EM Application Uncertainty - What do we know?

There is a lot of concern on both sides of the Emergency Medicine residency application process.  Some programs have reported dramatic increases in the number of applications they have received.  Many students are worried by how few interviews they have been offered.  Has something fundamentally changed in the application process that can explain what is going on?  The answer is that yes, there has been a change, but there is not more competition for residency spots than in previous years.  

Below is a dive into the preliminary ERAS data for 2021 taken from the ERAS Statistics page at AAMC.org.  The data shows that applicants have not (or at least not yet) applied to substantially more programs than in previous years.

The answer to what is going on, unfortunately, does not have data to back it up.  Anecdotally, many EM residency programs are reporting that their interview acceptance rates are way up this year.  Applicants who get offered interviews are reportedly saying “yes” to almost all of them and are rarely cancelling.  This is different from previous years and is depriving other applicants of the chance to interview.  

Every year we see the applicants with the best on paper applications get the majority of the interview offers in the early stages.  As their schedule fills up they decline interviews which are then offered to other applicants.  So far this year, that is not happening.  With travel not being a barrier the “haves” are able to hoard interviews without repercussions. 

A US MD Senior guarding their collection of Emergency Medicine interview offers.

If you have more than 12-15 interviews:  it’s time to let some go.  Making decisions is a core skill in EM.  Each program offering you an interview already wants to match you.  You can narrow your list and cancel or decline the ones that are not in your top 15.

If you don’t have very many interviews: hang in there.  More are coming.  Either when your peers start to drop them or when programs add interview slots as they recognize that many of the applicants interviewing with them early in the process are not genuinely interested in their program. 

And now the data deep dive...

Looking at this data can help answer some questions about this unprecedented match year for Emergency Medicine.  First is the data followed by some analysis.

The total number of applicants to EM has been trending up steadily.  Folks do not appear to have been scared away by the front-line nature of EM. Instead, the steady growth in applicants has continued.  It is important to note that this increase has been accompanied by a steady increase in the number of residency spots available, both from new EM Residencies opening and existing residencies increasing their class sizes.

In addition, the data in this table make it look like DO applicants have just discovered the wonders of EM, but that is not what is really going on.  Instead this data just reflects the move to a single-accreditation system under the ACGME.  All DO applicants to EM are now shown here, not just those who applied to ACGME residencies (by 2021 all residencies are under the ACGME).  

The Bottom Line: The number of applicants to EM has NOT gone up in a way that will affect your chances of matching.   

According to this data, which is preliminary, the number of applications per applicant has actually leveled off for the last few years for both US MD and DO applicants.  That big climb in DO applications is deceptive as it did not include the applications to osteopath-only programs before the merger.  IMG applicants have steadily increased their numbers of applications.  

What we don’t see here is the expected increase in applications due to uncertainty.  If this holds it may reflect improved dissemination and uptake of application advice.  Or there could be another wave of applications coming as applicants panic over not getting sufficient interviews.  We shall see. 

Bottom Line:  So far, there has not been an increase in the number of applications per applicant, despite anecdotal reports by residency programs of significantly increased application numbers.  

This table argues against a generalized increase in the number of applications programs are receiving. Some programs may be seeing a significant surge in applications, but there does not appear to be a dramatic increase for most programs.  One possibility is that there has been a real increase in the number of applicants at programs that were prohibitively expensive for applicants to apply to.  This could be programs in areas that required most applicants to fly to.  For example, a student on the east coast (where there is a heavy concentration of medical schools) faced a significant cost to interview on the west coast.  That financial barrier is gone. 

Conversely, if some programs have seen a significant increase in the number of applications they have received, but the overall average number has barely changed (+33 from 2019), then there would have to be a group of programs that have seen their number of applications decrease.  

The Bottom Line:  There will be more competition for interviews at some programs, but not at all.   

If you have questions, comments, or other interpretations of this data, please share them in the comments and we will try to figure this out together.

Where are the Emergency Medicine interviews? Asking for a friend...

On October 21 at 8 am EST your meticulously crafted ERAS applications were sent to your chosen EM Residency Programs.  Now you are waiting to hear who wants to meet you in a virtual interview.  And waiting.  It's been 5 days?!?  Where are the interviews?!?!

