SAEM 2014 for students and residents

The Society for Academic Emergency Medicine (SAEM) is holding their Annual Meeting in Dallas May 13 - 17th. SAEM has a reputation for being all about research, though it is more fair to describe the organization as being all about academics. Their Annual Meeting has a ton to offer the student considering a career in Emergency Medicine (and the resident thinking of staying in academics.  

From a student perspective, the big draw is the Medical Student Symposium and the Residency Fair that follows:

"May 16^th is the highlight for medical students at the SAEM Medical Student Symposium tailored for medical students applying to EM.  Panel discussions with current EM residents, roundtable discussions, and lunch with EM program directors will prepare EM bound students to understand the application and selection process."  

And here is the stated objective for the symposium:

Objectives:  The Medical Student Symposium is primarily tailored to medical students who have identified emergency medicine as their future specialty, but is also valuable for students still contemplating specialty choice.  The symposium includes presentations from seasoned EM educators, roundtable discussions geared for more individuated guidance, lunch with residency program directors, and a panel discussion with current EM residents.  Major themes for the symposium include the application and selection process. The program will be followed by the SAEM Residency and Fellowship Fair, providing students and residents with access to representatives from most EM programs across the country. 

At the completion of the session, participants should be able to:       
1. Assess their personal and career goals that might make EM a good fit.
2. Identify the multitude of career paths that exist within EM.
3. Optimize their fourth-year schedule.
4. Identify key factors and variables in selecting potential training programs.
5. Assemble a strong and compelling application package.
6. Perform their best during interviews.    

But wait, there is more. The SAEM Resident and Student Advisory Committee (RSAC), of which I am a member, has two events developed specifically for Emergency Medicine residents and medical students to provide opportunities to learn, network, and share ideas.  

1.  The RSAC sponsored Abstract Scavenger Hunt on May 14-16^th will allow teams of medical students and residents to seek out abstracts in the SAEM Program Committee Gallery of Excellence.  The mission is designed for participants to answer questions using QR codes with their own smart phones.  The team answering the most abstract questions correctly will win prizes including free registration to the 2015 SAEM Annual Meeting and gift cards to Starbucks and Amazon.  

2.  The Resident & Medical Student Reception will be held on Friday, May 16^th from 5:30-7:30 following the Residency and Fellowship Fair.  This event for medical students and residents is a great place to network with colleagues from across the country while mingling with leaders from SAEM committees and taskforces as they highlight opportunities for medical students and residents to become involved in Emergency Medicine at a national level early in your career.  (Including Ultrasound, Simulation, Women in EM, International EM, Social Media, Membership, Program, Ethics, and more) This reception, only for medical students and residents, is sponsored by ECI who will provide free drink tickets at their booth in the exhibitor hall. 

Both events are free and open to any resident or student attending the meeting. 

If you can make it to Dallas, I promise it will be worth the trip.  

How to use this blog...

EM Advisor is a blog whose purpose is to collect resources and advice that are valuable to medical students interested in pursuing a career in Emergency Medicine.

The blog has a simple construction:

Pages
These are static resources intended to guide you through the process of choosing and matching in EM.  These are periodically updated with the best advice we can find.  Examples of topics covered are: Is EM right for me?, Preparation and Expectations for EM Rotations, and a whole series on the application process covering everything from "Where to apply" to "what are Red Flags".

Posts
These appear periodically on the main page and are intended to be a catch-all of information for students considering Emergency Medicine.  Some are advice posts: How competitive is your application?, How to give good presentations, How to get procedures.  Others are recommendations of learning resources found in the world of Free Open Access Medical Education (FOAMed): the Flipped EM Classroom, EM Basic podcast, Academic Life in Emergency Medicine blog, to name just a few. The application process in EM is a cycle, so some posts provide timely (hopefully) updates and reminders on topics like Interviews, Rank Lists, and the dreaded what to do if you don't match.

The advice and suggestions found in this blog are by no means definitive. What is presented here are the opinions of a small number of EM educators.  However, we do attempt to represent the commonly held opinions and consensus recommendations from the members of organizations like the EM Council of Residency Directors (CORD) and Clerkship Director's in Emergency Medicine (CDEM).  

