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.

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.   

The Re-Applicant Playbook

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.

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.   

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.

Rules of the Road for Away Rotation Applications

Now that you have decided on EM (or are at least treating it as your front-runner), you will need to complete a Home and an Away rotation this summer and early fall. These rotations are where you will get the SLOEs that will be the most important part of your EM application. Take a look at this approach to your myriad of choices, and below is a discussion of the most common questions...

Vacillating on the VSAS

There are no perfect number of clerkship applications. First, self evaluate your competitiveness and the competitiveness of where you are applying to. Your local advisors should be able to help you get a sense of your competitiveness at this point.  Keep in mind that this is going to change as you complete rotations. For most students 4 applications will suffice. If you are a weaker applicant or looking at a more competitive market - consider 6. 

The Bird in the Hand

Many students get an invitation to one clerkship, but want to wait for their dream spot. In this application your goal is to ensure you have an away rotation during the spring and summer. You have a rotation, take it and smile. If you can manage a third rotation, keep your other applications in. If you cannot do a third rotation and still have applications outstanding call and let them know you appreciate their time but have accepted another opportunity. This is better than waiting and declining the spot. This proactive stance will win you points with the clerkship director and the coordinator (they may remember if you string them along). 

Check the Boxes

Read the paperwork from the program carefully, and complete it in a timely manner. There is no second chance for a first impression. You don't want to arrive and not be able to rotate because of paperwork. Health requirements vary at different institutions. Check with the undergraduate medical education office or health services at the hospital you are going to. They should be able to list what you need in detail. This is the time to jump through the hoop and just get it done.

Burn Baby Burn (or Don't!)

Declining an offered spot will be a small annoyance to the clerkship. If you need to, ensure you do it quickly and politely. Waiting weeks to decline hurts your impression with the program. They assume you are stringing them along and not genuinely interested in the program. Never accept a rotation and then back out of it if you want to get an interview there. Getting your perfect rotation is not worth the damage to your credibility elsewhere. If you discover a particular program is not a good fit and expect not to apply to them, go ahead and cancel. Just know that this program interprets withdrawing as disinterest and inconsiderate - not a good impression. The clerkship director and residency coordinator will recognize your name and will be reluctant to interview you.

Lucienne Lutfy-Clayton is an Associate Program Director and former Clerkship Director, she hates when students cancel on her clerkship making her scramble at the last minute.

Burning Questions for the New Application Year

The 2015 match is behind us and the application cycle for the 2016 match is already in full swing with third year students working the VSAS to line up their optimal elective rotations.  A recent discussion with Kara Barker, a third year student in the 2016 match, led to this post (have a look at her wonderful piece on "Choosing EM"). Along with her EM-interested classmates she generated a list of "Burning Questions" for the third year student embarking on EM.  Here are our answers:

1. What qualities do Program Directors look for in an EM resident and how can I best demonstrate these during the residency application process?

Each residency program is looking for something a little different in their applicants though there are certainly some common traits. Looking at the SLOE's (the Standard Letter of Evaluation) that are used as your recommendations gives you some clues: Commitment to EM. Work ethic. Ability to create an ED appropriate differential diagnosis and plan. Teamwork. Caring for patients. These letters of evaluation are a description of your performance and your potential in EM. They are the most important part of your application.

2. As an applicant, how do I best assess whether an EM residency program is a good fit for me?
What each applicant needs from a residency program is unique to that person. There is no universal best-fit. You need to weigh what really matters to you in your training and focus your search on programs that fit those criteria. Here is a more detailed discussion of Choosing Where to Apply. While you can figure out location, duration of training, and opportunities available in advance, you will not truly know if you are a good fit in the culture of a program until you go there for interview. 

3. How important are USMLE Step 1 and/or Comlex Level 1 board scores to the EM residency application process?
Board scores matter because they are one of the few objective measures Program Directors have. They will be used to screen the application pool. However, scores do not do a good job predicting who will excel in residency training and are less important than how you do on your EM rotations. Some programs will consider you even if you did not do well on Step 1. Have a look at this more detailed discussion of Board Scores.