(I know you don't really feel this way.  You get that to do proper application review takes time. But it is human nature to worry and to self-doubt, so I wanted to share some concrete information that may help in a year when there is a pronounced lack of solid information to go on.)

This year the County Program Unified Release Date is November 2* at 12 pm EST.  

This means that any program that is part of this agreement will not offer their interview spots until then.  Most of the self-identified "county" EM residencies participate, as do many other EM programs for whom this date makes sense.  This year it is reasonable to expect that the majority of the first wave of interview offers will go out around November 2.  

Therefore, there is no reason to panic right now.  Even if you don't have 12 interviews by November 4, it is still NOT time to panic.  After this first wave of offers there will be more.  Many programs do not release all their interview spots right away and all programs will have openings as applicants rearrange their schedules as higher priority interviews become available.  Every year this process takes a while to sort itself out.  

Have a look at this reference page on on the mechanics of interview season and submit your questions in the comments below.  

*A previous version of this post listed the Unified Release Date as November 3rd.  

Last Minute Questions for the Emergency Medicine Match

On Wednesday October 21 your applications will go to the EM Residency Programs you applied to.  So we are going to try to answer some common last minute questions that a lot of folks are asking.  These are questions where there is no evidence base for answers/recommendations, so what you are getting is one advisors opinion, informed by conversations with other advisors and PD's.

Question 1:  How should I describe work, research and volunteer experiences in ERAS - bullets or paragraph?  

Either is fine.  Applicants are paying more attention than usual to how they complete the ERAS application, probably because they have more time on their hands to craft and perfect these entries.  Just make sure you concisely explain what you did and what your role was.  This won't affect how programs rate your application.

Question 2:  Should I customize my Personal Statement to different regions or even to different programs?  

Maybe.  In previous years (and posts) I have pretty strongly said "no" - because this is a poor use of time and Program Directors generally felt this comes across as "too desperate" and unnecessarily raises concerns: "what is wrong with this persons application that they think they need to do this".  HOWEVER, this year is probably different.  You do not have the ability to do Away Rotations to demonstrate interest in a specific region or type of program.  You can and should use the "hometown" section of the application to clarify regions you have a connection to.  It is also common to include in your Personal Statement a section (usually closing paragraph) that describes what you are looking for in a Residency Program: academically and geographically.  And it would also be reasonable to have different versions of this closing paragraph for different geographies or types of programs.  This is OPTIONAL.  It may not help.  It may even hurt you if interpreted as desperation.  BUT, if you are concerned that there is no other way to make clear your interest in a region or in a type of program, then this MAY be helpful.  

Question 3:  Should I hold a spot for a late arriving letter or just fill all four spots with what I have now?

Hold a spot if it is an eSLOE from a residency program.  This application season is starting later than in years past but the date of the Match has not changed.  Programs are on a compressed timeline to review applications, and offer and complete interviews and rank lists.  And we all expect to interview more applicants than we normally do.  Programs will look at whatever you have on October 21 as they make INITIAL interview offers.  A late arriving letter can still impact your chances of getting a "wait list" interview when someone cancels later in the season.  Only an eSLOE from a residency program is a valuable enough addition to your application to move a program from "maybe" to "interview".  Other letters, even O-SLOE's, are unlikely to make a difference late in the process.

Question 4:  Should I be doing more than 10-12 interviews this year because programs are interviewing more people?    

Yes, but not many more.  The number of interviews (and ranks on your rank list) needed to reliably match in EM has been steady for many years at 10-12.  Even with the number of applications submitted per applicant steadily increasing over the last decade this number has not changed (because the number of residency spots has grown at the same pace as the number of people who are applying).  Ranking 10-12 programs gives a 95%+ chance of matching in EM.  BUT, that is based on non-pandemic application cycles.  This year we anticipate applicants are going to apply to more programs (because they have more available funds with interviews being virtual and less ability to audition) and programs will interview more applicants because they are worried that many of their applicants are not really interested but are just panic-applying.  HOWEVER, residency programs are limited in how much they can increase the number of interviews they do.  On the program end the virtual interview process takes just as much faculty and coordinator time, AND possibly more time, if you account for the challenges of trouble-shooting virtual interviews.  So while an applicant can pretty easily (though not wisely) double the number of applications they send out, the programs will need to make a huge investment of resources just to increase their number of interviews by 20-30%.  If you are an applicant without extenuating circumstances, like being in a complicated couples match, you can do 12-15 interviews and be confident in matching.  AND for most of you 12-15 is overkill, just like 10-12 was overkill for most applicants over the last decade (1/3 of applicants match to their #1 and more than half match in their top 3).  

