Match Day 2018 - Contingency Planning for the Unmatched

Match Day 2018 is friday, March 16.  That day is anxiety provoking for every student in the match as they find out where they are going to continue their training.  Even more stressful is monday the 12th, sometimes called "No-Match Day".  At 12 pm all programs and applicants find out if they matched or if they are going to have to scramble for a position in the SOAP.  Most applicants will get good new on monday and their worries will quickly shift from "if I match" to "where will I match?".  

This post is for applicants who get bad news on monday.  We will outline the big decision points and connect you with additional resources.

The first thing you need to do if you are notified that you did not match is to take a little time to grieve.  Even if you knew you were at risk to not match and this news is disappointing, but not a surprise, take a little time to wrap your head around it.  

Then you need to make a plan, or put into action the plan you already made.  

The big decision:  Do you still want to match into EM?

Using the SOAP process to get into EM, or finding a spot post-match, are not viable routes to get an EM training spot.  A very few lucky folks may make this happen but there are not enough spots for this to be something you plan for.  

The most commonly recommended path to pursue in setting up a re-application to EM next year is to get clinical training in a one year internship (surgical, medical, transitional, etc.).  Other options include matching to a categorical program (full course of training, like categorical IM or FP), extending medical school graduation to improve your application, or pursuing additional experience like a research project or masters degree after graduating on time.  Which option(s) is best for you depends on a variety of factors including why you did not match, how likely are you to be successful in reapplying, and which are available.  

Resources to help you make an informed decision:

• This previous EM Advisor post takes you through deciding what route to pursue in much more detail.
• This post: The Re-Applicant Playbook, takes you through self-assessing your situation and making plans to reapply.  It served as the foundation for an Advising Guideline written by the Council of Emergency Medicine Residency Directors (CORD-EM) Student Advising Task Force:  The Emergency Medicine Re-Applicant Applying Guide.  This guide adds national consensus and evidence based recommendations for those facing a second time through the application cycle.  All of the guides written by the Task Force live on their web-page.  
• There is a paucity of expert advice available for students who do not match, and even less literature.  However, a recent article published in Academic Medicine provided some insights for students who did not match.  The implications for the applicant to EM were discussed in this post on the CORD EM Blog.  

If you know of additional quality resources for the unmatched applicant to EM please share them in comments below and we will incorporate them into future resources.  

Adam Kellogg is an Associate Residency Director, former Medical Student Clerkship Director, a past Chair of the CORD-EM Student Advising Task Force, and an author on far too many of the resources for re-applicants.  Seriously, if you have some other good resources, share them!

"No Match" Day

Today applicants in the NRMP match find out if they successfully matched to a program. Unfortunately not every applicant with their sights set on Emergency Medicine received good news today. This post is to direct you towards help on what to do next:

For those without a match the SOAP process started at 11 am today and goes until Thursday, March 16th at 11 am.  

These two posts will guide you through the process of deciding what you should do now and planning your re-application:

• So You Didn't Match
• The Re-Applicant Playbook

The advice contained in the above posts will help you decide how best to spend the next year and what you should be considering when evaluating your options. 

Best of luck.

A Guide to the "Perfect" Rank List

A Guide to the “Perfect” Rank List

This is a guide to help students in the Emergency Medicine (EM) match formulate the best possible Rank List to fit their needs. This guide was prepared on behalf of the Council of Residency Directors in Emergency Medicine (CORD-EM) Student Advising Task Force, a group that seeks to provide guidance to students applying to EM and to all those that advise them.

Introduction:

Congratulations on finishing your interviews; now here comes the hard part, compiling your rank list!

Making your personal rank list has been associated with common symptoms such as confusion, insomnia, aggression, depression, elation, and general malaise. The goals of this blog are to review tips and recommendations based on the National Resident Matching Program (NRMP) data from 2009 to 2015, as well as expert opinions from your fellow residents and attending in order to alleviate the psychosomatic stressors affiliated with the entire process. At the end of the day, it is still your personal preferences, interview experience, and family-social obligations that will drive you to create your “perfect” rank list.

