A Guide to the "Perfect" Rank List

A Guide to the “Perfect” Rank List

This is a guide to help students in the Emergency Medicine (EM) match formulate the best possible Rank List to fit their needs. This guide was prepared on behalf of the Council of Residency Directors in Emergency Medicine (CORD-EM) Student Advising Task Force, a group that seeks to provide guidance to students applying to EM and to all those that advise them.

Introduction:

Congratulations on finishing your interviews; now here comes the hard part, compiling your rank list!

Making your personal rank list has been associated with common symptoms such as confusion, insomnia, aggression, depression, elation, and general malaise. The goals of this blog are to review tips and recommendations based on the National Resident Matching Program (NRMP) data from 2009 to 2015, as well as expert opinions from your fellow residents and attending in order to alleviate the psychosomatic stressors affiliated with the entire process. At the end of the day, it is still your personal preferences, interview experience, and family-social obligations that will drive you to create your “perfect” rank list.

Spoiler: There is NO spoon or the “Perfect” rank list. 

Background: 

According to the NRMP data from 2015, there were a total of 2352 applicants for 1821 nation-wide EM positions, with only 8 positions unfilled. The number of EM programs has been steadily increasing in the last decade, from 141 programs in 2009 to 171 programs in 2015 in order to meet the increased popularity of this amazing specialty, reflected by the 19% increase in total applicant since 2009 [Fig. 1]. Despite the rising number of programs, the NRMP dataset reveals a steady decline of unfilled position; in 2012, all programs were completely filled. Fortunately, 18 EM programs were added with 153 new available positions since 2012, allowing applicants to select from a larger pool of EM programs with less fear of scrambling.

Figure 1 – Application trends for EM Residency. Taken from NRMP dataset 2009-2015.

Questions to ponder:

What is the Matching Process?

The Matching Process is a time-honored (and feared) tradition where a mathematical algorism is used to place applicants into residency and fellow ship position (http://www.nrmp.org/match-process/match-algorithm/). The process begins by matching the applicant’s rank order list (ROL) to the respective programs. If the applicant cannot be matched to the first choice program, the computer algorithm will automatically attempt to place the applicant into the second, third, and so forth until he/she is matched. A tentative match occurs when a program also ranked the applicant “A” and either:

1. The program has an unfilled position, in which case there is room in the program to make a tentative match between the applicant “A” and program, or
2. The program does not have an unfilled position, but applicant “A” is more preferred by the program than another applicant “B” who already is tentatively matched to the program.  In that case, applicant “A” will be granted the position instead of “B.”

All matches are “tentative” because applicants who are matched to a program may be removed at any time from that program to make room for an applicant more preferred by the program (see example above).  When the applicant is removed from a tentative match, an attempt is made to re-match that applicant, starting from the top of the applicant’s ROL.  When the Match is complete, all tentative matches are considered “final.”

Will I get my first choice?

According to the 2014 NRMP data based on matched applicants to all specialties in relationship to their specific rank list, most students get their top 3 choices: 52%/16%/10%, as their 1^st/2^nd/3^rd choice [Fig 2]. This means that your top 3 rank list matter the most, so choose programs carefully! 

Figure 2 – Percent of Matches by Choice and Type of Applicants. Taken from NRMP 2014

Should I rank every program? 

This is a tricky question, but fortunately the answer is bluntly straight forward: YES!

When you leave a program out of the rank list, you will not be matched to that program, END OF STORY. If you were an EM applicant who failed to match in 2012, your only option to become an EM resident was to reapply for the following year as there were ZERO unfilled EM positions in the entire country. Fortunately by 2015, the number of unfilled programs rose to a total of 4, providing a small breathing room for the scramblers. 

My opinion, if you already invested your time and money for the interview, then just rank the program. It is okay to not rank a program, as long as you understand that the risk involves scrambling into a non-EM Program [Fig. 3].

  

“Scrubbing for EM in 2012 – Gonna need a bigger SOAP next year!”

Figure 3 – In 2012, NRMP reported zero unfilled EM positions across the country. Not matching meant scrambling to a Non-Emergency Medicine Program.  SOAP stands for Supplemental Offer and Acceptance Program®.

Which rank list reigns supreme? Applicants vs. the Residency 

Based on the NRMP Match Algorithm (as described above), the applicant rank list is reviewed before the program rank list, placing a higher priority to applicants’ preference over the residency’s. So, just like a game of blackjack, you, as the applicant are the “Dealer,” with just a slight advantage over the residency, aka “Player.”

