So you want to do emergency medicine? Great!...You’re already
making good decisions. Hopefully you will be reading this somewhere in your 4th year of medical school. The list of questions that follows was developed by medical students applying to EM who rotated at UF-Jax in 2012 (as well as a few tough ones that I came up with). Clinical directors in emergency medicine from all across the country were interviewed via teleconference or phone in a quest to find out the answers. Then all the answers were effectively smashed
together into cohesive answers. Not all perspectives were alike, and diversity in responses were excluded included.
All joking aside, I am sincere in my efforts (see Purpose page) and am excited to present this project to you in a expandable/collapsible question format. I hope this tool will prove useful in answering your questions as you move through the different stages of the match process.
Pre-Application 1) Who/what might be a good resource at my “non-EM” school for emergency medicine information?
There is a lot of stuff to figure out when going through the match, and for the student who doesn't have an EM residency at their home institution this can, well... make things a bit more complicated. Luckily for you, there are several places that can get you off to a running start. The internet has a lot of good rescources:
With all that said, it's hard to obtain all your information online. So, off-line resources can supplement what you've found online. A great place to start is with faculty at your school if you have academic EM faculty. Previous grads/alumni from your medical school who matched in EM can be an invaluable resource because they figured out how to navigate matching from your home institution. Dr's Heitz and Wald mention that even community doctors can help direct you in the right direction even though they may not be able to personally help with your endeveours if they have been out of residency for many years. Additionally, assigned mentors and deans will be able to direct students. Dr. Ander suggests going to regional EM meetings, such as SAEM regional meetings to network as well.
2) How many EM electives should I do in 4th year? Also, what non-EM rotations should I take in my 4th year electives to prepare me for residency?
The standard answer for most advisors was doing 2 core EM rotations just because of the importance of getting 2 EM SLORs. A third EM rotation was optional and could be taken in ultrasound, EM research, or in a fellowship such as toxicology, hyperbarics, etc. So, if you have don't have a home institution program then its recommended by most that you do two away rotations. Interestingly, Dr. Kman who has done research on the subject mentions that you can appear to "slight" one program by doing an away rotation at other program, because then every other institution wonders why you didn't do an away rotation with them. At the same time, away rotations are deemed necessary by most of the interviewees. Ideally you want to do your EM electives early in your 4th year. How early? Early enough so that your LORs come in by the time your Dean's letter is released from your school on November 1st. So July, August, September is NOT too early. If that doesn't work out for you, then no worries, students are still doing away rotations into December...although that is not quite ideal. How to set up the rest of your 4th year? I like the holistic way Dr. Heitz thinks about it. He explains that there are two ways to think about the rest of your 4th year, and the key is to blend the two views together when creating your 4th year schedule. In one sense think about 4th year as prep for your intern year--find your weaknesses and strengthen them. Most commonly recommended electives were ICU, radiology, cardiology, dermatology and surgical subspecialties such as ortho/hand, plastics, ENT, ophtho. However you don't want your 4th year to look exactly like intern year in EM--because then you haven't broadened your knowledge base. So, the 2nd way is to view your 4th year is as the last time you get to formally study something you're curious about or interested in outside of EM. Maybe your home institution has a really good infectious disease rotation, or maybe you've always been interested in congenital cardiac anomalies in pediatric cardiology. By combining these two views you broaden your knowledge base by following what you are naturally curious about and still prepare yourself for your intern year. 3) As a medical student, I don’t have a lot of money to do an away rotation. How important are away rotations in the match process?
There is a dichotomy of responses to this question with most responses weighing heavily toward away rotations being a necessity. "Very, very important." "Strongly recommended." and "Absolutely mandatory for the student without EM at their home school." Yet one states that "it's variable" and only more important for the student without a home EM residency. Dr. Kman points out that you can potentially "slight" other schools if you do not rotate at their institution. While most all feel that away rotations are critical, Dr's Avegno and Ander point out that there are also compelling reasons that may prevent someone from being able to do away rotations such as having small children or severe financial issues. So, why does most everyone feel so strongly about away rotations??? There are a couple reasons. One of the biggest is that it is that it helps you get your needed letters of recommendation. Additionally, when you get a SLOR from an academic EM attending, it is weighted much more heavily than a letter from a community EM doctor. Secondly, Dr. Lin says, "You want an external validator that says, 'Yes. I am still awesome.’” Dr. Heitz suggests that not having a SLOR because you rotated at a community site may hurt your chances of getting interviews because your letter writers’ names may not be known among the academic community. (See question 7 in Application Process for info about SLORs) Dr. Cooney makes the point that away rotations can actually trumph grades and board scores if you do really well on an away rotation. Remember programs will be sifting through a long rank list themselves. Students who have rotated will be much easier to remember. 4) What makes a student stand out on an EM rotation? And is there any studying/reading to do beforehand?
