EM Presentations 2.0

The not-so-secret "secret" of doing well on your Emergency Medicine (EM) rotations is to be able to give patient presentations the way that your supervisors want to hear them.

We have covered this in the past in a post on "The Secret to Honors", and that advice has not changed. The best way to make a good impression is with organized and focussed presentations that include a worst-first differential diagnosis and a plan appropriate to an acute care setting.  There is even a bit of literature to back-up this approach. The 3-Minute EM presentation article has been a staple of EM clerkships for years.

Some ingenious folks at the Emergency Medicine Residency Association (EMRA) and Clerkship Directors in Emergency Medicine (CDEM) have improved upon this resource with this video on Patient Presentations.  The 10 minutes invested will undoubtedly pay off on your EM rotation.

Enjoy!

Adam Kellogg is an Associate Residency Director. When he was a Clerkship Director he gave every student a copy of the 3 Minute EM Presentation.  Some of them even read it.  

A Fourth Years Perspective: Interviewing for the Osteopath

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

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

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

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

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

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

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

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

More VSAS Advice

We recently tackled the torturous VSAS system for setting up your crucial away rotations in this post: "Rules of the Road for Away Rotation Applications".

The fantastic team at Academic Life in Emergency Medicine (ALiEM) had the same idea.  Dr. Mike Gisondi assembled a panel for the latest video in their EM Match Advice series to address the same issue: VSAS 101 - Securing an Away Rotation.

This is a great resource.  Have a look and then check out the rest of this invaluable series.

Enjoy!

Adam Kellogg is an Associate Residency Director and former Clerkship Director, and he wishes he had thought of using Google Hangouts for panel interviews. Brilliant!

Rules of the Road for Away Rotation Applications

Now that you have decided on EM (or are at least treating it as your front-runner), you will need to complete a Home and an Away rotation this summer and early fall. These rotations are where you will get the SLOEs that will be the most important part of your EM application. Take a look at this approach to your myriad of choices, and below is a discussion of the most common questions...

Vacillating on the VSAS

There are no perfect number of clerkship applications. First, self evaluate your competitiveness and the competitiveness of where you are applying to. Your local advisors should be able to help you get a sense of your competitiveness at this point.  Keep in mind that this is going to change as you complete rotations. For most students 4 applications will suffice. If you are a weaker applicant or looking at a more competitive market - consider 6. 

The Bird in the Hand

Many students get an invitation to one clerkship, but want to wait for their dream spot. In this application your goal is to ensure you have an away rotation during the spring and summer. You have a rotation, take it and smile. If you can manage a third rotation, keep your other applications in. If you cannot do a third rotation and still have applications outstanding call and let them know you appreciate their time but have accepted another opportunity. This is better than waiting and declining the spot. This proactive stance will win you points with the clerkship director and the coordinator (they may remember if you string them along). 

Check the Boxes

Read the paperwork from the program carefully, and complete it in a timely manner. There is no second chance for a first impression. You don't want to arrive and not be able to rotate because of paperwork. Health requirements vary at different institutions. Check with the undergraduate medical education office or health services at the hospital you are going to. They should be able to list what you need in detail. This is the time to jump through the hoop and just get it done.

Burn Baby Burn (or Don't!)

Declining an offered spot will be a small annoyance to the clerkship. If you need to, ensure you do it quickly and politely. Waiting weeks to decline hurts your impression with the program. They assume you are stringing them along and not genuinely interested in the program. Never accept a rotation and then back out of it if you want to get an interview there. Getting your perfect rotation is not worth the damage to your credibility elsewhere. If you discover a particular program is not a good fit and expect not to apply to them, go ahead and cancel. Just know that this program interprets withdrawing as disinterest and inconsiderate - not a good impression. The clerkship director and residency coordinator will recognize your name and will be reluctant to interview you.

Lucienne Lutfy-Clayton is an Associate Program Director and former Clerkship Director, she hates when students cancel on her clerkship making her scramble at the last minute.

Burning Questions for the New Application Year

The 2015 match is behind us and the application cycle for the 2016 match is already in full swing with third year students working the VSAS to line up their optimal elective rotations.  A recent discussion with Kara Barker, a third year student in the 2016 match, led to this post (have a look at her wonderful piece on "Choosing EM"). Along with her EM-interested classmates she generated a list of "Burning Questions" for the third year student embarking on EM.  Here are our answers:

1. What qualities do Program Directors look for in an EM resident and how can I best demonstrate these during the residency application process?

