Rank List Run Down

Congratulations on being done with your interviews.  You can take your interview suit to the cleaners, or if you over-interviewed, you may just need to burn it.  You can check your frequent flyer miles to see if you can cover a ticket to somewhere warm.  You may even be able to step back and look objectively at the programs you recently interviewed with.  

Your last major residency application task is now upon you.  You have until February 26th to finalize your Rank List.  And you are likely putting a lot of time, thought, and stress into this decision.  

"How to make your Rank List" was one of the first topics we tackled here, and very little has changed about the whole process.  Our Rank List Tips still hold true, and you ultimately should still Go with your gut, in defiance of what your giant spreadsheet is telling you. 

While there are some differences between this year and last, overall competitiveness has not changed significantly.  The ratio of available spots to total applicants is the same.  Both numbers have been gradually and proportionally increasing for years. This does NOT appear to be what Medical School Dean's have been claiming, as the major change this year is in the number of applications each person has sent out AND in the number of interviews they have done.  I do not blame the Dean's for giving this advice, their job is to ensure that all of their students match.  They will do what they think is necessary to accomplish that goal.

The difference this year is that the "middle class" of applicants has shrunk.  There are fewer applicants with a number of programs to rank (8 - 10) who should feel comfortable about matching.  Instead, there appears to be an unusually large divide between the "haves" (>10 - 12 programs, AKA: the over-interviewers) and the "have nots" (<6 - 8 programs to rank).  This has introduced added uncertainty into an already stressful situation.  Programs fear that they have interviewed the same candidates as EVERYONE else and won't match enough of them.  Applicants with low numbers of interviews fear that they are only padding the back-end of rank lists at programs that interviewed extra or played it safe in offering interviews.  While most of the concern is likely unfounded, given the steady growth in BOTH spots and applicants, we will not know how this plays out until after the match.  

The advice that follows has held true in past years and is likely to still be relevant:   

1. Rank any program that you would consider to be better than scrambling (SOAPing) to a surgical pre-lim. year or to family medicine. There is effectively no scramble within EM.  If you don't match, your next shot at EM is next year.  
2. Rank programs in the order you like them.  The match algorithm favors the students. You will match to the program you rank highest that gets to your spot on its Rank List.  There is no advantage to you in ranking a more "realistic" program ahead of a "reach".  
3. Once you settle on your #1 program, you need to let them know.  Programs want to be liked, just like everyone else.  Just don't tell more than one program they are your #1.  The world of Residency Program Directors is a relatively small one and you don't want to get caught in a lie.

For more on making your rank list see these posts from Academic Life in Emergency Medicine: Making Your Rank List and Top 10 Tips When Making Your Rank List, as well as our post on Going with your gut that includes a more detailed explanation of the Match Algorithm in case you do not believe the whole "student weighted" thing.

Best of luck!  You are almost there.  

Learning Resource: Didactics Online

I recently met a student who created a website full of useful educational resources for medical students and others early in their EM careers.  Brandon Parker (@DidacticsOnline) is a soon-to-be EM resident and his site, Didactics Online covers a variety of topics.

The most recent post is on GI Bleeding.  Included on the page are a pdf of slides that are concise and focussed on what you need to know.  Short, sweet, and to the point.

The post before that is on Monitoring the Critically Ill Patient and has both a pdf of the slides as well as the accompanying podcast.

This site is different from a site like Flipped EM Classroom, which is trying to be a repository of all topics in EM.  Instead, Brandon has put together some very accessible dives into a few different topics, many of which are relevant to EM.

Some of the EM oriented topics are:

How to present a patient
Stroke and TIA
Migraines
Dizziness and Vertigo
ARDS
COPD

Have a look.

Learning Resource: The Flipped EM Classroom

Many educators feel that the future of didactic instruction is the "flipped classroom" model.  Students review materials at home before coming to class, sometimes watching on-line lectures/videos.  In the classroom they do their "homework", working through problems and concepts while the teacher(s) circulate and help the learners.  Many Emergency Medicine Residency Programs are adopting, or at least experimenting, with these concepts.