Which program should I rank 1^st?

Unfortunately, this article will not be able to tackle the complexity of picking the “perfect rank list.” Your rank list will likely be affected by numerous factors, some of which you may have known, while others surface as you progress through the interview trail [Table 1]. In writing this article, we have collected numerous strategies to assist in making the ideal rank list, but at the end, the most common advice was to “follow your gut feeling.” Nevertheless, this article includes some general and useful suggestions for picking out your top 3 programs:

1. Ask your local EM program directors for advice – Program Directors are there to help and guide you through the application process. Their knowledgebase is formidable and they read thousands of applications annually. Sure, some may try to persuade you to join their program, but that is a good sign.
2. You will make new friends – This may sound silly, but many applicants are reluctant to leave their medical school institution, fearing they will lose touch with their friends due to the increased distance. Rest assured, however, you WILL make new friends, either intra- or extra-departmental (or even outside the hospital, GASP!)
3. Location, Location, Location! – This is true with the housing market, and it is equally pertinent in residency selection. If a particular EM Residency is your dream program, but it’s located in a region that you are unfamiliar with, or have limited access to your hobbies (i.e. an outdoorsman in NYC or a Californian surfer in Colorado), then you should strongly reconsider. After all, your wellness matters.
4. Don’t be distracted by gizmos and gadgets – What differentiates a strong EM Residency program is the cohesive nature of the residents, the supportive faculty, and the willingness to respond to feedback. Fancy technologies such as EMR, CT/MRI scanners, and even scribes can be enticing, but they are only as functional as the organization that utilizes them. Friendly consults, however, are always added bonuses.
5. Are the residents happy? – This is one of the most important things to assess during your interviews dinners. Most accredited residency program ensures that you will learn to be an effective and efficient healer, as a result, why not have a good time? If the residents at the dinner seem miserable and depressed, that is a big RED FLAG!

Table 1 - Common Factors Affecting Rank List Decision Making

What if I don’t even know myself?

When all else fails, there is a trick you can play on yourself to test your subconscious mind.

• Step 1 – Grab a friend
• Step 2 – Write all of your EM programs on pieces of paper, then fold and place them in a bag.
• Step 3 – Pretend it is Match Day! Have your friend pull a random piece of paper from the bag and tell you that you’ve matched to the program listed on the paper. 
• Step 4 – Make facial expression (very important step)
• Step 5 – Ask your friend for your reaction.

Conclusion:

Please remember, you have already chosen one of the most rewarding and exciting field of medicine, and you will have a great education and experience regardless of where you match. Just make the list, cross your fingers, and get ready for the next exciting chapter of your life!

- Tony

Xiao Chi (Tony) Zhang is an Emergency Medicine Resident at Brown-Alpert School of Medicine and a member of the CORD-EM Student Advising Task Force.

Happy New Year!... and time to think about Match 2017

For students planning to apply for Emergency Medicine in the 2017 Match, the application cycle is already starting. 

Like everything else in EM, advanced planning is the secret to success in the moment. This post is to get you started on the application 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).

Some folks already have years of experience in emergency care and know that this is the specialty for them. For most a final decision on EM as a career cannot be made until you complete your first rotation. At most schools this will be early in your fourth year so 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 find help from residents who just went through this process provided by the EMRA mentorship program. 

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

Interview Advice from ALiEM

Over at the invaluable Academic Life in Emergency Medicine (ALiEM) blog, Christina Shenvi, MD PhD, has written a tremendous post full of great tips on the "Dos and Don'ts of Residency Interviewing".  I strongly recommend you check it out.  

How to excel during interview season is a topic we have tackled here in the past as well.  Have a look at this guide to scheduling your interviews.  Included are tips on how many interviews to do, managing all the travel, the value of the night before, and how to gracefully handle canceling interviews you no longer need.

We also have a separate guide to the interview day itself.  Included are tips on making a great first impression, having good questions, and a reminder to make sure that you interview the program too - that you get what you need out of the day.  

And a few other interview resources bouncing around the #FOAMed universe:

• Nikita Joshi (@njoshi8), also from ALiEM, posted some great tips for the residency interview process.
• The ALiEM series of Match Advice video discussions are excellent.  They are discussions by Program Directors from across the country and include one on Interviewing Strategies.
• The EM Stud podcast by Dr. N8 (@emstudpodcast) has covered The 7 P's of RSI (Really Stellar Interviewing) and done a 2 part Q&A on Interviewing (part 1 and part 2).

