Last Minute Questions for the Emergency Medicine Match

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

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

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

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

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

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

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

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

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

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

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

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

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!

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.

A Fourth Years Perspective: Interviewing for the Osteopath

Elizabeth Karr is a 4th year osteopathic medical student who matched in the 2015 EM Match to an allopathic program.  This post is the third in a series on a 4th years perspective. 
Part 1 was on what a third year students needs to know right now.  
Part 2 addressed applications and interviews.

Here in Part 3 Elizabeth addresses advice specific to osteopathic students navigating the match process.

The big question as an osteopathic student is whether or not to apply to AOA programs as well as ACGME, or to forgo one or the other.  As an osteopathic student, I have classmates that only applied AOA or only ACGME, and others like myself, whom applied to both. I think that you can do either, and then just wait and see how many interviews you end up with.

However, if you are applying to AOA programs there are a few things that should be kept in mind.  AOA programs have an allegiance to osteopathic medicine and other AOA programs.  If you want to get interview offers at DO programs, it is best to do an audition rotation at a DO program, and have a letter of recommendation from them.  AOA programs can write SLOE’s, however, SLOE’s are not required by AOA residency programs like they are for ACGME programs. Therefore, if you are only planning on participating in the AOA match, you could just ask for a general letter of recommendation instead of a SLOE.  

Ideally, an AOA rotation should be as early as possible in fourth year, as the AOA application process opens in June.  Many AOA programs have already filled the majority of their interview spots by the first of September, and it is not likely that you will be offered an interview much after mid-October.  Therefore, it is almost too late to submit your applications to AOA programs at the same time you submit ACGME applications in September.  It is best to have your AOA applications submitted by July, and then, if you would like, submit your ACGME applications in September.  

If you are applying to both the AOA match and the ACGME match, with the intention of doing the ACGME match if you end up with enough interviews, the advice I would give would be to plan out your AOA interviews for as late in the season as possible.  If you are offered an AOA interview and the only time you can interview is in September, then take the opportunity.  However, if you can choose a date in late October or better yet, in November or December, I would recommend doing this.  That way, if you have already been offered a good number of ACGME interviews  before your AOA interview dates approach, you can cancel your AOA interviews and rest assured you should match ACGME. This will save you money for your ACGME interviews; hotels, flights, rental cars, etc. can all add up. It is perfectly acceptable to cancel interviews as long as you give them ample time to fill your interview spot.

As for those who would like to do the ACGME match, there are a few things to think about. The advice I was given was to only apply to programs that were “D.O. friendly” and had graduates from osteopathic medical schools. However, I did apply to a couple of programs that only had one D.O and some that had none at all.  I chose to not count these in the number of programs I needed to apply to in order to get the number of interviews to ensure an ACGME match (which is usually in the 30-40 program range, to get 10 interviews). These were my long-shot programs that I was not expecting to be offered interviews at.  What I found though, was that some of these places did offer me interviews.  One program said they interview D.O.s every year and rank them highly, but never seem to match them.  Another program, who normally matches several D.O.s, had not matched a D.O. the prior year, yet told me that 16 out of 20 of their top applicants were D.O.s. Who knows why this happened.  Maybe it is because we are told that EM is so competitive that we should enter the AOA match, or maybe, the applicants didn’t like these programs as much.  It is a mystery.

All in all, the thing to think about at the end of interview season is what programs you liked the most and how many of each (AOA vs ACGME) programs you interviewed at.  For D.O. students, statistics show that people who interview at, and rank, 7 ACGME programs have an 80% chance of matching, whereas ranking 12 programs moves that up to a 95% chance.  Overall, it comes down to which program you liked best.  If your top program is AOA, then rank it and enter the AOA match.  However, if you have 3 AOA interviews and 7-10 ACGME interviews and your top three programs are ACGME, the odds would be in your favor to enter the ACGME match and forgo the AOA.

A Fourth Years Perspective: Applications and Interviews

Elizabeth Karr is a 4th year medical student in the 2015 EM Match.  This post is the second in a series - a 4th years perspective. Part 1 was on what a third year students needs to know right now. This post tackles the next steps in planning your application year.