Spoiler: There is NO spoon or the “Perfect” rank list. 

Background: 

According to the NRMP data from 2015, there were a total of 2352 applicants for 1821 nation-wide EM positions, with only 8 positions unfilled. The number of EM programs has been steadily increasing in the last decade, from 141 programs in 2009 to 171 programs in 2015 in order to meet the increased popularity of this amazing specialty, reflected by the 19% increase in total applicant since 2009 [Fig. 1]. Despite the rising number of programs, the NRMP dataset reveals a steady decline of unfilled position; in 2012, all programs were completely filled. Fortunately, 18 EM programs were added with 153 new available positions since 2012, allowing applicants to select from a larger pool of EM programs with less fear of scrambling.

Figure 1 – Application trends for EM Residency. Taken from NRMP dataset 2009-2015.

Questions to ponder:

What is the Matching Process?

The Matching Process is a time-honored (and feared) tradition where a mathematical algorism is used to place applicants into residency and fellow ship position (http://www.nrmp.org/match-process/match-algorithm/). The process begins by matching the applicant’s rank order list (ROL) to the respective programs. If the applicant cannot be matched to the first choice program, the computer algorithm will automatically attempt to place the applicant into the second, third, and so forth until he/she is matched. A tentative match occurs when a program also ranked the applicant “A” and either:

1. The program has an unfilled position, in which case there is room in the program to make a tentative match between the applicant “A” and program, or
2. The program does not have an unfilled position, but applicant “A” is more preferred by the program than another applicant “B” who already is tentatively matched to the program.  In that case, applicant “A” will be granted the position instead of “B.”

All matches are “tentative” because applicants who are matched to a program may be removed at any time from that program to make room for an applicant more preferred by the program (see example above).  When the applicant is removed from a tentative match, an attempt is made to re-match that applicant, starting from the top of the applicant’s ROL.  When the Match is complete, all tentative matches are considered “final.”

Will I get my first choice?

According to the 2014 NRMP data based on matched applicants to all specialties in relationship to their specific rank list, most students get their top 3 choices: 52%/16%/10%, as their 1^st/2^nd/3^rd choice [Fig 2]. This means that your top 3 rank list matter the most, so choose programs carefully! 

Figure 2 – Percent of Matches by Choice and Type of Applicants. Taken from NRMP 2014

Should I rank every program? 

This is a tricky question, but fortunately the answer is bluntly straight forward: YES!

When you leave a program out of the rank list, you will not be matched to that program, END OF STORY. If you were an EM applicant who failed to match in 2012, your only option to become an EM resident was to reapply for the following year as there were ZERO unfilled EM positions in the entire country. Fortunately by 2015, the number of unfilled programs rose to a total of 4, providing a small breathing room for the scramblers. 

My opinion, if you already invested your time and money for the interview, then just rank the program. It is okay to not rank a program, as long as you understand that the risk involves scrambling into a non-EM Program [Fig. 3].

  

“Scrubbing for EM in 2012 – Gonna need a bigger SOAP next year!”

Figure 3 – In 2012, NRMP reported zero unfilled EM positions across the country. Not matching meant scrambling to a Non-Emergency Medicine Program.  SOAP stands for Supplemental Offer and Acceptance Program®.

Which rank list reigns supreme? Applicants vs. the Residency 

Based on the NRMP Match Algorithm (as described above), the applicant rank list is reviewed before the program rank list, placing a higher priority to applicants’ preference over the residency’s. So, just like a game of blackjack, you, as the applicant are the “Dealer,” with just a slight advantage over the residency, aka “Player.”

Which program should I rank 1^st?

