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 If you have spent any time looking around the pages of this site you already know that a lot of the advice is quite outdated.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

So You Want To Rock Your Rotation?

 This post by Dr. Margaret Goodrich is a one stop guide to excelling on your EM Rotation. In this very weird year, impacted by the COVID pandemic, you may only get to do one EM rotation. Make it count.

Professionalism

While some of this may seem redundant to what you’ve been told in the past, sometimes it just needs to be
said again. While your clinical knowledge is part of your evaluation, another major part is HOW you do the job
and your interactions with others. 

Be punctual

The old adage of “if you’re on time, you’re late”. This applies to shifts, conferences, SIM, workshops, meetings… basically everything. Plan for travel time, figuring out where you’re supposed to be, parking, etc.

Dress for success

Thankfully in the ER that means clean scrubs and close-toed shoes. Depending on the rotation, they may have a dress code for conference/didactic sessions. Whatever it is, respect it. It is worth bringing a business casual outfit (or two) and even a suit (some will interview you while you’re there).

Attitude

Come in to work ready to work! This is a job that demands you be “on” the entire shift. Be ready for that.  Show that you are excited to be on your rotation, in the department and working alongside potentially future colleagues. Your attitude will affect those around you. Think about what kind of influence you want to be.

Take Initiative

This shows that you want to be there and want to learn in the ER. Each program is different with how they get you involved in patient care (will have you just sign up and see them, will direct you towards patients), get a sense of this then find ways to be proactive about it. However, even if you know how to do a procedure, DO NOT just start doing it without talking to your resident/attending. Touch base with them, let them know you’re willing to do it and ask how they would like for you to proceed.

Be Inquisitive

This job is ALWAYS changing and there is always something to learn, especially early on. When you’re thinking about a patient’s care, ask “what else?”

• What else should be on my differential?
• What else could be an intervention?
• What else could be part of this work up?

Find something that was interesting on each shift, then go home and learn more about it. A chief complaint,
an intervention, a procedure, etc.

Respect

Be courteous to those you interact with (residents, attendings, program coordinators, nurses, techs,
secretaries, cleaning staff, patients, families… LITERALLY EVERYONE). Believe me, it will be noticed
if you are rude to someone. The value of “please” and “thank you” cannot be understated

Honesty

Be open and honest with your senior resident/attending. If you haven’t done something before, THAT IS FINE! It would be unrealistic to expect that as a medical student you are proficient at many EM skills. That’s the whole point of residency. It is UNACCEPTABLE to lie to your senior/attending about your skill level. If you haven’t done it, just say so. Then demonstrate that you are eager to learn about it (YouTube is great to find a quick video, or check out this website: https://www.emra.org/students/advising-resources/skill-demonstration-videos-and-topics-pertaining-to-em/ ) and be prepared to try!

Effective Communication

This is going to be paramount throughout your career. Now is a great time to continue working on it!

Who’s who?

Make an effort to learn the names of the people you work with. It will take time, but it makes communication
more personal, easier and more direct.

Closed loop communication

Make sure the person you’re talking to actually knows you’re talking to them (using names is really helpful
here), they hear what you want, and verbalize that they understand what you want them to do.

Example: “Joe, please get an EKG on Mr. Smith.” “Ok Doctor, I will get an EKG on Mr. Smith.”

This ensures that the other person is aware an action needs to get done. It also provides them with an opportunity to tell you that it is beyond their scope of practice or that they are not able to perform that now. Which means that you can find someone else to get it done and not wonder why it hasn’t been done after an hour.

This is not only important for general patient care, but imperative for resuscitations/trauma/high acuity
patients when things can become chaotic quickly or the patient requires a number of interventions
simultaneously.

Respect

We already mentioned it, but it’s worth mentioning again.

Feedback

How to make the most out of what your preceptors are telling you!

Blind spots

We all have them. Feedback from your preceptors is a great way to discover areas that you need work on
that you weren’t aware of.  Make note of these somewhere (on your phone, a physical notebook, stone tablet, whatever), then evaluate how you can work on them.

Setting up your shift for feedback

Some preceptors are more conscientious about giving feedback than others. To help you get feedback, decide something specific that you want to work on before your shift. Once you arrive, tell your preceptor what you would like to work on and ask them for feedback on it at the end. This does two things:

1. It makes you be cognizant of a specific goal for the day rather than “get better”
2. It sets up your preceptor to know that you are actively looking for feedback and that they should be keeping in mind your goal for the day. It helps them to give more direct feedback rather than “nice job”

But what if I don’t like the feedback?

Inevitably, you’re going to get feedback you don’t like/rubs you the wrong way at some point. We’ve all
been there. When this happens, our natural response is to get defensive. Take a minute, think about
why you’re getting that feedback. Is there something that you didn’t realize before (blind spot)?
What can you do to fix it?

