach Jarou (@zachjarou), a resident at the Denver Health EM Residency, and myself, was just published on EM Resident. We looked at recent match data and a survey of residency program directors to figure out how we got here and what we can do going forward.

This is a long article, with a lot of data, but after reading it you should have a better idea of where you stand in the application process AND what you can do now to improve your chances.

http://www.emresident.org/emergency-medicine-match/

As the Trail Begins

As you get ready to go out on the interview trail, you need to know what will allow you to shine to maximize your match. 

Scheduling
Realistically you can only do two interviews each week. If you try to make swings into areas, doing back-to-back interview days, you are going to miss out on getting to know the places you visit. Instead of hopping about the country a la Planes Trains and Automobiles, leave yourself extra time. Plan to get in for your interview at least mid-day, the day before. This will allow you to fully participate in the whole interview experience. This means you need to be judicious in choosing interviews if you have been offered more than 10-12. You simply can’t fit more in and do them justice. 

The Night Before
The evening prior to your interview the program will host a social event, usually a dinner or cocktails with residents, interviewees, and possibly some attendings. This is a great opportunity for you to see how the program is from the resident perspective, and observe the groups interactions. You can get many questions answered from different viewpoints, and this is a great time to see how you fit with each group. On reflection, many applicants find this to be the most useful part of the interview when making their decision about a program. Do not miss it just so you can pack another interview in.  

Look Professional

Avoid checking baggage when you fly to an interview.  It will get lost and you will show up to interview day in jeans. While this happens to a few folks every year, it is easily avoidable by sticking to a carry on.

On interview day, arrive early so that you guarantee not to be late. You should be wearing a well fit suit. Men should wear suits with a tie, and women should wear either a dress, skirt, or pants with a matching jacket. Try your suit on now and have it altered or get another, if it no longer fits you well. While it may seem superficial you never want to loose favor because of perceived lack of preparation. The shabbily dressed student might end up being the ill prepared resident. You have a limited amount of time to make an impression, make it a good one.

Have Questions

At the interview you will want to have a list of questions. Everyone is going to ask what questions you have, if you have none - you look disinterested. Don’t fall into this trap. It is easy to have questions. First, have some basic questions you ask at all programs. These should be what matters to you and what is helping you stratify programs. Next, look at the residency website and come up with 3-5 specific question for each program. If you know ahead of time who you will interview with, look them up and have questions about their interests or role within the program. Everyone, absolutely everyone, enjoys talking about themselves. If you don’t know ahead of time, ask what your interviewer’s role is, then ask some follow ups specific to that role. 

Engage

Keep up your energy and interest level throughout the interview. Lean forward, listen, and smile. Avoid slouching, leaning backward, and swearing at all cost. If you do any of these things you will be perceived to be disinterested, and unprofessional. As interviews go on this will get harder than it sounds. Despite your current fervor, after a few months of interviews you will be tired, bored, and ready for a break. You will begin to show disinterest just from the monotony of it all. This is one of the reasons you should focus on 10-12 interviews at a variety of programs you are interested in. 

If you go on more you will have a quickly diminishing return on your investment of time and money. Your chance of matching with eight programs on your rank list is >90%. Your chance of matching passes 99% with twelve programs on your rank list. More programs will not increase your chance of matching: you already maxed it. Remember, you have more control than you think: more than 50% of you will get your first choice and 80% of you will get within your top three. As you move forward think about both the time, effort, and money going into each interview, and compare this with the likely outcome. If you have 10-12 interviews at places you want, you have no need to do more. 

Cancelling

Canceling interviews with enough time for the program to get another applicant in, is courteous to the program, and generous to your fellow applicant. If you realize that you have enough interviews for your rank list, you can begin canceling those that would go to your bottom. The key is canceling early enough, that the program can get another applicant in for that day. Generally the longer lead time, the better. A few days and even a week is difficult to re-arrange, so ideally cancel more than two weeks ahead of time. If you are worried the programs will be insulted, remember they want to maximize their match list as well. Give them enough notice and there will be no hard feelings. If you are one of the many great candidates that doesn’t have enough interviews, you should consider freeing up January. There will be more cancelations as the interview process continues and you will need flexibility to accept on shorter notice.  