Now, what about residency applications, interviews, and traveling? Start looking at programs during the spring/summer of your third year to decide where you want to apply.  Think about what is important to you in a program; the level of trauma, opportunities for fellowship training, experience in sports medicine/pediatrics/critical care/aeromedicine, specific off service rotations, vacation time, work-life balance. Consider whether you are looking for a three-year program or a four-year program; do you want an extra year of experience, and what does that extra year do to add to your learning. Also think about geographic location that you would like to be in, as this is the place you will be living for the next three to four years. Come up with a list of criteria that are important to you and find the programs that fit them.   

I think the biggest part of the application process is making sure you submit your application as soon as possible after the ERAS system opens (mid-September). It doesn’t have to be submitted on the day the application cycle opens, but within the first week is best.  Also, the application doesn’t have to be 100% complete when you submit it: You can always add more SLOE’s or general letters of recommendation,  and you can also add on programs.

After submission, patience becomes a virtue that you will learn, as it won’t be until mid-October or early-November when programs start contacting you regarding interviews.  Of note, many programs utilize an electronic system for scheduling interviews and you need to sign up within an hour of getting the e-mail from a program or the interview spots they offer will already be full. So, if the opportunity is there, check your e-mails regularly. I am not someone to constantly be on my smart phone, but during the fall, my phone was set to fetch my e-mails every 15 minutes during the day.

I do wish someone had suggested I take a month off from rotations to do interviews.  This process takes time, and sometimes you have no choice as to when to schedule an interview.  It is recommended you rank at least ten programs to ensure a match. This means ten residency dinners and ten interview day. That is 20 days right there.  Then if you have a long way to travel, you may need another day to drive or fly. It is time consuming. I personally took two weeks off and then was also able to schedule 2-3 interviews each month during rotations.  Most rotations know you are interviewing and they can be flexible with your schedule and give you two days off.  However, it is not acceptable to miss an entire week of your four week rotation.

When you are accepted to an interview, you should do everything in your power to go to the interview dinner.  It is an opportunity to get to know what the residents are like outside of the program.  They will be your colleagues, but they will also be the people you will be with for the next three to four years.  Most residencies tend to have like minded people, and you need to find the program in which you feel that you fit in.  The dinner is also an opportunity to ask candid questions and learn more about the program.  They are usually casual and last for anywhere from two to four hours. If your travel gets delayed, most of the time it is okay to show up late. If this is the case, try to notify the resident contact that you are still trying to attend.

After an interview, it is a great idea to write down your initial thoughts.  How you felt about the program. How you fit in with the other residents, staff, ect.  What you liked about the program, or what you didn’t like.  The NRMP has a “Prism” app that can be downloaded to your phone to rank different categories and compare programs side-by-side.  It was something that I found very helpful, and all in all aligned with my opinions of the programs. In the end though, it is important to know what your gut feeling is about a place, and how you think you fit in with the program itself and the people in the program.  

After interview season is done, you have a few weeks to think about your rank order list.  Don’t over think it.  There is likely to be 1-3 programs that are at the forefront in your mind.  Followed by several programs in the middle of the list in which all seem equivocal.  Lastly, there is the bottom of the list; the programs that did not impress you, but would be better than not matching into EM at all.  Talk about it with your significant other, family, friends, etc.  Then you have to go with your gut and submit your rank list.  Once it is submitted, you can rest easy and wait until match day!  Also, statistics indicate that 50% of applicants will match to their top choice, and 75% will match to one of their top three choices.  It seems the odds are in our favor, so best of luck.  Lastly, have some easy rotations planned for the end of the year, because after the excitement of interview season, everyone will be ready for a break!

Look for Elizabeth's next post, An Osteopaths Perspective on Interview Season, coming soon...

Stop Second Guessing Yourself

We have covered your rank list in great detail, but with the Rank List certification deadline approaching (February 25 at 9 pm), many of you are starting to second guess your top programs. This is normal. Everybody does this. You hear from friends, advisors, and deans, and they all have different opinions on where you should go. Remember to focus on what YOU want, above all else.

Think about the top 3-4 programs on your list. Picture them in your mind and see which one causes the biggest smile to split across your face. That is your number one. Stop perseverating - that is YOUR number one. 