What do I actually do with the feedback?

Attempt to make an active change. There is no point in getting feedback if you don’t make an adjustment.
If it is in the middle of shift and it’s something that could be done on your next patient encounter, try to
do it then. If it’s the end of shift, consider it as your goal for your next shift or for the topic that you’re going to learn
about before next shift.

During Shift

The art of actually doing things.

Workflow

Starting to develop good habits now can help you as you start residency. Below is a general outline for
ED workflow:

STEP 1: Pick up a patient. This will vary by institution. Touch base with the senior resident/attending to see if there is anyone to see and ask them how they would like for you to see new patients throughout the day. Wait for them to tell you? Pick up new patients on the board? Ask them each time a new patient is available?

STEP 2: QUICK chart evaluation, review documented vital signs (if available). Do NOT wait 15 minutes to go see the patient. If you’re picking them up you should be ready to see them shortly.

STEP 3: Actually see the patient, do your HPI and exam. *IF AT ANY POINT you have concerns about vital signs, mental status, a specific exam finding that would require EMERGENT attention, quickly excuse yourself from the room and find your preceptor.* You will not be faulted for grabbing preceptors sooner rather than later if you’re concerned about the patient.

STEP 4: Develop your differential and management plan. There are a number of different mnemonics but one that I like is SPIT:

• Serious - all the big bad terrible things that as an ER doc you need to at least consider
• Probable - while you have to consider all the terrible things, what do you actually think is going on
• Interesting - what’s the zebra diagnosis to consider?
• Testing/treatment - what labs, imaging, medications, fluids, etc would you want to help you evaluate and treat the patient?

Your preceptors will usually want the serious differential items FIRST, but also include the other items on your differential as well.  Know that your management plans are not going to be perfect. That’s part of learning. You will learn more by developing a plan and presenting it then discussing with your preceptor why they agree or disagree. If you simply wait for them to develop the plan for you, you won’t learn as much.

STEP 5: Follow up on testing. It’s always great if you know the results before the preceptor. Think about what the results mean (even if they are normal/reassuring), and what the next steps would be.

STEP 6: Reassess the patient. If the patient has received an intervention, how are they doing after that? Is there something else you want to do as an additional intervention?

STEP 7: Determine what you think the disposition is. This is helpful to think about after your first encounter with the patient because it helps you to get a sense of where the visit is headed. Obviously things change, but it will help to try and get a sense of: sick or not sick? Going home or getting admitted? Is there a safety reason why they shouldn't be discharged (like social work or case management needs)?

Procedures

There will likely be some opportunity to do procedures during your rotation. Again, this will depend on the institution and your preceptors. Be eager and willing, but as stated above DO NOT LIE ABOUT YOUR ABILITIES/EXPERIENCE. If you haven’t done it before, inform your preceptor, preferably not in front of the patient.

Find a resource to help you learn how to do procedures that you haven’t done before, like this website: https://www.emra.org/students/advising-resources/skill-demonstration-videos-and-topics-pertaining-to-em/

Know the indications, contraindications and technique of the procedure. Ask for help if you need it.

Notes

This is incredibly institution dependent. Some will allow you to write notes, others will not. If you are allowed to write notes, certainly do your best with it. You should get more instruction from the institution on what your specific duties are

Daily goal

Determine what you want to work on for the day. It’s more helpful if it’s specific, rather than “get better”. Inform your preceptor of what you’re working on for the day.

Presentations

This is something you will be doing throughout the rest of your career (think about admitting patients,
consultants, etc.). In the ER, we do more focused presentations than on other services.
Look at this website: https://www.emra.org/students/advising-resources/patient-presentations/ 

Dr. Margaret Goodrich is a Medical Education Fellow at UMMS-Baystate Department of Emergency Medicine and an expert on excelling as a learner in EM.

Guide to Sub-Internship Success - Be a Rotation Rockstar

[This guest post is a guide to succeeding on EM rotations by Dr. Duncan Grossman, a first year resident at Maimonedes Medical Center in Brooklyn, NY.  Originally created for his fellow EM bound students at the University of New England, the guide has been adapted for all and is a great perspective on how to succeed on EM rotations. 

- Adam]

This guide reviews what to expect on your sub-internships and how you can look like a rockstar. I'll also include a list of resources -- some of which you *must* use, some of which will be up to you.

CHAPTER ONE -- WHAT TO EXPECT

Typically your first day will consist of some sort of orientation. You'll meet your clerkship director and other rotators, do some paperwork, maybe meet a resident or two. You'll get a tour of the ED and they'll set some sort of outline about what to expect for your four weeks. They'll mention SLOEs this day too, probably -- since you're rotating during prime SLOE months, they kind of already know you want one.