It's amazing how the answers started to repeat themselves. So is there anything students can do to prepare for the rotation? Dr. Avegno puts it best in stating that sometimes "you have to jump in and get your feet wet" as it’s really hard to read up on stuff because you don't know what you will see. Many others echoed that same response. Even with that being said, Dr. Avegno and others agree that it's to your benefit to have knowledge of bread and butter Emergency Medicine topics that you KNOW you will see. CDEM Curriculum: Student Portal is a great place to start to cover the some basics for med students in EM. Across the top of the page you'll find information about how to approach common chief complaints, specific diseases, training modules and tests that will help you look like a rockstar on your rotation. So what about when you are on shift? Some stuff is obvious, like showing up a few minutes early, and staying late if there's something to do. Be 100% involved in what is going on- so that means turning off your cell phones, no texting during shifts, and don't surf the internet. Be a team player, friendly, and positive. Don't be argumentative or a brown noser. You should really just be focused on working hard, learning, and giving good patient care. Always stay busy while on shift. If it is slow or gridlocked figure out how you can help nurses or techs put in IVs, NG tubes, or foleys. Other things aren't as obvious. After seeing a patient, but before presenting the case to a resident, Dr's Kman and Ander suggest looking up information in a pocket reference book about a diagnosis before presenting to a resident or attending. That will help you be able to answer any questions about the disease entity and treatment if you get asked questions. I really like Tarascon Adult Emergency Pocketbook as a pocket reference, but Epocrates and Pepid are also good medical apps on phones. Also, importantly, be able to identify any instability (abnormal vital signs) or potential instability (concerning patient story). Recognize the importance of other sources of information when obtaining a history such as triage notes, nursing documentation, nursing homes notes, and possibly contacting nursing homes or families for demented patients. Remember, as you present your case to a resident or attending, people will judge your intelligence, or lack thereof, based on how well you present cases to residents/attendings. So that makes case presentations one thing you want to be good at while on shift. Presentations in the ED need be short enough to keep people's attention yet long enough to cover the necessary information. Easier said than done, especially when you are just beginning. Several people mentioned the 3 Minute EM Medical Student Presentation to help you improve this skill. Also, listen to how effective residents present, and ask for guidance from them. After presenting a patient case, follow the patient through their ED course. Most residents and faculty care more about quality of patient care that the student provides rather than quantity. As long you are being diligent with your work and staying busy with patient care, most could care less about quantity of patients seen. Quantity will come with time and in my opinion, students carrying 2 (max 3) patients at a time is optimal. Students often do a decent job getting a history and physical, however I think it’s hard for students to appreciate that there is this whole big second half of patient care in the ED. All the things that are done after the inital H+P to the point at which the patient leaves the ED are commonly overlooked by rotating students. Paying attention to this will make you look like a rockstar. This deficit in recognizing the second half is not because students aren't trying, its really a factor of the student not yet being an EM resident and not yet being responsible for that second half. I've seen students who are really trying to impress residents want pick up charts one after another to show initiative. However, they fall short of following up on the second half of the patient care on all these patients they present. It's a rookie mistake, don't do it. Let me elaborate on this second half of patient care from a resident perspective. In doing your EM rotations you want to prove to people that you can be a good EM resident. Part of being a resident is making sure things happen for patient care. There are always things you can do to help expedite your patient’s care. If you need a urinalysis on the patient, then bring the patient the cup to urinate in and show them the bathroom. If your patient needs an XR or CT scan then ask the resident if it's okay for you to push them to XR/CT. It’s not scutwork if it is directly affecting the care of your patient. If the patient needs a procedure, then help get the equipment together at bedside for you and the resident to do it together. Of course there are people in place to help make all these things happen, but if your ED is like most, then those resources are likely getting overwhelmed. If labs are taking a long time to get back, call down to lab to make sure there are no issues. Additionally it may be helpful to have the extensions to lab, XR, CT, etc. Find out the numbers and use them to help expedite care for your patients. Watch for the lab results to return, follow up Xrays and other imaging studies. That means pull them up on the computer and look at it yourself, not only look at the radiology read. You should be telling the resident/attending that the studies are back, not the other way around. You will able to do this because you will be seeing far fewer patients than the resident. When a student has pointed out to me that labs are back, or said "Hey, I have our patient's x-ray pulled up. Will you take a look at it with me?" or "I'm going to go ahead and push our patient to x-ray, okay?" I've been impressed. Students usually don't beat me to the data or realize that the patient