Quantity and Quality

Interviews are your opportunity to try out a variety of programs and see how they will fit you. With a reasonable plan you can schedule, travel, and arrive at 10-12 spots ready to shine, and succeed in the match. Remember to maximize this opportunity by focusing your energy on a selection of interviews, with questions and observations that matter to you and your learning.

Lucienne Lutfy-Clayton is a Clerkship Director and Associate Residency Director, and has had her luggage lost too many times.  

#ACEP14 is upon us... "Should I go?"

The American College of Emergency Physicians (ACEP) is the largest EM organization in the United States.  Their largest annual meeting, the Academic Assembly (#ACEP14), starts this weekend.  Thousands of Emergency Physicians, and other acute care providers, from all over the world will be descending on the McCormick Place convention center in Chicago.

As part of this event the Emergency Medicine Resident Association will be hosting a week of events as well.  For students pursuing a career in EM the highlights are the Student Symposium and the Residency Fair, both happening on Sunday, October 26.

If you are in the 2015 match, you can make an argument that there is little value in going to this now as most of the interview offers are out already.  That is a good point.  Many of the Program Director's have already made up their minds about their interview offers and wait lists.

Another viewpoint would be that this is the MOST important Residency Fair to go to for someone in this years match.  Especially if you do not have the 10-12 interviews that correlate with a 99% match rate.  With the increased number of applications that each program is receiving (without an increase in the overall number of applicants), most program directors are expecting to make more use of their "wait list" than ever before.

A nice introduction and conversation with the program leadership staffing the Residency Fair may very well impact your spot on that wait list.

Adam Kellogg is an Associate Residency Director and former Emergency Medicine Clerkship Director.  He is currently training residents he met at the EMRA Residency Fair.  

Where are the interviews?

This is an update to last years post on the same topic.  The mismatch appears to be worsening between the number of programs applied to AND the number that an applicant needs to apply to...

This is an anxiety provoking time of year for both sides in the EM residency match process.  Most residency programs start interviews by early November, and they are worried that in the increased numbers of applications they are receiving, they are not going to invite the right applicants to fill their classes.  But right now, we are not worried about the residencies. They are going to be fine.

As an applicant for EM residency you find yourself in one of two groups:

• Group A:  The Fortunate Few - You have too many interviews (more than 10 - 12) and you are not sure which ones you are going to actually do.  You may even have 15 or more and think that you are going to want to do that many.  
• Group B:  Everybody Else - 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 the name suggests, theirs are good problems to have.  Unless you have special circumstances, like a difficult couples match (EM-ortho, EM-EM, EM-Derm), at 10 to 12 offers, 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 20.  You will match 95% of the time if you rank 10 or more programs.  If you look at the graph below (from the NRMP's Charting Outcomes from the 2014 Match), having a number of interviews beyond 8 - 10 does not really prevent someone from not matching.  There is a no 100% guaranteed number.  If the quality of your interviews are poor, it does not matter how many you do.

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 interview spots.  They will start to give some of 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 (i.e. a SLOE came in late), send a polite email or call the contact person 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.

Don't waste your time and money applying to more EM programs.  This seems tempting, but it will not help.  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.  And they have already offered most of their interviews and created a Wait List.

Open up your January.  Interviews opportunities are going to become available, especially in January. Applicants with a lot of interviews in November and December will realize they are good and will cancel January interviews.  You may get short notice offers to come interview and you want to be ready to respond.  You may have had your heart set on that Beach Medicine elective in May, but you are better off moving whatever you are doing in January to a later block.

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.

Adam Kellogg is an Associate Residency Director and former Emergency Medicine Clerkship Director.  He thoroughly enjoys polite emails that provide new information about a residency applicant. 

Dropping dead over Application Deadlines

For students applying to EM for the 2015 match (2014-15 Interview season), this is a very stressful time.  September 15 has become a terrifying deadline.  The idea has emerged that your application must be "complete" on September 15th or you will be behind the rest of the applicant pool and end up scrambling.  The blame for this resides on well-meaning advisors, Dean's, blogs, and the pervasive fear of failure that highly motivated people use to keep themselves highly motivated.