You'll work a variety of shifts. These may include nights, fast-track, shifts on the ambulance, or any combination.

Remember, you're at a residency program, so there are weekly lectures for the residents that you'll attend. In addition, you may have specific med-student lectures. During these they may do skills labs (central lines, splinting, lumbar punctures), SIM labs, and they may have you do a presentation. Don't stress about presentations -- no one is looking to eviscerate you, just to see that you put some effort in and learned something.

Some places have a test on the last day. Some don't.

Most places will offer you a guaranteed interview at the end. Some will not.

CHAPTER TWO -- ON SHIFT

Consider listening to a podcast or quickly reviewing a topic on your way in, just to get in the mindset.

The hardest part of these rotations (in my opinion) is that you'll likely be paired up with a new attending for every shift. That means you need to establish rapport and trust at the beginning every single time. Don't get lazy with your appearance or enthusiasm -- remember, you are always auditioning.

At the beginning of the shift, introduce yourself to the attending, residents, and even to some of the nurses & techs (these people can be a gold mine of knowledge and may grab you for cool stuff). You might say something like, "Hey there, I know you're busy, but I just wanted to introduce myself: my name is Duncan and I'm your med student for today for the 7a-7p shift." 

(Pro-tip: I try to say the hours of my shift at the beginning because sometimes your attending will be working different hours, so instead of awkwardly saying no when they ask you to see a patient at 6:59pm, you set the expectation.)

If it's not crazy busy, I always try to ask, "What are your expectations of me for this shift?" This does three things. 1 -- It shows you are enthusiastic and you care. 2 -- It sets what you should be doing. 3 -- It allows your attending/resident to realize what they want out of you, so you're all on the same page.

See patients (obvs). There's a fine line between being proactive and being annoying, so ask if there's anyone to see and if your preceptor says not yet, then just chill out. Read, go walk someone to x-ray, familiarize yourself with the equipment carts -- always be doing something, even if it's small. Some places will steer you toward patients, some will tell you to sign up for them... It just depends.

Seeing patients is the fun part -- we'll address some pearls later in the email.

Once you've seen them, you need to present. We'll cover *how* to present later, but when you're ready, you should say, "Dr. Johnson, I saw the patient in room 3 and I'm ready to present whenever you're free." Sometimes you'll present immediately. Sometimes an hour later. Sometimes you'll never present it. That's just the ED for you.

Volunteer to do procedures (suturing, IVs, splinting) for all the patients, but especially your own.

**Fun Tip** I scribbled down super interesting patients and little knowledge nuggets in the back of my notebook and kept a running list through the whole rotation. It may be as simple as "Lovers Fx = b/l calcaneal fx" or a chief complaint like "central retinal artery occlusion." It could also be something for you to look up later, like, "Pics of ultrasound fetal pole."

CHAPTER THREE -- END OF SHIFT

You'll likely turn in an evaluation sheet to your preceptor at the end of your shift. (Consider doing it 30min before the end so you're not giving it to them while they're running out the door.) They know they have to do it, so you don't have to make a huge production out of it. A simple, "Dr. Johnson, can I leave my evaluation at your computer?" will suffice.

But you're NOT DONE THERE -- this is your time to shine, peeps. This is when you ask, "What can I do to be better on my next shift? What can I improve on?" This is gold on your evaluation. Be humble, don't be defensive about critical feedback, and thank them sincerely. Then thank everyone around you.

Pat yourself on the back, take a breath, and chill out.

__________________________________

__________________________________

RESOURCES

Just like studying for boards and school, when looking at this insane list of resources, find what works for you.

With that said, there are a couple of mandatory (in my opinion) resources that you need to have under your belt. I listed those under "Mandatory." Then just pick a couple from the other lists.

MANDATORY:

1) Patient Presentations -- Document

http://emergency.med.ufl.edu/files/2013/02/The-3-Minute-Emergency-Medicine-Medical.pdf 

2) Patient Presentations -- Video

https://www.emra.org/emresident/article/making-the-most-of-patient-presentations/ 

3) Clinical rules -- App (Download onto your phone!)

https://www.mdcalc.com/ 

4) Chief complaint driven guide to differentials -- *BEFORE YOU BUY* you may get this for free with an EMRA membership, which you should def get. If it's not free, I'd still recommend buying it -- it's a great resource to start organizing your thoughts with regard to chief complaints.

https://www.amazon.com/Basics-Emergency-Medicine-3rd-Ed/dp/1929854471

PODCASTS:

1) EM Basic Podcast -- 30 min episodes -- Super dry but really covers the nuts and bolts of stuff you need to know for routine emergency medicine. Listen to him on 2x speed. He also has "show notes" which are a GOLD MINE of information, and I'm actually making flashcards out of them before internship.