Question 5:  Wait a minute!  I should be doubling the number of programs I apply to?!?

NO!  That is totally unnecessary.  But fear and uncertainty have steadily driven up the number of applications per applicant for the last decade.  And this year has produced an abundance of fear and uncertainty.  As an applicant your chances of matching are exactly the same as they have been in the past.  The proportion of available EM residency spots to applicants who want them (spots/applicants) has not changed.  Because you can't go to most of the programs you will eventually rank the most important thing to do this year is research programs throughout the process.  Hopefully you have been doing this already.  You want to make good use of your interview time so choose places to apply that you are actually interested in and have already vetted for matching what you are looking for.  A plan of "apply to a ton, see where you get interviews, and then learn about the programs on interview day" is going to work even more poorly than usual this year.  Programs are going to be looking to interview applicants who are obvious fits for their program: geographically and academically.  A smart application is one where most of the programs on your "core list" (the 20-30 realistic programs, NOT the longshots) make sense for you. Your geographic ties are clear: connection from med school, college, work/life spent there, or explained in PS.  AND your academic profile (degree, scores, specialty interests like US, wild med, research, etc.) match what they advertise they are looking for.  

I bet these questions generate even MORE questions.  We will try to respond quickly to anything you put in the comments section, so fire away!

New Program in California: UHS SoCal

 There is a new EM residency program in California that is recruiting for the 2021 Match.  From their Program Manager:

We are thrilled to announce that our new Emergency Medicine Residency at UHS SoCal MEC has received initial accreditation by the ACGME!! We are a Three-Year Categorical program based in Temecula, CA and approved for 10 residents per year. Our Sponsoring Institution, UHS SoCal MEC, is comprised of 5 hospitals recognized for quality of care and patient safety. The program is integrated with 3 of these sites: the primary site is Temecula Valley Hospital (TVH), a busy advanced primary stroke center and STEMI receiving hospital. The other integrated sites include Inland Valley Medical Center, southwest Riverside County's only trauma center, and Rancho Springs Medical Center, which provides the region's only dedicated pediatric emergency services.The program provides EMS Medical Direction for Riverside County, a comprehensive ultrasound and simulation curriculum, PICU experience at Rady Children's Hospital San Diego with lodging provided, and opportunities for healthcare advocacy.

The Program Director(PD) is Stephen R. Hayden, prior PD at UC San Diego, Past President of CORD, Editor-in-Chief of the Journal of Emergency Medicine, and an Editor for the 5-Minute Emergency Medicine Consult and Research in the Acute Care Setting. The Associate Program Director (APD) is Robert Steele, an Associate Professor and was one of the founding physicians at TVH and UHS SoCAL MEC. Between them, Drs. Hayden and Steele have over 25 years experience in residency leadership and GME!

 Accepting applications and scheduling interviews via ERAS this interview season and we expect to start our first residency class in July 2021. Please spread the word to EM bound medical students and help us begin our journey!!

Keri Kinley, C-TAGME | Emergency Medicine Program Manager | Keri.Kinley@uhsinc.com | O: (951) 331-2535 | UHS Southern California Medical Education Consortium | Universal Health Services, Inc. | 31700 Temecula Pkwy., Parkway Suites #2-GME, Temecula, CA 92592 | 

www.socalresidency.com

Emergency Medicine Application Advising Q&A on September 11, 2020

We will be part of a Zoom Q&A for students in the 2021 Emergency Medicine Match:

Acing Your Applications: Expert Advice from Baystate EM - Friday 9/11 @ 1pm EST

The UMMS-Baystate Faculty includes three past Chairs of the CORD-EM Advising Students Committee (ASC-EM), the creator of the EMATCH Tool, a co-developer of the EMRA Match Residency Navigator, and the authors of the EM Advisor Blog.

