Assessing Competitiveness - Part 2

In Part 1 we introduced how to assess your own competitiveness.

An even more difficult task is determining competitiveness of the programs you are considering spending your application dollars on.

The most important thing to remember about assessing programs is that "perceived competitiveness" has little to do with how good your training experience is going to be at that program.  "Perceived competitiveness" determines how hard it is to get an interview at the program.  Your experience training at the program is going to be determined by the educators, the clinical environment, your class mates, etc, etc. (as addressed in "Where to Apply").

What follows are some characteristics that may help you predict which programs have a high degree of "perceived competitiveness" = "harder to get an interview."

In descending order:

1.  Is the program in a region that is highly desirable and where there are not many other programs?  For example: many people in their 20's prefer big cities to small ones.  Another example: there are many more programs on the East Coast than on the West Coast, so West is even more sought after. (Last note both the Northeast and West Coast want letters and rotations from their own coast, if you did not rotate in their region this will be a hale mary for you.)

2.  Does the program have "EM-famous" faculty?  Prominent figures in the world of EM, particularly those who would be visible to students (i.e. #FOAMed > past-presidents of ACEP).
Is there a popular blog or, podcast out of this program. Were you dying to hear a lecture by an attending? Is one of the attendings an author of a book you keep handy?

3.  Academic affiliation with a University that sounds impressive?  If your mom would be impressed with the affiliation, that counts.

4.  Age of program?  Older, very well established programs are often more competitive than their newer neighbors, especially if they played prominent roles in the history of EM.

5.  A multitude of fellowships, especially the ACGME approved ones (Toxicology, Pedi EM, EMS, Sports Medicine, Hyperbaric)? More fellows can be a surrogate for more academic stuff going on.

The mistake often made by applicants is to only apply to programs with high degrees of "perceived competitiveness".  If you are an average or below average applicant, you should be applying to programs across the spectrum.  This will ensure that you get enough interviews to not be a sweaty mess on Match Day.


You need to do the math:

The number of interviews you will get is a product of your competitiveness times the perceived competitiveness of the programs you apply to:

Above average candidate X Uber only = some interviews :|

Average candidate X Full Spectrum = Uber interviews :)

Average candidate X Uber only = few interviews :(

Below Average candidate X Uber only = no interviews :((


Lastly remember this is advise so you can maximize your application and interviews. There is nothing wrong with applying to a program you have always dreamed of joining, even if you are not an above average candidate, just realize the interview may not come.

Assessing Competitiveness - Part 1

Step 1 is to figure out how competitive a candidate your are.  Your advisor's should be able to help you sort yourself into one of three "buckets":  the average candidate, the above average candidate, and the below average candidate.

Above average candidates have:

• Honors in everything clinical
• Board scores that are above average (>240)

Above average candidates have little to worry about and should not be reading blog entry's on how to get a residency. Make a list of spots you like and would like to train (15-20).

An average candidate is going to match in EM if they make a reasonable list of programs to apply to.

The average applicant has:

• Board scores that are in the neighborhood of average (~220  >220).
• EM grades and letters that sum up as: going to do well in EM (Honors or High Pass with a supportive letter, & hopefully followed by Honors on the second rotation).
• No red flags.

Goal is a diverse list in different regions of the country (25-40).

If you fall short on any of those criteria you should consider yourself to be a below average candidate and plan appropriately.  This means applying to lots of programs (40-50), not wasting money on the most competitive programs, and having a back-up plan for not matching in EM.

This is additionally complicated if you are an Osteopathic or Foreign Medical Graduate looking to join an Allopathic EM program.  Only some programs (68%) will even consider your application.  The programs open to you have their pick of candidates and they are looking for the cream of the crop.  If your not at least an average candidate AND you are from an Osteopathic or non-U.S. school, your chances are slim and you need a back-up residency plan like IM or Family Medicine.

Fortunately, the receptive programs are easy to find by going to their website.  Look at their "residents" pages and see where their residents came from.  If you see residents who are D.O.'s or are from your country/med school, they will probably give your application a fair review.