Here are the actual deadlines that are set in stone:

• September 15th - ERAS opens and you can upload the portions of the application you have control over
• October 1st - the "Deans Letter" (MSPE) comes out
• February 25th - Rank List deadline for both sides
• March 16th - Yes/No day for applicants and beginning of SOAP
• March 20th - Match Day

You will notice a LARGE gap in there between 10/1 and 2/25.  That is because every single residency program has a different timeline for when they start reviewing applications, offering interviews, and conducting interviews.  There is no hard and fast deadline by which you must have your application "complete" (MSPE and 3 LOR's, plus PS, boards, and ERAS app).

However, there is some consensus among EM program directors (the people who are actually making these decisions):

1. Applicants should have everything within their control uploaded Sept. 15
2. A single EM SLOE is needed for application review and consideration for interview
3. Very few applicants will have more than one EM SLOE uploaded on Sept. 15
4. Most interviews of outside applicants (those who did not complete their clerkship) will be OFFERED in the second half of October and early November

These are NOT absolute rules.  You may know someone who gets 5 interview offers by October 1.  Feel free to hate them, but remember that there are very few of these folks and they are undeserving of your scorn. 

The biggest variable between programs is how many letters need to be submitted before they will review your application.  Some insist on 3 letters before they will review.  Others only care if there is at least 1 EM SLOE.  This becomes an individual judgement call.  That second SLOE that won't be in until mid-October may raise the quality of your application.  But settling for one SLOE and two other letters will have your application in front of more eyes sooner.  This is where you need a local personal advisor, or SAEM e-advisor.  Or you can ask us in the comments.

Get your personal statement written (15 drafts is more than enough).  

Gather all your resume stuff and write brief descriptions of your roles.

Confirm your letter writers.

Choose your programs.

Good luck! 

Learning Resource: FOAMcast

The world of FOAMed (Free Open Access Medical Education) is over-flowing with resources discussing cutting edge, controversial, and high risk topics.  This is why we use it.

However, much of the popular and best FOAMed content is not ideal in the early stages of assimilating the broad knowledge base required for Emergency Medicine.  You should try walking with EMbasic, before you go running with EMCrit and Smart EM.

A new addition to the list of resources for EM learners at all stages is the FOAMcast podcast by Lauren Westafer (@LWestafer) and Jeremy Faust (@jeremyfaust).  These short, easily digestible podcasts summarize a recent piece of hot new FOAM and pair it with a review of core content material that every emergency provider should know.

Recent episodes have covered Anaphylaxis, Neonatal Jaundice, and First Trimester Bleeding.

Have a listen.  You won't be disappointed!

FOAMCAST

Why FOAM it alone?

To SLOE or not to SLOE

This summer as you rock your rotations, get your information uploaded to ERAS, and get your application for EM residency buffed and ready for prime time, one question comes up, are all EM letters better than a combination of SLOE and non-SLOE/EM letters.

SLOE are the Standard Letter of Evaluations, used by EM faculty to compare students to their fellow applicants, and predict their future potential success within an EM residency. These letters were designed by an EM task force, to minimize grade inflation, and focus on the student's characteristics and potential, when compared to their peers. Program faculty like to see two or more SLOE to consider an application complete, and consider for an interview.

Non SLOE letters of recommendation, within EM are usually used  by non-residency EM faculty. They can be useful for community EM faculty to endorse a students attributes toward EM. While not ideal they are still within EM and are read and considered. Non EM letters, tend to be considered less useful, because they frequently do not reflect on the applicants attributes that apply to EM. Many students are intelligent, hard working, and enthusiastic, but not all can translate these attributes into the fast paced, chaotic EM environment.

Council of Residency Directors list serve recently had an active discussion on this topic and program leadership consistently expressed they want to see 2 EM SLOE from program faculty.  All EM letters is generally preferable to non-EM letters. The one instance non EM/SLOE can be helpful is when it comes from a supervisor who has worked with the student closely over time. If a student did  a longitudinal research, public health project, or graduate degree, the mentor of this project's endorsement  is supportive for the application, adds another perspective of the student, and it's absence could be suspicious.