Our panel of experts: Lucienne Lutfy-Clayton, Liza Smith, and Adam Kellogg, will answer all of your questions on how to make the most of your application to Emergency Medicine.

UPDATE: The recording is available on the Baystate EM Seminars page.

Participants do not need to be planning to apply to the UMMS-Baystate residency, or even anywhere in New England, to join in. Our panel has expertise in advising applicants across the United States and are happy to provide advice to all.  

Alternative SLOE's for Emergency Medicine in the 2021 COVID Match

EM Residency Programs will start seeing applications on October 21st.  The goal is to have all of your Letters of Recommendation uploaded to your application by that date, which has been pushed back compared to previous years.  Despite more time to complete rotations most applicants in the 2021 match have not had access to as many EM rotations as in a "normal year". 

To address this the Council of Residency Directors for Emergency Medicine (CORD-EM)  created several additional SLOE templates for use by letter writers who are NOT faculty at an EM Residency Program.  

1. The SLOE Sub-Specialty Rotation - for use by EM Sub-specialty Clerkship Directors (Pedi EM, Ultrasound, Toxicology, etc.)
2. The SLOE Non-EM RESIDENCY Faculty - for Emergency Physicians not affiliated with a residency program (community hospital or academic center without a residency).  
3. The O-SLOE - The "O" stands for "other rotation" or "Off service".  This is for non-EM letter writers like Trauma, Family Med, Critical Care, IM, etc.  

Ask all your letter writers to use these letter templates.  They guide the writer to give the EM Program Directors the information they want to know.  This is not always intuitive to writers from other disciplines.  

While these alternative SLOE's should be a significant improvement from traditional narrative letters the expected hierarchy of letters remains: 

SLOE from EM Program Leadership >> EM Sub-specialty SLOE or SLOE from EM Faculty at a Residency Program > SLOE from EM Faculty NOT at a Program > O-SLOE >>>>>Narrative letter

 Program Directors expect that letters of recommendation will remain the most important part of your application to Emergency Medicine, so make sure you get the right ones.   

So You Want To Rock Your Rotation?

 This post by Dr. Margaret Goodrich is a one stop guide to excelling on your EM Rotation. In this very weird year, impacted by the COVID pandemic, you may only get to do one EM rotation. Make it count.

Professionalism

While some of this may seem redundant to what you’ve been told in the past, sometimes it just needs to be
said again. While your clinical knowledge is part of your evaluation, another major part is HOW you do the job
and your interactions with others. 

Be punctual

The old adage of “if you’re on time, you’re late”. This applies to shifts, conferences, SIM, workshops, meetings… basically everything. Plan for travel time, figuring out where you’re supposed to be, parking, etc.

Dress for success

Thankfully in the ER that means clean scrubs and close-toed shoes. Depending on the rotation, they may have a dress code for conference/didactic sessions. Whatever it is, respect it. It is worth bringing a business casual outfit (or two) and even a suit (some will interview you while you’re there).

Attitude

Come in to work ready to work! This is a job that demands you be “on” the entire shift. Be ready for that.  Show that you are excited to be on your rotation, in the department and working alongside potentially future colleagues. Your attitude will affect those around you. Think about what kind of influence you want to be.

Take Initiative

This shows that you want to be there and want to learn in the ER. Each program is different with how they get you involved in patient care (will have you just sign up and see them, will direct you towards patients), get a sense of this then find ways to be proactive about it. However, even if you know how to do a procedure, DO NOT just start doing it without talking to your resident/attending. Touch base with them, let them know you’re willing to do it and ask how they would like for you to proceed.

Be Inquisitive

This job is ALWAYS changing and there is always something to learn, especially early on. When you’re thinking about a patient’s care, ask “what else?”

• What else should be on my differential?
• What else could be an intervention?
• What else could be part of this work up?

Find something that was interesting on each shift, then go home and learn more about it. A chief complaint,
an intervention, a procedure, etc.