Unfortunately, this article will not be able to tackle the complexity of picking the “perfect rank list.” Your rank list will likely be affected by numerous factors, some of which you may have known, while others surface as you progress through the interview trail [Table 1]. In writing this article, we have collected numerous strategies to assist in making the ideal rank list, but at the end, the most common advice was to “follow your gut feeling.” Nevertheless, this article includes some general and useful suggestions for picking out your top 3 programs:

1. Ask your local EM program directors for advice – Program Directors are there to help and guide you through the application process. Their knowledgebase is formidable and they read thousands of applications annually. Sure, some may try to persuade you to join their program, but that is a good sign.
2. You will make new friends – This may sound silly, but many applicants are reluctant to leave their medical school institution, fearing they will lose touch with their friends due to the increased distance. Rest assured, however, you WILL make new friends, either intra- or extra-departmental (or even outside the hospital, GASP!)
3. Location, Location, Location! – This is true with the housing market, and it is equally pertinent in residency selection. If a particular EM Residency is your dream program, but it’s located in a region that you are unfamiliar with, or have limited access to your hobbies (i.e. an outdoorsman in NYC or a Californian surfer in Colorado), then you should strongly reconsider. After all, your wellness matters.
4. Don’t be distracted by gizmos and gadgets – What differentiates a strong EM Residency program is the cohesive nature of the residents, the supportive faculty, and the willingness to respond to feedback. Fancy technologies such as EMR, CT/MRI scanners, and even scribes can be enticing, but they are only as functional as the organization that utilizes them. Friendly consults, however, are always added bonuses.
5. Are the residents happy? – This is one of the most important things to assess during your interviews dinners. Most accredited residency program ensures that you will learn to be an effective and efficient healer, as a result, why not have a good time? If the residents at the dinner seem miserable and depressed, that is a big RED FLAG!

Table 1 - Common Factors Affecting Rank List Decision Making

What if I don’t even know myself?

When all else fails, there is a trick you can play on yourself to test your subconscious mind.

• Step 1 – Grab a friend
• Step 2 – Write all of your EM programs on pieces of paper, then fold and place them in a bag.
• Step 3 – Pretend it is Match Day! Have your friend pull a random piece of paper from the bag and tell you that you’ve matched to the program listed on the paper. 
• Step 4 – Make facial expression (very important step)
• Step 5 – Ask your friend for your reaction.

Conclusion:

Please remember, you have already chosen one of the most rewarding and exciting field of medicine, and you will have a great education and experience regardless of where you match. Just make the list, cross your fingers, and get ready for the next exciting chapter of your life!

- Tony

Xiao Chi (Tony) Zhang is an Emergency Medicine Resident at Brown-Alpert School of Medicine and a member of the CORD-EM Student Advising Task Force.

Advice for the International EM Applicant

This post is by Max Hockstein, a US citizen who went to medical school in the caribbean and who successfully matched into a U.S. Emergency Medicine residency in 2015.  He is now starting his internship and wanted to share some advice on navigating the EM match as an international applicant...

Before you choose EM

Over the past few years, emergency medicine has become increasingly competitive.  As you get started as an International Medical Graduate (IMG) applicant you need to know what you are getting into.  According to the Results and Data from the 2015 Main Residency Match there were 1821 emergency medicine PGY-1 positions with 2352 total applicants.  Of those, 739 were “independent applicants” (31.4%), which includes those who went to med school internationally.  EM had a 99.6% fill rate with almost 80% of those spots going to US allopathic seniors and 11% filled by osteopaths. This adds up to some sobering news for the international applicant.  Just 4% of spots were filled by IMG’s who were US citizens and just 2% by non-US citizen IMG’s. And that left 30% of independent applicants unmatched among those who listed EM as their only specialty (did not hedge with also applying to another specialty).  

Why is this?  

IMG’s are still considered (by some) to be second-rate applicants.  In addition, residency program directors (PD's) get many, many applications, and they need a way to screen them.  When the NRMP conducted a program director survey in 2014 83% of PD’s ranked being a graduate of an American medical school at a high level of importance. And less than half (47%) of PD’s will interview and rank IMG’s.  

About rotations

One of the most difficult things about IMG’s matching into emergency medicine is their ability to get their foot in the door because clerkships are hard to schedule.  The holy-grail clerkship is one where you can get a departmental Standardized Letter of Evaluation (SLOE) from an emergency medicine residency.   Because international schools are not affiliated with academic EM programs, we have to find places that not only allow rotators, but foreign rotators.  There’s no registry of places that allow IMG rotators because hospitals change their policies so quickly.  Your first step should be to ask your school where students that have successfully matched into EM have rotated.  The second place you can look is your schools’ (and other foreign schools) match list – see where IMG’s have matched and call those departments to see if you can schedule a rotation there.  The last, and unfortunately the most common way, is to call the departments where you’re interested in rotating (and potentially applying to) to see if they’ll let you rotate.  This takes time: you are busy and the clerkship coordinators are definitely busy – it can be a tough job.    

