Consensus Statement on 2021-22 EM Match - Implications for Applicants

 The COVID-19 pandemic is anticipated to impact the 2021-22 Residency Application cycle, though in different ways than this past year.  The Coalition for Physician Accountability (CoPA) released guidelines for Away rotations in general and all of the Emergency Medicine stakeholder organizations put together a detailed Consensus Statement that you can read here.  

Despite this attempt to provide clarity, there are still a lot of questions as to what this really means for students, especially those without a traditional "home" rotation available.  

Below is some Q&A on common questions that have come up in response to these guidelines.

When can students complete "away" rotations?  These are not supposed to be available before August 1, 2021.  However, this restriction does not apply to students without a "home" rotation.  Those students can take the first available opportunity at an institution that is open to "away" rotators.  

How many rotations can students complete?  The recommendation is one or two rotations at Residency Programs (usually called something like "Sub-Internship" or "Advanced Elective").  If two rotations, then either one "home" and one "away" or two "away" rotations.  Other EM rotations do not count towards this total, including sub-specialty rotations (like Ultrasound or Pedi-EM) that take place at a Residency Program.  

What if I have two separate "home" sites available to me?  While this is not available for many students, you can do both, but you should then NOT do an away rotation.  If you are looking to be considered outside of the region where your medical school is you are likely to be better off doing only one of the "home" sites and doing an "away" rotation somewhere else you are interested in going to.  

How many SLOE's should I have this year?  The recommendation is two SLOE's from Residency Program Leadership (Residency SLOE).  The other letters in your application can be from the other types of SLOE's, but two Residency SLOE's should always take precedence in planning your application.  However, having just one of these letters is NOT going to be disqualifying.  Having three or four Residency SLOE's is strongly discouraged and will likely result in some application reviewers down-rating your application.  

Do I need to do an "away"?  Only having one Residency SLOE will not hurt your application.  However, there is added value in having two separate residencies evaluate your performance and candidacy for EM.  If one letter is not particularly strong the other letter can compensate for that, especially if growth is shown from one rotation to the next.  This is why EM has always preferred that students do two rotations.  The lack of a second SLOE may have hurt some applicants in the 2021 Match who would not have faced similar challenges getting interviews in a previous year when a second letter would have been available to provide reassurance.  

There is still a lot we don't know about what the 2021-22 Application cycle will look like, including whether interviews will be in-person, virtual, or a hybrid of the two.  

If you have other questions, or want some additional clarification, please submit those in the comments section below.

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!

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.   

Changes to ERAS Application Timeline and Virtual Interviews

The advising information on this blog has been updated to reflect what we knew about the process before the COVID-19 pandemic turned everything upside down.  As the changes to the process for the 2021 Emergency Medicine Match start to become clear we are going to start sharing that information.  

There are major updates on the timing of the application cycle and how interviews are likely to be conducted.

First, ERAS is making this announcement:
"ERAS has determined that on Wednesday, October 21, 2020, residency programs will gain access to applications and MSPEs will be released to residency programs. These date changes are reflected on the ERAS 2021 Residency Application Timeline."

This is a significant delay from previous years when ERAS opened to programs on September 15 and the MSPE arrived on October 1.  The clear benefit of this change is that there will be another full month of rotations that can generate letters of recommendation (SLOE's) that will arrive in time for the initial application review by programs.  That review will start in earnest that last week of October.  The beginning of interviews will likely be pushed back several weeks as well, though this will vary by program.

On the subject of interviews, the AAMC just released a recommendation that all interviewing should be conducted virtually.  This is NOT a binding directive, at least not yet.  It would be reasonable to expect that at least some interviews in this upcoming application season will be done over video chat.

While the rationale for this recommendation is clearly to reduce the health risks associated with travel, there is the additional benefit of eliminating travel costs for the applicant. Given how much money is spent on the application and interview process, it is quite possible that the adoption of video-interviewing will be a lasting change in the interview process.

What we do not yet know is the impact these changes, and those that follow, will have on applicant and program behavior.  As more information becomes available we will provide further updates.  For now, applicants should continue to work on getting 2 EM rotations, knowing that clerkships ending in mid-October will now yield SLOE's that programs will be able to review.

COVID-19 and the 2021 EM Match: Everything on this site is wrong!

We have endeavored to keep the advice on this site based on the best evidence and consensus recommendations, AND thoroughly up to date with changes in the EM Match.  That has all gone out the window with the COVID-19 Pandemic (plus Step 1 going to Pass/Fail and the SVI getting cancelled).  As anyone reading this probably knows, most medical schools are banning travel by students and limiting the clinical contact they are allowed to have at home.  Most hospitals are also not accepting visiting students.  And we don't know when this will end or what "normal" will look like when things get back to "normal".

The Advising Students Committee (ASC-EM) of the Council of Residency Directors in EM (CORD-EM) authored this Consensus Statement to start to address the impact COVID-19 is going to have students in the 2021 EM Match.  We urge you to read this through as it will hopefully offer some reassurance that the students are not being forgotten, and give you an idea of what is planned to support you. 

As for the problem of everything on this site being wrong, that is going to take a while.  When one of our authors gets COVID and is sent home to self-quarantine all the updates will happen quickly. Until then, like the folks delivering all my Amazon packages, cleaning the empty shelves at the grocery store, and working around the clock making more PPE (thank you!), we are a little short on time.

We will get the Applying Pages updated for this scary new world. In the meantime, stay safe and start studying for Step 2.

Adam Kellogg is an Associate Residency Director, past Chair of the ASC-EM, a contributor to the Consensus Statement, and a master of social distancing.