Applying Wisely - EM Match 2017

This is an update of a post from last year. This is a long one with many links to other materials.  The goal was to make a one stop guide to submitting your application by 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 (you have been able to submit applications since early September and programs will see them on September 15th).  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 enough interviews.  The magic number of interviews completed 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 actually figure out where to apply: look at the EMRA Match Residency Index.

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 publicly 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 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 an interview.  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 need a real advisor

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 a past 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.  

Want a $50 gift card and a risk free chance to practice for interviews?

Consider participating in the AAMC's research project that is a new addition to the application to Emergency Medicine this year – the AAMC is launching a Standardized Video Interview as a pilot for the emergency medicine specialty during the 2016-17 residency recruitment season. Here is the link to the webpage describing the study.

Applying to EM - you are eligible to participate in this research study as part of their ERAS application. Participants will receive a $50 gift card code to Amazon.com. Here is a link to the informed consent.

What's the point – This is your chance to answer standard interview questions without any risk to your application. The questions being used are common ones you will encounter during your interviews. Ever dream of getting a look at the questions before the test - well here is your chance. Here are some hints to succeed.

How does it work –  Each applicant will receive 6 questions with 30 seconds to read the question and 3 minutes to answer each - the interview is followed by a brief survey on your experience.  Here is a link with details about what to expect.

Bottom line – While the AMMC hopes that the Standardized Video Interview will be a valuable tool for all specialties in years to come, this is a true pilot and will be assessed as such.  Neither students nor program directors will have access to the videos or get a score. Applicants will need a video enabled device like a smart phone, laptop, or tablet.

This is a good time for you to familiarize yourself to standard interview questions, as well as dusting off that suit, and getting in the mindset of looking for the right fit for residency. This is the AAMC’s toolkit to succeed.

Lucienne Lutfy-Clayton is the Chair of CORD's Student Advising Task Force and an APD at UMASS Baystate Health. She is currently enjoying some away time with her family and wants to come back to see all your amazing applications ready to go.

The CORD EM Blog

Disclosure:  I am also an editor for the CORD EM blog, writing and editing posts by members of the CORD Student Advising Task Force (SATF).  

The Council of Emergency Medicine Residency Directors (CORD EM) recently started their own blog. This new Free Open Access Medical Education (FOAMed) resource is growing to include a variety of resources for those involved in emergency medicine (EM) education. One of the content areas (and the reason this is being mentioned here) is from the CORD EM Student Advising Task Force (SATF).

On the first Thursday of each month the SATF will publish a post with information crucial to students applying to EM, and all those that advise them.  Their first two posts should be of great interest:

• HireVue - The Pre-Interview Interview, where the video interviews that all EM applicants are being asked to conduct are explained.  This pilot program is being rolled out by the American Association of Medical Colleges (AAMC) just in EM this year.  
• Student Advising: A Comprehensive Guide and FAQ, where the most up-to-date versions of the CORD SATF Emergency Medicine Applying Guide and Applicant FAQ were shared. These resources contain the most current applicant advising recommendations available, based on Clerkship Director and Program Director consensus and the best available evidence.  

Future posts will highlight more invaluable resources for students including advising recommendations for applicants in Special Circumstances and highlighting of the most useful resources for students.  

Reflections on a balanced intern year

This post by Ashley Rider, a second year EM resident, is for the all the band new residents starting their internship.

Intern year is special. We finally have the responsibility that we have been yearning for, but it is appropriately coupled with layers of protective guidance from upper levels, fellows, and attendings. The hours can be long and grueling, but they tick away surrounded by people that understand your challenges, offer support when days are tough, and inspire you to be your best.

Striking a balance between your resident duties and life outside of the hospital can be one of the greatest sources of strain during intern year. Finding the time to keep in touch with friends and family in far away places is exceedingly difficult. You will probably miss some holidays. Your work schedule may be incompatible with many important events. Stressors may feel like they come from all directions—patient care, residency requirements, student loans, car issues, apartment fixes, and your relationships. Meanwhile, you are expected to work toward mastering the specialty of emergency medicine.

You will be functioning on limited bandwidth every day, week, and month this year. Time must be prioritized.

Once a month…

Get organized.

♦      Streamline your life. For all of those monthly bills, activate automatic recurring payments. You would be surprised how quickly the 1st of the month sneaks up on you. Ask your landlord about alternative payment methods or direct bank transfers. If you have roommates, brainstorm ways to consolidate payments. The fewer minor tasks you have to remember, the more your cognitive faculties can be applied to other areas of your life.

♦      Allow Google calendar to be your best friend, by helping you keep your best friends. Plug in event reminders and birthdays. Make a habit of checking your morning email of calendar events to avoid tardy birthday wishes or Mother’s day cards. Put your shift hours into a calendar, and then share it with family, friends, and significant others so that they know when you are available. With the beginning of each month, map out your upcoming events compared to your work schedule. On the eve before a new rotation, allow yourself 15 minutes of quality time with the GCal to plan ahead.