Now that you have a sense how competitive you are, you can try to figure out the programs...

Communication Breakdown: Zebras, not Unicorns

In my last post I discussed the role of presentations in determining how a student is perceived by their evaluators.  Today I want to hone in on one particular part of the presentation:  the Differential Diagnosis.

The usual advice given to students on how to construct an "EM appropriate" differential is to go "worst first".  This means that the first diseases you discuss are those most likely to result in morbidity and mortality for the patient.  This is important in the ED as this is the place where all the sickest patients get funneled to.  In most out-patient settings acutely ill patients are a terrifying rarity.  In the ED they are the routine.  If you do not think of a life-threatening diagnosis, your chances of lucking into it are low.  "Worst first" is a safety net for us and our patients.

Every student has probably heard the truism, "When you hear hoof beats, think horses, not zebras."  The problem with this clever turn of phrase is that zebras are real.  If you have ever been to a zoo, or the Serengeti, you have seen them.  Positioned as we are, at the bottom of the medical pathology funnel, the ED is the Serengeti of medicine:  the place where zebras roam.  Or at least the zoo of medicine.

Not all uncommon diseases (zebras) are dangerous.  The uncommon and bad ones, like aortic dissection (~200 times less common than MI) are the ones we must be vigilant against and belong on our differentials when we "hear hoofbeats" (i.e. "chest pain").  Zebras that are not particularly dangerous do not need to appear on your differentials.

There are still diagnoses we should ignore, diseases that do not belong in an ED differential.  These are the ones that are neither common nor dangerous.  These are the ones we will only find in text books.  For EM, the truism should be changed to, "When you hear hoofbeats, do not think of Unicorns".

Once a student is able to reliably think of the dangerous zebras, the life threats, I encourage them to order their list by probability.  When first getting used to EM it is okay for your differential for a 25 year old man with pleuritic, reproducible chest pain and normal vitals to be "AMI, dissection, PE, pneumothorax, and espophageal rupture".  You have included the bad stuff.  But you have not given weight to prevalence of disease or your own clinical impression.  This is not what your supervisors are actually doing.

Instead, once you are reliably thinking of all the bad diagnoses, you can start presenting your differential the way the residents do.  Start with what you think the patient actually has, and why.  And that can be a common and less dangerous diagnosis.  You need to follow that "horse" with the less likely but more concerning differentials (the zebras), why you do not think the patient has them, and how far you want to go in tracking them down.   You can even tack a unicorn on at the end, so long as you do not want to actually pursue that mythical beast.

Happy hunting!

The Secret to Honors- Presentation Presentation Presentation

Now that Dr Kellogg has told why you need great communication, including presentations, here are some hints for how to be a rock star. Giving a superb presentation is a sure fire way to get honors in your EM clerkship. While it may seem each supervisor wants something different, there are some common features wanted by all. If you can master these basic aspects of the presentation and then tailor the finishing touches to your supervisor, you will succeed. 

Make sure to read The 3 Minute EM Presentation. It is a road map for success. 

First you must give an ordered, structured presentation: Don’t jump around or be too casual this is interpreted as lack of interest or knowledge.

Begin with the chief complaint - Set The Stage

“This is a 65yo male with h/o cad presenting with 1 hour of precordial chest pain.”

Follow with the history of present illness - Paint The Picture

Put the pieces you have gathered in the history together but make sure you have a reason for what you say.

Focus on the chief complaint, with the seven cardinal descriptors, followed by pertinent positives and negatives.

“The chest pain began 1 hr ago, while he was mowing the lawn, he describes it as a pressure over his central chest, radiating to the left jaw, associated with nausea, diaphoresis and shortness of breath. It increased with walking and decreased with rest and abated on arrival to the er. He had similar symptoms last year when he underwent catheterization with 2 stents.

He denies radiation to back, paraesthesia, pleuritic pain, change with position, or calf symptoms.”

