AAEM 2014 Med Student Track

The American Academy of Emergency Medicine has their annual meeting coming up in February.  It will be at the Midtown Hilton in New York City February 11 - 15, 2014.

They are going to have a whole track just for medical students on February 12:

Wednesday, February 12, 2014

7:30am-8:00am	Networking breakfast
8:00am-9:00am	Pearls & Pitfalls of Emergency Medicine
9:30am-10:00am	Finding your Match: Types of Residency Programs
10:00am-11:00am	Program Director Panel
11:00am-11:15am	Break
11:15am-11:45am	Career Paths in Emergency Medicine
11:45am-12:15pm	Ultrasound in the Emergency Department

This is a great opportunity to learn more about the specialty and about navigating the application process.

Blogs are fun and all but getting to interact with actual people is even better.

Where are the interviews?!?

This is an anxiety provoking time of year.  Interviews start soon and right now you fall into one of two groups:

Group A - You have too many interviews (more than 10 - 12) and you are not sure which ones you are going to actually do.

Group B - You don't have enough interviews (less than 10-12) and you are in a panic over having to scramble to another specialty.

Let's deal with Group A first, as they are easy.  Unless you have special circumstances, like a difficult couples match (EM-ortho, EM-EM, EM-Derm), you already have all the interviews you will need.  And as programs start to get into their Wait Lists, you are going to get more offers.  In your Personal Statement you talked about what a great team player you are, now is your chance to prove it.  Politely decline some of those interview offers. Throw them back.  As programs higher on your list contact you with an opening, let another one go.  Most people do not want to do more than 10 - 12 interviews.  No one has stayed sane doing more than 15.  You will match 99% of the time if you rank more than 8 programs.

If you are in Group B, you are nodding vigorously right now.  You are waiting for interview offers because your colleagues are holding on to all of the spots right now.  They will start to give them back.  More spots will become available.  What you need to do right now is make sure that when those spots open up, you get consideration for them.

Make sure your application is complete.  If a letter was not uploaded, many programs will not have even reviewed your application before giving out all of their interview spots.  If your application was completed late for any reason, send a polite email to the coordinators of your most important programs.  Showing a little extra interest, courteously, can make the difference in who on the Wait List gets offered an interview.  This is the most useful thing you can do to increase your interview chances.

What you are thinking about doing is applying to more programs.  The programs will know that you just applied to them.  Most EM programs have the luxury of being picky about who they interview.  They are not going to be interested in looking at the application of someone who only recently became interested in them.  Not when they already had hundreds of more enthusiastic applicants.

Polite interaction with programs that already have your application is your best bet.  Be available on short notice.  Be courteous with whoever you get in touch with.  Be ready to bring your A-game on the interviews you get.  It only takes one program to rank you competitively to get you into EM.

Link: ALiEM Interview Tips

Nikita Joshi (@njoshi8) over at the incomparable Academic Life in Emergency Medicine site recently posted some great tips for the residency interview process.

This is a great list of recommendations.  I would add particular emphasis to "Being interested".  You should have questions ready to go for anyone you talk to.  The benefits are both for you and the program.  You get as much information as possible and impress upon the program how interested you are.  An applicant without any questions is presumed disinterested.  Even if the Residency Director answered every question you had during the "sales pitch", you should still ask about the things that matter to you.  You may even get different answers from a different source.

Another point that deserves a little more emphasis is "Remember that you are interviewing the program as well".  Once you have cleared the hurdle of getting an interview they want to like you.  You have met their academic standards and something about your application drew their attention. No one will sour on you for asking insightful questions.  Ask about the factors that matter most to you, from an educational perspective.  Both sides benefit from you making sure that this is going to be a good fit.

Assessing Competitiveness - Part 2

In Part 1 we introduced how to assess your own competitiveness.

An even more difficult task is determining competitiveness of the programs you are considering spending your application dollars on.

The most important thing to remember about assessing programs is that "perceived competitiveness" has little to do with how good your training experience is going to be at that program.  "Perceived competitiveness" determines how hard it is to get an interview at the program.  Your experience training at the program is going to be determined by the educators, the clinical environment, your class mates, etc, etc. (as addressed in "Where to Apply").

What follows are some characteristics that may help you predict which programs have a high degree of "perceived competitiveness" = "harder to get an interview."

In descending order:

1.  Is the program in a region that is highly desirable and where there are not many other programs?  For example: many people in their 20's prefer big cities to small ones.  Another example: there are many more programs on the East Coast than on the West Coast, so West is even more sought after. (Last note both the Northeast and West Coast want letters and rotations from their own coast, if you did not rotate in their region this will be a hale mary for you.)