When deciding the order of the next few programs, continue to follow your heart. The Match is student weighted, so you get preference. The order you rank the programs matters. You want your list to reflect your true desire to train at the program. Put the spreadsheet down, stop talking to everyone, and focus on how you feel overall about each program. Above that, these are the common pitfalls to avoid:

Squirrel - Being distracted by shiny objects 

Many of the superficial attributes of a program are not going to determine if you are satisfied with your experience training there:

Programs with big names in EM, and those your parents recognize are usually tremendous programs, but that only matters if they were a tremendous fit for you. Don’t elevate a program based solely on reputation or how much you anticipate others will be impressed.

Helicopters, aerospace medicine and hyperbarics are cool, but that won’t be where you spend the majority of your time. Choose to elevate a program based on elements that actually make up a large part of your experience training there.

Location is really important for most people. Though being in a location that others think is cool, but you don’t see yourself in, shouldn’t count as an asset. This is not a vacation, you will live there - make sure it is someplace you want to be, more than visit.

Glossing over glaring negatives

There are only a few things in a program that will have an enormous impact on your training experience:

Program Director - If you didn’t click with the PD- think hard before ranking this program highly. This is not a person you can avoid.

Residents - If they weren’t really happy, or you don’t see yourself as a part of their group, this is not the program for you.

Curriculum - ensure the educational approach, the design of the rotations, and the responsibilities on shifts match up with your needs.

Being Flattered by attention

Be careful to not allow a program’s perceived response to you influence your ranking. Many programs purposefully withhold telling students how well they were liked, while others may overestimate where you are on their rank list. This is a time to trust yourself and be wary of being influenced.

In the end you need to trust your gut, rank your programs in the order you want to be there. Keep in mind more than half of you will get your top choice, and 80% will get in your top 3. You have the control. Use it wisely.

For more on making your rank list see these posts from Academic Life in Emergency Medicine's EM match advise: Making Your Rank List and Top 10 Tips When Making Your Rank List, as well as our post on Going with your gut that includes a more detailed explanation of the Match Algorithm in case you do not believe the whole "student weighted" thing.

Lucienne Lutfy-Clayton is a former Clerkship Director and Associate Residency Director. She believes in shaping destiny, and that things work out as they were meant to. "Life is what you make it, so you might as well trust yourself." 

The Trail Ends and The Ranking Begins

Today we had our last interview of the season, and I expect each of you are winding down as well. Congratulations on all you have accomplished and getting it all done. Your well-worn interview suit can go to the cleaners, trash or bonfire. You can start planning that amazing trip you have earmarked for spring. And it is also time to step back and look objectively at the programs you interviewed with.  

Your last major residency application task is your rank list.  You have until  9pm on February 25th to finalize your Rank List.  And if you are anything like me, you are on the third iteration of your complex spreadsheet desperately trying to sort through them all. 

"How to make your Rank List" was one of the first topics we tackled here, and very little has changed about this part of the process. Our Rank List Tips still hold true, and you ultimately should still Go with your gut, in defiance of what your giant spreadsheet is telling you. 

There are some differences between this year and last, however overall competitiveness has not changed significantly. The ratio of available spots to total applicants is the same. Both numbers have been gradually and proportionally increasing for years. This does NOT appear to be what Medical School Dean's have been claiming, as the major change this year is in the number of applications each person has sent out AND in the number of interviews they have done. I do not blame the Dean's for giving this advice, their job is to ensure that all of their students match. They will do what they think is necessary to accomplish that goal.

The difference this year is that there are fewer applicants with a number of programs to rank (8 - 10) who should feel comfortable about matching. Instead, there appears to be an unusually large divide between the "haves" (>10 programs, AKA: the over-interviewers) and the "have nots" (<8 programs to rank). This has introduced added uncertainty into an already stressful situation.  Programs fear that they have interviewed the same candidates as EVERYONE else and won't match enough of them.  Applicants with low numbers of interviews fear that they are only padding the back-end of rank lists at programs that interviewed extra or played it safe in offering interviews. Most of the concern is likely unfounded, given the steady growth in BOTH spots and applicants, though we will not know how this plays out until after the match.  

