Application Overload

The Emergency Medicine match feels more competitive than ever before.  This perception is NOT supported by the best available data from the NRMP.  

The Numbers

There has been a steady increase in the number of applicants to EM each year, mostly driven by an increase in the number of allopathic graduating seniors (see Table 1 below). The number of "non-traditional applicants" (including osteopathic and international graduates) has actually leveled off.  

At the same time, opportunities to train in EM have increased. The number of PG1 positions available in the EM match has steadily gone up (blue line in Table 1).  This increase comes from both new programs opening and class expansion in existing EM programs. The result is that the ratio of available training spots to the number of applicants has not significantly changed. The ratio of available spots to those who want them is the same.  

Table 1 - Proportional increase in both number of applicants and number of training positions in Emergency Medicine.

What has changed is the number of programs that each student applies to (see Table 2).  For many years the average number was approximately 25 programs applied to per student.  Starting in 2010 there has been a dramatic increase from year to year in the number of programs applied to by each applicant. The trend is similar among "non-traditional" applicants.  

Table 2 - Increase in programs applied to per allopathic applicant in the match.  

The Consequences

Each residency program is receiving dramatically more applications. This has made the competition greater for their interview offers. Not for the actual interviews, because the relative number of applicants has not changed - just for the interview offer.

Programs have had to change how they review applications and choose who to offer interviews to. Faculty time is a finite resource at most programs. There may not have been more time available to dedicate to in-depth application review. Furthermore, the time period to review applications was compressed in 2013 when the MSPE release date moved up to October 1st.

Programs had little choice but to become more efficient at reviewing applicants. Options include only reviewing parts of the application, those portions felt to be more objective or higher yield (the SLOE's). Another option is to make greater use of the filters ERAS provides, such as setting a cut-off for step 1 scores.  Additionally, programs can give more attention to applicants from schools or regions that have been high yield in the past.  

With this increase in efficiency comes a loss of variability in applicant review. The same group of applicants will appear strong to most programs. These applicants will then receive the majority of the interview offers. This fortunate group of applicants will need to reject interview offers before they "trickle down" to the rest of the pool.

Some of the fortunate will choose to do more than the 12 interviews they need to be >95% assured of matching. Even so, most programs have responded to the overload of applications by interviewing greater numbers of applicants in the hopes of not missing anyone they want to meet.

In Summary

1. The perception that EM is getting more competitive is not real
2. There is greater competition for early interview offers
3. Interview offers are concentrated in a fortunate few
4. Interview opportunities will "trickle down" to most applicants
5. For advice on how to get those interviews check out the FAQ section on this post on Acing the Interview

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

Acing the Interview

Your applications are in and interviews are rapidly approaching, so lets go over how to ace the interview

Firstly, lets address interview etiquette:

In recent years faculty have noticed some disturbing trends - from the moment you accept your interview you are representing yourself and your school.  Avoid unprofessional behavior by following these recommendations.

When you receive an invitation the majority of programs will be using an online service for booking. Go on line when you are off duty. Choose a slot that works for your schedule. Avoid doing this while you are working clinically - your patients deserve your attention when you are duty. For index details see our page on scheduling.

If you find that you need to change or cancel your interview, do so as far in advance as possible so that another applicant has the opportunity to take the slot. Never cancel within a week of your interview - you will be costing another applicant an interview and insulting the program that has been saving you a spot. Cancelling at the last minute is considered unprofessional behavior and may even be referred back to your own program or dean. If you realize you will not attend an interview for any reason notify the program as soon as you know.

Not showing up for a scheduled interview is absolutely unacceptable. If there is an emergency notify the program immediately.

Suits are expected - try your suit on and ensure it fits. Wear comfortable shoes - you will be walking.

Plan for travel and weather - Nearly all programs have a pre-interview event the night before you interview. Plan 2 days per interview - meaning you can fit 2 per week easily, but 3 will often lead to issues. You want to be early so leave plenty of time and dress appropriately.  When flying don’t check your bag to ensure your suit makes it to your interview with you. The Interview Day page gives you in depth answers to all your questions on the day itself.