2.  Does the program have "EM-famous" faculty?  Prominent figures in the world of EM, particularly those who would be visible to students (i.e. #FOAMed > past-presidents of ACEP).
Is there a popular blog or, podcast out of this program. Were you dying to hear a lecture by an attending? Is one of the attendings an author of a book you keep handy?

3.  Academic affiliation with a University that sounds impressive?  If your mom would be impressed with the affiliation, that counts.

4.  Age of program?  Older, very well established programs are often more competitive than their newer neighbors, especially if they played prominent roles in the history of EM.

5.  A multitude of fellowships, especially the ACGME approved ones (Toxicology, Pedi EM, EMS, Sports Medicine, Hyperbaric)? More fellows can be a surrogate for more academic stuff going on.

The mistake often made by applicants is to only apply to programs with high degrees of "perceived competitiveness".  If you are an average or below average applicant, you should be applying to programs across the spectrum.  This will ensure that you get enough interviews to not be a sweaty mess on Match Day.


You need to do the math:

The number of interviews you will get is a product of your competitiveness times the perceived competitiveness of the programs you apply to:

Above average candidate X Uber only = some interviews :|

Average candidate X Full Spectrum = Uber interviews :)

Average candidate X Uber only = few interviews :(

Below Average candidate X Uber only = no interviews :((


Lastly remember this is advise so you can maximize your application and interviews. There is nothing wrong with applying to a program you have always dreamed of joining, even if you are not an above average candidate, just realize the interview may not come.

Assessing Competitiveness - Part 1

Step 1 is to figure out how competitive a candidate your are.  Your advisor's should be able to help you sort yourself into one of three "buckets":  the average candidate, the above average candidate, and the below average candidate.

Above average candidates have:

• Honors in everything clinical
• Board scores that are above average (>240)

Above average candidates have little to worry about and should not be reading blog entry's on how to get a residency. Make a list of spots you like and would like to train (15-20).

An average candidate is going to match in EM if they make a reasonable list of programs to apply to.

The average applicant has:

• Board scores that are in the neighborhood of average (~220  >220).
• EM grades and letters that sum up as: going to do well in EM (Honors or High Pass with a supportive letter, & hopefully followed by Honors on the second rotation).
• No red flags.

Goal is a diverse list in different regions of the country (25-40).

If you fall short on any of those criteria you should consider yourself to be a below average candidate and plan appropriately.  This means applying to lots of programs (40-50), not wasting money on the most competitive programs, and having a back-up plan for not matching in EM.

This is additionally complicated if you are an Osteopathic or Foreign Medical Graduate looking to join an Allopathic EM program.  Only some programs (68%) will even consider your application.  The programs open to you have their pick of candidates and they are looking for the cream of the crop.  If your not at least an average candidate AND you are from an Osteopathic or non-U.S. school, your chances are slim and you need a back-up residency plan like IM or Family Medicine.

Fortunately, the receptive programs are easy to find by going to their website.  Look at their "residents" pages and see where their residents came from.  If you see residents who are D.O.'s or are from your country/med school, they will probably give your application a fair review.

Now that you have a sense how competitive you are, you can try to figure out the programs...

Communication Breakdown: Zebras, not Unicorns

In my last post I discussed the role of presentations in determining how a student is perceived by their evaluators.  Today I want to hone in on one particular part of the presentation:  the Differential Diagnosis.

The usual advice given to students on how to construct an "EM appropriate" differential is to go "worst first".  This means that the first diseases you discuss are those most likely to result in morbidity and mortality for the patient.  This is important in the ED as this is the place where all the sickest patients get funneled to.  In most out-patient settings acutely ill patients are a terrifying rarity.  In the ED they are the routine.  If you do not think of a life-threatening diagnosis, your chances of lucking into it are low.  "Worst first" is a safety net for us and our patients.

Every student has probably heard the truism, "When you hear hoof beats, think horses, not zebras."  The problem with this clever turn of phrase is that zebras are real.  If you have ever been to a zoo, or the Serengeti, you have seen them.  Positioned as we are, at the bottom of the medical pathology funnel, the ED is the Serengeti of medicine:  the place where zebras roam.  Or at least the zoo of medicine.

Not all uncommon diseases (zebras) are dangerous.  The uncommon and bad ones, like aortic dissection (~200 times less common than MI) are the ones we must be vigilant against and belong on our differentials when we "hear hoofbeats" (i.e. "chest pain").  Zebras that are not particularly dangerous do not need to appear on your differentials.