Next you will review pertinent past medical history, medications, allergies, social history, and review of systems - Fill In The Background

Keep the focus on what relates to the chief complaint, not everything you learned.

“The patient has a history of hypertension, hyperlipidemia, CAD, Cath with stent x2 1 yr ago. He takes metoprolol last dose this morning, Aspirin 81mg last dose this am, and statin. He has NKDA. He does not smoke, drink alcohol or use cocaine, he does not use medications for erectile dysfunction.”

While you may know all about this patient’s h/o appendicitis at age 12 it does not relate to the complaint so leave it out.

Then relay the physical exam -

Again focus on what is important for the chief complaint. 

“vital signs stable, pt appears in no distress conversant, lungs CTAB, CV s1s2 RRR without m/g/h/t/ with full equal distal pulses no JVD, abd soft nd nt bs normoactive, ext no c/c/e symmetric calves”

Now you summarize the patient - Grab Your Audience 

This is your opportunity to pull your supervisor back in and show how you can interpret, assess, and plan. Your supervisor is likely being pulled in 5 different directions, you need to command their attention. 

“In summary this is a 65yo with h/o CAD presenting with exertional chest pain concerning for ACS.”

next move quickly to your differential and plan: Don’t get run over by your supervisor and never get the chance to show what you know and think.

“While ACS seems most likely we must consider dangerous causes of similar presentations including dissection, pulmonary emboli, esophageal rupture, and common mimickers of precordial chest pa in such as gerd, pneumonia, musculoskeletal pain and bronchitis.”

“My plan is to intervene with medication for pain, while supplying 02 as needed, and keep the patient on the cardiac monitor. To investigate his sx I would like an EKG, chest xray and laboratory studies to include cardiac enzymes.”

Remember to address: 

Interventions-what you do for the patient 

Investigations-what you do to investigate the chief complaint and differential

EM presentations are succinct, directed toward the chief complaint, focused on both dangerous and probable causes of the symptoms, and above all convey a clear picture of the patient and context for concern.  Remember to set the stage, paint the picture, fill in the background, and grab your audience. This is skill it takes concentration, practice and fortitude. Listen to the verbal and non-verbal feedback you are getting and tailor your presentation to your audience.

Communication Breakdown: Presentable Presentations

If you want to be a better clinician the most important area to improve your skills is communication.

Really.

Of course you need medical knowledge, but that takes a while to build.  And you need procedural proficiency but that also takes time and opportunities.  And you need to learn to function in different clinical environments, each with it's own set of processes, rules, and traditions.  That also takes time and  you start over with each new place.

But communication.  That is something you already have experience with and does not require a prolonged investment of time.  What it takes is the desire to actually communicate better.  With patients, with staff, with other services, and with your supervisors.

Not coincidentally, communication is also the skill that can most dramatically improve your evaluations during your EM rotations.  We will tackle the other areas of communication later.  Today we are diving into the art of presentations.

A really good, focussed, well organized presentation to your supervisor is the most effective way to convince them of your skills.  You will be evaluated in many areas.  Knowledge base, focussed history taking and exam skills, ability to form a differential, and ability to make a plan all being fairly typical of what your supervisors will be assessing you on.  To know exactly what they are asked to assess you on in writing you a "letter" take a look at the SLOE.

You will sometimes be directly observed to see how well you relate to patients and gather info from them.  However, in most rotations these skills will more often be assessed when you present to your supervisor.  More direct observation would be better, and as we will discuss below, more fair.  The pace of most ED's and a common belief that watching you will change your behavior (The Hawthorne Effect) prevents direct observation from happening more often.

If your presentations are going to be this important to the perception of your abilities then it is critically important that you make them good.  Relay only the pertinent HPI details and exam findings and you will appear able to distill information and focus.  Describe an appropriate DDx, giving weight to life threats and common problems, and they will believe you have a strong and well-organized knowledge base.  Share a plan that includes tests and treatment, and that is practical in the ED setting, and they will believe you understand EM practice.