4. If my USMLE Step 1 and/or Comlex Level 1 scores are not competitive, can I compensate with improved USMLE Step 2 and/or Comlex Level 2 scores?
Yes. Many Residency Directors put more stock in Step 2 scores as the material is closer to being clinically relevant. In general, if you are not happy with your Step 1 you should put extra effort into step 2 and take them in time to have the results appear in your application (August).  

5. In addition to board scores, Standardized Letters of Evaluation (SLOEs) and successful completion of EM audition rotations, is there anything else I can do to distinguish myself from other EM residency program applicants?
Those are the most important part of your application and carry the most weight. Some Residency Directors put a lot of emphasis on research projects. Others like to see service and volunteer experience. And others are big on involvement in local/national EM organizations. Do those things if they suit your interests and you can do them well. When they come up on your interviews you will want to be able to talk about them passionately. Here is some more depth on what goes into the ERAS application.

6. How important are grades and letters from non-EM clinical rotations to the strength of my EM residency applications?
Your EM grades and letters are the most important part of your application. Programs will look at your grades from other rotations but the impact on your application quality is small. There is too much variability in grading from school to school. Letters from rotations in other specialties are also not very helpful. Rounding out your set with a non-EM letter is fine, and will not hurt you, so long as you have enough information in your EM letters. Here is another link to that more detailed discussion of Letters.  

7. Given the importance of securing at least two EM clinical audition rotations AND given the number of other students also competing to secure these rotations, what can I do to make sure I am invited to rotate in the programs I am interested in?
You can appeal to the Clerkship Director by email and hover on the VSAS site waiting for an opening but there are only so many spots. Be ready to make a switch late in the process if someone drops a rotation. Ultimately, doing two EM rotations is more important than where you do them. The value of the SLOE to the student is that by being standardized and asking to compare you to your peers, it gives a Program Director who has never met you a trustworthy impression of you. That will get you interview opportunities at places you have no other connection to. Here are some more thoughts on EM rotations.

8. If I am not able to secure a clinical EM audition rotation within the department associated with my top choice residency, is there anything else I can do to demonstrate my skills and my interest to this program?
The clinical EM rotations are typically the hardest ones to get into as they are the sources of real grades and SLOEs. However, if you just looking to get in the door and make an impression, consider doing a specialty elective like Ultrasound, Pediatric EM, Toxicology, etc. You will often be able to interact with the Program Director's while doing these rotations and you can learn about the culture of the program. Doing a rotation like Trauma surgery at the same institution is generally NOT a good idea. You will likely be too busy to make an impression on the ED.

If you have other Burning Questions you would like answered please leave them in the comments below. Good luck setting up those rotations!

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. He knows that this whole "Standardized Letter of Evaluation" thing sounds scary but they are better for everyone. Really.

A Fourth Years Perspective: What a third year student needs to know right now

Elizabeth Karr is a 4th year medical student in the 2015 EM Match.  This post is a 4th years perspective on what a 3rd year needs to know.

As I started Fourth Year, I was told that this year would be the hardest yet, and this advice has proven true.  You start out going on your audition rotations, wanting to put your best foot forward and impress the people you are working with.  However, you are also still learning the craft of Emergency Medicine (EM), formulating your differential, perfecting the three minute presentation, and learning the basics of emergency medicine. Then interviews start and you are traveling all the time, which is exhausting in and of itself, and on the interviews you are selling yourself.  You have to answer the same questions 50 thousand times, and yet you still want to sound like you are not giving a rehearsed statement.

Fourth Year Rotations

What I now know at the end of it all: just take a breath, relax, and be yourself.  Audition at sites whose residency programs truly interest you.  Choose a program that you want to learn more about or a program you have heard is a great learning experience for students--not necessarily just your number one or two pick.  If you have a number one choice, it may be better to do that as your second rotation. This will allow for your first rotation to polish your EM skills for your second rotation. The knowledge and skills you acquire will help you to shine at your top program. Also, if you are doing an away rotation in another specialty at a site you are interested in, contact the program director or student coordinator and see if you can do a shift in their emergency room and get an inside perspective on the program.