In the end the desire of program leadership is what matters, this is the audience you want to impress. Get SLOEs, as many as you can from different programs, and if you have been involved in a long term project, get your mentor's recommendation as well. Generally non-EM letters are unlikely to aid your application in EM.

So You Got a High Pass

So You Got a High Pass....

This time each year, I hear from many students that they are devastated by their grade on their first EM rotation. There appears to be a common misconception that a High Pass is a death knell. This is far from the case, we are frequently swayed to interview students who receive High Pass on their first EM endeavor. 

So why you ask, do we get excited for those who weren’t rock stars from day one? The answer is simple: If you could choice to train one of two runners, they both run the 100 in 12 seconds one with perfect form, and the other with horrible form, who do you choose? We choose the second, if you teach her good form she will beat the first.  The student who gets a High Pass on their first rotation, and Honors on the second will outdistance the rock star every time. Our great search in residency is for the teachable student. 

So what can you do to become this sought after teachable candidate? You need to improve in each aspect of EM. This is the time to be proactive; call or write the clerkship director at your first rotation, and get the specifics you need to address. 

For most this falls into two categories: 

1. Approach
2. Application

The approach for EM that is successful is proactive, energetic, and enthused. You want to go in, and light the place on fire. Be forceful, everywhere, and ahead. Run to action, put gloves on, and think what they will need next, and supply it. Never pass up an opportunity to get involved, or do even a menial task. You will be noticed and given more. Being reserved, quiet, or contemplative is likely to result in evaluations below your ability. Be willing to put your thoughts out there, and show how you can apply yourself. 

The application is realizing there are discrete skills in EM, you need to have them. The first is the EM presentation, read The Three Minute EM Presentation learn it, and do it. The second is the weighted differential, keep it wide, focused on the worst possible diagnoses, that could present like your patient, the probable reasons for this presentation, and the interesting (Zebra) that could present like this. Have this ready before your presentation, so you can amend your presentation to include the pertinent positive, and negatives for this differential. Review common EM core content, by reading texts, review books, or listen to EM basic or FOAMcast. The Plan is the last step, come up with how you will address your differential. Less is often more, don’t forget to start with your interventions for the patient, and then go to ancillary testing, that helps discriminate your differential. Now make it happen, be the first to recheck the patient, check test results, and think what you will do with the positive or negative result. 

Turn your disappointment into determination. Show us you can and will learn the form, and beat the natural. 

Learning Resource: Closing the Gap

For fourth year students interested in Emergency Medicine this is the time when most are finally getting to do EM rotations. There are a lot of objectives packed into these four week blocks. You need to figure out if this is really the kind of medicine you want to practice. You need to "audition", showing your aptitude and fit for EM, and secure letters of recommendation evaluation. You also want to start improving your clinical skills and getting some procedural experiences under your belt.  The latter is where todays post come in.

The scope of EM practice includes numerous procedures, including high stakes ones like pericardiocentesis, cricothyrotomy, and resuscitative thoracotomies. While you will learn to do these eventually, at this stage it will be higher yield to focus on the procedures that are more readily available, like wound management. You should get opportunities to do wound repair during your rotations and your future residency will expect you to arrive with some degree of experience with basic wound closure techniques.

The world of FOAMed (Free Open Access Medical Education) is overflowing with great resources for procedural education. The "Closing the Gap" site, lacerationrepair.com, is a particularly nice resource that consists of a set of videos and annotations covering the majority of wound repair techniques you need to know. Start with simple interrupted sutures, check out the corner stitch, and work your way through the advanced techniques, like layered closure.

Enjoy!

Got to Get Away (for a Rotation)

Now that you have picked EM as your area of interest, you need to arrange your year. The first step is your home EM clerkship. Ideally you want to rotate as early as possible.  Use this month to hone your skills, be open to feedback, and show how you can learn and grow as a clinician. This spring you need to find your away rotation. Your away is your opportunity to see a new spot, experience a program your interested in, and compare and contrast what is important for your learning. 

As with most of the residency process, you get out what you put in. First you need to do some legwork. SAEM’s clerkship directory is the best spot to look at regions, narrow your choices, and investigate programs. The map allows you to click on a state and view all the clerkships, with information about the individual rotations. 

