Navigating the New World of Applying to Emergency Medicine

 If you have spent any time looking around the pages of this site you already know that a lot of the advice is quite outdated. We used to have some hard data on the Emergency Medicine Match, and where we lacked that there was expert consensus opinion from groups like the CORD-EM Advising Students Committee and the Emergency Medicine Residency Associate (EMRA). They even published a book together. There is still a lot of useful advice to found on topics like choosing EM and preparing for rotations. But the actual Match process has been turned upside down in the last few years.  In this post I am going to try to connect you with the best resources we have to help you navigate this new world.  

The CORD ASC-EM MyERAS Guide

This exceptional document takes you through all the changes to the ERAS application and includes balanced recommendations with transparency on where there is controversy or data is lacking. A must read for anyone applying to EM.  

The CORD ASC-EM Resources page

A compilation of various special population advising guides, virtual interview advice, student planners and much more. These guides do get updated annually, though the pace of change in the match has been hard to keep up with. 

EMRA Hangouts

This series of recorded discussions covers the changes to the EM application process for this application cycle. 

EMRA Match

The premiere residency (and clerkship) navigator program. The information is not perfect but the data provided is what previous applicants have asked for.  

ALiEM Match Advice Series

This podcast series is a great place to understand how the match has changed, how program directors look at these events, and to get additional insights on the updated ERAS process. 

Understanding the SLOE

EM has unique Standardized Letters of Evaluation (SLOE) that will be one of the most important parts of your application. This information page from CORD should help you better understand them. 

I hope you find these resources helpful.  

- Adam

Preference Signaling for Emergency Medicine - How to Use Your Program Signal Tokens well

Preference Signaling is Here

One of the biggest challenges for applying to Emergency Medicine residencies is conveying genuine interest. Just applying to a program is not sufficient as many students apply to programs they have no desire to train at. Over-application is a completely rational response to a system where it is difficult to assess personal competitiveness and where the consequences of not getting enough interviews can be not matching in your desired specialty. This still leaves programs attempting to sift the “serious” applicants out of the pool of those who apply. We use surrogate markers like geographic ties, applicant interests and experiences that align with program strengths, or recent experience with applicants from that school.  

In response a common practice developed of applicants also sending an emailed “letter of interest” outside ERAS. This is more work for the students and disliked by many Program Directors, especially when the letter did not add anything not already in the application they just received. If Program Director’s assume that applicants send these letters to all of the programs they applied to, they have no meaning.  

Enter the idea of “preference signaling” by applicants to programs. The applicant does not have to write an additional letter and the program knows this signal has value as each applicant is limited to 5. How this came to be is covered really well in the Council of Residency Directors in Emergency Medicine (CORD-EM) Preference/Program Signaling Supplemental Guide. What I want to discuss here is how to approach using your 5 precious signals. 

The goal is to positively influence Program Directors at places you have genuine interest and  who would not have offered you an interview if there was no signal. Right now we don’t know for sure how programs will respond to a signal, but we can make some educated assumptions. Based on surveys, discussion forums, and data from other specialties, it is likely that a signal will make most programs more likely to interview you. However, the big exception will be among programs who receive an overwhelming number of signals. They will either make a signal a requirement for them to consider an application or ignore the signals entirely. This choice will depend on their assumptions around how applicants will use the signals. 

Let's Talk Strategy

So how should you strategize using your signals? Here are a few general “rules” that apply to most applicants:

1. Use your signals on program you are genuinely interested in 

2. Don’t signal programs you are rotating at unless they explicitly tell you that you need to

3. Signals are best used on programs where you might get an interview, but are not definitely getting one

1. Don’t waste them on programs where the signal is unlikely to convince them to interview you

2. Don’t waste them on programs that are highly likely to interview you anyway

4. Use your signals on program you are genuinely interested in 

1. This is in here twice because there is real potential to over-game this system - don’t lose sight of the goal is to go somewhere you want

Even following those rules you can still come up with very different strategies for how to use your signals. Your training and career goals, self-assessment of your competitiveness as an applicant (aided by an experienced advisor) and your risk tolerance should all factor into your personal strategy.