It is recommended you do your first audition rotation early in fourth year, because these are the rotations in which you will obtain your Standardized Letters of Evaluation (SLOE’s). SLOE’s are letters of recommendation that are often written by an Emergency Medicine residency, not just by individual physicians.  If you look at the following link, it will make sense as to why this is so: http://med.fau.edu/pdfs/SLOE_Standard_Letter_of_Evaluation.pdf  Ideally, you want to have at least two SLOE’s by the time applications are due in September. When you submit these, along with any other letters of recommendation, it gives programs a way to see how you compare, side-by-side, to other emergency medicine applicants. Programs also want to see that you are improving from one evaluation to another.

These SLOE’s will be obtained from your audition rotations, or possibly from a home rotation if your school has an EM program. As you start your first audition rotation, everyone is aware that it is your first rotation.  You are not expected to know everything and have all the answers, or even earn the grade of honors. It is expected you are interested in the field of EM, you learn from your experiences day in and day out, and you show growth over the month-long rotation.  It is appreciated if you show initiative; want to see patients, work on your differentials, volunteer to perform procedures even if you have never done it before.  Most of all, just enjoy the experience.  Don’t be set on trying to impress everyone, and be ready to admit when you didn’t ask your patients something, or if you don’t know the treatment for disease-X.  You are not expected as a fourth year student to have all the answers.

As for the number of EM rotations you need to do, you have to do at least two in order to get two SLOEs.  I have classmates that did five rotations, and others that only did two.  It is up to you.  I actually ended up doing a very late rotation in January, as that was the only time the program could accommodate me.  That program director told me he really likes to see interested students doing rotations late in the season, because you stick out so much more in their mind when it comes to ranking for residency.  With that said, programs are not likely to forget you if you rotate early in fourth year and are a good candidate for the program.  January was also the end of interview season, and by that time, I was exhausted and yet still had to be on my A-game as I was rotating at a place which I was also interviewing at. However, a late rotation was a good reminder of how much I enjoy emergency medicine and why I was spending all the time and money going on interviews. If you are doing a late rotation, make sure you weigh the pros and cons.

Also, in third year or early in fourth year you should try to connect with a mentor: an advisor, faculty member, program director in whom you can share your application with and discuss any lingering questions.  Most people in EM want to see you succeed and match into the program of your choosing.  It is great to have someone to ask questions, look over your personal statement, advise to the number of programs to apply to, and give you an unbiased opinion on your competitiveness in the EM match.

Look for Elizabeth's next post, the Interview Season, coming soon...

Dropping dead over Application Deadlines

For students applying to EM for the 2015 match (2014-15 Interview season), this is a very stressful time.  September 15 has become a terrifying deadline.  The idea has emerged that your application must be "complete" on September 15th or you will be behind the rest of the applicant pool and end up scrambling.  The blame for this resides on well-meaning advisors, Dean's, blogs, and the pervasive fear of failure that highly motivated people use to keep themselves highly motivated.

Here are the actual deadlines that are set in stone:

• September 15th - ERAS opens and you can upload the portions of the application you have control over
• October 1st - the "Deans Letter" (MSPE) comes out
• February 25th - Rank List deadline for both sides
• March 16th - Yes/No day for applicants and beginning of SOAP
• March 20th - Match Day

You will notice a LARGE gap in there between 10/1 and 2/25.  That is because every single residency program has a different timeline for when they start reviewing applications, offering interviews, and conducting interviews.  There is no hard and fast deadline by which you must have your application "complete" (MSPE and 3 LOR's, plus PS, boards, and ERAS app).

