So you did not match...

This is an update of our advice for the student who finds themself in the unfortunate position of having NOT matched in Emergency Medicine. There are some changes from last years post on the same topic. As always the advice that follows is based on the experiences of applicants who did not match in recent years and the compilation of recommendations from the members of the Clerkship Directors in Emergency Medicine (CDEM) and Council of Residency Directors in EM (CORD EM). 

First step: take a breath, your life is not over. Your goal of training in Emergency Medicine is still alive. While it is difficult 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 huge decision:  Do you SOAP (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 advice that follows will be useful to 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. SOAP into an open EM spot at a program they had not previously applied to.
2. Take a year off and do research or pursue a graduate degree like an MPH to improve your CV.
3. Extend your med school training to a fifth year and improve your application for next year.
4. SOAP into another discipline with the intention of reapplying next year.

Let's address each of these options:

1.  Using the SOAP to get into an open categorical PG1 EM spot is almost impossible.  There were just 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 SOAP spot in EM. In 2014 there were 14 unfilled positions in the match, which is still not very many (family med had 142 and surgery prelim had 449). There is no reason that you cannot try to SOAP into EM but you need a back-up plan in place.

2.  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. 

3.  Extending medical school may be the best option for some students, if your school will allow you to do that. The clear downside is cost, which is likely huge. If the price or rules of your school (ask your dean) are not deal-breakers you can build an extra-year of experiences that will make you a better qualified candidate for next years match. This is a particularly good option for solid candidates whose applications suffered from being late to EM or being complete late in the application cycle. If more opportunities to interview were all you needed to get your 10 to 12 interviews, then extending will let you do that. This option also leaves you available to fill a last minute opening that comes up after the match (though you cannot count on that kind of luck). 

4.  Lastly, is the most common back-up plan: doing a year of something else. The clinical experience will certainly better prepare you for your EM training and can make you a stronger candidate. Putting yourself through the application process again can only enhance the perception of your commitment to EM. Many applicants have been successful using this pathway to eventually match to EM. If you choose this option there are two primary considerations in this decision:  What kind of year to do?  Where to do it?

If I want to reapply to EM, what specialty should I SOAP into?

There is significant disagreement among CDEM and CORD 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, 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 SOAP as less are available. The best way to have a Transitional year as back-up is to apply and interview for it, not to scramble (too late).

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 rigorous, AND at the end you don’t have a job. However, 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 you are open and upfront with your 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.

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.  

What do you do if you find out at noon on Monday, March 16th, that you did not match?

1. Call your dean and find out what your options are.
2. Call your EM advisor for a personalized recommendation on what you should do. You can also contact us by email or in the comments.
3. Schedule as many clinical EM rotations as you can for the rest of the year. Get SLOE's from all of these rotations so that you can include better letters than you had this year and so that you can meet as many people within EM who can advise and advocate for you. 

Best of luck!

-Adam

Adam Kellogg is an Associate Residency Director and formerly an Emergency Medicine Clerkship Director.  He is a member of the CORD EM Student Advising Task Force and of the SAEM Resident and Student Advisory Committee. Some of his favorite Emergency Physicians did not match on their first try.  

Why Emergency Medicine?

Kara Barker is a third year medical student who is embarking on the year-long journey to match to an EM residency. This is how she made that decision.    

Prior to starting medical school, my experience with Emergency Medicine (EM) was limited to an ER visit with my nephew following an unfortunate run-in with a homemade arrow and a few late night TV episodes of Bizarre ER. During medical school one of my instructors - a retired EM doc - piqued my interest in this field with her wild stories about her time “on the front line of medicine”.  When I had to pick my third year elective rotation, I decided to see for myself what all the excitement was about. After just one day in the Emergency Department I was done searching for my future specialty.  I was done trying to figure out what I want to be when I grow up. I was hooked.  