An added wrinkle...

Certain states have requirements to be eligible for licensure which have to do with the rotations (clerkships) that you did during third/fourth years.  There are two terms you’ll being hearing a lot on this topic: Green-book and Blue-book.  Green-book rotations mean that the rotation has an associated residency while Blue-book rotations means there is no associated residency with an established rotation.  States that are stricter about licensure requirements (for example, Texas) require that all of your rotations be Green-book to be granted licensure after doing residency in that state.  This does not mean that you can’t do residency in one of the more selective states – it just means that you can’t get licensed after residency until you pass your boards if you did Blue-book rotations when you were a student.  

Your application

ERAS opens September 15th – your application needs to be complete (with the exception of possibly one SLOE) by then.  This means you need to have your last SLOE in ERAS by October 1st at the latest.  This means the optimal time to do your rotations is before September.  When you’re setting up your core rotations (third year), do them all back-to-back because (most, if not all) EM rotations require that your core rotations be complete prior to the rotation.  

One of the reasons that program directors want to see SLOE’s from ED’s with residency programs is because one of the questions on the SLOE is how that program plans to rank that applicant – it gives the SLOE more context.  Because of the demand to do clerkships at Emergency Departments with affiliated residencies, some non-academic departments offer rotations.  The bottom line is: do a rotation at a non-academic department if you have to in order to get at least two SLOE’s, but know that having a residency affiliated SLOE is preferred to any other letter you could receive.

There’s no statistically favored number of programs that guarantee you a certain number of interviews.  Apply to programs that you know have matched IMG’s over the past few years (do this by looking at the match lists published by the schools) as well as applying to programs you’re generally interested in.  If you haven’t heard from programs that you’re interested in, or are lacking in interviews, don’t be bashful.  Call coordinators, email program directors – be enthusiastic but not overbearing or demanding.  And be ready at a moment’s notice later in the interview season – spots open up during interview days – and you need to jump on them, they’re not easy to come by.  Though they are scheduled in a rush, these interviews carry just as much weight as any other and programs will appreciate your flexibility.  All that said, hedge your bets.  EM is difficult to interview for and match into.  Apply broadly for emergency medicine but also apply for other specialties you see yourself succeeding in.  If you don’t match into EM – do not rely on SOAP.  Vanishingly few (if any) international applicants in recent history have SOAPed into EM.    

The interview

Once you get interviews, you have to knock them out of the park!  Beyond having impeccable interview skills, you need to be prepared to address the awkward flamingo in the room: the IMG thing.  You have to be able to explain why you took the IMG route – and turn it into something that makes you into the applicant that they must have.  For example, if you had problems with standardized testing, you need to be able to show that it was a struggle that you overcame, emerging stronger and better prepared for having persevered.  

And finally, the rank list

From the 2014 Match data, to have an over 90% chance of matching into EM as an IMG, an applicant had to rank over ten programs. And though no number of interviews guaranteed a 100% match rate, having ten programs to rank as your goal should leave you feeling pretty safe.  When it comes time to ranking – don’t try to outsmart the algorithm.  The match is applicant-weighted.  Go with the conventional wisdom: rank based on where you want to go – there’s no trick to ranking as an IMG.  Again, hedge your bets – rank all programs (EM or otherwise) you interviewed with.  Remember, you’d rather your rank list be too long, not too short.

So you did not match...

This is an update of our advice for the student who finds themself in the unfortunate position of having NOT matched in Emergency Medicine. There are some changes from last years post on the same topic. As always the advice that follows is based on the experiences of applicants who did not match in recent years and the compilation of recommendations from the members of the Clerkship Directors in Emergency Medicine (CDEM) and Council of Residency Directors in EM (CORD EM). 