♦      Make time for your classmates. Believe it or not, your co-interns may be the people you see the least as you are carted off to the obligatory off-service intern rotations. Some of my most cherished moments of intern year were my class dinners. On the last day of every rotation one person would coordinate an outing that allowed us to catch up while visiting new areas of our city. Your co-interns understand everything you are going through. Revisiting your special bond every few weeks might be revitalizing enough to plunge into the next month’s “new job.”

Once a week…

Establish routines for learning and wellness.

♦      Attend conference. This is five hours a week dedicated to your education. Be engaged!  Take advantage of the protected time to learn from faculty, guest speakers, and peers. Bring ideas, bounce your thoughts, and ask questions. We only get this for 3 or 4 short years—don’t miss out! It is a tremendous component of our education with the unique flair of our residency program. That’s something CME will not offer in the decades to come.

♦      Keep in touch with family and friends. Vacations do not come often enough. Make a phone call to the parents, siblings, and friends that made you who you are. They want to hear how you’re doing! This may need to happen on the drive home, while folding laundry, or during an apartment clean. Put your emergency medicine multitasking capabilities to good use, and you will find the time.

♦      Reflect. Relax. Treat yo’self. GME requires approximately one day off a week. Set aside at least one hour on that day to do something that makes YOU happy. Take a walk, write, go to the gym, read, do Yoga, lounge in the park, hit the mall, or go for a hike. Whatever it takes to recharge and reset—you deserve a break!

Each day…

Aim to give 100%.

♦      Sleep. Time is always going to be limited but sleep is necessary. Every hour of sleep debt you accrue will chip away at your potential as a learner and as provider of patient care. On those days you have to wake up at 4am, go to bed earlier! Sleep hygiene is key: put away electronics, keep your room dark, and avoid food/exercise/alcohol/caffeine before going to bed. In emergency medicine we also have to tackle rotating schedules and night shifts. Invest in dark curtains and an eye mask to get your needed rest during the day. The routine you develop this year will set you up for a career of shift work, so make them good habits.

♦      Read about your patients. Pick at least one patient per shift and peruse a relevant up to date article, book chapter, or residency resource. At the peak of your exhaustion, a few minutes at the end of the day may seem unthinkable, so practice “learning on go.” Look up articles as clinical questions come up and scan them when you find free moments (e.g. waiting to present to the attending, walking to your mode of transportation at the end of a shift, or during the 5 minutes before sign-out). Furthermore, don’t let that time spent go to waste. Be sure to organize your learning, whether in a notes app, on old-fashioned pen and paper, or through Evernote. Screen time will be limited this year, so try to find ways to learn that don’t involve your computer.

♦      Stuff is going to happen. You are going to have bad days. You might get a flat tire on the way to work. You might make a medical error. You might feel overwhelmed and utterly useless—it happens to everyone. But remember that this too shall pass, every day comes to an end, and tomorrow is a new start (this goes back to the importance of sleep!)

Every Hour…

Brace yourself for the many challenges you will encounter.

♦      Prepare yourself for patients based on the differential for their chief complaint. Before you go to see him or her, have the top 5 most concerning diagnoses at the forefront of your mind. While interviewing the patient, collect all evidence that helps you to rule in or our these diagnoses, and formulate a plan from there. This active thought process will help you develop your practice style much more than a shotgun approach. Take a few minutes each day to follow up your patients. Did they come back to the ED after discharge? What became of them in the hospital? It will ultimately make you a better provider.

♦      Know your team. Nurses will save you and will frequently aid your decision-making. If you are worried about a patient, call rapid response and respiratory therapy. Social workers may be able to provide suggestions and resources that you didn’t even know existed. Call radiology to talk through an x-ray that you didn’t initially read correctly, because someday you may be the sole provider interpreting overnight films. Finally, remember all those dosages we never learned in medical school? Pharmacy will be your saving grace. If you are unsure about a medication interaction, dosing regimen, or the available of a drug, call your friendly pharmacist.

♦      Hypoglycemia is our Achilles Heel. For patients, always check a D-stick upon arrival. You can cure quite a few presumed altered mental statuses, or even CVAs. For yourself, recognize that glucose is the fuel for the brain. Keep a couple of granola bars (fun size snickers count, too) for that delayed meal or busy high acuity shift.

Each Moment…

Keep a positive attitude.

♦      Learn something from every case you see. It might be an agitated psychiatric patient, but they, like all your patients, are in the emergency room as a last resort. Give them your best doctoring. Investigate all organic possibilities. Hone your communication skills with difficult patients while you have the time. Learn what labs to order and what paperwork to fill out. Know where the snacks are kept. Your R2 self will be glad you took the time to learn the basics. Everything you tuck away this year will make the road ahead less bumpy.

