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. 

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.