3 vs. 4 Year Residency - Which is better?

This is a draft of an article I am writing for the SAEM (Society for Academic Emergency Medicine) Newsletter. The goal is to provide some perspective on a question that students applying for EM often struggle with: "Should I apply to 3 year or 4 year residency programs?"

Many Emergency Physicians have strong opinions as to which length of training is better: 3 years vs. 4 years.  This often directly correlates with the duration of training they themselves completed. Though there is some crossover with graduates of three year programs who ultimately feel that four years is better, just as there are some four year graduates who wish they had been done in three.

These arguments are frequently built around the financial implications, the quality of the training, and the impact on career options.  There are advantages and disadvantages to both formats. However, which is overall “better” may be the wrong question to ask. What matters more is the best fit for the individual applicant.  

The “$200k” mistake

This is a common perception among those who trained at a three year program, or who regret doing a four year program.  The extra year cost them a significant amount of attending income.  The financial argument against four years of training is hard to dispel if your primary driver is monetary. If making as much money as you possibly can, as quickly as you can, is highly important to you, then you are probably not agonizing over this decision. Targeting an intense clinical education at a three year program is likely to leave you satisfied with your training experience.

Conversely, if you are considering an academic career you will be giving up far more of your total earning potential than will be lost in one extra year of training (academic emergency physicians are usually paid less than their peers in community practice).  There is a similar reduced financial impact of an extra year of training if you choose to work in a highly competitive market where emergency physicians are paid less.

More is always better

Four years can be considered better training simply by virtue of being longer. However, competency is achieved at variable times. Some residents are already competent after two years of training while others may need more than the four. In general, having a fourth year of directly supervised practice gives you a greater chance of achieving competency, or even proficiency, while supervised. Though you may not find yourself as a clinician, confident in your skills and practice patterns, until your fifth or sixth year in emergency medicine. By then you will be an attending on either pathway.

A different way to think about this would be to consider your confidence as a clinician, more than your actual competence.  Having more supervision during your first few formative years should appeal to those who have concerns about when they will achieve competence and proficiency.  

The pathway to academics

Historically, four years of training was considered an advantageous path to an academic job, particularly as a four year program is unlikely to hire the graduate of a three-year program to supervise their senior residents (who are the same post-graduate level). This advantage has diminished over time as post-residency fellowship training has become more common.

There certainly remains several advantages to an additional year of training when considering academics.  You have more time during your training to figure out what direction you want your career to take. I am the Associate Program Director at a three-year residency and I see my brand new third years having to make career altering decisions about the next stage of their career that would be easier to make a year later.  You also have more time during training to explore and develop areas of interest, to get involved in research, and to actually complete projects.  And you will often be better prepared as a teacher when your senior year of training includes supervising junior residents (which is much more common at four year programs).  This pre-attending supervisory experience can both develop your teaching skills and allow you to make a more informed decision on pursuing an academic career.  

Fellowship training is now commonly seen as the best path to an academic position. Many graduates of four year residencies are opting to complete a fellowship to gain the additional expertise and to cultivate a specific niche within emergency medicine. The shift towards fellowship training has made completion of a three year residency a much more viable path to an academic career. Particularly if as a student you already know your career destination and which fellowship will get you there.

The extra-time in training is only as valuable as what you actually accomplish. Doing more training, getting a certificate or additional certification, is not the same as being productive in that time. Avoid approaching the fellowship decision as though completing one, regardless of effort invested, will get you the job that you want. Similarly, it is entirely possible that in a three-year residency you can accomplish the things that will make you an impressive candidate for an academic position. Though you will need to be particularly driven and focussed to make that happen.  

The verdict

Ultimately this discussion is not about which option is better because that answer does not exist. What matters is which program is the right fit for what you need from your training. That fit may relate to the length of the training program, or the composition of the curriculum, or the mentorship that you will receive there. The best program for you is going to be the one that best fits your personality, your learning style, and your needs and future goals. Regardless of how many years that program lasts. If you choose for those reasons you will be satisfied with your training irrespective of how long it was.

Adam Kellogg is an Associate Residency Director and a former Clerkship Director. He is member of the SAEM Resident and Student Advisory Committee. He thinks he did a 3 year residency, but it was so long ago he is no longer sure.  

Advice for the International EM Applicant

This post is by Max Hockstein, a US citizen who went to medical school in the caribbean and who successfully matched into a U.S. Emergency Medicine residency in 2015.  He is now starting his internship and wanted to share some advice on navigating the EM match as an international applicant...

Before you choose EM

Over the past few years, emergency medicine has become increasingly competitive.  As you get started as an International Medical Graduate (IMG) applicant you need to know what you are getting into.  According to the Results and Data from the 2015 Main Residency Match there were 1821 emergency medicine PGY-1 positions with 2352 total applicants.  Of those, 739 were “independent applicants” (31.4%), which includes those who went to med school internationally.  EM had a 99.6% fill rate with almost 80% of those spots going to US allopathic seniors and 11% filled by osteopaths. This adds up to some sobering news for the international applicant.  Just 4% of spots were filled by IMG’s who were US citizens and just 2% by non-US citizen IMG’s. And that left 30% of independent applicants unmatched among those who listed EM as their only specialty (did not hedge with also applying to another specialty).  