Here are some examples that are a little more concrete: 

Maximum Value - For the applicant worried about their competitiveness for interviews. Use your signals on programs you are interested in BUT that you expect to NOT get a lot of signals (less popular locations, less well-known, newer, or other evidence of being a less competitive program). The less signals a program gets the greater value each signal has. 

Shooting for the Stars - For the applicant who is above average on paper and in the eyes of an experienced EM advisor. Use your signals on programs that are likely to get lots of signals. You will get many other interviews regardless and it may be necessary to signal the more “popular” programs to have a chance at an interview. 

Balanced - For most applicants who don’t want to overthink this. Use three signals on programs that you are genuinely interested in and that are realistic for you (nothing about the program is telling you that this should be a hard interview to get). Use one signal on a program you are really interested in but where you suspect you don’t have a realistic chance at an interview. Use one on an acceptable program you expect to not get a lot of signals. 

There is no evidence on what a “winning” strategy is for using Preference Signaling this year. If you have other ideas on how to approach this, put them in the comments below and we can talk them out.  

Most important take home:  Use your signals, and use them at places you are interested in. 

Adam Kellogg has not done a very good job keeping this site updated during the pandemic. That has been fixed now with most of the Advising “pages” updated for 2022. 

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.

New Program outside Philadelphia and in the 2021 Match!

There is another new Emergency Medicine residency program that has been approved to recruit for this 2021 match.  The Pottstown/Phoenixville EM Residency in suburban Philadelphia will be in ERAS soon.  The Program Director, Ernest Leber, would like to hear from interested students through the email at the end of the message below:

I have been approved for a new EM program with Tower Health at Pottstown and Phoenixville Hospitals. Our program will  be a 3-year community EM program here in suburban Philly. We will have rotations at Pottstown, Phoenixville and Reading Hospitals. We have an excellent and enthusiastic group of physicians ready to train residents/learners.

We are recruiting for a July 2021 start. The process of getting listed in ERAS takes time but should be completed within the next couple of days which does not leave us much time for students to forward us their app and for us to interview. Please pass my email address on to any students you think may be interested in my program. They can email me directly to set up an interview before we get listed on ERAS.

Ernest.Leber@towerhealth.org

Thanks everyone
~Ernie

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.

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.

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!

SVI Update - What do these scores mean?!?

This is just a quick post regarding the Standardized Video Interview (SVI) that all students applying to EM were required to participate in.  In June I wrote about the SVI to give applicants some perspective on how the EM Program Directors saw this project.  

With the release of SVI scores to the applicants a discussion has sprung up among the Program Directors about its utility this year and in the future.  This started with concerns over poor correlation between the impression an advisor had of an applicant and the score they received.

From this discussion the general consensus is that Program Directors are NOT using the SVI score to make significant decisions.  They are evaluating how well it correlates with their impressions of their advisees, and later, of the applicants they interview.  

This should be reassuring to all those worried that the SVI has thrown a monkey-wrench into their application plans.  

Programs get your applications tomorrow.  Submit everything that is in your control (PS, ERAS application, board score release) and assign letters to your programs.  Then do your best to have a great weekend.  You have worked hard, take a couple days off (if you can).  
Adam Kellogg is an Associate Residency Director, former Clerkship Director, past-Chair of the CORD Student Advising Task Force, and incredibly grateful he didn't have to submit a video of himself answering "interview questions" to all the EM programs he applied to.  And not just because that would have used up a lot of VHS tapes.  

Rank List Resources

For students in the 2017 ACGME match your certified Rank List is due at 9 am on February 22.  There are lots of great resources to help you figure out how to put this together.  In this post we are going to connect you with a couple of those:

The EM Advisor comprehensive guide to creating your “perfect” Rank List.  This was updated last year by Tony Zhang, an Emergency Medicine Resident and member of the CORD Student Advising Task Force. Written by someone who recently went through this process and with recommendations supported by data and expert opinion of a group committed to increasing transparency in the match process and the quality of advising. A version of this guide is part of the CORD SATF Applying Guide to Emergency Medicine.

