Rules of the Road for Away Rotation Applications

Now that you have decided on EM (or are at least treating it as your front-runner), you will need to complete a Home and an Away rotation this summer and early fall. These rotations are where you will get the SLOEs that will be the most important part of your EM application. Take a look at this approach to your myriad of choices, and below is a discussion of the most common questions...

Vacillating on the VSAS

There are no perfect number of clerkship applications. First, self evaluate your competitiveness and the competitiveness of where you are applying to. Your local advisors should be able to help you get a sense of your competitiveness at this point.  Keep in mind that this is going to change as you complete rotations. For most students 4 applications will suffice. If you are a weaker applicant or looking at a more competitive market - consider 6. 

The Bird in the Hand

Many students get an invitation to one clerkship, but want to wait for their dream spot. In this application your goal is to ensure you have an away rotation during the spring and summer. You have a rotation, take it and smile. If you can manage a third rotation, keep your other applications in. If you cannot do a third rotation and still have applications outstanding 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 (they may remember if you string them along). 

Check the Boxes

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 be able to list what you need in detail. This is the time to jump through the hoop and just get it done.

Burn Baby Burn (or Don't!)

Declining an offered spot will be a small annoyance to the clerkship. If you need to, ensure you do it quickly and politely. Waiting weeks to decline hurts your impression with the program. They assume you are stringing them along and not genuinely interested in the program. Never accept a rotation and then back out of it if you want to get an interview there. Getting your perfect rotation is not worth the damage to your credibility elsewhere. If you discover a particular program is not a good fit and expect not to apply to them, go ahead and cancel. Just know that this program interprets withdrawing as disinterest and inconsiderate - not a good impression. The clerkship director and residency coordinator will recognize your name and will be reluctant to interview you.

Lucienne Lutfy-Clayton is an Associate Program Director and former Clerkship Director, she hates when students cancel on her clerkship making her scramble at the last minute.

Burning Questions for the New Application Year

The 2015 match is behind us and the application cycle for the 2016 match is already in full swing with third year students working the VSAS to line up their optimal elective rotations.  A recent discussion with Kara Barker, a third year student in the 2016 match, led to this post (have a look at her wonderful piece on "Choosing EM"). Along with her EM-interested classmates she generated a list of "Burning Questions" for the third year student embarking on EM.  Here are our answers:

1. What qualities do Program Directors look for in an EM resident and how can I best demonstrate these during the residency application process?

Each residency program is looking for something a little different in their applicants though there are certainly some common traits. Looking at the SLOE's (the Standard Letter of Evaluation) that are used as your recommendations gives you some clues: Commitment to EM. Work ethic. Ability to create an ED appropriate differential diagnosis and plan. Teamwork. Caring for patients. These letters of evaluation are a description of your performance and your potential in EM. They are the most important part of your application.

2. As an applicant, how do I best assess whether an EM residency program is a good fit for me?
What each applicant needs from a residency program is unique to that person. There is no universal best-fit. You need to weigh what really matters to you in your training and focus your search on programs that fit those criteria. Here is a more detailed discussion of Choosing Where to Apply. While you can figure out location, duration of training, and opportunities available in advance, you will not truly know if you are a good fit in the culture of a program until you go there for interview. 

3. How important are USMLE Step 1 and/or Comlex Level 1 board scores to the EM residency application process?
Board scores matter because they are one of the few objective measures Program Directors have. They will be used to screen the application pool. However, scores do not do a good job predicting who will excel in residency training and are less important than how you do on your EM rotations. Some programs will consider you even if you did not do well on Step 1. Have a look at this more detailed discussion of Board Scores.

4. If my USMLE Step 1 and/or Comlex Level 1 scores are not competitive, can I compensate with improved USMLE Step 2 and/or Comlex Level 2 scores?
Yes. Many Residency Directors put more stock in Step 2 scores as the material is closer to being clinically relevant. In general, if you are not happy with your Step 1 you should put extra effort into step 2 and take them in time to have the results appear in your application (August).  

5. In addition to board scores, Standardized Letters of Evaluation (SLOEs) and successful completion of EM audition rotations, is there anything else I can do to distinguish myself from other EM residency program applicants?
Those are the most important part of your application and carry the most weight. Some Residency Directors put a lot of emphasis on research projects. Others like to see service and volunteer experience. And others are big on involvement in local/national EM organizations. Do those things if they suit your interests and you can do them well. When they come up on your interviews you will want to be able to talk about them passionately. Here is some more depth on what goes into the ERAS application.

6. How important are grades and letters from non-EM clinical rotations to the strength of my EM residency applications?
Your EM grades and letters are the most important part of your application. Programs will look at your grades from other rotations but the impact on your application quality is small. There is too much variability in grading from school to school. Letters from rotations in other specialties are also not very helpful. Rounding out your set with a non-EM letter is fine, and will not hurt you, so long as you have enough information in your EM letters. Here is another link to that more detailed discussion of Letters.  

7. Given the importance of securing at least two EM clinical audition rotations AND given the number of other students also competing to secure these rotations, what can I do to make sure I am invited to rotate in the programs I am interested in?
You can appeal to the Clerkship Director by email and hover on the VSAS site waiting for an opening but there are only so many spots. Be ready to make a switch late in the process if someone drops a rotation. Ultimately, doing two EM rotations is more important than where you do them. The value of the SLOE to the student is that by being standardized and asking to compare you to your peers, it gives a Program Director who has never met you a trustworthy impression of you. That will get you interview opportunities at places you have no other connection to. Here are some more thoughts on EM rotations.

8. If I am not able to secure a clinical EM audition rotation within the department associated with my top choice residency, is there anything else I can do to demonstrate my skills and my interest to this program?
The clinical EM rotations are typically the hardest ones to get into as they are the sources of real grades and SLOEs. However, if you just looking to get in the door and make an impression, consider doing a specialty elective like Ultrasound, Pediatric EM, Toxicology, etc. You will often be able to interact with the Program Director's while doing these rotations and you can learn about the culture of the program. Doing a rotation like Trauma surgery at the same institution is generally NOT a good idea. You will likely be too busy to make an impression on the ED.

If you have other Burning Questions you would like answered please leave them in the comments below. Good luck setting up those rotations!

Adam Kellogg is an Associate Residency Director and formerly an Emergency Medicine Clerkship Director.  He is a member of the CORD EM Student Advising Task Force and of the SAEM Resident and Student Advisory Committee. He knows that this whole "Standardized Letter of Evaluation" thing sounds scary but they are better for everyone. Really.