However, there is some consensus among EM program directors (the people who are actually making these decisions):

1. Applicants should have everything within their control uploaded Sept. 15
2. A single EM SLOE is needed for application review and consideration for interview
3. Very few applicants will have more than one EM SLOE uploaded on Sept. 15
4. Most interviews of outside applicants (those who did not complete their clerkship) will be OFFERED in the second half of October and early November

These are NOT absolute rules.  You may know someone who gets 5 interview offers by October 1.  Feel free to hate them, but remember that there are very few of these folks and they are undeserving of your scorn. 

The biggest variable between programs is how many letters need to be submitted before they will review your application.  Some insist on 3 letters before they will review.  Others only care if there is at least 1 EM SLOE.  This becomes an individual judgement call.  That second SLOE that won't be in until mid-October may raise the quality of your application.  But settling for one SLOE and two other letters will have your application in front of more eyes sooner.  This is where you need a local personal advisor, or SAEM e-advisor.  Or you can ask us in the comments.

Get your personal statement written (15 drafts is more than enough).  

Gather all your resume stuff and write brief descriptions of your roles.

Confirm your letter writers.

Choose your programs.

Good luck! 

To SLOE or not to SLOE

This summer as you rock your rotations, get your information uploaded to ERAS, and get your application for EM residency buffed and ready for prime time, one question comes up, are all EM letters better than a combination of SLOE and non-SLOE/EM letters.

SLOE are the Standard Letter of Evaluations, used by EM faculty to compare students to their fellow applicants, and predict their future potential success within an EM residency. These letters were designed by an EM task force, to minimize grade inflation, and focus on the student's characteristics and potential, when compared to their peers. Program faculty like to see two or more SLOE to consider an application complete, and consider for an interview.

Non SLOE letters of recommendation, within EM are usually used  by non-residency EM faculty. They can be useful for community EM faculty to endorse a students attributes toward EM. While not ideal they are still within EM and are read and considered. Non EM letters, tend to be considered less useful, because they frequently do not reflect on the applicants attributes that apply to EM. Many students are intelligent, hard working, and enthusiastic, but not all can translate these attributes into the fast paced, chaotic EM environment.

Council of Residency Directors list serve recently had an active discussion on this topic and program leadership consistently expressed they want to see 2 EM SLOE from program faculty.  All EM letters is generally preferable to non-EM letters. The one instance non EM/SLOE can be helpful is when it comes from a supervisor who has worked with the student closely over time. If a student did  a longitudinal research, public health project, or graduate degree, the mentor of this project's endorsement  is supportive for the application, adds another perspective of the student, and it's absence could be suspicious.

In the end the desire of program leadership is what matters, this is the audience you want to impress. Get SLOEs, as many as you can from different programs, and if you have been involved in a long term project, get your mentor's recommendation as well. Generally non-EM letters are unlikely to aid your application in EM.

So EM is right for you, now you need a plan….

So EM is right for you, now you need a plan….

Step One:
Rotations
You need to do a home and an away rotation in EM as early as possible. Read the link to get all the details about choosing the right rotation.

This will give you exposure, personal advising, and feedback. It is incredibly important to do two things: 1-recognize the feedback you get, 2- demand feedback you haven't gotten in real time.

• You will get feedback on every step, of every encounter - your job is to recognize it. While you present, notice what your supervisor does: glazed eyes = too much information, confused look = add details, fidgeting = speed it up. Every supervisor will want something different and you need to continually adapt to every one that you work with. Start with a formal, organized presentation, and then edit it throughout your shift to fit the non-verbal feedback you are getting. This article gives a great architecture to start with. 
• Next you need to demand feedback. You can ask at the end of your shift, but often you will hear "you did a great job." More effective is a proactive approach. Self reflect and decide what you need to work on, then at the beginning of the shift let your supervisor know what you want to work on today. This lets them focus on the area you need help in and immediately lets them know you are open and eager for feedback and want to improve. This also allows the supervisor to note how you incorporate feedback and feed this into your evaluation. 