First step: take a breath, your life is not over. Your goal of training in Emergency Medicine is still alive. While it is difficult to see now, the hurdles, trips, and falls teach us more than our successes. You will grow and learn from this and become a better care giver for having struggled through this. 

You are now faced with a huge decision:  Do you SOAP (scramble) into something else with the plan to train in that specialty? Or are you still intent on EM even if it is not this year?

The advice that follows will be useful to those not willing to give up on EM.  One key thing to remember when deciding which group you are in: not matching this year does not mean you would not be an outstanding Emergency Physician. There are many great unmatched candidates out there who would have a spot if it were not for late applications, poor advising, a bad test score, or just bad luck.   

So what are your options if you are still intent on EM?

  

Most people come up with one or more of the following plans:

1. SOAP into an open EM spot at a program they had not previously applied to.
2. Take a year off and do research or pursue a graduate degree like an MPH to improve your CV.
3. Extend your med school training to a fifth year and improve your application for next year.
4. SOAP into another discipline with the intention of reapplying next year.

Let's address each of these options:

1.  Using the SOAP to get into an open categorical PG1 EM spot is almost impossible.  There were just 2 spots in 2013, with 686 US seniors without a match in EM. The chance of getting one of those 2 spots is 0.2%.  To put it another way 99.8% of US seniors who did not match in EM did not get a SOAP spot in EM. In 2014 there were 14 unfilled positions in the match, which is still not very many (family med had 142 and surgery prelim had 449). There is no reason that you cannot try to SOAP into EM but you need a back-up plan in place.

2.  There is near universal agreement that taking a year off for research will hurt you more than it helps you. Program Directors just do not care that much, especially about the kind of research you can set up and complete in one year (just not rigorous/impressive enough).  Many Program Directors are happy to interview re-applicants who have gained some clinical experience, but often do not bother if an applicant did research for the year.  There is significantly less agreement about what a degree like an MPH would do for you - which means that some people will be interested and others will not. 

3.  Extending medical school may be the best option for some students, if your school will allow you to do that. The clear downside is cost, which is likely huge. If the price or rules of your school (ask your dean) are not deal-breakers you can build an extra-year of experiences that will make you a better qualified candidate for next years match. This is a particularly good option for solid candidates whose applications suffered from being late to EM or being complete late in the application cycle. If more opportunities to interview were all you needed to get your 10 to 12 interviews, then extending will let you do that. This option also leaves you available to fill a last minute opening that comes up after the match (though you cannot count on that kind of luck). 

4.  Lastly, is the most common back-up plan: doing a year of something else. The clinical experience will certainly better prepare you for your EM training and can make you a stronger candidate. Putting yourself through the application process again can only enhance the perception of your commitment to EM. Many applicants have been successful using this pathway to eventually match to EM. If you choose this option there are two primary considerations in this decision:  What kind of year to do?  Where to do it?

If I want to reapply to EM, what specialty should I SOAP into?

There is significant disagreement among CDEM and CORD about what kind of prelim PG1 year is best, or if you should go for a categorical program (contract for full course of training) instead.  Here are the options and some explanation:

Transitional prelim year - thought of by the majority of Program Directors to be the best option for a re-applicant. You split the year between surgery and medicine and get to do many of the things you would be doing as an EM1. It is more rigorous and impressive than a year of IM and your future EM program may be able to give you credit for some of the months. The downside is finding a suitable one that fits your other needs (see below).  There is also possible lack of flexibility for doing EM months and interviewing, and at the end of it you are left without a job if you do not match into something else. In recent years these have become increasingly difficult to find in the SOAP as less are available. The best way to have a Transitional year as back-up is to apply and interview for it, not to scramble (too late).

Surgery prelim year - students choose to do this but few Program Directors think it is necessary, or even more helpful than a Transition or IM year. That being said, there are some who think the more rigorous/abusive Surgery year is more impressive. Again, you are left without a job after one year.