The advice that follows has held true in past years and is likely to still be relevant:   

1. Rank any program that you would consider to be better than scrambling (SOAPing) to a surgical pre-lim. year or to family medicine. There is effectively no scramble within EM.  If you don't match, your next shot at EM is next year.  
2. Rank programs in the order you like them.  The match algorithm favors the students. You will match to the program you rank highest that gets to your spot on its Rank List.  There is no advantage to you in ranking a more "realistic" program ahead of a "reach".  
3. Once you settle on your #1 program, you need to let them know.  Programs want to be liked, just like everyone else. Just don't tell more than one program they are your #1.  The world of Residency Program Directors is a relatively small one and you don't want to get caught in a lie. 

For more on making your rank list see these posts from Academic Life in Emergency Medicine's EM match advise: Making Your Rank List and Top 10 Tips When Making Your Rank List, as well as our post on Going with your gut that includes a more detailed explanation of the Match Algorithm in case you do not believe the whole "student weighted" thing.

Best of luck!  You are almost there.  

Lucienne Lutfy-Clayton is a Clerkship Director and Associate Residency Director. She believes in this whole "student-weighted match algorithm" business and thinks that you should too.  

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/

As the Trail Begins

As you get ready to go out on the interview trail, you need to know what will allow you to shine to maximize your match. 

Scheduling
Realistically you can only do two interviews each week. If you try to make swings into areas, doing back-to-back interview days, you are going to miss out on getting to know the places you visit. Instead of hopping about the country a la Planes Trains and Automobiles, leave yourself extra time. Plan to get in for your interview at least mid-day, the day before. This will allow you to fully participate in the whole interview experience. This means you need to be judicious in choosing interviews if you have been offered more than 10-12. You simply can’t fit more in and do them justice. 

The Night Before
The evening prior to your interview the program will host a social event, usually a dinner or cocktails with residents, interviewees, and possibly some attendings. This is a great opportunity for you to see how the program is from the resident perspective, and observe the groups interactions. You can get many questions answered from different viewpoints, and this is a great time to see how you fit with each group. On reflection, many applicants find this to be the most useful part of the interview when making their decision about a program. Do not miss it just so you can pack another interview in.  

Look Professional

Avoid checking baggage when you fly to an interview.  It will get lost and you will show up to interview day in jeans. While this happens to a few folks every year, it is easily avoidable by sticking to a carry on.

On interview day, arrive early so that you guarantee not to be late. You should be wearing a well fit suit. Men should wear suits with a tie, and women should wear either a dress, skirt, or pants with a matching jacket. Try your suit on now and have it altered or get another, if it no longer fits you well. While it may seem superficial you never want to loose favor because of perceived lack of preparation. The shabbily dressed student might end up being the ill prepared resident. You have a limited amount of time to make an impression, make it a good one.

Have Questions

At the interview you will want to have a list of questions. Everyone is going to ask what questions you have, if you have none - you look disinterested. Don’t fall into this trap. It is easy to have questions. First, have some basic questions you ask at all programs. These should be what matters to you and what is helping you stratify programs. Next, look at the residency website and come up with 3-5 specific question for each program. If you know ahead of time who you will interview with, look them up and have questions about their interests or role within the program. Everyone, absolutely everyone, enjoys talking about themselves. If you don’t know ahead of time, ask what your interviewer’s role is, then ask some follow ups specific to that role. 

Engage

Keep up your energy and interest level throughout the interview. Lean forward, listen, and smile. Avoid slouching, leaning backward, and swearing at all cost. If you do any of these things you will be perceived to be disinterested, and unprofessional. As interviews go on this will get harder than it sounds. Despite your current fervor, after a few months of interviews you will be tired, bored, and ready for a break. You will begin to show disinterest just from the monotony of it all. This is one of the reasons you should focus on 10-12 interviews at a variety of programs you are interested in. 

If you go on more you will have a quickly diminishing return on your investment of time and money. Your chance of matching with eight programs on your rank list is >90%. Your chance of matching passes 99% with twelve programs on your rank list. More programs will not increase your chance of matching: you already maxed it. Remember, you have more control than you think: more than 50% of you will get your first choice and 80% of you will get within your top three. As you move forward think about both the time, effort, and money going into each interview, and compare this with the likely outcome. If you have 10-12 interviews at places you want, you have no need to do more. 