R.E.B.E.L. EM and the Importance of Airway

In this brave new world of FOAMed one of the big challenges is vetting which sources of information are worth following. The work of Salim Rezaie (@SRRezaie) on his R.E.B.E.L. EM blog, should be a a must read for anyone trying to keep up in EM. He is a prolific contributor to #FOAMed with recent posts exploring the need for an insulin bolus in DKA and what actually matters in post-LP headaches.  But the one that prompted this long over-do "shout out" was a review of preoxygenation and apneic oxygenation that you should go read right now.

Your communication skills are probably those most critical to your overall success in medicine, but you can argue that airway skills come in a close second. If you train at an ACGME-approved residency program in the U.S. you will be required to perform 35 intubations to meet requirements.  Ask any Emergency Physician and they will tell you that 35 is just the beginning. Real competence likely happens somewhere around "triple digits". 

You have to start somewhere, and early in the development of your airway skills you are going to need some extra time to figure out where you are and what you are looking at.  These techniques for maintaining excessive oxygenation during the peri-intubation period are good for the patient and great for your chances of completing the intubation. The FOAMed world is full of wonderful Airway resources, and R.E.B.E.L. EM is a good place to start.  

Also see this primer on intubation from The Short Coat by Lauren Westafer (@LWestafer) and this lecture by Rich Levitan posted on the EMCrit blog by Scott Weingart (@emcrit).

Choose EM?

Most people reading this have probably already made their choice of specialty and have chosen EM.   But if you are undecided, having "buyer's remorse", or someone recently disappointed in not matching into what has become a very competitive specialty in the U.S., have a look at this recent post from Life in the Fast Lane on "Choose EM".

The first picture is as good a summary as I have found of what makes this specialty wonderful and unique.  

The second picture is a reminder that even the best job in the world has it's drawbacks.  If this was easy, everyone would do it.   

Congratulations to everyone who successfully matched in 2014!

So you did not match...

If you are reading this you are in the unfortunate position of having NOT matched in Emergency Medicine (or you have a degree of morbid curiosity).  The advice that follows is based on the experiences of applicants who did not match in recent years and the compilation of a discussion from the list serve used by most Program Directors in Emergency Medicine. 

First take a breath, your life is not over. While it is impossible to see now, the hurdles, trips, and falls teach us more than our successes. You will grow and learn from this and become a better care giver for having struggled through this. 

You are now faced with a big decision:  

Do you want to scramble into something else with the plan to train in that specialty? 

Or are you still intent on EM even if it is not this year?

The following advice is for those not willing to give up on EM.  One key thing to remember when deciding which group you are in: not matching this year does not mean you would not be an outstanding Emergency Physician. There are many great unmatched candidates out there who would have a spot if it were not for late applications, poor advising, a bad test score, or just bad luck.   

So what are your options if you are still intent on EM?

  

Most people come up with one or more of the following plans:

1. Scramble into an open EM spot at a program they had not previously applied to.
2. Scramble into another discipline with the intention of reapplying next year.
3. Take a year off and do research or pursue a graduate degree like an MPH to improve your CV.

Scrambling into an open categorical PG1 EM spot is almost impossible.  There were 2 spots in 2013, with 686 US seniors without a match in EM. The chance of getting one of those 2 spots is 0.2%.  To put it another way 99.8% of US seniors who did not match in EM did not get a scramble spot in EM.

There is near universal agreement that taking a year off for research will hurt you more than it helps you.  Program Directors just do not care that much, especially about the kind of research you can set up and complete in one year (just not rigorous/impressive enough).  Many Program Directors are happy to interview re-applicants who have gained some clinical experience, but often do not bother if an applicant did research for the year.  There is significantly less agreement about what a degree like an MPH would do for you - which means that some people will be interested and others will not. 

So that leaves the most common reality of doing a year of something else.  The clinical experience will make you a stronger candidate and better prepare you for your EM internship.  Putting yourself through the application process again will enhance the perception of your commitment (something that often suffers in the applications of late converts to EM).  There are two primary considerations in this decision:  What kind of year to do?  Where to do it?