Success is achieved with knowledge and planning:

Be realistic 

• Similar to your applications the goal is targeted interviews that allow you to compare and contrast programs and find your fit. More is not always better. 
• You should aim for 10-12 interviews this gives you a 95-99% chance of matching and is the best you can do.
• Most students match in their top 3, so 12 is plenty for almost everyone.
• It is expensive and time consuming to interview - don’t accept more than 12 interviews:  you will either cancel them or not be at your best when attending. 

Be yourself 

• You want to be you. The interview is your opportunity to see how you fit at each program. This only works if you are yourself (the non-trash-talking, well dressed version of yourself).

Be enthusiastic 

• While this sounds easy it can get hard after you have been on a bunch of interviews.
• Use your body language to show your interest. Lean forward, make eye contact, and smile (in a not creepy fashion)
• Ask questions that you care about. 

Be Informed 

• Do your research ahead of time to understand each program and develop questions specific to each program. Again, they should be questions that matter to you, so you can reflect on the individual program.
• If you know who you will be interviewing with look at the program website and learn what their role is. Then you can better ask questions to their interests, experience, and strengths.

ALiEM has a great Do's and Dont's post that goes into the many pitfalls of residency interviewing.

Frequently Asked Questions:

• Does it matter if I book an interview at the beginning or end of the season?
• No. Programs realize you are booking when you can attend. We will not read disinterest if you book and interview later in the calendar.
• Do I have to answer questions about my marital status, family planning or sexual orientation ?
• No. We should not ask you personal questions that are not directly referenced in your ERAS application. Only if you choose to bring them up will they be discussed.
• Should I schedule my top choice last?
• It makes little difference what order you put your interviews. If you will feel more confident having a few already done before your dream program go ahead and schedule that way. Most students find that their dream program changes and becomes clear regardless of the order.
• Do I need to go to the pre-interview dinner?
• Yes. Make every effort to be at the pre-interview event at each program. This allows you to meet residents in a casual setting and get a real feel for the program. It also shows the program how you interact in a social setting and gives them a picture of your fit with their residents.
• What if I checked my bag and it was lost?
• Let the program know. It happens every year and we understand, but avoid this by carrying your bag on.
• What should I wear to the pre-interview event?
• These events are usually casual - a nice outfit you would wear to go to dinner with friends will be fine.
• How many interviews do I need?
• 10-12 predicts better than 95% of matching, but you only need one. The NMRP has data for match success by number of interviews feel free to peruse. 
• What is the biggest mistake you see in interviews?
• Swearing, talking poorly or disrespectfully toward another program, and appearing disinterested. The sloppily dressed candidate, slouching with no questions, and who doesn’t want to have a conversation is not appealing, no matter how good they look on paper.
• What questions should I expect?
• Expect to be asked about your interests, research, and experiences both clinically, academically, and those outside of medical school. If it on ERAS it is likely to come up at some point. 
• If I have a red flag will it come up during interviews?
• Yes, programs will want to hear in your own words how you have dealt with adversity. 
• Should I rehearse my answers?
• This can help and hurt. You want to be comfortable and honest, but don’t rehearse your answer word for word to where it seems practiced or insincere. If you get the chance, do a mock interview with an advisor or use the HireVue pilot study to get some common questions under your belt. 
• What if I’m not getting enough interviews?
• First Trouble shoot the common errors that hold up interviews:
• Check your spam folder - that is where all of mine were. 
• Check ERAS and make sure you have released your USMLE/COMLEX transcripts and designated your letters. Ensure everything you can control is uploaded and available.
• Make sure you have time open in December and January for interviews that may come in later.
• There are a few options. if you have a late letter that might not have been seen, target a few programs you are really interested in that you feel you are a good match for and email their residency coordinator to give them a heads up to recheck you application. Do this at only a few programs - do not bombard your entire list.
• Talk to your advisor and have them look over your application. They can’t tell you what your letters say but they can help try and trouble shoot your application and see if there is anything that you can do specific to your situation.
• Consider a back-up plan. You don’t need to enact it but think about what you will do if you don’t match, so you have a plan in place.
• Why not just apply to another 50 programs?
• While this is tempting, shock and awe rarely works. If you are not getting interviews, more this far into the season is unlikely to fix the problem. 
• There is a steadily diminishing return for applications beyond 30. This costs you money and is unlikely to help.