Next you need to go on VSAS. This is the visiting students application service. You can use this to apply for the majority of clerkships. The site is cumbersome, so here our my top three tips:

1. Know the programs you are interested in first - you can review their individual applicant requirements. Rotations will have their own block dates, forms, and application timing. You will want to make multiple applications, in order to ensure you have an away rotation. Three to four should be plenty. VSAS has tutorials that will walk you through the process step by step.
2. "Patience Daniel son" - the process is slow but this is how to get the rotation you want. Many programs accept applications on a rolling basis and will notify you if you have a slot 6-8 weeks in advance. You can use the tracking option to keep an eye on your application process, and even change your preferences for rotations at an institution. 
3. Ensure you fill in all the forms -  there are a lot of forms but you need to complete them all. Incomplete applications will either fall to the bottom of the stack, or never even reach the clerkship director. If you fail to meet the requirements you will not rotate. The tutorial for forms is the most important to review: complete and upload them properly.

Some students are met with the dilemma of being accepted into one clerkship, while they are waiting for another to give them an answer. My advice is to take the bird in the hand. While it is tempting to wait it out, what is most important is that you have an away rotation. If you have done your research up front, each of your applications is to a spot you would like to rotate at. Be excited you have the rotation and get yourself ready to shine. If you only have time for one away rotation, let the other programs know you have accepted another spot and look forward to meeting them during interviews. 

So EM is right for you, now you need a plan….

So EM is right for you, now you need a plan….

Step One:
Rotations
You need to do a home and an away rotation in EM as early as possible. Read the link to get all the details about choosing the right rotation.

This will give you exposure, personal advising, and feedback. It is incredibly important to do two things: 1-recognize the feedback you get, 2- demand feedback you haven't gotten in real time.

• You will get feedback on every step, of every encounter - your job is to recognize it. While you present, notice what your supervisor does: glazed eyes = too much information, confused look = add details, fidgeting = speed it up. Every supervisor will want something different and you need to continually adapt to every one that you work with. Start with a formal, organized presentation, and then edit it throughout your shift to fit the non-verbal feedback you are getting. This article gives a great architecture to start with. 
• Next you need to demand feedback. You can ask at the end of your shift, but often you will hear "you did a great job." More effective is a proactive approach. Self reflect and decide what you need to work on, then at the beginning of the shift let your supervisor know what you want to work on today. This lets them focus on the area you need help in and immediately lets them know you are open and eager for feedback and want to improve. This also allows the supervisor to note how you incorporate feedback and feed this into your evaluation. 

Step Two:
Audition

You are auditioning, you need to put your best face forward. You want to present yourself, at your best every day, and in every interaction. You want to be the worry free student, always willing to help, looking to do more, and happy to put in extra effort and time. Don't ask for special treatment, special schedules, or lots of days off. Don't call out unless you are seriously ill. Don't show up late to lectures because you stopped for breakfast.

As Amal Mattu says "be a Tigger": show up with a smile, positive attitude, and energy to spare. Be the person everyone wants to work with, especially the nurses and techs. Always be respectful, professional, and appropriate. EM tends to be a casual atmosphere, but resist the urge to be too casual. It is easy to step over the line when trying to fit in. Realize you are not in the same position as the residents or attendings and err on the side of caution. Be professional at all times. lean forward, look interested and acknowledge areas to improve.


Step Three:
The SLOE

You need to get your letters of recommendation. Your rotation is the basis for your letter, the more you can show the kind of resident you will be, the better your letter will reflect your abilities. The SLOE compares you to your peers. Your goal is to show your positive attributes and that you can grow and improve in 4 weeks. Set a time to meet with the program director and clerkship director, to discuss your interest in their program and get recommendations for your application. Set goals for yourself and meet them.

With these three steps you are well on your way to succeeding in your EM application

EM Mentoring 101

The biggest downside to seeking advice from a blog like this one is the lack of diversity of opinions.  Even if the author has tried to incorporate best practices from many sources, the info you get will still be filtered through their personal biases. This is why you need to seek out more than one opinion on the really big questions. A local advisor is going to be your ideal resource, so long as they are keeping up with trends in the Emergency Medicine application and match process. Another option is the SAEM e-advising program that can match you up with a faculty member from the region of the country you are interested in.