Step Two:
Audition

You are auditioning, you need to put your best face forward. You want to present yourself, at your best every day, and in every interaction. You want to be the worry free student, always willing to help, looking to do more, and happy to put in extra effort and time. Don't ask for special treatment, special schedules, or lots of days off. Don't call out unless you are seriously ill. Don't show up late to lectures because you stopped for breakfast.

As Amal Mattu says "be a Tigger": show up with a smile, positive attitude, and energy to spare. Be the person everyone wants to work with, especially the nurses and techs. Always be respectful, professional, and appropriate. EM tends to be a casual atmosphere, but resist the urge to be too casual. It is easy to step over the line when trying to fit in. Realize you are not in the same position as the residents or attendings and err on the side of caution. Be professional at all times. lean forward, look interested and acknowledge areas to improve.


Step Three:
The SLOE

You need to get your letters of recommendation. Your rotation is the basis for your letter, the more you can show the kind of resident you will be, the better your letter will reflect your abilities. The SLOE compares you to your peers. Your goal is to show your positive attributes and that you can grow and improve in 4 weeks. Set a time to meet with the program director and clerkship director, to discuss your interest in their program and get recommendations for your application. Set goals for yourself and meet them.

With these three steps you are well on your way to succeeding in your EM application

The New SLOE is Revealed

The SLOR has been revamped to emphasize its true utility as a letter of evaluation. The new SLOE, retains many of the previous features to define each candidates fit, commitment and abilities in EM, while striving to be both standardized and accurate. 

Departmental SLOEs are often composed by the clerkship director, with input from the program director, and faculty that worked with you. Personal SLOEs can be written by any faculty member with whom you have had extended clinical contact. You should strive to have two departmental SLOEs done by October.  A personal SLOE can act as an additional letter of evaluation.

The SLOE continues to relate the author's credentials, provides a global assessment of each candidate, allows for peer to peer comparison, and for personal written comments about each student. 

The SLOE begins with background information including the type of SLOE, author, length of your and the author’s relationship, nature of your contact, the grade during your rotation, how many EM rotations you’ve completed, and last years grade distribution for the clerkship. In the new SLOE there is an added space to distinguish required and elective rotations. This will allow programs to view the grade scale in context of the rotators, and continue to discourage grade inflation.

The new SLOE also defines the author's relationship to the residency program. Since SLOE's are not solely used by the program administrators, this better defines how closely the author influences and understands the ranking process.

Next the SLOE establishes the students qualifications for EM, in comparison to other applicants. Your commitment to EM, work ethic, differentials and treatment plans are each compared with your peers, and categorized as “Above Peers,” “At level of peers,” and “Below Peers.” In the new SLOE the descriptors of candidates now emphasizes team work, and ability to communicate a caring nature to patients. These two essential characteristics of the EM candidate have replaced the personality questions on the previous SLOR, to shift focus from personality traits to skills.

The predicted amount of guidance each student will need is now defined in comparison to peers.  Students are ranked as needing, “Less than peers,” “The same amount as peers,” or “More than peers.” Given this guidance the author predicts your success as “Outstanding,” “Excellent,” or “Good.” 

Next the Global Assessment of each candidate with ranking compared to other EM candidates recommended in the last academic year, as “Top 10%,” “Top 1/3,” “Middle 1/3,” and “Lower 1/3.” The number of applicants recommended in each category last year, and the number of letters written last year are listed, to allow for both context and comparison. Finally the expected placement of each student on the programs rank list as “Top 10%,” “Top 1/3,” “Middle 1/3,” and “Lower 1/3,”  or “Unlikely to be on our rank list.” 

After each applicant is compared to peers there is a comments section with the emphasis clearly on addressing areas of concern and strength. Detailed information about the rotation itself, the residency program and grading system, are now separated onto the program demographics form easily accessed at the cord website, or it can be attached to each letter. This allows all programs to define their theory and unique approach, without adding bulk to the evaluation itself.

This new streamlined SLOE's name may be quirky but it's aim is true: to create concise accurate and useful evaluations, to maximize students matching at the program best suited to their abilities and needs.