There were several aspects of this experience that helped me end my search for a specialty:  

Variety.  We saw a tremendous variety of patients each and every shift.  We treated babies, elderly and everyone in between. We treated psychiatric patients, pregnant women, the critically ill, prison inmates, college students, the addicted, veterans, and many more.  We had the opportunity to meet and help people from every walk of life. There was never a dull moment.

Multifaceted Challenge.  Every shift offered interesting and diverse challenges.  The EM physicians had to possess the tools to address the most critical issues in all other specialties. These tools included both medical knowledge and the skills needed to perform a multitude of procedures. During my first twelve hour shift we reduced a shoulder, placed a central line, treated an anaphylactic reaction, evaluated a suicidal patient, treated a miscarriage, placed a chest tube, and sutured multiple lacerations.

And the challenge did not end with just having medical knowledge and procedural skills.  The EM physicians also had to have exceptional interpersonal skills – they had to be mind-reader, therapist and trusted confidant all wrapped in one.  In a matter of minutes, they had to be able to enter a room, read the patient and their situation and then establish that patient’s trust to solicit critical information in order to initiate appropriate care.    

Teamwork.  Every day, the EM physicians worked closely with a large group of individuals including Emergency Nurses, Physicians Assistants, Medical Assistants, Interpreters, and many other members of the healthcare system. The team I was fortunate enough to briefly be a part of worked together like a well-oiled machine. The staff looked out for one another, anticipated each other’s needs, and collectively worked hard to deliver the best patient care possible.  The losses were mourned together and the successes and triumphs were celebrated together.  There were tense moments, there was a lot of laughter and, importantly, there was never a lonely moment.

Impact.  On many days we were with patients during some of their most vulnerable moments.  This meant that we had the opportunity to make a huge impact on their lives - whether by initiating a lifesaving treatment, easing someone’s pain, or simply taking the time to sooth a worried family member.  I was inspired every day by what a privilege and responsibility this area of medicine carries with it.  

In my opinion, EM physicians have one of the most interesting and challenging jobs out there.  As a third year medical student, I feel fortunate to have found a specialty that inspires me.  Now, I look forward to moving on to the next step in my journey – ending up in the emergency department . . . as one of these inspiring healthcare providers.

I hope reading this helps you decide if EM is right for you.

- Kara

A Fourth Years Perspective: What a third year student needs to know right now

Elizabeth Karr is a 4th year medical student in the 2015 EM Match.  This post is a 4th years perspective on what a 3rd year needs to know.

As I started Fourth Year, I was told that this year would be the hardest yet, and this advice has proven true.  You start out going on your audition rotations, wanting to put your best foot forward and impress the people you are working with.  However, you are also still learning the craft of Emergency Medicine (EM), formulating your differential, perfecting the three minute presentation, and learning the basics of emergency medicine. Then interviews start and you are traveling all the time, which is exhausting in and of itself, and on the interviews you are selling yourself.  You have to answer the same questions 50 thousand times, and yet you still want to sound like you are not giving a rehearsed statement.

Fourth Year Rotations

What I now know at the end of it all: just take a breath, relax, and be yourself.  Audition at sites whose residency programs truly interest you.  Choose a program that you want to learn more about or a program you have heard is a great learning experience for students--not necessarily just your number one or two pick.  If you have a number one choice, it may be better to do that as your second rotation. This will allow for your first rotation to polish your EM skills for your second rotation. The knowledge and skills you acquire will help you to shine at your top program. Also, if you are doing an away rotation in another specialty at a site you are interested in, contact the program director or student coordinator and see if you can do a shift in their emergency room and get an inside perspective on the program.

It is recommended you do your first audition rotation early in fourth year, because these are the rotations in which you will obtain your Standardized Letters of Evaluation (SLOE’s). SLOE’s are letters of recommendation that are often written by an Emergency Medicine residency, not just by individual physicians.  If you look at the following link, it will make sense as to why this is so: http://med.fau.edu/pdfs/SLOE_Standard_Letter_of_Evaluation.pdf  Ideally, you want to have at least two SLOE’s by the time applications are due in September. When you submit these, along with any other letters of recommendation, it gives programs a way to see how you compare, side-by-side, to other emergency medicine applicants. Programs also want to see that you are improving from one evaluation to another.