One benefit to all is that a lot of on-line resources are being produced.  A great example is that work of The Flipped EM Classroom.   The foundation for the content covered is the Clerkship Directors in Emergency Medicine (CDEM) Curriculum for medical students, so it makes a strong foundation of knowledge.  Think of this like a souped-up, FOAMed, multi-media version of the "First Aid for the EM Clerkship"-type books.

There are small, easily-digested, modules on "Approach to..." a variety of common ED complaints like:  Abdominal Pain, Poisoning, Trauma, etc.

There are also Disease Specific reviews grouped by organ system.  For example, in the Cardiovascular group there are Abdominal Aortic Aneurysm, Acute Heart Failure, Pulmonary Embolism, and more.

For third years soon to start EM rotations: this is the knowledge base and approach that your supervisors are going to be looking for.  Get a jump on understanding this information from an EM perspective.

For fourth years going into EM.  Your program is going to be expecting you to have this foundation of knowledge when you show up.  If you don't, you will get feedback like, "knowledge base is behind that of peers".  Any you don't want that.

Enjoy!

The big DO decision

We just added a guide for the osteopathic student interested in training in an allopathic EM residency.  The advice is a little late for anyone applying on this application cycle.  However, there is a dilemma facing many of the DO students who have interviews at both allopathic and osteopathic residencies.  What do you do about the DO match?

EM is competitive, very competitive.  Goal number one is to match into a training spot, even if it is not the perfect location.  You need to make rationale decisions based on what is going to give you the best chance to match.  That being said, you can predict whether you have drawn enough interest from the allopathic programs to safely withdraw from the osteopathic match in January.

Most students are going to fall into one of three groups.  For two of these, the decision is easy:

1. Has only 1 or 2 allopathic interviews.  If you find yourself in this group, you should stay in the osteopathic match.  The chances of being left without a spot are too great.
2. Has 10 or more allopathic interviews.  This group can withdraw from the osteopathic match, if their top programs are allopathic.  These programs are going to rank you on their list.  The odds are excellent (>95%) that if you rank 8 or more programs, one of them is going to rank you high enough that you match there.  
3. Has 3 - 9 allopathic interviews.  This group has the toughest decisions to make.  You are going to have to decide on whether to gamble on the allopathic match.  The safe play is to rank several DO programs and stay in that match, moving only to the allopathic match if you do not get one of those.  If you have greater risk tolerance, you can take a chance and withdraw from the DO match.  All it takes is one program ranking you high enough to match there.  There is no one size fits all answer.  The best way to figure out what is right for you is to look at your individual situation with a trusted advisor.

Effective Interviews - Part 2: What's Hot?

In part 1 of "Effective Interviews" we covered the basics of how to get the most out of your interview days.  In part 2 we are going to raise your interview game with a discussion of what topics are "hot" in Emergency Medicine in the fall of 2013.

While on the interview trail you are discovering the "hot topics" to talk about from your fellow applicants.  This is the default topic.  The one you go to when you are out of other questions or because everyone says you should ask about it.  For a long time this was Trauma, as in: "What is your Trauma experience like?"  For a few years now Ultrasound has usurped this spot.  This year, another shift is likely upon us: "What role does Social Media have in your education program?".  The most mainstream of EM publications, the Annals of Emergency Medicine, just published an article about Twitter.

Twitter is a great window into what is being discussed and debated in EM.  All you have to do is follow a few of the disseminators of #FOAMed (@emlitofnote, @njoshi8, @emcrit, @CriticalCareNow, @srrezaie, @precordialthump, @LWestafer, just to name a few) and you will quickly be caught up on the discussion.