♦      Be humble. You leaned a lot in medical school, but remember this is only the foundation. Always develop a differential, even if you are certain of the diagnosis. Consider the input of every member of your team. Recognize when you were wrong, and use your mistakes to improve care of the next patient. There is always more to learn!  

♦      May your every task be aimed toward taking good care of patients.  Just don’t forget about yourself along the way.

For additional pearls straight from the chiefs, see the ALiEM post on residency secrets to success:  https://www.aliem.com/2016/top-10-success-resident/

Welcome to emergency medicine. Best of luck with every month, week, day, hour, and moment this year!

Ashley Rider, PGY-2 Highland Emergency Medicine

CDEM Curriculum - EM Stud and SATF Resources

The Clerkship Directors in Emergency Medicine (CDEM) is the National Organization representing Undergraduate Medical Education in Emergency Medicine.  CDEM is comprised of medical student educators who are committed to enhancing medical student education.  They have recently revamped their web presence with the fantastic new CDEMCurriculum.com site.  Any student interested in EM should spend some time poring over this site as it is the single best resource available.  In this post we highlight the tip of that content iceberg. 

Curricula
Among the resources available are the Student Curricula that give the site its name.  Included are focussed reviews of the major adult and pediatric complaints with an emphasis on what the student needs to know.  A student familiar with all of this material would have a knowledge base that any supervisor would find impressive.  

EM Stud Podcast
There are an amazing number of podcasts out there, but don't you wish there was a podcast for the student interested in EM?  Well it turns out that the EM Stud podcast is what you are looking for.  Started independently by Dr. Nate Lewis (@ERDrN8), it is now the official CDEM podcast for students.  His co-host, Dr. J. Scott Wieters (@EMedCoach), recently recorded an incredibly insightful Match Analysis with Dr. Mike Van Meter.  Just packed with great insights that impact your application.  Previous episodes cover a variety of topics including the dreaded VSAS and How to Run Third Year Like a Boss, among many others. 

Student Advising Resources
The CDEM site also hosts the Advising Resources created by the Council of Residency Directors in EM (CORD-EM) Medical Student Advising Task Force.  This group of Program Directors, Clerkship Directors, Residents and Students collaborate to improve the quality of available student advising and increase the transparency in the EM application process.  Currently available resources you can download from the CDEM site include a comprehensive Guide to Applying to EM, a concise set of Frequently Asked Questions, a Student Planner, and a collection of the best Advising Resources currently available.  

This should keep you busy for a while.  Enjoy!

Adam Kellogg is an Associate Residency Director, former Medical Student Clerkship Director, and the immediate-past Chair of the aforementioned CORD-EM Student Advising Task Force. He wishes that the EM Stud podcast existed when he was a medical student.  Or any podcast for that matter.    

The Re-Applicant Playbook

The Emergency Medicine match has become more competitive than ever. In 2016 there was 1 spot unfilled in the match. Programs are getting more applications than ever before and students are doing more interviews. The audition, application and interview cycle is compressed over just a few months. If just one thing goes wrong with their application a qualified candidate can find themselves without an EM residency on match day.

In the So You Didn't Match post we explored the options available to those still dedicated to pursuing training in EM.  Now we are going to look at the next step: becoming a successful re-applicant.

Unfortunately there is no standardized "playbook" that you can follow in re-applying to EM.  The causes for struggling in the match are too varied and the solutions are too personal.  You need to design your own playbook. The information below will hopefully get you started. As always, there is no substitute for discussing your individual situation with an experienced advisor.

Diagnosis

The first step is an honest self assessment.  Analyze where your application went wrong. What were the weaknesses of your application? Were there potential concerns (Red Flags) that did not get addressed in your Personal Statement? Here are some of the most common issues that can lead to application reviewers not offering an interview:  

• Late or incomplete application
• Failure or low score on USMLE or COMLEX
• Lack of SLOE's or late arriving
• Below average SLOE's that do not show improvement
• Extension of medical school for academic reasons
• Professionalism issues 
• Non-U.S. allopathic med school

Most students who do not match had limited interview opportunities (less than 10 interviews).  Those who completed double-digit interviews and yet still did not match likely had issues within the interview day.  

Get some feedback. Self assessment can be difficult especially if self-criticism is involved. Get some outside help from your advisors and the programs where you rotated and interviewed. You may feel as though your advisors let you down when you did not match. However, they may have based their advice on faulty or incomplete information. Did they have a complete picture of your application when you talked? Looking at everything retrospectively, they may be able to give you useful advice now. The programs where you interviewed should have a complete picture of you as an applicant, including letters your advisor was not privy to. Reach out to them and politely request honest feedback on where your application fell short.  You will get some answers like, "We don't do that" or "It was just a really competitive year".  Though if you make it clear that you are seeking honest feedback to guide your future decisions you may find some willing to give you objective analysis of where things went wrong.