Interview Explosion Day

For students applying for Emergency Medicine in the 2016 match October is an anxiety provoking month.  You completed your application, selected your programs, and coaxed letters and SLOE's out of your advisors, mentors, and rotation supervisors.  And now you are waiting to find out if your application strategy was a good one.  Hopefully you "Applied Wisely".

On the residency program side: they have been furiously reviewing applications and either offering their initial wave of interviews or preparing to do so TODAY (October 16th).  A group of residency programs, the "County Program Group", started a movement to use a single interview offer date to offer out their first wave of interviews.  The idea was to give the students all of their interviews offers at one time so they can make a decision on which to actually sign up for.  They shared this plan with the other EM program directors, many of whom committed to participate.  This means that a lot of interview offers are going out in the afternoon and evening of October 16th.  As those with interview offers already know, other programs had to start offering interviews earlier than today because of they start their interviews in the next couple of weeks.

The effect of this is that you will not really know how well your initial application strategy worked until tomorrow.  There will be a few folks who have more interview offers than they can possibly do.  And their will be a vast majority who are nervous that they are not going to get enough interviews to feel secure with their rank list.  As the applicants with excess interview offers start to cancel, the interviews will trickle down to the rest of the applicant pool.  Take a look here for more on Scheduling Interviews.

If you find yourself with an uncomfortably low number of interviews there are a few things you can do right now:  

1. Check your "spam folder" for interview offers sent by "Interview Broker".  This is a software many programs use to schedule interviews and some email clients are tagging these emails as spam.  You may have offers you did not know about.  
2. Double check your ERAS.  Make sure you have released your USMLE and/or COMLEX transcript and check to see that everything you have control over is actually uploaded.  If your scores or important letters (SLOE's) are missing, your application is likely to be considered incomplete by many programs and has not yet gotten fully reviewed.  Even with most interview spots offered out by today you still have opportunities to interview as programs start making use of their "Wait Lists". 
3. Reevaluate your schedule in December and January.  Are you going to have time those months, especially January, to go on interviews on shorter notice.  These interviews count just the same as those done earlier and you want your schedule to be flexible.

If you are in the enviable position of having lots of interviews (more than 12) it is time to make your priority list.  Pre-rank all of the programs you applied to in the order you actually want to interview there.  When you have more than you need, start to let go of the ones you are less interested in.  This is a service to your fellow students and future colleagues and is certainly what you would hope others would do if the tables were turned.  

Good luck!

Adam Kellogg is an Associate Residency Director and a former Clerkship Director. He is the Chair of the CORD Student Advising Task Force whose mission is to improve the quality of the advising students receive who are applying to Emergency Medicine.  

Applying Wisely - Quality over Quantity

This is a long post with many links to other materials.  The goal was to make a one stop guide to submitting your application on September 15th.

Application season is about to begin in full force for students applying for allopathic (ACGME) residencies in Emergency Medicine (EM).  As an advisor the most common question I am hearing is “How many programs should I apply to?”.  This is a great question.  This is a timely question (applications open in less than two weeks and you need your part of the application done ASAP!).  This also may be the wrong question to be asking.  

In this post I am going to recommend that you approach choosing which programs to apply to with the goal of making a high quality, high yield application list specific to you.  This is an alternative to the “shotgun” approach that you may be hearing recommended - “apply to 50 or more programs”.  

The Goal

You need to get sufficient interviews.  The magic number of interviews complete to assure matching is 10-12 (95-99% chance of matching in EM).  And because the match is student weighted the majority of applicants get into one of their top 3 programs with many getting their #1.  If you have 10 - 12 interviews you are going to match (unless you bomb all of them).  For a much deeper dive into match data and what it means, take a look at this article from EM Resident: Diagnosing the Match.  You can also have a look at the data from NRMP for yourself.

So why not just apply to 50 or more programs when ERAS makes it so easy?  This is your future, what is a few more hundreds of dollars?  The problem is that even if you shotgun out 50 applications you may still not get 10-12 interviews if you choose those programs poorly.  So even if you are determined to go shock and awe with your applications, you are still going to need to be smart about which programs to apply to.  

Applying Wisely

In order to build a quality list of programs to apply to, you need to answer these four question for yourself:

1. Where you need to be?  
2. How do you want to train?
3. How competitive are the programs you are looking at?
4. How competitive are you?