http://embasic.org/ 

2) EM Clerkship Podcast -- 6 min episodes -- Really short but awesome overviews of chief complaints, ddx's, procedures, etc. Good to cover a lot of info in a little time.

http://emclerkship.com/

3) EM:RAP -- Variable time -- I just started listening to this but everyone raves about it. Free with your EMRA membership. Their "C3" lectures will cover Core Clinical Content. All the rest is gravy. They have their own app.

https://www.emrap.org/

4) EMCrit -- 30-60min -- So these are pretty advanced and honestly, I don't think they're going to be particularly high-yield for your rotations. But I have friends who love it.

https://emcrit.org/

5) The Emergency Medical Minute -- 5min -- This is just a whole bunch of recordings of residents lecturing their co-residents on tiny topics. Kind of like the clerkship podcast above but less formal and tackling less core content.

https://emergencymedicalminute.com/

6) Core EM Podcast -- 20min -- Great podcast covering core content. Two hosts.

https://coreem.net/

7) PEM Playbook -- 60min -- Pure gold for pediatric emergency medicine. Listen to this if you have a couple peds EM shifts thrown in or if you're doing a PEM rotation.

http://pemplaybook.org/

BOOKS:

1) Tintinalli's Manual -- Small version of the biggest name in EM textbooks. Carried this with me in my backpack and would bring it to shift, looking up diagnoses and treatments of patients I had. Highly recommend.

https://www.amazon.com/Tintinallis-Emergency-Medicine-Manual-Eighth/dp/0071837027/ref=sr_1_1?s=books&ie=UTF8&qid=1522592440&sr=1-1&keywords=tintinalli+emergency+medicine+pocket

2) Tintinalli's Just The Facts -- I think it's physically bigger, but more succint?

https://www.amazon.com/Tintinallis-Emergency-Medicine-Facts-Third/dp/007174441X/ref=sr_1_3?s=books&ie=UTF8&qid=1522592563&sr=1-3&keywords=tintinalli

3) Rapid Interpretation of EKGs -- If you have NO IDEA where to start with EKGs, make sure you read through this.

https://www.amazon.com/Rapid-Interpretation-EKGs-Sixth-Dubin/dp/0912912065/ref=sr_1_1?s=books&ie=UTF8&qid=1522592858&sr=1-1&keywords=dubin+ekg

4) ECGs for the Emergency Physician -- A whole book of EKGs to quiz yourself.

https://www.amazon.com/ECGs-Emergency-Physician-Amal-Mattu/dp/0727916548/ref=sr_1_1?s=books&ie=UTF8&qid=1522592807&sr=1-1&keywords=ekg+emergency+medicine

5) Antibiotic Guide -- Should be free with EMRA. Used it a couple times, def not mandatory. They have an app, too.

https://www.amazon.com/EMRA-Antibiotic-Guide-Brian-Levine/dp/1929854455/ref=sr_1_1?s=books&ie=UTF8&qid=1522592924&sr=1-1&keywords=emra+antibiotic+guide+2018

APPS:

1) MD Calc, as listed above. Learn how to use PERC, Canadian Head CT, PECARN, Wells (PE and DVT), San Francisco Syncope.

2) Epocrates for drugs

3) Medscape -- good for drugs and diseases but is occasionally incorrect

4) WikEM -- a wikipedia page specifically for emergency medicine. Really great resource -- you can plug in chief complaints and it'll give you an EM specific wiki page.

5) PalmEM -- recommended to me but I couldn't justify $20 for an app. Looks cool.

VIDEOS: (My favorite, personally!)

1) EM:RAP -- Just found this. Def gonna watch these.

https://www.youtube.com/watch?v=Po7mIrOKPwc

2) EM in 5 -- This is my absolute favorite. Biased because it's done by the clerkship director at my soon-to-be-residency, but I think this is my absolute favorite resource.

https://www.youtube.com/user/aebargren

3) Emergency Medicine Cases -- These guys have a podcast too

https://emergencymedicinecases.com/rapid-reviews-videos/

Good luck out there!

-Duncan

Non-VSAS Rotation Option

This time of year many applicants are frustrated by their lack of progress getting EM Away elective rotations scheduled.  Looking at non-VSAS sites can work really well.  And this service we just heard about might help too.

Robyn Hoelle, the program director from North Florida Regional Medical Center in Gainesville sent this out:
I wanted to make sure that all of you out there who are mentoring students looking for EM rotations knew that many of us have withdrawn from VSAS. We are a part of Clinical Nexus which manages our rotations. There are 60 Hospitals on this system and the students only have to put in one application to be able to apply for rotations in all of the participating hospitals. It is free for the students. 

We don't know much about this resource, but it could be really helpful to those looking for rotations in the Southeast. Please share your experiences using Clinical Nexus in the comments.  

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!

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.