There are also web-based alternatives. One of the best I have yet encountered is the EM Mentoring 101 website put together by Christine Swenton when she was an EM resident at the UF Jacksonville program.  Back in 2012 she interviewed experienced Clerkship Directors and medical student advisors from across the country and collected their ideas and opinions into a one-stop site. Go have a look. I do not think you will be disappointed.

SAEM 2014 for students and residents

The Society for Academic Emergency Medicine (SAEM) is holding their Annual Meeting in Dallas May 13 - 17th. SAEM has a reputation for being all about research, though it is more fair to describe the organization as being all about academics. Their Annual Meeting has a ton to offer the student considering a career in Emergency Medicine (and the resident thinking of staying in academics.  

From a student perspective, the big draw is the Medical Student Symposium and the Residency Fair that follows:

"May 16^th is the highlight for medical students at the SAEM Medical Student Symposium tailored for medical students applying to EM.  Panel discussions with current EM residents, roundtable discussions, and lunch with EM program directors will prepare EM bound students to understand the application and selection process."  

And here is the stated objective for the symposium:

Objectives:  The Medical Student Symposium is primarily tailored to medical students who have identified emergency medicine as their future specialty, but is also valuable for students still contemplating specialty choice.  The symposium includes presentations from seasoned EM educators, roundtable discussions geared for more individuated guidance, lunch with residency program directors, and a panel discussion with current EM residents.  Major themes for the symposium include the application and selection process. The program will be followed by the SAEM Residency and Fellowship Fair, providing students and residents with access to representatives from most EM programs across the country. 

At the completion of the session, participants should be able to:       
1. Assess their personal and career goals that might make EM a good fit.
2. Identify the multitude of career paths that exist within EM.
3. Optimize their fourth-year schedule.
4. Identify key factors and variables in selecting potential training programs.
5. Assemble a strong and compelling application package.
6. Perform their best during interviews.    

But wait, there is more. The SAEM Resident and Student Advisory Committee (RSAC), of which I am a member, has two events developed specifically for Emergency Medicine residents and medical students to provide opportunities to learn, network, and share ideas.  

1.  The RSAC sponsored Abstract Scavenger Hunt on May 14-16^th will allow teams of medical students and residents to seek out abstracts in the SAEM Program Committee Gallery of Excellence.  The mission is designed for participants to answer questions using QR codes with their own smart phones.  The team answering the most abstract questions correctly will win prizes including free registration to the 2015 SAEM Annual Meeting and gift cards to Starbucks and Amazon.  

2.  The Resident & Medical Student Reception will be held on Friday, May 16^th from 5:30-7:30 following the Residency and Fellowship Fair.  This event for medical students and residents is a great place to network with colleagues from across the country while mingling with leaders from SAEM committees and taskforces as they highlight opportunities for medical students and residents to become involved in Emergency Medicine at a national level early in your career.  (Including Ultrasound, Simulation, Women in EM, International EM, Social Media, Membership, Program, Ethics, and more) This reception, only for medical students and residents, is sponsored by ECI who will provide free drink tickets at their booth in the exhibitor hall. 

Both events are free and open to any resident or student attending the meeting. 

If you can make it to Dallas, I promise it will be worth the trip.  

How to use this blog...

EM Advisor is a blog whose purpose is to collect resources and advice that are valuable to medical students interested in pursuing a career in Emergency Medicine.

The blog has a simple construction:

Pages
These are static resources intended to guide you through the process of choosing and matching in EM.  These are periodically updated with the best advice we can find.  Examples of topics covered are: Is EM right for me?, Preparation and Expectations for EM Rotations, and a whole series on the application process covering everything from "Where to apply" to "what are Red Flags".

Posts
These appear periodically on the main page and are intended to be a catch-all of information for students considering Emergency Medicine.  Some are advice posts: How competitive is your application?, How to give good presentations, How to get procedures.  Others are recommendations of learning resources found in the world of Free Open Access Medical Education (FOAMed): the Flipped EM Classroom, EM Basic podcast, Academic Life in Emergency Medicine blog, to name just a few. The application process in EM is a cycle, so some posts provide timely (hopefully) updates and reminders on topics like Interviews, Rank Lists, and the dreaded what to do if you don't match.