Location, Location, Location

There are ~170 allopathic EM programs.  Applying to all of them is crazy (and not effective).  Most applicants have a regional preference (ie - northeast, west coast, Texas, etc).  Others have a type of area they want/need to live in (ie -urban with public transport, or rural so they can raise chickens, or suburban with access to a large enough city to support an EM program).  You should choose an area, or type of area, that interests you and let that narrow your focus.  Within these areas will be a variety of programs that are likely to be looking for different things in their applicants and to have different levels of competitiveness.  That variety will be really important in keeping your application balanced.   

Program Characteristics

Every program in EM is held to rigorous standards by the ACGME and RRC to ensure you emerge as a competent Emergency Physician (EP).  How they get you there can be quite variable.  These characteristics can help you sort the programs and to start determining which ones are going to be a better fit for how you want to train.  

Some common examples of easy to determine characteristics are how many years the training is (3 years vs. 4 years), the types of off-service rotations they do, the patient population, the sites they rotate at, the structure of their didactics, the fellowships available, their research emphasis, etc.  For a little more depth on these consideration have a look at this page:  Choosing where to Apply.  To start figuring this out have a look at the EMRA Match tool.

You should use these characteristics to help you pre-screen programs.  However, your eventual decision on how to rank them will be strongly influenced by factors that are hard to assess from reviewing a programs web site:  their culture of wellness, their education and adult learner philosophy, the residents happiness and satisfaction, and whether you feel like you would fit in.  This is why we still do interviews.  

Program Competitiveness

In the last couple years some private companies have attempted to help students applying to EM rank the EM Residency Programs.  Lacking access to actual program data they relied upon alumni rankings of the programs.  I have no idea if this actually resulted in a list of which programs provide the best training (though I have my doubts).  I am certain that their lists did not address the most meaningful measure of program competitiveness from the standpoint of the applicant:  How many people applied to the program?  That is not publically available information.  

You can estimate which programs get the most applications, as we outline in this post we did on Assessing PROGRAM Cometitiveness.  

To sum up, the more of these characteristics a program meets, the more applications they are likely to receive:

1. Is the program in a highly desirable place to live?
2. Does the program have “name brand” recognition that would look impressive on your CV?
3. Is the program “EM famous” for their faculty or their longevity within the specialty?

The programs that receive the most applications can fill all their interview slots with above average applicants.  So how do you know if you are above average?

Your Competitiveness

While determining program competitiveness is an inexact science (to put it charitably), assessing your own competitiveness is somewhat easier to do.  This is a guide to Assessing YOUR Competitiveness that we previously wrote.  

To sum up - the applicant field breaks up into three broad categories:

1. Above average and have it made
2. Average and will match
3. Below average and at risk

Where you fall is based mostly on your board scores and the EM rotation grades and the SLOE’s that came from those rotations.  These are the characteristics that all programs will give some weight to.  The other characteristics of your application (clinical grades, work and service experiences, scholarship and research) can all have an impact on how programs rate your application and whether they offer you interviews.  This will not be consistent from program to program, or reviewer to reviewer.  Thus you need to get your application in front of a variety of reviewers at realistic programs.  

Summary

To sanely navigate the match process: gauge your competitiveness and build a list of programs to apply to that has a foundation of realistic programs, with appealing characteristics, that are in areas that work for you and your family.  You can apply outside of this group, because you never know what might catch a reviewers eye, but you cannot consider those applications to be a realistic part of your foundation.

If you are an above average candidate you have the option to be a sniper.  Choose 20-25 programs that highly interest you and get all the interviews you need.  

If you are an average candidate, you are going to match.  Choose 20-25 programs that appear realistic and add another 10 or so that may be a stretch.

If you are at risk, or in an applicant group that many programs will not seriously consider (Osteopathic students, those training Internationally), you should apply to ~40 realistic programs.  Any program that does not seem realistic does not count towards your 40.  

For more detailed perspective for Osteopathic applicants have a look at this page of Advice for Osteopaths.  International Applicants should read this post by Max Hockstein, MD.

You also need to get some personalized advice.  These recommendations are a good place to start but are too generic to use as your sole source of advice.  EMRA has a great mentorship service you should use.  Feel free to contact us with specific questions in the comments or via email.  EMRA also maintains a page of other resources for medical students that can connect you with more opinions and advice.

Good luck and get those applications in!

Adam Kellogg is an Associate Residency Director and a former Clerkship Director. He is the Chair of the CORD Student Advising Task Force whose mission is to improve the quality of the advising students receive who are applying to Emergency Medicine.  

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.