Medicine prelim year - often provides greater flexibility for getting EM elective time early (when you can get a new letter) and for interviewing. And you will usually be treated better. Some Program Directors are less impressed because it is not as rigorous, AND at the end you don’t have a job. However, finding a categorical IM program that will let you start as a PG2 should be an option if matching into EM does not work.  

Medicine or Family categorical spot - same benefits and downsides as a one year Medicine spot but with the advantage that you still have a training position should you be unable to jump to EM. There is an additional downside of needing to break a contract should you match in EM. This rarely is a problem so long as you are open and upfront with your IM Program Director. Re-application is hard, and they know they have a good chance of keeping you, so being supportive of your plans keeps you happy with them.  After a Transition year this is the second most recommended option by EM Program Directors because you have a fallback position if you do not match in EM.

Where you do your year is MORE important than what kind of year you do.

The ideal position is one where you will have the opportunity to do an EM elective early (August, September) in an ED that has a residency program you are interested in joining.  This gives you access to new letters from people in an EM residency. Most EM Program Directors agree that these letters will be the most important part of your re-application. You are better off doing a conditional Medicine year at a hospital with an EM residency than doing a Transitional year at a hospital without an EM residency. You need access to EM faculty who teach EM residents, and the EM Program Director at your hospital can be your best advisor in getting a spot in their program, or another.  

What do you do if you find out at noon on Monday, March 16th, that you did not match?

1. Call your dean and find out what your options are.
2. Call your EM advisor for a personalized recommendation on what you should do. You can also contact us by email or in the comments.
3. Schedule as many clinical EM rotations as you can for the rest of the year. Get SLOE's from all of these rotations so that you can include better letters than you had this year and so that you can meet as many people within EM who can advise and advocate for you. 

Best of luck!

-Adam

Adam Kellogg is an Associate Residency Director and formerly an Emergency Medicine Clerkship Director.  He is a member of the CORD EM Student Advising Task Force and of the SAEM Resident and Student Advisory Committee. Some of his favorite Emergency Physicians did not match on their first try.  

Diagnosing the Match

We are in the heart of EM residency interview season here in the United States. This has been an anxiety provoking year for all involved.

Applicants and their advisors are worried because they do not have as many interviews as they expected.

Residency programs have unprecedented numbers of applications this year and are worried they are not interviewing enough candidates.

The Council of Residency Directors (CORD) Student Advising Task Force and the Emergency Medicine Residency Association (EMRA) worked together to try to shed some light on these events. The result of this collaboration, written by Zach Jarou (@zachjarou), a resident at the Denver Health EM Residency, and myself, was just published on EM Resident. We looked at recent match data and a survey of residency program directors to figure out how we got here and what we can do going forward.

This is a long article, with a lot of data, but after reading it you should have a better idea of where you stand in the application process AND what you can do now to improve your chances.

http://www.emresident.org/emergency-medicine-match/

So you did not match...

If you are reading this you are in the unfortunate position of having NOT matched in Emergency Medicine (or you have a degree of morbid curiosity).  The advice that follows is based on the experiences of applicants who did not match in recent years and the compilation of a discussion from the list serve used by most Program Directors in Emergency Medicine. 

First take a breath, your life is not over. While it is impossible to see now, the hurdles, trips, and falls teach us more than our successes. You will grow and learn from this and become a better care giver for having struggled through this. 

You are now faced with a big decision:  

Do you want to scramble into something else with the plan to train in that specialty? 

Or are you still intent on EM even if it is not this year?

The following advice is for those not willing to give up on EM.  One key thing to remember when deciding which group you are in: not matching this year does not mean you would not be an outstanding Emergency Physician. There are many great unmatched candidates out there who would have a spot if it were not for late applications, poor advising, a bad test score, or just bad luck.   

So what are your options if you are still intent on EM?

  

Most people come up with one or more of the following plans:

1. Scramble into an open EM spot at a program they had not previously applied to.
2. Scramble into another discipline with the intention of reapplying next year.
3. Take a year off and do research or pursue a graduate degree like an MPH to improve your CV.