In short be professional, sign up for 10-12 interviews, be a non-trash talking, well dressed, interested version of yourself. Plan ahead for pre-interview events, weather and traffic so you are on time and get the full experience. As you go through your interviews, allow yourself to focus on how you fit at each program, and what matters most to you during this next phase of your training.

Lucienne Lutfy-Clayton MD FACEP

Associate Program Director EM UMMS Baystate

True story - literally every interview offer she received was rejected by her medical school email account - it took her until November 1st to figure it out and finally start scheduling. Interviewed at 10 programs and she matched at her #1 choice. 

Applying Wisely - EM Match 2017

This is an update of a post from last year. This is a long one with many links to other materials.  The goal was to make a one stop guide to submitting your application by September 15th.

Application season is about to begin in full force for students applying for allopathic (ACGME) residencies in Emergency Medicine (EM).  As an advisor the most common question I am hearing is “How many programs should I apply to?”.  This is a great question.  This is a timely question (you have been able to submit applications since early September and programs will see them on September 15th).  This also may be the wrong question to be asking.  

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

The Goal

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

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

Applying Wisely

In order to build a quality list of programs to apply to, you need to answer these four question for yourself:

1. Where you need to be?  
2. How do you want to train?
3. How competitive are the programs you are looking at?
4. How competitive are you?

Location, Location, Location

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

Program Characteristics

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

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

To actually figure out where to apply: look at the EMRA Match Residency Index.

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

Program Competitiveness

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

You can estimate which programs get the most applications, as we outline in this post we did on Assessing PROGRAM Cometitiveness.  

To sum up, the more of these characteristics a program meets, the more applications they are likely to receive:

1. Is the program in a highly desirable place to live?
2. Does the program have “name brand” recognition that would look impressive on your CV?
3. Is the program “EM famous” for their faculty or their longevity within the specialty?

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

Your Competitiveness

While determining program competitiveness is an inexact science (to put it charitably), assessing your own competitiveness is somewhat easier to do.  This is a guide to Assessing YOUR Competitiveness that we previously wrote.  

To sum up - the applicant field breaks up into three broad categories:

1. Above average and have it made
2. Average and will match
3. Below average and at risk

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

Summary

To sanely navigate the match process: gauge your competitiveness and build a list of programs to apply to that has a foundation of realistic programs, with appealing characteristics, that are in areas that work for you and your family.  You can apply outside of this group, because you never know what might catch a reviewers eye, but you cannot consider those applications to be a realistic part of your foundation.

If you are an above average candidate you have the option to be a "sniper".  Choose 20-25 programs that highly interest you and get all the interviews you need.  

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

If you are at risk, or in an applicant group that many programs will not seriously consider (Osteopathic students, those training Internationally), you should apply to ~40 realistic programs.  Any program that does not seem realistic does not count towards your 40.  

For more detailed perspective for Osteopathic applicants have a look at this page of Advice for Osteopaths.  International Applicants should read this post by Max Hockstein, MD.

You need a real advisor

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

Good luck and get those applications in!

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

Want a $50 gift card and a risk free chance to practice for interviews?

Consider participating in the AAMC's research project that is a new addition to the application to Emergency Medicine this year – the AAMC is launching a Standardized Video Interview as a pilot for the emergency medicine specialty during the 2016-17 residency recruitment season. Here is the link to the webpage describing the study.

Applying to EM - you are eligible to participate in this research study as part of their ERAS application. Participants will receive a $50 gift card code to Amazon.com. Here is a link to the informed consent.

What's the point – This is your chance to answer standard interview questions without any risk to your application. The questions being used are common ones you will encounter during your interviews. Ever dream of getting a look at the questions before the test - well here is your chance. Here are some hints to succeed.

How does it work –  Each applicant will receive 6 questions with 30 seconds to read the question and 3 minutes to answer each - the interview is followed by a brief survey on your experience.  Here is a link with details about what to expect.

Bottom line – While the AMMC hopes that the Standardized Video Interview will be a valuable tool for all specialties in years to come, this is a true pilot and will be assessed as such.  Neither students nor program directors will have access to the videos or get a score. Applicants will need a video enabled device like a smart phone, laptop, or tablet.

This is a good time for you to familiarize yourself to standard interview questions, as well as dusting off that suit, and getting in the mindset of looking for the right fit for residency. This is the AAMC’s toolkit to succeed.