The advice and suggestions found in this blog are by no means definitive. What is presented here are the opinions of a small number of EM educators.  However, we do attempt to represent the commonly held opinions and consensus recommendations from the members of organizations like the EM Council of Residency Directors (CORD) and Clerkship Director's in Emergency Medicine (CDEM).  

R.E.B.E.L. EM and the Importance of Airway

In this brave new world of FOAMed one of the big challenges is vetting which sources of information are worth following. The work of Salim Rezaie (@SRRezaie) on his R.E.B.E.L. EM blog, should be a a must read for anyone trying to keep up in EM. He is a prolific contributor to #FOAMed with recent posts exploring the need for an insulin bolus in DKA and what actually matters in post-LP headaches.  But the one that prompted this long over-do "shout out" was a review of preoxygenation and apneic oxygenation that you should go read right now.

Your communication skills are probably those most critical to your overall success in medicine, but you can argue that airway skills come in a close second. If you train at an ACGME-approved residency program in the U.S. you will be required to perform 35 intubations to meet requirements.  Ask any Emergency Physician and they will tell you that 35 is just the beginning. Real competence likely happens somewhere around "triple digits". 

You have to start somewhere, and early in the development of your airway skills you are going to need some extra time to figure out where you are and what you are looking at.  These techniques for maintaining excessive oxygenation during the peri-intubation period are good for the patient and great for your chances of completing the intubation. The FOAMed world is full of wonderful Airway resources, and R.E.B.E.L. EM is a good place to start.  

Also see this primer on intubation from The Short Coat by Lauren Westafer (@LWestafer) and this lecture by Rich Levitan posted on the EMCrit blog by Scott Weingart (@emcrit).

Choose EM?

Most people reading this have probably already made their choice of specialty and have chosen EM.   But if you are undecided, having "buyer's remorse", or someone recently disappointed in not matching into what has become a very competitive specialty in the U.S., have a look at this recent post from Life in the Fast Lane on "Choose EM".

The first picture is as good a summary as I have found of what makes this specialty wonderful and unique.  

The second picture is a reminder that even the best job in the world has it's drawbacks.  If this was easy, everyone would do it.   

Congratulations to everyone who successfully matched in 2014!

So you did not match...

If you are reading this you are in the unfortunate position of having NOT matched in Emergency Medicine (or you have a degree of morbid curiosity).  The advice that follows is based on the experiences of applicants who did not match in recent years and the compilation of a discussion from the list serve used by most Program Directors in Emergency Medicine. 

First take a breath, your life is not over. While it is impossible 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 big decision:  

Do you want to 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 following advice is for 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. Scramble into an open EM spot at a program they had not previously applied to.
2. Scramble into another discipline with the intention of reapplying next year.
3. Take a year off and do research or pursue a graduate degree like an MPH to improve your CV.

Scrambling into an open categorical PG1 EM spot is almost impossible.  There were 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 scramble spot in EM.

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. 

So that leaves the most common reality of doing a year of something else.  The clinical experience will make you a stronger candidate and better prepare you for your EM internship.  Putting yourself through the application process again will enhance the perception of your commitment (something that often suffers in the applications of late converts to EM).  There are two primary considerations in this decision:  What kind of year to do?  Where to do it?

There is significant disagreement 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 (if you belong to surgery during those months), 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 scramble as less are available with other specialties incorporating internship into their training program.  The best way to have a Transitional year as back-up is to apply and interview for it, not to scramble.

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 punishing and at the end you don’t have a job.  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 people are open and upfront with their 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: 

Location, Location, Location

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.  

Finally, something you can do now:  

Schedule EM electives for as much of the rest of this year as you can.  Get SLOE’s from all of these rotations.  These letters will help your re-application and you get to know more people within the specialty.  Unforeseen openings happen, even as soon as July 1, and the more people who know you, the better your chance at getting one of those.

