The Emergency Medicine match has become more competitive than ever. In 2016 there was 1 spot unfilled in the match. Programs are getting more applications than ever before and students are doing more interviews. The audition, application and interview cycle is compressed over just a few months. If just one thing goes wrong with their application a qualified candidate can find themselves without an EM residency on match day.
In the So You Didn't Match post we explored the options available to those still dedicated to pursuing training in EM. Now we are going to look at the next step: becoming a successful re-applicant.
Unfortunately there is no standardized "playbook" that you can follow in re-applying to EM. The causes for struggling in the match are too varied and the solutions are too personal. You need to design your own playbook. The information below will hopefully get you started. As always, there is no substitute for discussing your individual situation with an experienced advisor.
Most students who do not match had limited interview opportunities (less than 10 interviews). Those who completed double-digit interviews and yet still did not match likely had issues within the interview day.
Get some feedback. Self assessment can be difficult especially if self-criticism is involved. Get some outside help from your advisors and the programs where you rotated and interviewed. You may feel as though your advisors let you down when you did not match. However, they may have based their advice on faulty or incomplete information. Did they have a complete picture of your application when you talked? Looking at everything retrospectively, they may be able to give you useful advice now. The programs where you interviewed should have a complete picture of you as an applicant, including letters your advisor was not privy to. Reach out to them and politely request honest feedback on where your application fell short. You will get some answers like, "We don't do that" or "It was just a really competitive year". Though if you make it clear that you are seeking honest feedback to guide your future decisions you may find some willing to give you objective analysis of where things went wrong.
Late Application
Some issues are easy to mitigate. If your application went in late or was not complete until late in the review process (late November) you are going to make sure that does not happen again. Everything you have control over will be submitted to ERAS by October 1st. And if you did not have SLOE's in your application, or if they came in late, you will correct that too.
Bad Strategy
Application strategy is also an easier fix if you applied to a limited collection of programs for geographic reasons or if you only targeted the biggest "names" in the best locations. This time you are going to apply to a diverse group of programs with a focus on those that are realistic. You will likely apply to a lot of programs but the key is not just in quantity. Well chosen programs that will see you as a reasonable candidate are your priority.
Med School Misadventures
Preclinical or clerkship failures that required remediation, or other academic or professionalism issues, will always be in your MSPE (Dean's Letter). You can't make them go away but you can better address them in your application. Application reviewers will go right to your Personal Statement when they find something concerning in your application. Failure to address a "red flag" can lead to your application ending up on the discard pile without further review. Own your mistakes. Learn from your failures. Those are skills all Emergency Physicians need to possess so you may as well demonstrate them now.
Interview Issues
Torpedo Letter
You can also receive a harmful letter without a notably concerning grade. Academic performance may have been good but questions were raised about your fit at a particular type of program. There could have been interpersonal or communication concerns raised that did not affect your grade but they felt the need to share.
Why you got a bad SLOE really comes down to a couple possibilities. The first is what the defensive parts of our brains wants to believe: it was all a misunderstanding or an unfair evaluation process. And that does occasionally happen. Making this assumption can only harm your chances as a re-applicant. The more frequent cause was an inability to meet expectations or a genuine lapse in professionalism. This is a hard job and it puts a lot of stress on those who do it. The clinical approach does not come naturally to most and takes work to adopt. And we all have moments where we are not our best self. Any one of those under the bright lights of an audition can spoil a letter.
If you suspect a letter to be harmful do not use it in your re-application. Do not ignore that it happened. Try to take ownership and learn from this experience. Try to identify if there were valid concerns that you need to address. If you fail to do this then your next performance on an EM rotation will be no better. Those subsequent EM experiences are what will ultimately determine the success of your re-application. You need to upgrade your application with very supportive SLOE's that make it clear you have developed the skills to succeed.
That is the ultimate goal for your re-application. To present a clear picture of someone who is going to succeed in the difficult environment of residency training. Show that you can learn and that you have grown. Leave no doubt that this humbling experience has left you more dedicated and better prepared to succeed.
Adam Kellogg is an Associate Residency Director, former Medical Student Clerkship Director, the immediate-past Chair of the CORD-EM Student Advising Task Force.
In the So You Didn't Match post we explored the options available to those still dedicated to pursuing training in EM. Now we are going to look at the next step: becoming a successful re-applicant.
Unfortunately there is no standardized "playbook" that you can follow in re-applying to EM. The causes for struggling in the match are too varied and the solutions are too personal. You need to design your own playbook. The information below will hopefully get you started. As always, there is no substitute for discussing your individual situation with an experienced advisor.