EMRA just published something with a similar goal: Creating the Perfect Rank Order List: Real Advice from Current EM Residents.  They used a different format to develop their recommendations, sending a survey to residents training in Emergency Medicine and drawing themes from those responses.  They do a nice job showing the variety of different viewpoints and approaches that can be taken in creating a Rank List. Definitely worth a read.

Creating your Rank List is your final anxiety-inducing task of your year long application process.  Once you get this done you can sit back and relax.

Best of luck!

Happy New Year!... and on to the 2018 Match...

The 2017 Match is just a couple months away.  This post is for those planning to apply for Emergency Medicine in the 2018 Match. 

Like everything else in EM, advanced planning is the key to success in the Match. This post is the updated guide to the resources on this blog.

Throughout the year various authors contribute "Posts" that appear in reverse chronological order on the landing page.  Standard blog set-up.  

Down the right hand side of the web-page you will find a "Featured Post", a topic that we want to keep at the top even as other posts come up.  

Below that is a collection of static "Pages". These cover a variety of topics pertinent to the different stages of your application and contain general advice.  These are updated periodically to reflect changes in the Application and Match process. 
The most frequently viewed are:

• Applying - Letters of Recommendation
• EM Rotations - Where, When, and How?
• Applying- the Boards

Below the "Pages" are the collection of "Labels" - all the Posts on the site sorted by topic.  The most useful are linked across the top of the web-page, just below the header. These can help you find more on a specific topic.

**********

The advice you find on this blog is not one-size-fits-all. We try to reflect the consensus opinions of the membership of Clerkship Directors in Emergency Medicine (CDEM) and the Council of Residency Directors (CORD), but we do not speak for them. Nor does their membership always agree. When something is controversial, we try to address that controversy. We believe we are a source of sound, balanced, and accurate advice on becoming an emergency physician in the United States. We also have no doubt that you will find different opinions elsewhere. 

To help you sort through all of the differing opinions you may find, you need the guidance of a local EM advisor, in addition to your Dean. You need someone who knows the EM application process and can help you navigate issues specific to students from your school and region. If you cannot find anyone, or you need advice from a different region you can find help from residents who just went through this process provided by the EMRA mentorship program. 

Adam Kellogg is an Associate Residency Director and a previous Emergency Medicine Clerkship Director.  He is the past-chair of the CORD EM Student Advising Task Force and a member of the SAEM Resident and Student Advisory Committee. He has written for EM Resident about Diagnosing the Match. 

Application Overload

The Emergency Medicine match feels more competitive than ever before.  This perception is NOT supported by the best available data from the NRMP.  

The Numbers

There has been a steady increase in the number of applicants to EM each year, mostly driven by an increase in the number of allopathic graduating seniors (see Table 1 below). The number of "non-traditional applicants" (including osteopathic and international graduates) has actually leveled off.  

At the same time, opportunities to train in EM have increased. The number of PG1 positions available in the EM match has steadily gone up (blue line in Table 1).  This increase comes from both new programs opening and class expansion in existing EM programs. The result is that the ratio of available training spots to the number of applicants has not significantly changed. The ratio of available spots to those who want them is the same.  

Table 1 - Proportional increase in both number of applicants and number of training positions in Emergency Medicine.

What has changed is the number of programs that each student applies to (see Table 2).  For many years the average number was approximately 25 programs applied to per student.  Starting in 2010 there has been a dramatic increase from year to year in the number of programs applied to by each applicant. The trend is similar among "non-traditional" applicants.  

Table 2 - Increase in programs applied to per allopathic applicant in the match.  

The Consequences

Each residency program is receiving dramatically more applications. This has made the competition greater for their interview offers. Not for the actual interviews, because the relative number of applicants has not changed - just for the interview offer.