But if none of the preceding paragraph made any sense to you, here are some of the big topics under discussion in 2013:

• Social Media in Education - you should probably have an opinion or stance on this.  Many of your interviewers will.   Though you shoudl be ready for otherwise wonderful and enthusiastic educators to be very skeptical of the whole concept.  They may also be more interested in your understanding of professionalism as it relates to Facebook/Twitter/Snapchat/etc.
• Thrombolysis for Acute Ischemic Stroke - this is being debated vigorously in EM with ACEP releasing a policy statement that has led to much consternation from many practicing Emergency Physicians.  This has recently been discussed really well on the ERCast podcast.  The LITFL blog also did a good discussion to review as well.
• Video vs. Direct Laryngoscopy - This is being hotly debated in EM right now with very knowledgable people on both sides of the "Is direct laryngoscopy dead?" debate.  As someone about to begin your training, knowing the programs philosophy on airway management is going to be really important to your education.  What do they do?  What do they teach?  This is way more important to your eventual career than how they get Trauma experience (A comes before T, after all).

Other topics of recent discussion also include:

Transexamic Acid (TXA) in Bleeding Trauma Patients - Review by Napolitano et al.

Novel anti-coagulants and newly approved treatments - Dabigatran, Rivaroxaban, Prothrombin Complex Concentrates

And just this past week, the value of Therapeutic Hypothermia (aka Targeted Temperature Management [TTM]) in Cardiac Arrest came under renewed scrutiny.

So much to know.  Maybe you should get that Twitter handle after all...

Effective Interviews - Part 1: The Basics

The interview process is a huge expenditure of precious resources on both sides.  If you are going to go to the trouble and expense of interviewing at a residency program, you owe it to yourself to come prepared.

The Program Director will almost invariably give you some kind of overview of the program or "sales pitch".  This may even include perceived weaknesses and plans for improvement.  Even if their presentation seems balanced, they are still emphasizing the programs strengths, just as you did with your application.  You will have an opportunity to talk individually with the Program Director and other members of the residency and you owe it to yourself to dig deeper.

Since you are reading a blog about getting into EM, you have likely encountered lists of "must ask" questions.  I think there is no such thing as the "right questions" to ask.  I would much rather discuss topics that the applicant has a genuine interest in.  Answering the same questions over and over again is not enjoyable for either side.  Instead, ask about what really matters to you.  Find out if this is a place that is going to meet those needs.  If you have made it this far without deciding what really matters to you in your future training program, now is a great time to start thinking about it.

The questions you ask should be thoughtful enough that you cannot just answer them from going on the programs website for 5 minutes.  Though this is a great way to find things to discuss.  Make your question a level deeper than the website goes.  For example:  Don't ask, "What kind of rotations do the interns do?".  That is invariably on the website.  But you can ask what the experience is like on specific rotations, and if they have any concerns about the objectives being reached.

If you are going to put all this effort into coming up with good questions, you should feel comfortable asking the same questions of all of your interviewers.  You may get different answers depending on who you ask.  For example:  the Program Director and the Pedi EM Fellowship director may have very different perceptions of the EM residents pediatric experience.  You will have to decide whose opinion to put more stock in, but this information can be incredibly valuable.

One particularly important area to explore, that will not be addressed by the website is the stability of the program.  If there are changes to the size of the residency, the curriculum, the physical plant, or the program director or chairman, find out how these came about and what impact these are expected to have.  Change is often a good thing, but abrupt change is often not.  Particularly when there is not a cohesive forward-thinking plan for the future.

A few other general interview tips.  These may seem obvious, but a remarkable number of students break these "rules", usually to the detriment of their chance to match:

1. Go to whatever they have the night before.  This is essential to getting a feel for the culture of the program. 
2. Be on time for the interview.  In fact, be early.  Leave yourself enough time that even if you get lost, you will still have plenty of time.  Inability to plan ahead is not a sought after trait in Emergency Physicians.
3. Dress professionally.  You do not need to wear your black or funeral-gray suit, however you also should not look like you are going tailgating or clubbing right after the interview.
4. Be respectful to everyone, especially the coordinators.  Especially the coordinators!
5. Be yourself.  The professional version of yourself.

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.