Respect

Be courteous to those you interact with (residents, attendings, program coordinators, nurses, techs,
secretaries, cleaning staff, patients, families… LITERALLY EVERYONE). Believe me, it will be noticed
if you are rude to someone. The value of “please” and “thank you” cannot be understated

Honesty

Be open and honest with your senior resident/attending. If you haven’t done something before, THAT IS FINE! It would be unrealistic to expect that as a medical student you are proficient at many EM skills. That’s the whole point of residency. It is UNACCEPTABLE to lie to your senior/attending about your skill level. If you haven’t done it, just say so. Then demonstrate that you are eager to learn about it (YouTube is great to find a quick video, or check out this website: https://www.emra.org/students/advising-resources/skill-demonstration-videos-and-topics-pertaining-to-em/ ) and be prepared to try!

Effective Communication

This is going to be paramount throughout your career. Now is a great time to continue working on it!

Who’s who?

Make an effort to learn the names of the people you work with. It will take time, but it makes communication
more personal, easier and more direct.

Closed loop communication

Make sure the person you’re talking to actually knows you’re talking to them (using names is really helpful
here), they hear what you want, and verbalize that they understand what you want them to do.

Example: “Joe, please get an EKG on Mr. Smith.” “Ok Doctor, I will get an EKG on Mr. Smith.”

This ensures that the other person is aware an action needs to get done. It also provides them with an opportunity to tell you that it is beyond their scope of practice or that they are not able to perform that now. Which means that you can find someone else to get it done and not wonder why it hasn’t been done after an hour.

This is not only important for general patient care, but imperative for resuscitations/trauma/high acuity
patients when things can become chaotic quickly or the patient requires a number of interventions
simultaneously.

Respect

We already mentioned it, but it’s worth mentioning again.

Feedback

How to make the most out of what your preceptors are telling you!

Blind spots

We all have them. Feedback from your preceptors is a great way to discover areas that you need work on
that you weren’t aware of.  Make note of these somewhere (on your phone, a physical notebook, stone tablet, whatever), then evaluate how you can work on them.

Setting up your shift for feedback

Some preceptors are more conscientious about giving feedback than others. To help you get feedback, decide something specific that you want to work on before your shift. Once you arrive, tell your preceptor what you would like to work on and ask them for feedback on it at the end. This does two things:

1. It makes you be cognizant of a specific goal for the day rather than “get better”
2. It sets up your preceptor to know that you are actively looking for feedback and that they should be keeping in mind your goal for the day. It helps them to give more direct feedback rather than “nice job”

But what if I don’t like the feedback?

Inevitably, you’re going to get feedback you don’t like/rubs you the wrong way at some point. We’ve all
been there. When this happens, our natural response is to get defensive. Take a minute, think about
why you’re getting that feedback. Is there something that you didn’t realize before (blind spot)?
What can you do to fix it?

What do I actually do with the feedback?

Attempt to make an active change. There is no point in getting feedback if you don’t make an adjustment.
If it is in the middle of shift and it’s something that could be done on your next patient encounter, try to
do it then. If it’s the end of shift, consider it as your goal for your next shift or for the topic that you’re going to learn
about before next shift.

During Shift

The art of actually doing things.

Workflow

Starting to develop good habits now can help you as you start residency. Below is a general outline for
ED workflow:

STEP 1: Pick up a patient. This will vary by institution. Touch base with the senior resident/attending to see if there is anyone to see and ask them how they would like for you to see new patients throughout the day. Wait for them to tell you? Pick up new patients on the board? Ask them each time a new patient is available?

STEP 2: QUICK chart evaluation, review documented vital signs (if available). Do NOT wait 15 minutes to go see the patient. If you’re picking them up you should be ready to see them shortly.

STEP 3: Actually see the patient, do your HPI and exam. *IF AT ANY POINT you have concerns about vital signs, mental status, a specific exam finding that would require EMERGENT attention, quickly excuse yourself from the room and find your preceptor.* You will not be faulted for grabbing preceptors sooner rather than later if you’re concerned about the patient.

STEP 4: Develop your differential and management plan. There are a number of different mnemonics but one that I like is SPIT:

• Serious - all the big bad terrible things that as an ER doc you need to at least consider
• Probable - while you have to consider all the terrible things, what do you actually think is going on
• Interesting - what’s the zebra diagnosis to consider?
• Testing/treatment - what labs, imaging, medications, fluids, etc would you want to help you evaluate and treat the patient?