Scrambling into an open categorical PG1 EM spot is almost impossible.  There were 2 spots in 2013, with 686 US seniors without a match in EM. The chance of getting one of those 2 spots is 0.2%.  To put it another way 99.8% of US seniors who did not match in EM did not get a scramble spot in EM.

There is near universal agreement that taking a year off for research will hurt you more than it helps you.  Program Directors just do not care that much, especially about the kind of research you can set up and complete in one year (just not rigorous/impressive enough).  Many Program Directors are happy to interview re-applicants who have gained some clinical experience, but often do not bother if an applicant did research for the year.  There is significantly less agreement about what a degree like an MPH would do for you - which means that some people will be interested and others will not. 

So that leaves the most common reality of doing a year of something else.  The clinical experience will make you a stronger candidate and better prepare you for your EM internship.  Putting yourself through the application process again will enhance the perception of your commitment (something that often suffers in the applications of late converts to EM).  There are two primary considerations in this decision:  What kind of year to do?  Where to do it?

There is significant disagreement about what kind of prelim PG1 year is best, or if you should go for a categorical program (contract for full course of training) instead.  Here are the options and some explanation:

Transitional prelim year - thought of by the majority of Program Directors to be the best option for a re-applicant.  You split the year between surgery and medicine and get to do many of the things you would be doing as an EM1.  It is more rigorous and impressive than a year of IM and your future EM program may be able to give you credit for some of the months.  The downside is finding a suitable one that fits your other needs (see below).  There is also possible lack of flexibility for doing EM months and interviewing (if you belong to surgery during those months), and at the end of it you are left without a job if you do not match into something else.  In recent years these have become increasingly difficult to find in the scramble as less are available with other specialties incorporating internship into their training program.  The best way to have a Transitional year as back-up is to apply and interview for it, not to scramble.

Surgery prelim year - students choose to do this but few Program Directors think it is necessary, or even more helpful than a Transition or IM year.  That being said, there are some who think the more rigorous/abusive Surgery year is more impressive.  Again, you are left without a job after one year.

Medicine prelim year - often provides greater flexibility for getting EM elective time early (when you can get a new letter) and for interviewing.  And you will usually be treated better. Some Program Directors are less impressed because it is not as punishing and at the end you don’t have a job.  Finding a categorical IM program that will let you start as a PG2 should be an option if matching into EM does not work.  

Medicine or Family categorical spot - same benefits and downsides as a one year Medicine spot but with the advantage that you still have a training position should you be unable to jump to EM.  There is an additional downside of needing to break a contract should you match in EM.  This rarely is a problem so long as people are open and upfront with their IM Program Director.  Re-application is hard, and they know they have a good chance of keeping you, so being supportive of your plans keeps you happy with them.  After a Transition year this is the second most recommended option by EM Program Directors because you have a fallback position if you do not match in EM.

Where you do your year is MORE important than what kind of year you do: 

Location, Location, Location

The ideal position is one where you will have the opportunity to do an EM elective early (August, September) in an ED that has a residency program you are interested in joining.  This gives you access to new letters from people in an EM residency.  Most EM Program Directors agree that these letters will be the most important part of your re-application.  You are better off doing a conditional Medicine year at a hospital with an EM residency than doing a Transitional year at a hospital without an EM residency.  You need access to EM faculty who teach EM residents, and the EM Program Director at your hospital can be your best advisor in getting a spot in their program or another.  

Finally, something you can do now:  

Schedule EM electives for as much of the rest of this year as you can.  Get SLOE’s from all of these rotations.  These letters will help your re-application and you get to know more people within the specialty.  Unforeseen openings happen, even as soon as July 1, and the more people who know you, the better your chance at getting one of those.

I hope you find this advice helpful and I strongly encourage you to contact me if you have any questions.  I am happy to be of help.

Best of luck.

-Cien

Lucienne Lutfy-Clayton M.D. FACEP

Assistant Professor of Emergency Medicine

Tufts University School of Medicine

Emergency Medicine Clerkship Director

Co-Director Emergency Medicine Simulation

Baystate Medical Center

759 Chestnut St

Springfield MA 01199

tel: 413-794-5999

lucienne.Lutfy-Clayton@bhs.org