These SLOE’s will be obtained from your audition rotations, or possibly from a home rotation if your school has an EM program. As you start your first audition rotation, everyone is aware that it is your first rotation.  You are not expected to know everything and have all the answers, or even earn the grade of honors. It is expected you are interested in the field of EM, you learn from your experiences day in and day out, and you show growth over the month-long rotation.  It is appreciated if you show initiative; want to see patients, work on your differentials, volunteer to perform procedures even if you have never done it before.  Most of all, just enjoy the experience.  Don’t be set on trying to impress everyone, and be ready to admit when you didn’t ask your patients something, or if you don’t know the treatment for disease-X.  You are not expected as a fourth year student to have all the answers.

As for the number of EM rotations you need to do, you have to do at least two in order to get two SLOEs.  I have classmates that did five rotations, and others that only did two.  It is up to you.  I actually ended up doing a very late rotation in January, as that was the only time the program could accommodate me.  That program director told me he really likes to see interested students doing rotations late in the season, because you stick out so much more in their mind when it comes to ranking for residency.  With that said, programs are not likely to forget you if you rotate early in fourth year and are a good candidate for the program.  January was also the end of interview season, and by that time, I was exhausted and yet still had to be on my A-game as I was rotating at a place which I was also interviewing at. However, a late rotation was a good reminder of how much I enjoy emergency medicine and why I was spending all the time and money going on interviews. If you are doing a late rotation, make sure you weigh the pros and cons.

Also, in third year or early in fourth year you should try to connect with a mentor: an advisor, faculty member, program director in whom you can share your application with and discuss any lingering questions.  Most people in EM want to see you succeed and match into the program of your choosing.  It is great to have someone to ask questions, look over your personal statement, advise to the number of programs to apply to, and give you an unbiased opinion on your competitiveness in the EM match.

Look for Elizabeth's next post, the 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.  

A New Year and a New Application Cycle

For students interested in Applying to Emergency Medicine for the 2016 Match, the application cycle starts now. Really. 

This post is to get you started on the process and to serve as a guide to some of the resources on this blog.

Your first task is to decide if EM is right for you as a career (be sure to follow the links to ERcast and St.Emlyn's at the bottom of the page - they offer very helpful perspectives).

You may not be able to make a final decision on EM until you complete your first rotation but you will need to lay the groundwork for your application in advance. As you are planning your fourth year schedule, these are some of the biggest questions to consider (linked to what we have to say about them):

• When and where are you going to do EM rotations?
• Away rotation?
• What kind of letters will you need?
• What should you be collecting for the ERAS application?
• When should you take step 2?
• How do you know if you are a competitive applicant?
• How do you know which programs are competitive?
• How do you choose which programs to apply to?

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

To help you sort through all of the differing opinions you may find, you need the guidance of a local EM advisor, in addition to your Dean. You need someone who knows the EM application process and can help you navigate issues specific to students from your school and region. If you cannot find anyone, or you need advice from a different region you can often find help from SAEM's e-advisors program or the EMRA mentorship program. 

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

The EMStud Podcast

I recently became aware of a new resource that every medical student interested in Emergency Medicine should check out: the EMStud podcast.

Started this fall by Dr. N8 (@emstudpodcast), they are hitting on key topics of importance to students applying to EM. They have covered The 7 P's of RSI (Really Stellar Interviewing), had a 2 part Q&A on Interviewing (part 1 and part 2), and most recently got the rank list discussion started with 100 Days to Match Day.

These short (well under 20 minutes!) podcasts hit the key points that students need to know. He also provides links to longer form advice for those seeking more. EMStud is a welcome addition to the growing collection of resources for students interested in EM.

Enjoy!