Programs have had to change how they review applications and choose who to offer interviews to. Faculty time is a finite resource at most programs. There may not have been more time available to dedicate to in-depth application review. Furthermore, the time period to review applications was compressed in 2013 when the MSPE release date moved up to October 1st.

Programs had little choice but to become more efficient at reviewing applicants. Options include only reviewing parts of the application, those portions felt to be more objective or higher yield (the SLOE's). Another option is to make greater use of the filters ERAS provides, such as setting a cut-off for step 1 scores.  Additionally, programs can give more attention to applicants from schools or regions that have been high yield in the past.  

With this increase in efficiency comes a loss of variability in applicant review. The same group of applicants will appear strong to most programs. These applicants will then receive the majority of the interview offers. This fortunate group of applicants will need to reject interview offers before they "trickle down" to the rest of the pool.

Some of the fortunate will choose to do more than the 12 interviews they need to be >95% assured of matching. Even so, most programs have responded to the overload of applications by interviewing greater numbers of applicants in the hopes of not missing anyone they want to meet.

In Summary

1. The perception that EM is getting more competitive is not real
2. There is greater competition for early interview offers
3. Interview offers are concentrated in a fortunate few
4. Interview opportunities will "trickle down" to most applicants
5. For advice on how to get those interviews check out the FAQ section on this post on Acing the Interview

Adam Kellogg is an Associate Residency Director and a former Clerkship Director. He is a past Chair of the CORD Student Advising Task Force, whose mission is to improve the quality of the advising students receive who are applying to Emergency Medicine.

Applying Wisely - EM Match 2017

This is an update of a post from last year. This is a long one with many links to other materials.  The goal was to make a one stop guide to submitting your application by September 15th.

Application season is about to begin in full force for students applying for allopathic (ACGME) residencies in Emergency Medicine (EM).  As an advisor the most common question I am hearing is “How many programs should I apply to?”.  This is a great question.  This is a timely question (you have been able to submit applications since early September and programs will see them on September 15th).  This also may be the wrong question to be asking.  

In this post I am going to recommend that you approach choosing which programs to apply to with the goal of making a high quality, high yield application list specific to you.  This is an alternative to the “shotgun” approach that you may be hearing recommended - “apply to 50 or more programs”.  

The Goal

You need to get enough interviews.  The magic number of interviews completed to assure matching is 10-12 (95-99% chance of matching in EM).  And because the match is student weighted the majority of applicants get into one of their top 3 programs with many getting their #1.  If you have 10 - 12 interviews you are going to match (unless you bomb all of them).  For a much deeper dive into match data and what it means, take a look at this article from EM Resident: Diagnosing the Match.  You can also have a look at the data from NRMP for yourself.

So why not just apply to 50 or more programs when ERAS makes it so easy?  This is your future, what is a few more hundreds of dollars?  The problem is that even if you shotgun out 50 applications you may still not get 10-12 interviews if you choose those programs poorly.  So even if you are determined to go "shock and awe" with your applications, you are still going to need to be smart about which programs to apply to.  

Applying Wisely

In order to build a quality list of programs to apply to, you need to answer these four question for yourself:

1. Where you need to be?  
2. How do you want to train?
3. How competitive are the programs you are looking at?
4. How competitive are you?

Location, Location, Location

There are ~170 allopathic EM programs.  Applying to all of them is crazy (and not effective).  Most applicants have a regional preference (ie - northeast, west coast, Texas, etc).  Others have a type of area they want/need to live in (ie -urban with public transport, or rural so they can raise chickens, or suburban with access to a large enough city to support an EM program).  You should choose an area, or type of area, that interests you and let that narrow your focus.  Within these areas will be a variety of programs that are likely to be looking for different things in their applicants and to have different levels of competitiveness.  That variety will be really important in keeping your application balanced.   