There is significant disagreement about what kind of prelim PG1 year is best, or if you should go for a categorical program (contract for full course of training) instead.  Here are the options and some explanation:

Transitional prelim year - thought of by the majority of Program Directors to be the best option for a re-applicant.  You split the year between surgery and medicine and get to do many of the things you would be doing as an EM1.  It is more rigorous and impressive than a year of IM and your future EM program may be able to give you credit for some of the months.  The downside is finding a suitable one that fits your other needs (see below).  There is also possible lack of flexibility for doing EM months and interviewing (if you belong to surgery during those months), and at the end of it you are left without a job if you do not match into something else.  In recent years these have become increasingly difficult to find in the scramble as less are available with other specialties incorporating internship into their training program.  The best way to have a Transitional year as back-up is to apply and interview for it, not to scramble.

Surgery prelim year - students choose to do this but few Program Directors think it is necessary, or even more helpful than a Transition or IM year.  That being said, there are some who think the more rigorous/abusive Surgery year is more impressive.  Again, you are left without a job after one year.

Medicine prelim year - often provides greater flexibility for getting EM elective time early (when you can get a new letter) and for interviewing.  And you will usually be treated better. Some Program Directors are less impressed because it is not as punishing and at the end you don’t have a job.  Finding a categorical IM program that will let you start as a PG2 should be an option if matching into EM does not work.  

Medicine or Family categorical spot - same benefits and downsides as a one year Medicine spot but with the advantage that you still have a training position should you be unable to jump to EM.  There is an additional downside of needing to break a contract should you match in EM.  This rarely is a problem so long as people are open and upfront with their IM Program Director.  Re-application is hard, and they know they have a good chance of keeping you, so being supportive of your plans keeps you happy with them.  After a Transition year this is the second most recommended option by EM Program Directors because you have a fallback position if you do not match in EM.

Where you do your year is MORE important than what kind of year you do: 

Location, Location, Location

The ideal position is one where you will have the opportunity to do an EM elective early (August, September) in an ED that has a residency program you are interested in joining.  This gives you access to new letters from people in an EM residency.  Most EM Program Directors agree that these letters will be the most important part of your re-application.  You are better off doing a conditional Medicine year at a hospital with an EM residency than doing a Transitional year at a hospital without an EM residency.  You need access to EM faculty who teach EM residents, and the EM Program Director at your hospital can be your best advisor in getting a spot in their program or another.  

Finally, something you can do now:  

Schedule EM electives for as much of the rest of this year as you can.  Get SLOE’s from all of these rotations.  These letters will help your re-application and you get to know more people within the specialty.  Unforeseen openings happen, even as soon as July 1, and the more people who know you, the better your chance at getting one of those.

I hope you find this advice helpful and I strongly encourage you to contact me if you have any questions.  I am happy to be of help.

Best of luck.

-Cien

Lucienne Lutfy-Clayton M.D. FACEP

Assistant Professor of Emergency Medicine

Tufts University School of Medicine

Emergency Medicine Clerkship Director

Co-Director Emergency Medicine Simulation

Baystate Medical Center

759 Chestnut St

Springfield MA 01199

tel: 413-794-5999

lucienne.Lutfy-Clayton@bhs.org

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.  

Learning Resource: Didactics Online

I recently met a student who created a website full of useful educational resources for medical students and others early in their EM careers.  Brandon Parker (@DidacticsOnline) is a soon-to-be EM resident and his site, Didactics Online covers a variety of topics.

The most recent post is on GI Bleeding.  Included on the page are a pdf of slides that are concise and focussed on what you need to know.  Short, sweet, and to the point.

The post before that is on Monitoring the Critically Ill Patient and has both a pdf of the slides as well as the accompanying podcast.

This site is different from a site like Flipped EM Classroom, which is trying to be a repository of all topics in EM.  Instead, Brandon has put together some very accessible dives into a few different topics, many of which are relevant to EM.

Some of the EM oriented topics are:

How to present a patient
Stroke and TIA
Migraines
Dizziness and Vertigo
ARDS
COPD

Have a look.