has not yet gone to x-ray. This is simply because they aren't yet trained to think about that second half of patient care. Also, have an interpretation for the results and a plan for what you think should be done next. For example if someone is in DKA, you should know the general treatment for DKA. Your on-shift references listed above will help you with this hurdle. Realize that you may be wrong and that's okay. It's part of the learning process. Also, keep your patient updated about lab results and plan of care. Do these things for the patients you are personally following. Of course all facilities will run a little differently, so figure out all those little additional things residents do for their patients and take the initiative to do them. Additionally, disposition decision making is especially important in Emergency Medicine. Disposition means “where does the patient go after our workup is finished?” Will the patient be admitted or discharged? If they are admitted, whom should they be consulted to and should they go to a floor bed or an ICU? Have a plan for disposition, while understanding that you may be wrong. And that's okay. You're learning. All of these little things are noticed by the residents and faculty you are working with. If you can focus in on this second half of patient care then you will be a step ahead of 80-90% of medical students in my opinion. Also, make daily improvements. Dr. Fix and others state that you can clinically stand out by asking for feedback and being flexible enough to actually incorporate that into your next case or next shift. Ask for feedback on something specific too, not just "what can I improve on." Additionally, go home and read on cases that you see. Then next time you see the resident or attending that you worked with on a certain case you can reconnect with them and say "Hey, remember that case we had together, I read about it and learned [insert cool learning point here]." Application Process 1) With variables such as board scores, grades, extracurricular activities, how do I judge how competitive I am for emergency medicine?
Some of the most objective data can be found at the NRMP website. NRMP Charting Outcomes looks at each specialty and demographic data on matched and unmatched applicants. From a program's perspective, Dr. Wald states there are 4 different areas of an application that essentially determines an applicant’s competitiveness. The four areas are clinical clerkship grades, grade in EM rotation, board scores, and letters of recommendation (not necessarily in that order). Only occasionally does EM leadership, extracurricular activities or research play a central role in an applicant's competitiveness. Other responses were more nebulous because neither programs nor applicants are of a cookie cutter design. It can be like comparing apples and oranges. There can be tremendous differences between what individual programs are looking for in students, just as there are tremendous differences in what students are looking for in programs. Each program places different values on qualities of applicants. While one residency may value leadership, another school may value research activities more. With that being said, the best way to determine how competitive you are for EM is to ask an academic EM advisor. And yes, that was the overwhelming response to this question. He or she can give an accurate judgment of how competitive you are as an applicant. (Don't have an EM mentor? See E-advisor in question #1) 2) There are a lot of EM programs. Is there a lot of difference between them? Does where I match really affect my training all that much?
The general feeling toward these questions is that if you graduate from an accredited EM program, then you will be a solid EM doctor. Many respondents stated that all residencies teach the same basic material because the Residency Review Committee (RRC) puts such strict guidelines on teaching requirements. However, it is important to recognize that different programs will have different strengths. Programs that have fellowships will often be stronger in the area of their fellowship. Additionally, patient populations can vary a lot depending on where you train. Programs that are inner city will give more exposure to an indigent population, uncontrolled diabetes, and HIV than community settings. EM residencies that are part of large research institutions may have a slightly different patient population than other places. Geography also plays a role in a program's strengths. A program in the southeast US will have more exposure to envenomations than a program in the northeast. Likewise, residents in programs in the north will see patients with different environmental exposures than residents who train in the south. The deeper you look, the better you’ll be able to ferret out the subtle differences between programs 'X" and 'Y.' Talking to EM mentors, E-advisors, reviewing the SAEM residency catalog (link in question #1), and spending some time at the program while interviewing will help clarify individual strengths and weaknesses of a particular program. The key is figuring out what you are looking for. If you know you want to do a fellowship, then programs that offer the fellowship that you're interested in may be higher on your rank list. If you know you want to do trauma when you finish then programs that have a level one trauma center will provide you a more experience in what you are looking for. However, if you know you want work in the community after finishing residency, then maybe a residency with a community setting will have the biggest appeal to you. On the flip side of that, maybe you want to train at a big research institution and bring that information back to the community. It's all really about what you want. It think Dr. Avengo captures it best:
3) There is no official ranking of the programs. How do I figure out which ones are the competitive/desirable ones I should apply to?