Program Characteristics

Every program in EM is held to rigorous standards by the ACGME and RRC to ensure you emerge as a competent Emergency Physician (EP).  How they get you there can be quite variable.  These characteristics can help you sort the programs and to start determining which ones are going to be a better fit for how you want to train.  

Some common examples of easy to determine characteristics are how many years the training is (3 years vs. 4 years), the types of off-service rotations they do, the patient population, the sites they rotate at, the structure of their didactics, the fellowships available, their research emphasis, etc.  For a little more depth on these consideration have a look at this page:  Choosing where to Apply.  

To actually figure out where to apply: look at the EMRA Match Residency Index.

You should use these characteristics to help you pre-screen programs.  However, your eventual decision on how to rank them will be strongly influenced by factors that are hard to assess from reviewing a programs web site:  their culture of wellness, their education and adult learner philosophy, the residents happiness and satisfaction, and whether you feel like you would fit in.  This is why we still do interviews.  

Program Competitiveness

In the last couple years some private companies have attempted to help students applying to EM rank the EM Residency Programs.  Lacking access to actual program data they relied upon alumni rankings of the programs.  I have no idea if this actually resulted in a list of which programs provide the best training (though I have my doubts).  I am certain that their lists did not address the most meaningful measure of program competitiveness from the standpoint of the applicant:  How many people applied to the program?  That is not publicly available information.  

You can estimate which programs get the most applications, as we outline in this post we did on Assessing PROGRAM Cometitiveness.  

To sum up, the more of these characteristics a program meets, the more applications they are likely to receive:

1. Is the program in a highly desirable place to live?
2. Does the program have “name brand” recognition that would look impressive on your CV?
3. Is the program “EM famous” for their faculty or their longevity within the specialty?

The programs that receive the most applications can fill all their interview slots with above average applicants.  So how do you know if you are above average?

Your Competitiveness

While determining program competitiveness is an inexact science (to put it charitably), assessing your own competitiveness is somewhat easier to do.  This is a guide to Assessing YOUR Competitiveness that we previously wrote.  

To sum up - the applicant field breaks up into three broad categories:

1. Above average and have it made
2. Average and will match
3. Below average and at risk

Where you fall is based mostly on your board scores and the EM rotation grades and SLOE’s that came from those rotations.  These are the characteristics that all programs will give some weight to.  The other characteristics of your application (clinical grades, work and service experiences, scholarship and research) can all have an impact on how programs rate your application and whether they offer you an interview.  This will not be consistent from program to program, or reviewer to reviewer.  Thus you need to get your application in front of a variety of reviewers at realistic programs.  

Summary

To sanely navigate the match process: gauge your competitiveness and build a list of programs to apply to that has a foundation of realistic programs, with appealing characteristics, that are in areas that work for you and your family.  You can apply outside of this group, because you never know what might catch a reviewers eye, but you cannot consider those applications to be a realistic part of your foundation.

If you are an above average candidate you have the option to be a "sniper".  Choose 20-25 programs that highly interest you and get all the interviews you need.  

If you are an average candidate, you are going to match.  Choose 20-25 programs that appear realistic and add another 10 or so that may be a stretch.

If you are at risk, or in an applicant group that many programs will not seriously consider (Osteopathic students, those training Internationally), you should apply to ~40 realistic programs.  Any program that does not seem realistic does not count towards your 40.  

For more detailed perspective for Osteopathic applicants have a look at this page of Advice for Osteopaths.  International Applicants should read this post by Max Hockstein, MD.

You need a real advisor

You also need to get some personalized advice.  These recommendations are a good place to start but are too generic to use as your sole source of advice.  EMRA has a great mentorship service you should use.  Feel free to contact us with specific questions in the comments or via email.  EMRA also maintains a page of other resources for medical students that can connect you with more opinions and advice.

Good luck and get those applications in!

Adam Kellogg is an Associate Residency Director and a former Clerkship Director. He is a past Chair of the CORD Student Advising Task Force, whose mission is to improve the quality of the advising students receive who are applying to Emergency Medicine.