Lucienne Lutfy-Clayton is the Chair of CORD's Student Advising Task Force and an APD at UMASS Baystate Health. She is currently enjoying some away time with her family and wants to come back to see all your amazing applications ready to go.

The CORD EM Blog

Disclosure:  I am also an editor for the CORD EM blog, writing and editing posts by members of the CORD Student Advising Task Force (SATF).  

The Council of Emergency Medicine Residency Directors (CORD EM) recently started their own blog. This new Free Open Access Medical Education (FOAMed) resource is growing to include a variety of resources for those involved in emergency medicine (EM) education. One of the content areas (and the reason this is being mentioned here) is from the CORD EM Student Advising Task Force (SATF).

On the first Thursday of each month the SATF will publish a post with information crucial to students applying to EM, and all those that advise them.  Their first two posts should be of great interest:

• HireVue - The Pre-Interview Interview, where the video interviews that all EM applicants are being asked to conduct are explained.  This pilot program is being rolled out by the American Association of Medical Colleges (AAMC) just in EM this year.  
• Student Advising: A Comprehensive Guide and FAQ, where the most up-to-date versions of the CORD SATF Emergency Medicine Applying Guide and Applicant FAQ were shared. These resources contain the most current applicant advising recommendations available, based on Clerkship Director and Program Director consensus and the best available evidence.  

Future posts will highlight more invaluable resources for students including advising recommendations for applicants in Special Circumstances and highlighting of the most useful resources for students.  

Reflections on a balanced intern year

This post by Ashley Rider, a second year EM resident, is for the all the band new residents starting their internship.

Intern year is special. We finally have the responsibility that we have been yearning for, but it is appropriately coupled with layers of protective guidance from upper levels, fellows, and attendings. The hours can be long and grueling, but they tick away surrounded by people that understand your challenges, offer support when days are tough, and inspire you to be your best.

Striking a balance between your resident duties and life outside of the hospital can be one of the greatest sources of strain during intern year. Finding the time to keep in touch with friends and family in far away places is exceedingly difficult. You will probably miss some holidays. Your work schedule may be incompatible with many important events. Stressors may feel like they come from all directions—patient care, residency requirements, student loans, car issues, apartment fixes, and your relationships. Meanwhile, you are expected to work toward mastering the specialty of emergency medicine.

You will be functioning on limited bandwidth every day, week, and month this year. Time must be prioritized.

Once a month…

Get organized.

♦      Streamline your life. For all of those monthly bills, activate automatic recurring payments. You would be surprised how quickly the 1st of the month sneaks up on you. Ask your landlord about alternative payment methods or direct bank transfers. If you have roommates, brainstorm ways to consolidate payments. The fewer minor tasks you have to remember, the more your cognitive faculties can be applied to other areas of your life.

♦      Allow Google calendar to be your best friend, by helping you keep your best friends. Plug in event reminders and birthdays. Make a habit of checking your morning email of calendar events to avoid tardy birthday wishes or Mother’s day cards. Put your shift hours into a calendar, and then share it with family, friends, and significant others so that they know when you are available. With the beginning of each month, map out your upcoming events compared to your work schedule. On the eve before a new rotation, allow yourself 15 minutes of quality time with the GCal to plan ahead.

♦      Make time for your classmates. Believe it or not, your co-interns may be the people you see the least as you are carted off to the obligatory off-service intern rotations. Some of my most cherished moments of intern year were my class dinners. On the last day of every rotation one person would coordinate an outing that allowed us to catch up while visiting new areas of our city. Your co-interns understand everything you are going through. Revisiting your special bond every few weeks might be revitalizing enough to plunge into the next month’s “new job.”

Once a week…

Establish routines for learning and wellness.

♦      Attend conference. This is five hours a week dedicated to your education. Be engaged!  Take advantage of the protected time to learn from faculty, guest speakers, and peers. Bring ideas, bounce your thoughts, and ask questions. We only get this for 3 or 4 short years—don’t miss out! It is a tremendous component of our education with the unique flair of our residency program. That’s something CME will not offer in the decades to come.

♦      Keep in touch with family and friends. Vacations do not come often enough. Make a phone call to the parents, siblings, and friends that made you who you are. They want to hear how you’re doing! This may need to happen on the drive home, while folding laundry, or during an apartment clean. Put your emergency medicine multitasking capabilities to good use, and you will find the time.