Diagnosis
The first step is an honest self assessment. Analyze where your application went wrong. What were the weaknesses of your application? Were there potential concerns (Red Flags) that did not get addressed in your Personal Statement? Here are some of the most common issues that can lead to application reviewers not offering an interview:- Late or incomplete application
- Failure or low score on USMLE or COMLEX
- Lack of SLOE's or late arriving
- Below average SLOE's that do not show improvement
- Extension of medical school for academic reasons
- Professionalism issues
- Non-U.S. allopathic med school
Most students who do not match had limited interview opportunities (less than 10 interviews). Those who completed double-digit interviews and yet still did not match likely had issues within the interview day.
Get some feedback. Self assessment can be difficult especially if self-criticism is involved. Get some outside help from your advisors and the programs where you rotated and interviewed. You may feel as though your advisors let you down when you did not match. However, they may have based their advice on faulty or incomplete information. Did they have a complete picture of your application when you talked? Looking at everything retrospectively, they may be able to give you useful advice now. The programs where you interviewed should have a complete picture of you as an applicant, including letters your advisor was not privy to. Reach out to them and politely request honest feedback on where your application fell short. You will get some answers like, "We don't do that" or "It was just a really competitive year". Though if you make it clear that you are seeking honest feedback to guide your future decisions you may find some willing to give you objective analysis of where things went wrong.
Treatment
You think you have identified the problems. Are they fixable?Late Application
Some issues are easy to mitigate. If your application went in late or was not complete until late in the review process (late November) you are going to make sure that does not happen again. Everything you have control over will be submitted to ERAS by October 1st. And if you did not have SLOE's in your application, or if they came in late, you will correct that too.
Bad Strategy
Application strategy is also an easier fix if you applied to a limited collection of programs for geographic reasons or if you only targeted the biggest "names" in the best locations. This time you are going to apply to a diverse group of programs with a focus on those that are realistic. You will likely apply to a lot of programs but the key is not just in quantity. Well chosen programs that will see you as a reasonable candidate are your priority.
Med School Misadventures
Preclinical or clerkship failures that required remediation, or other academic or professionalism issues, will always be in your MSPE (Dean's Letter). You can't make them go away but you can better address them in your application. Application reviewers will go right to your Personal Statement when they find something concerning in your application. Failure to address a "red flag" can lead to your application ending up on the discard pile without further review. Own your mistakes. Learn from your failures. Those are skills all Emergency Physicians need to possess so you may as well demonstrate them now.
Board Problems
Having failed a step of the boards will always be on your transcript. If you had not retaken and passed the exam by the time rank list decisions were made in February you would have been considered "unrankable". The compensation for a low score is to improve on a subsequent step of the boards AND to show that the rest of your skills outweighs a poor showing on a multiple choice test. If you are doing an internship this year, demolish step 3. Leave no doubt that you will pass your EM boards (which is all that your USMLE/COMLEX can be expected to predict). Interview Issues
Did you do a number of interviews associated with a high probability of matching (10+) but were unsuccessful? There could be issues in how you interview. It might be hard to get someone to tell you that you make a bad first impression in interview situations. Seek some help with interview prep from someone you can trust to be honest about your conversation style and body language.
Rough Rotation
The hardest thing to decipher can be whether you had a harmful letter. You should certainly suspect this if you received a grade below what most EM applicants receive on that rotation (Pass on a rotation where most EM applicants get at least a High Pass, or a High Pass on rotations that give lots of Honors). Even if grade distribution information is not publicly available (check your MSPE) you may be able to get a sense of what EM bound students typically got from your fellow rotators and classmates. Torpedo Letter
You can also receive a harmful letter without a notably concerning grade. Academic performance may have been good but questions were raised about your fit at a particular type of program. There could have been interpersonal or communication concerns raised that did not affect your grade but they felt the need to share.
Why you got a bad SLOE really comes down to a couple possibilities. The first is what the defensive parts of our brains wants to believe: it was all a misunderstanding or an unfair evaluation process. And that does occasionally happen. Making this assumption can only harm your chances as a re-applicant. The more frequent cause was an inability to meet expectations or a genuine lapse in professionalism. This is a hard job and it puts a lot of stress on those who do it. The clinical approach does not come naturally to most and takes work to adopt. And we all have moments where we are not our best self. Any one of those under the bright lights of an audition can spoil a letter.
If you suspect a letter to be harmful do not use it in your re-application. Do not ignore that it happened. Try to take ownership and learn from this experience. Try to identify if there were valid concerns that you need to address. If you fail to do this then your next performance on an EM rotation will be no better. Those subsequent EM experiences are what will ultimately determine the success of your re-application. You need to upgrade your application with very supportive SLOE's that make it clear you have developed the skills to succeed.
That is the ultimate goal for your re-application. To present a clear picture of someone who is going to succeed in the difficult environment of residency training. Show that you can learn and that you have grown. Leave no doubt that this humbling experience has left you more dedicated and better prepared to succeed.
Adam Kellogg is an Associate Residency Director, former Medical Student Clerkship Director, the immediate-past Chair of the CORD-EM Student Advising Task Force.
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