Let's take two hypothetical students:  Student A and Student B, and put them on a hypothetical rotation together.  Student A is well read, with great board scores, and spends a lot of time with his patients getting their history and explaining their care.  Student A gives long, very detailed presentations, and does not suggest a DDX or plan because he does not feel confident that he knows enough to create a good one.  Student B prefers to learn by doing, has mediocre scores, and moves fast, talks fast, and is all over the department.  Student B gives short, focussed presentations and is willing to throw out a DDx and plan even though they are often wrong and get changed.  Student A may turn out to be the better physician but Student B is usually going to do much better on her ED rotation.  If you empathize with Student A this should seem patently unfair.  And that is because it is unfair.  Most emergency physicians are high energy, decisive, and direct people and they usually value those attributes in others.

This is not to say that the ideal is Student B.  Those who incorporate the best qualities of both Student A and Student B are those most likely to experience long term success.  Student B is just going to have an easier time getting in to EM.

If you believe your presentations need work, a good road map to get you started is The 3 Minute EM Presentation.

Good luck!

The New SLOE is Revealed

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

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

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

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

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

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

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

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

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

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

Communication Breakdown: Get 'em booked

One of the most intimidating tasks for a student in the ED is getting patients admitted.  You want the responsibility.  You want the sense of ownership.  You want to prove that you can be persuasive and get things done.  Successfully booking an admission accomplishes all of these things. I am more impressed with a student who can complete a tough admission than if they can close a complex laceration.  

Conversely, should the admitting conversation not go well, you may feel embarrassed or inadequate.  If your supervisor has to take over, their evaluation of your performance may go down.  

There is no surefire, guaranteed, approach that will sell even the obstructionist medicine resident.  But there are some things you can do to keep your admission call from going down in flames.

Walk a mile in their clogs

Understand the perspective of the person on the other end of the phone.  This may be easier as a student, having recently been on these other services,  than a couple years from now when you are firmly entrenched in the ways of the ED.  

Dig up those detailed IM presentation skills and give them a deluge of data.  Often times they do not want you to tell them what you think is wrong with the patient, they want you to give them the information so that they arrive at the same conclusion you did.  This is, of course, the exact opposite of what we are looking for in the ED - for you to make an assessment and come up with a plan.  

But if you are talking to a surgeon, you need to give them a very specific reason for why the patient should be admitted to them.  Not, “because they have belly pain”, instead, “we believe they have appendicitis”.  

Use the hammer

The hammer is the point that cannot be argued, that no physician behaving in a remotely professional manner can ignore:  “the best interest of the patient”.  This is a powerful tool.  You will encounter many objections from people you have contacted asking them to do work.  You have added to their task list.  They may be thinking in terms of what your request means for their day/night/weekend.  By judiciously using “the best interest of the patient” you can wear down almost anyone.  

In the same vein, you will often encounter pushback on “social admits”.  These are patients who cannot go home, but not for a strictly medical reason.  These patients are very frustrating for in-patient doctors and so they will often work hard to convince you that they do not need to take them in the first place.  But if a patient is unsafe, or can’t walk, or can’t control their pain at home, going back to “the best interest of the patient” is a hard thing to argue effectively.  

Practice makes perfect

If possible, run your admitting presentation by one of your supervisors.  If that is not time practical, at least make sure that the reasons for the admission are clear.  Make sure that you understand why the patient will benefit from being in the hospital.  If you do not know or if you are struggling to put the rationale into words, this is probably not a good admit for you to attempt because you are likely to fail.  

It is important to remember that even if you do everything right, sometimes you will have to call in your supervisor because the person on the other end of the phone is not being reasonable.  This has happened to everyone.  Making your calls within earshot of your supervisor helps them realize when it is not you that is the problem.  

If you want additional tools for getting others in medicine to do what you want, have a listen to an EMRAP Educators Edition podcast with Dr. Chad Kessler on communicating with consultants.  

Good luck!