Simply put: “It depends on what is competitive and desirable to you. That is different for everyone. If you and your entire extended family live in San Francisco, then San Francisco will be desirable and competitive to you." --Dr. Lin. She brings out a great point that many others echoed. The best program for a particular student will likely vary from person to person. This answer overlaps a bit with the previous answer, i.e. matching to your best program requires some insight into where you fit in best. Don't be fooled into thinking that just because a program is hard to match into means it is the best for you. "Some programs are more academic, some are more county. Some are bigger, some are smaller. You are going to graduate any program in EM with an excellent education and be able to work in the field. I think the key is to find one that matches the geographic location of you and your partner. Find one that you will be happy at, and one that fits your learning style. Don't get too bogged down on what is or isn't a good program. " --Dr. Ander With the above being true, how does one determine which programs are more difficult to match to? This is an important question to every applicant who doesn't have straight A's/Honors and to those who did not make a 260 on their boards. As archaic as it may sound, "word of mouth" is probably be best way to get a feel about how EM programs compare to each other in nationwide competitiveness. Talk to E-advisors, program directors, or EM mentors that are involved in academic medicine to get an understanding of how hard it is to match at programs that you are applying to. Other answers were primarily generalizations. Generally programs at a top medical schools, and California/west coast programs are very competitive. Additionally, typically community and rural programs are less competitive just because most EM residents want the big city experience. However, I really didn't get a lot of good answers beyond that to direct students toward determining how competitive individual residencies are. So, talk to people who are in the know! 4) How do I gauge how many residencies to apply to? Are there any basic guidelines you recommend?
The summation of all the answers comes down to this:
Indeed, Dr. Wald. And when you ask 9 national leaders in EM this question, you get answers that only slightly correlate with each other. It's pretty apparent that it is just difficult to give an accurate answer to this question. However, let me explain a consensus way to approach the problem. In answering this question for yourself, first you have to figure out how competitive you are, and then you can ballpark how many programs to apply to. The NRMP Charting Outcomes can give you the most up to date information to compare your demographic data against those just matched to EM. Based on the NRMP data, you are very likely to match if you rank 10-12 programs. So, the real question is, how many programs should you apply to in order to get a minimum of 10-12 interviews to put on your rank list? Let's say you are the average EM applicant. That means based on NRMP data your scores for Step 1 and Step 2 were 223 and 234, respectfully. The recommended number of schools to apply to ranged from 20 to 40 programs for the average student, depending on who was answering the question. If you are highly competitive with excellent grades, excellent board scores, and excellent LORs then perhaps you can apply to around 20 programs. For those of you that are less competitive should be thinking about applying to more programs while recognizing that the extra cost for the additional applications is relatively insignificant in comparison to the 100K+ that you are already in debt. If you feel that you are less competitive please refer to Questions 5 and 6 in Application Process.
5) I really want to do EM, but I feel like my scores aren’t the best. What can I do
to improve application so it will get noticed? If I don’t match, is a good idea/worth it to do a transitional/prelim year and then reapply?
The number one thing you can do to improve your application is to do an away rotation in EM and really shine by getting high pass or honors. This is more effectively done at the beginning of the 4th year. If doing a core EM rotation early isn't possible (different programs have different externship requirements), consider doing an EM ultrasound or EM research rotation at a program you are interested in. Recognize that there can be a lot of competition to do an externship and applying early (March/April of your 3rd year) can help improve your chances of securing an extern spot. Doing well on this rotation and getting a strong EM SLOR will help you get noticed in the pile of your competitors.
The second most cited way to strengthen your application is to take Step 2 early in your fourth year, and do well on it. It can be a game changer for the mediocre student. EM programs typically value the Step 2 score more than the Step 1 score because it shows that you can take the clinical information and apply it. You could consider contacting the program coordinator/PD and letting them know you are interested in their program and ask if you can shadow sometime, especially if you find yourself in the area. Going to EMRA student residency fairs (at ACEP or SAEM national meetings) and introducing yourself to the PD's of places that you want to go may help get your name noticed. Your personal statement is also a good place to highlight what makes you different than the other candidates. Beyond that, it seems that you are pretty much differentiated by the strength of your application. It's really not clear if these last 3 suggestions will actually make a difference. Usually any brief research experiences or extracurricular activities won't help the student who already isn't competitive. If you have large deficits in your application you may need to consider a longer 1 year longitudinal project with a mentor that can write you a stellar letter or consider getting an MPH. What about doing a transitional year? It seemed as though the general consensus was that you can try a transitional year if you don't match, but it doesn't guarantee anything. The most positive response was "If you don't match in EM the first time, then I think doing a prelim year and showing us that you can clinically do the work is a good idea" by Dr. Heitz. Dr. Wald was less optimistic with "Very rarely do we see someone who is interested in EM, doesn't match, and then reapplies and matches." A transitional year is much more likely to help the applicant who didn’t match because they decided on EM late, rather than the student who didn’t match because they are a weak candidate. In the end, it seems to remain unclear if doing a transitional year will actually help you match into EM the next year though, because you are thrown into the same competitive pot. 6) How do I know when to start thinking about applying to other specialties as a backup?