I hope you find this advice helpful and I strongly encourage you to contact me if you have any questions.  I am happy to be of help.

Best of luck.

-Cien

Lucienne Lutfy-Clayton M.D. FACEP

Assistant Professor of Emergency Medicine

Tufts University School of Medicine

Emergency Medicine Clerkship Director

Co-Director Emergency Medicine Simulation

Baystate Medical Center

759 Chestnut St

Springfield MA 01199

tel: 413-794-5999

lucienne.Lutfy-Clayton@bhs.org

Rank List Run Down

Congratulations on being done with your interviews.  You can take your interview suit to the cleaners, or if you over-interviewed, you may just need to burn it.  You can check your frequent flyer miles to see if you can cover a ticket to somewhere warm.  You may even be able to step back and look objectively at the programs you recently interviewed with.  

Your last major residency application task is now upon you.  You have until February 26th to finalize your Rank List.  And you are likely putting a lot of time, thought, and stress into this decision.  

"How to make your Rank List" was one of the first topics we tackled here, and very little has changed about the whole process.  Our Rank List Tips still hold true, and you ultimately should still Go with your gut, in defiance of what your giant spreadsheet is telling you. 

While there are some differences between this year and last, overall competitiveness has not changed significantly.  The ratio of available spots to total applicants is the same.  Both numbers have been gradually and proportionally increasing for years. This does NOT appear to be what Medical School Dean's have been claiming, as the major change this year is in the number of applications each person has sent out AND in the number of interviews they have done.  I do not blame the Dean's for giving this advice, their job is to ensure that all of their students match.  They will do what they think is necessary to accomplish that goal.

The difference this year is that the "middle class" of applicants has shrunk.  There are fewer applicants with a number of programs to rank (8 - 10) who should feel comfortable about matching.  Instead, there appears to be an unusually large divide between the "haves" (>10 - 12 programs, AKA: the over-interviewers) and the "have nots" (<6 - 8 programs to rank).  This has introduced added uncertainty into an already stressful situation.  Programs fear that they have interviewed the same candidates as EVERYONE else and won't match enough of them.  Applicants with low numbers of interviews fear that they are only padding the back-end of rank lists at programs that interviewed extra or played it safe in offering interviews.  While most of the concern is likely unfounded, given the steady growth in BOTH spots and applicants, we will not know how this plays out until after the match.  

The advice that follows has held true in past years and is likely to still be relevant:   

1. Rank any program that you would consider to be better than scrambling (SOAPing) to a surgical pre-lim. year or to family medicine. There is effectively no scramble within EM.  If you don't match, your next shot at EM is next year.  
2. Rank programs in the order you like them.  The match algorithm favors the students. You will match to the program you rank highest that gets to your spot on its Rank List.  There is no advantage to you in ranking a more "realistic" program ahead of a "reach".  
3. Once you settle on your #1 program, you need to let them know.  Programs want to be liked, just like everyone else.  Just don't tell more than one program they are your #1.  The world of Residency Program Directors is a relatively small one and you don't want to get caught in a lie.

For more on making your rank list see these posts from Academic Life in Emergency Medicine: Making Your Rank List and Top 10 Tips When Making Your Rank List, as well as our post on Going with your gut that includes a more detailed explanation of the Match Algorithm in case you do not believe the whole "student weighted" thing.

Best of luck!  You are almost there.  

Learning Resource: Didactics Online

I recently met a student who created a website full of useful educational resources for medical students and others early in their EM careers.  Brandon Parker (@DidacticsOnline) is a soon-to-be EM resident and his site, Didactics Online covers a variety of topics.

The most recent post is on GI Bleeding.  Included on the page are a pdf of slides that are concise and focussed on what you need to know.  Short, sweet, and to the point.

The post before that is on Monitoring the Critically Ill Patient and has both a pdf of the slides as well as the accompanying podcast.

This site is different from a site like Flipped EM Classroom, which is trying to be a repository of all topics in EM.  Instead, Brandon has put together some very accessible dives into a few different topics, many of which are relevant to EM.

Some of the EM oriented topics are:

How to present a patient
Stroke and TIA
Migraines
Dizziness and Vertigo
ARDS
COPD

Have a look.