♦      Reflect. Relax. Treat yo’self. GME requires approximately one day off a week. Set aside at least one hour on that day to do something that makes YOU happy. Take a walk, write, go to the gym, read, do Yoga, lounge in the park, hit the mall, or go for a hike. Whatever it takes to recharge and reset—you deserve a break!

Each day…

Aim to give 100%.

♦      Sleep. Time is always going to be limited but sleep is necessary. Every hour of sleep debt you accrue will chip away at your potential as a learner and as provider of patient care. On those days you have to wake up at 4am, go to bed earlier! Sleep hygiene is key: put away electronics, keep your room dark, and avoid food/exercise/alcohol/caffeine before going to bed. In emergency medicine we also have to tackle rotating schedules and night shifts. Invest in dark curtains and an eye mask to get your needed rest during the day. The routine you develop this year will set you up for a career of shift work, so make them good habits.

♦      Read about your patients. Pick at least one patient per shift and peruse a relevant up to date article, book chapter, or residency resource. At the peak of your exhaustion, a few minutes at the end of the day may seem unthinkable, so practice “learning on go.” Look up articles as clinical questions come up and scan them when you find free moments (e.g. waiting to present to the attending, walking to your mode of transportation at the end of a shift, or during the 5 minutes before sign-out). Furthermore, don’t let that time spent go to waste. Be sure to organize your learning, whether in a notes app, on old-fashioned pen and paper, or through Evernote. Screen time will be limited this year, so try to find ways to learn that don’t involve your computer.

♦      Stuff is going to happen. You are going to have bad days. You might get a flat tire on the way to work. You might make a medical error. You might feel overwhelmed and utterly useless—it happens to everyone. But remember that this too shall pass, every day comes to an end, and tomorrow is a new start (this goes back to the importance of sleep!)

Every Hour…

Brace yourself for the many challenges you will encounter.

♦      Prepare yourself for patients based on the differential for their chief complaint. Before you go to see him or her, have the top 5 most concerning diagnoses at the forefront of your mind. While interviewing the patient, collect all evidence that helps you to rule in or our these diagnoses, and formulate a plan from there. This active thought process will help you develop your practice style much more than a shotgun approach. Take a few minutes each day to follow up your patients. Did they come back to the ED after discharge? What became of them in the hospital? It will ultimately make you a better provider.

♦      Know your team. Nurses will save you and will frequently aid your decision-making. If you are worried about a patient, call rapid response and respiratory therapy. Social workers may be able to provide suggestions and resources that you didn’t even know existed. Call radiology to talk through an x-ray that you didn’t initially read correctly, because someday you may be the sole provider interpreting overnight films. Finally, remember all those dosages we never learned in medical school? Pharmacy will be your saving grace. If you are unsure about a medication interaction, dosing regimen, or the available of a drug, call your friendly pharmacist.

♦      Hypoglycemia is our Achilles Heel. For patients, always check a D-stick upon arrival. You can cure quite a few presumed altered mental statuses, or even CVAs. For yourself, recognize that glucose is the fuel for the brain. Keep a couple of granola bars (fun size snickers count, too) for that delayed meal or busy high acuity shift.

Each Moment…

Keep a positive attitude.

♦      Learn something from every case you see. It might be an agitated psychiatric patient, but they, like all your patients, are in the emergency room as a last resort. Give them your best doctoring. Investigate all organic possibilities. Hone your communication skills with difficult patients while you have the time. Learn what labs to order and what paperwork to fill out. Know where the snacks are kept. Your R2 self will be glad you took the time to learn the basics. Everything you tuck away this year will make the road ahead less bumpy.

♦      Be humble. You leaned a lot in medical school, but remember this is only the foundation. Always develop a differential, even if you are certain of the diagnosis. Consider the input of every member of your team. Recognize when you were wrong, and use your mistakes to improve care of the next patient. There is always more to learn!  

♦      May your every task be aimed toward taking good care of patients.  Just don’t forget about yourself along the way.

For additional pearls straight from the chiefs, see the ALiEM post on residency secrets to success:  https://www.aliem.com/2016/top-10-success-resident/

Welcome to emergency medicine. Best of luck with every month, week, day, hour, and moment this year!

Ashley Rider, PGY-2 Highland Emergency Medicine