Cancelling

Canceling interviews with enough time for the program to get another applicant in, is courteous to the program, and generous to your fellow applicant. If you realize that you have enough interviews for your rank list, you can begin canceling those that would go to your bottom. The key is canceling early enough, that the program can get another applicant in for that day. Generally the longer lead time, the better. A few days and even a week is difficult to re-arrange, so ideally cancel more than two weeks ahead of time. If you are worried the programs will be insulted, remember they want to maximize their match list as well. Give them enough notice and there will be no hard feelings. If you are one of the many great candidates that doesn’t have enough interviews, you should consider freeing up January. There will be more cancelations as the interview process continues and you will need flexibility to accept on shorter notice.  

Quantity and Quality

Interviews are your opportunity to try out a variety of programs and see how they will fit you. With a reasonable plan you can schedule, travel, and arrive at 10-12 spots ready to shine, and succeed in the match. Remember to maximize this opportunity by focusing your energy on a selection of interviews, with questions and observations that matter to you and your learning.

Lucienne Lutfy-Clayton is a Clerkship Director and Associate Residency Director, and has had her luggage lost too many times.  

Rank List Run Down

Congratulations on being done with your interviews.  You can take your interview suit to the cleaners, or if you over-interviewed, you may just need to burn it.  You can check your frequent flyer miles to see if you can cover a ticket to somewhere warm.  You may even be able to step back and look objectively at the programs you recently interviewed with.  

Your last major residency application task is now upon you.  You have until February 26th to finalize your Rank List.  And you are likely putting a lot of time, thought, and stress into this decision.  

"How to make your Rank List" was one of the first topics we tackled here, and very little has changed about the whole process.  Our Rank List Tips still hold true, and you ultimately should still Go with your gut, in defiance of what your giant spreadsheet is telling you. 

While there are some differences between this year and last, overall competitiveness has not changed significantly.  The ratio of available spots to total applicants is the same.  Both numbers have been gradually and proportionally increasing for years. This does NOT appear to be what Medical School Dean's have been claiming, as the major change this year is in the number of applications each person has sent out AND in the number of interviews they have done.  I do not blame the Dean's for giving this advice, their job is to ensure that all of their students match.  They will do what they think is necessary to accomplish that goal.

The difference this year is that the "middle class" of applicants has shrunk.  There are fewer applicants with a number of programs to rank (8 - 10) who should feel comfortable about matching.  Instead, there appears to be an unusually large divide between the "haves" (>10 - 12 programs, AKA: the over-interviewers) and the "have nots" (<6 - 8 programs to rank).  This has introduced added uncertainty into an already stressful situation.  Programs fear that they have interviewed the same candidates as EVERYONE else and won't match enough of them.  Applicants with low numbers of interviews fear that they are only padding the back-end of rank lists at programs that interviewed extra or played it safe in offering interviews.  While most of the concern is likely unfounded, given the steady growth in BOTH spots and applicants, we will not know how this plays out until after the match.  

The advice that follows has held true in past years and is likely to still be relevant:   

1. Rank any program that you would consider to be better than scrambling (SOAPing) to a surgical pre-lim. year or to family medicine. There is effectively no scramble within EM.  If you don't match, your next shot at EM is next year.  
2. Rank programs in the order you like them.  The match algorithm favors the students. You will match to the program you rank highest that gets to your spot on its Rank List.  There is no advantage to you in ranking a more "realistic" program ahead of a "reach".  
3. Once you settle on your #1 program, you need to let them know.  Programs want to be liked, just like everyone else.  Just don't tell more than one program they are your #1.  The world of Residency Program Directors is a relatively small one and you don't want to get caught in a lie.

For more on making your rank list see these posts from Academic Life in Emergency Medicine: Making Your Rank List and Top 10 Tips When Making Your Rank List, as well as our post on Going with your gut that includes a more detailed explanation of the Match Algorithm in case you do not believe the whole "student weighted" thing.

Best of luck!  You are almost there.