Each residency program is looking for something a little different in their applicants though there are certainly some common traits. Looking at the SLOE's (the Standard Letter of Evaluation) that are used as your recommendations gives you some clues: Commitment to EM. Work ethic. Ability to create an ED appropriate differential diagnosis and plan. Teamwork. Caring for patients. These letters of evaluation are a description of your performance and your potential in EM. They are the most important part of your application.

2. As an applicant, how do I best assess whether an EM residency program is a good fit for me?
What each applicant needs from a residency program is unique to that person. There is no universal best-fit. You need to weigh what really matters to you in your training and focus your search on programs that fit those criteria. Here is a more detailed discussion of Choosing Where to Apply. While you can figure out location, duration of training, and opportunities available in advance, you will not truly know if you are a good fit in the culture of a program until you go there for interview. 

3. How important are USMLE Step 1 and/or Comlex Level 1 board scores to the EM residency application process?
Board scores matter because they are one of the few objective measures Program Directors have. They will be used to screen the application pool. However, scores do not do a good job predicting who will excel in residency training and are less important than how you do on your EM rotations. Some programs will consider you even if you did not do well on Step 1. Have a look at this more detailed discussion of Board Scores.

4. If my USMLE Step 1 and/or Comlex Level 1 scores are not competitive, can I compensate with improved USMLE Step 2 and/or Comlex Level 2 scores?
Yes. Many Residency Directors put more stock in Step 2 scores as the material is closer to being clinically relevant. In general, if you are not happy with your Step 1 you should put extra effort into step 2 and take them in time to have the results appear in your application (August).  

5. In addition to board scores, Standardized Letters of Evaluation (SLOEs) and successful completion of EM audition rotations, is there anything else I can do to distinguish myself from other EM residency program applicants?
Those are the most important part of your application and carry the most weight. Some Residency Directors put a lot of emphasis on research projects. Others like to see service and volunteer experience. And others are big on involvement in local/national EM organizations. Do those things if they suit your interests and you can do them well. When they come up on your interviews you will want to be able to talk about them passionately. Here is some more depth on what goes into the ERAS application.

6. How important are grades and letters from non-EM clinical rotations to the strength of my EM residency applications?
Your EM grades and letters are the most important part of your application. Programs will look at your grades from other rotations but the impact on your application quality is small. There is too much variability in grading from school to school. Letters from rotations in other specialties are also not very helpful. Rounding out your set with a non-EM letter is fine, and will not hurt you, so long as you have enough information in your EM letters. Here is another link to that more detailed discussion of Letters.  

7. Given the importance of securing at least two EM clinical audition rotations AND given the number of other students also competing to secure these rotations, what can I do to make sure I am invited to rotate in the programs I am interested in?
You can appeal to the Clerkship Director by email and hover on the VSAS site waiting for an opening but there are only so many spots. Be ready to make a switch late in the process if someone drops a rotation. Ultimately, doing two EM rotations is more important than where you do them. The value of the SLOE to the student is that by being standardized and asking to compare you to your peers, it gives a Program Director who has never met you a trustworthy impression of you. That will get you interview opportunities at places you have no other connection to. Here are some more thoughts on EM rotations.

8. If I am not able to secure a clinical EM audition rotation within the department associated with my top choice residency, is there anything else I can do to demonstrate my skills and my interest to this program?
The clinical EM rotations are typically the hardest ones to get into as they are the sources of real grades and SLOEs. However, if you just looking to get in the door and make an impression, consider doing a specialty elective like Ultrasound, Pediatric EM, Toxicology, etc. You will often be able to interact with the Program Director's while doing these rotations and you can learn about the culture of the program. Doing a rotation like Trauma surgery at the same institution is generally NOT a good idea. You will likely be too busy to make an impression on the ED.

If you have other Burning Questions you would like answered please leave them in the comments below. Good luck setting up those rotations!

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 knows that this whole "Standardized Letter of Evaluation" thing sounds scary but they are better for everyone. Really.

A Fourth Years Perspective: Applications and Interviews

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

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

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

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

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

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

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

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

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

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.