There are still diagnoses we should ignore, diseases that do not belong in an ED differential.  These are the ones that are neither common nor dangerous.  These are the ones we will only find in text books.  For EM, the truism should be changed to, "When you hear hoofbeats, do not think of Unicorns".

Once a student is able to reliably think of the dangerous zebras, the life threats, I encourage them to order their list by probability.  When first getting used to EM it is okay for your differential for a 25 year old man with pleuritic, reproducible chest pain and normal vitals to be "AMI, dissection, PE, pneumothorax, and espophageal rupture".  You have included the bad stuff.  But you have not given weight to prevalence of disease or your own clinical impression.  This is not what your supervisors are actually doing.

Instead, once you are reliably thinking of all the bad diagnoses, you can start presenting your differential the way the residents do.  Start with what you think the patient actually has, and why.  And that can be a common and less dangerous diagnosis.  You need to follow that "horse" with the less likely but more concerning differentials (the zebras), why you do not think the patient has them, and how far you want to go in tracking them down.   You can even tack a unicorn on at the end, so long as you do not want to actually pursue that mythical beast.

Happy hunting!

The Secret to Honors- Presentation Presentation Presentation

Now that Dr Kellogg has told why you need great communication, including presentations, here are some hints for how to be a rock star. Giving a superb presentation is a sure fire way to get honors in your EM clerkship. While it may seem each supervisor wants something different, there are some common features wanted by all. If you can master these basic aspects of the presentation and then tailor the finishing touches to your supervisor, you will succeed. 

Make sure to read The 3 Minute EM Presentation. It is a road map for success. 

First you must give an ordered, structured presentation: Don’t jump around or be too casual this is interpreted as lack of interest or knowledge.

Begin with the chief complaint - Set The Stage

“This is a 65yo male with h/o cad presenting with 1 hour of precordial chest pain.”

Follow with the history of present illness - Paint The Picture

Put the pieces you have gathered in the history together but make sure you have a reason for what you say.

Focus on the chief complaint, with the seven cardinal descriptors, followed by pertinent positives and negatives.

“The chest pain began 1 hr ago, while he was mowing the lawn, he describes it as a pressure over his central chest, radiating to the left jaw, associated with nausea, diaphoresis and shortness of breath. It increased with walking and decreased with rest and abated on arrival to the er. He had similar symptoms last year when he underwent catheterization with 2 stents.

He denies radiation to back, paraesthesia, pleuritic pain, change with position, or calf symptoms.”

Next you will review pertinent past medical history, medications, allergies, social history, and review of systems - Fill In The Background

Keep the focus on what relates to the chief complaint, not everything you learned.

“The patient has a history of hypertension, hyperlipidemia, CAD, Cath with stent x2 1 yr ago. He takes metoprolol last dose this morning, Aspirin 81mg last dose this am, and statin. He has NKDA. He does not smoke, drink alcohol or use cocaine, he does not use medications for erectile dysfunction.”

While you may know all about this patient’s h/o appendicitis at age 12 it does not relate to the complaint so leave it out.

Then relay the physical exam -

Again focus on what is important for the chief complaint. 

“vital signs stable, pt appears in no distress conversant, lungs CTAB, CV s1s2 RRR without m/g/h/t/ with full equal distal pulses no JVD, abd soft nd nt bs normoactive, ext no c/c/e symmetric calves”

Now you summarize the patient - Grab Your Audience 

This is your opportunity to pull your supervisor back in and show how you can interpret, assess, and plan. Your supervisor is likely being pulled in 5 different directions, you need to command their attention. 

“In summary this is a 65yo with h/o CAD presenting with exertional chest pain concerning for ACS.”

next move quickly to your differential and plan: Don’t get run over by your supervisor and never get the chance to show what you know and think.

“While ACS seems most likely we must consider dangerous causes of similar presentations including dissection, pulmonary emboli, esophageal rupture, and common mimickers of precordial chest pa in such as gerd, pneumonia, musculoskeletal pain and bronchitis.”

“My plan is to intervene with medication for pain, while supplying 02 as needed, and keep the patient on the cardiac monitor. To investigate his sx I would like an EKG, chest xray and laboratory studies to include cardiac enzymes.”

Remember to address: 

Interventions-what you do for the patient 

Investigations-what you do to investigate the chief complaint and differential

EM presentations are succinct, directed toward the chief complaint, focused on both dangerous and probable causes of the symptoms, and above all convey a clear picture of the patient and context for concern.  Remember to set the stage, paint the picture, fill in the background, and grab your audience. This is skill it takes concentration, practice and fortitude. Listen to the verbal and non-verbal feedback you are getting and tailor your presentation to your audience.