Treatment

You think you have identified the problems. Are they fixable?  

Late Application
Some issues are easy to mitigate.  If your application went in late or was not complete until late in the review process (late November) you are going to make sure that does not happen again. Everything you have control over will be submitted to ERAS by October 1st. And if you did not have SLOE's in your application, or if they came in late, you will correct that too. 

Bad Strategy
Application strategy is also an easier fix if you applied to a limited collection of programs for geographic reasons or if you only targeted the biggest "names" in the best locations. This time you are going to apply to a diverse group of programs with a focus on those that are realistic. You will likely apply to a lot of programs but the key is not just in quantity. Well chosen programs that will see you as a reasonable candidate are your priority. 

Med School Misadventures
Preclinical or clerkship failures that required remediation, or other academic or professionalism issues, will always be in your MSPE (Dean's Letter).  You can't make them go away but you can better address them in your application. Application reviewers will go right to your Personal Statement when they find something concerning in your application.  Failure to address a "red flag" can lead to your application ending up on the discard pile without further review. Own your mistakes. Learn from your failures. Those are skills all Emergency Physicians need to possess so you may as well demonstrate them now.

Board Problems

Having failed a step of the boards will always be on your transcript. If you had not retaken and passed the exam by the time rank list decisions were made in February you would have been considered "unrankable". The compensation for a low score is to improve on a subsequent step of the boards AND to show that the rest of your skills outweighs a poor showing on a multiple choice test. If you are doing an internship this year, demolish step 3. Leave no doubt that you will pass your EM boards (which is all that your USMLE/COMLEX can be expected to predict). 

Interview Issues

Did you do a number of interviews associated with a high probability of matching (10+) but were unsuccessful?  There could be issues in how you interview.  It might be hard to get someone to tell you that you make a bad first impression in interview situations.  Seek some help with interview prep from someone you can trust to be honest about your conversation style and body language.

Rough Rotation

The hardest thing to decipher can be whether you had a harmful letter. You should certainly suspect this if you received a grade below what most EM applicants receive on that rotation (Pass on a rotation where most EM applicants get at least a High Pass, or a High Pass on rotations that give lots of Honors).  Even if grade distribution information is not publicly available (check your MSPE) you may be able to get a sense of what EM bound students typically got from your fellow rotators and classmates. 

Torpedo Letter
You can also receive a harmful letter without a notably concerning grade. Academic performance may have been good but questions were raised about your fit at a particular type of program. There could have been interpersonal or communication concerns raised that did not affect your grade but they felt the need to share.  

Why you got a bad SLOE really comes down to a couple possibilities. The first is what the defensive parts of our brains wants to believe: it was all a misunderstanding or an unfair evaluation process. And that does occasionally happen. Making this assumption can only harm your chances as a re-applicant. The more frequent cause was an inability to meet expectations or a genuine lapse in professionalism. This is a hard job and it puts a lot of stress on those who do it. The clinical approach does not come naturally to most and takes work to adopt. And we all have moments where we are not our best self. Any one of those under the bright lights of an audition can spoil a letter.   

If you suspect a letter to be harmful do not use it in your re-application. Do not ignore that it happened. Try to take ownership and learn from this experience. Try to identify if there were valid concerns that you need to address. If you fail to do this then your next performance on an EM rotation will be no better.  Those subsequent EM experiences are what will ultimately determine the success of your re-application. You need to upgrade your application with very supportive SLOE's that make it clear you have developed the skills to succeed.

That is the ultimate goal for your re-application. To present a clear picture of someone who is going to succeed in the difficult environment of residency training. Show that you can learn and that you have grown. Leave no doubt that this humbling experience has left you more dedicated and better prepared to succeed.  

Adam Kellogg is an Associate Residency Director, former Medical Student Clerkship Director, the immediate-past Chair of the CORD-EM Student Advising Task Force.   

Application Resources from the CORD SATF

The CORD EM Student Advising Task Force has produced a set of application resources for medical students and those who advise them.  These were created with the input of all the groups who care about quality medical student advising (CORD, CDEM, EMRA, AAEM/RSA).  

You can find these resources on the CDEM Curriculum website, along with a whole bunch of other great resources: 
http://cdemcurriculum.com/2016/04/06/student-advising-task-force/ 

Included are a comprehensive guide to the application process, a more concise FAQ, a list of the best resources currently available, and a planner to help guide you through the process.  

Enjoy!

Adam Kellogg is an Associate Residency Director and a previous Emergency Medicine Clerkship Director.  He was Chair of the CORD EM Student Advising Task Force until very recently. Full disclosure - he served as an editor for these resources.