Why is this?  

IMG’s are still considered (by some) to be second-rate applicants.  In addition, residency program directors (PD's) get many, many applications, and they need a way to screen them.  When the NRMP conducted a program director survey in 2014 83% of PD’s ranked being a graduate of an American medical school at a high level of importance. And less than half (47%) of PD’s will interview and rank IMG’s.  

About rotations

One of the most difficult things about IMG’s matching into emergency medicine is their ability to get their foot in the door because clerkships are hard to schedule.  The holy-grail clerkship is one where you can get a departmental Standardized Letter of Evaluation (SLOE) from an emergency medicine residency.   Because international schools are not affiliated with academic EM programs, we have to find places that not only allow rotators, but foreign rotators.  There’s no registry of places that allow IMG rotators because hospitals change their policies so quickly.  Your first step should be to ask your school where students that have successfully matched into EM have rotated.  The second place you can look is your schools’ (and other foreign schools) match list – see where IMG’s have matched and call those departments to see if you can schedule a rotation there.  The last, and unfortunately the most common way, is to call the departments where you’re interested in rotating (and potentially applying to) to see if they’ll let you rotate.  This takes time: you are busy and the clerkship coordinators are definitely busy – it can be a tough job.    

An added wrinkle...

Certain states have requirements to be eligible for licensure which have to do with the rotations (clerkships) that you did during third/fourth years.  There are two terms you’ll being hearing a lot on this topic: Green-book and Blue-book.  Green-book rotations mean that the rotation has an associated residency while Blue-book rotations means there is no associated residency with an established rotation.  States that are stricter about licensure requirements (for example, Texas) require that all of your rotations be Green-book to be granted licensure after doing residency in that state.  This does not mean that you can’t do residency in one of the more selective states – it just means that you can’t get licensed after residency until you pass your boards if you did Blue-book rotations when you were a student.  

Your application

ERAS opens September 15th – your application needs to be complete (with the exception of possibly one SLOE) by then.  This means you need to have your last SLOE in ERAS by October 1st at the latest.  This means the optimal time to do your rotations is before September.  When you’re setting up your core rotations (third year), do them all back-to-back because (most, if not all) EM rotations require that your core rotations be complete prior to the rotation.  

One of the reasons that program directors want to see SLOE’s from ED’s with residency programs is because one of the questions on the SLOE is how that program plans to rank that applicant – it gives the SLOE more context.  Because of the demand to do clerkships at Emergency Departments with affiliated residencies, some non-academic departments offer rotations.  The bottom line is: do a rotation at a non-academic department if you have to in order to get at least two SLOE’s, but know that having a residency affiliated SLOE is preferred to any other letter you could receive.

There’s no statistically favored number of programs that guarantee you a certain number of interviews.  Apply to programs that you know have matched IMG’s over the past few years (do this by looking at the match lists published by the schools) as well as applying to programs you’re generally interested in.  If you haven’t heard from programs that you’re interested in, or are lacking in interviews, don’t be bashful.  Call coordinators, email program directors – be enthusiastic but not overbearing or demanding.  And be ready at a moment’s notice later in the interview season – spots open up during interview days – and you need to jump on them, they’re not easy to come by.  Though they are scheduled in a rush, these interviews carry just as much weight as any other and programs will appreciate your flexibility.  All that said, hedge your bets.  EM is difficult to interview for and match into.  Apply broadly for emergency medicine but also apply for other specialties you see yourself succeeding in.  If you don’t match into EM – do not rely on SOAP.  Vanishingly few (if any) international applicants in recent history have SOAPed into EM.    

The interview

Once you get interviews, you have to knock them out of the park!  Beyond having impeccable interview skills, you need to be prepared to address the awkward flamingo in the room: the IMG thing.  You have to be able to explain why you took the IMG route – and turn it into something that makes you into the applicant that they must have.  For example, if you had problems with standardized testing, you need to be able to show that it was a struggle that you overcame, emerging stronger and better prepared for having persevered.  

And finally, the rank list

From the 2014 Match data, to have an over 90% chance of matching into EM as an IMG, an applicant had to rank over ten programs. And though no number of interviews guaranteed a 100% match rate, having ten programs to rank as your goal should leave you feeling pretty safe.  When it comes time to ranking – don’t try to outsmart the algorithm.  The match is applicant-weighted.  Go with the conventional wisdom: rank based on where you want to go – there’s no trick to ranking as an IMG.  Again, hedge your bets – rank all programs (EM or otherwise) you interviewed with.  Remember, you’d rather your rank list be too long, not too short.

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.