Your preceptors will usually want the serious differential items FIRST, but also include the other items on your differential as well.  Know that your management plans are not going to be perfect. That’s part of learning. You will learn more by developing a plan and presenting it then discussing with your preceptor why they agree or disagree. If you simply wait for them to develop the plan for you, you won’t learn as much.

STEP 5: Follow up on testing. It’s always great if you know the results before the preceptor. Think about what the results mean (even if they are normal/reassuring), and what the next steps would be.

STEP 6: Reassess the patient. If the patient has received an intervention, how are they doing after that? Is there something else you want to do as an additional intervention?

STEP 7: Determine what you think the disposition is. This is helpful to think about after your first encounter with the patient because it helps you to get a sense of where the visit is headed. Obviously things change, but it will help to try and get a sense of: sick or not sick? Going home or getting admitted? Is there a safety reason why they shouldn't be discharged (like social work or case management needs)?

Procedures

There will likely be some opportunity to do procedures during your rotation. Again, this will depend on the institution and your preceptors. Be eager and willing, but as stated above DO NOT LIE ABOUT YOUR ABILITIES/EXPERIENCE. If you haven’t done it before, inform your preceptor, preferably not in front of the patient.

Find a resource to help you learn how to do procedures that you haven’t done before, like this website: https://www.emra.org/students/advising-resources/skill-demonstration-videos-and-topics-pertaining-to-em/

Know the indications, contraindications and technique of the procedure. Ask for help if you need it.

Notes

This is incredibly institution dependent. Some will allow you to write notes, others will not. If you are allowed to write notes, certainly do your best with it. You should get more instruction from the institution on what your specific duties are

Daily goal

Determine what you want to work on for the day. It’s more helpful if it’s specific, rather than “get better”. Inform your preceptor of what you’re working on for the day.

Presentations

This is something you will be doing throughout the rest of your career (think about admitting patients,
consultants, etc.). In the ER, we do more focused presentations than on other services.
Look at this website: https://www.emra.org/students/advising-resources/patient-presentations/ 

Dr. Margaret Goodrich is a Medical Education Fellow at UMMS-Baystate Department of Emergency Medicine and an expert on excelling as a learner in EM.

New Program in California

A new program just announced they will be in the 2021 EM match:

 I am beyond excited to announce that our new EM program at Saint Agnes Medical Center in Fresno, CA has just received initial accreditation.  We will be using ERAS and NRMP to obtain our initial class of 8 residents for July, 2021. Super excited to be apart of this amazing family.

------------------------------
Jesse Kellar
EM Program Director
Saint Agnes Center Emergency Medicine Residency Program
Fresno CA

Great Question: Should I really only do 1 rotation?

The ACGME and EM parent organizations have come out with a very strong message that students should focus on home rotations only and NOT pursue the usually recommended strategy of a home rotation and one or more away rotations.  For those without a home EM residency to rotate at the  recommendation circulating is to do a single away rotation.  This is very different advice from a "normal" year. 

This has led to a lot of appropriately concerned students wondering: 

"Should I really only do 1 EM rotation?"

The official answer, and the one for most students, is "Yes! One rotation is fine."

Programs are NOT going to be expecting more than one rotation and one Group EM SLOE from a Residency Program Leadership team. 

However, application advice is never one-size-fits-all.  Depending on your individual circumstances it may be very reasonable to do two rotations.  Some examples where doing a second rotation will not be held against you by Residency Program Directors:

1. The second rotation is a community EM month, not at a residency program
2. Your school is affiliated with more than one EM residency (multiple "home" options) AND your local advisors recommend rotating at more than one of them
3. Your school has no home EM program (a so called "orphan school")***

***This third one is controversial.  Most programs will not be upset with an applicant from an orphan school who does 2 rotations, but some may be annoyed.  My opinion is that the benefits of a second rotation in your schedule make this worthwhile. Surge in cases in many regions may lead to cancellation of rotations.  Early rotations may have clinical limitations that don't let you have a full experience.  Second rotation performance is often better, especially for students who did not have as much EM infrastructure at their school.  

Another question:

"So... can I do 3 or 4 rotations?"

Answer:  No.