Every student should have a goal for Match Day. That goal should be to match into training program. Every year there will be students who don't match in to emergency medicine. It's my goal with this question to give students a reasonable set of guidelines to help them decide whether it's practical for them to apply to EM. I've seen people I care about not match into the specialty of their choice. Sometimes it's surprising, but sometimes it's not. Either way it's difficult to watch. I want to prevent that from happening to anyone that I can. The following are 'red flags' as detailed by the interviews conducted. If any are in your application, know that it will be a significant impediment to matching into EM.
* Programs get judged by graduates passing rates on boards (Step 3 and beyond) when they get accredited, so programs hesitate to take anyone who has proved they have difficulties passing exams. **Many don’t believe being a DO is an impediment to becoming a successful emergency medicine physician, however it can make it more challenging to match into an EM residency. Osteopathic candidates should investigate whether the schools they are applying to are DO friendly or not. Foreign grads are in a similar situation and likewise should investigate the policies of the programs they are applying to. *** Dr. Cooney points out that sometimes it requires some degree of self awareness to realize that EM may not be for them. Dr. Wald mentions that occasionally there are students who have decent board scores/grades but don't perform very well clinically on their EM rotation. Frequently these students lack insight into what works or what doesn't work for them. If your perception of your performance differs significantly from others, it may mean that you need to re-evaluate what works for you. If your rotation evaluation differs significantly from how you think you performed this should be an indicator to discuss your performance with the clerkship director or your mentor. 7) When is a good goal to have my ERAS in by? LOR in??
Do you feel like there is a difference between SLORS and other LORs? How many letters should I have? Do they all have to be from EM?
When is a good goal to have my ERAS in by? The general consensus is that you should submit your ERAS application as early as possible, meaning within the first couple days of ERAS opening in mid September. The only reasonable things to be missing would be LORs and the dean’s letter. While most everyone agrees on that, different programs pull information off ERAS with different time courses. Some programs check back to ERAS many times throughout interview season to check for completion of applications, other programs only pull information off ERAS once. These differences among programs create slight variations on recommendations regarding when the ERAS application should be completed. Some programs only offer interviews when everything is complete. Dr. Heitz explains, "You want to have everything done by the time the deans letters come out because a lot of programs will download the application once when the deans letter comes out. Then the programs are done [downloading applications]." However, other programs may offer interviews even with an incomplete number of LORs submitted, because "if you are a strong applicant, they don't need 4 LORs to say that you are a good candidate," says Dr. Lin. Dr. Fix suggests, "Put a slot for your letters in your application where you know you plan to do away rotations. Also, it's always okay to email a program coordinator to let them know you are interested and let them know your ERAS has been updated with a new SLOR."
Remember that it is your responsibility to assure that your application is complete. Don’t procrastinate. Often times gentle email reminders are necessary to assure timely submission of LORs. What are SLORs and how are they different than LORs? A SLOR stands for Standardized Letter of Recommendation and is unique to emergency medicine. Only academic EM physicians can write SLORs. The CORD website has a page dedicated to explaining SLORs and gives links to SLOR templates. A LOR, or Letter of Recommendation, is a letter that is in prose format, can be written by anyone, and is probably what comes to mind when you think of letters of recommendation. Are SLORs weighted significantly different than LORs in an application? Dr. Cooney had a comprehensive answer to the above question. Other's shared the same sentiment. "This was discussed on the CORD (Council of Residency Directors) website. The consensus was that a composite SLOR with a consensus of all faculty was weighted the highest. After that a solo SLOR written by one faculty member was next highest. Weighted next was a general LOR from an EM faculty member. After that were EM letters from community sites, followed by letters from off service rotations, then finally research letters. There is a general pecking order to letters, even within SLORs." Dr. Heitz mentioned that although he feels that a regular LOR adds a more personal perspective on an applicant, some programs will barely look at these non-standardized letters because the information can be so variable.
Do the letters all need to be from EM doctors? Most agree that it is a good goal to have all your letters from EM or atleast 2 SLORs. However, it seems to be acceptable to have one letter from outside of EM because it can be tough to get your EM rotations early in the 4th year. If you have to get a letter outside of EM then get it from someone who knows you extensively. If you get a letter from outside of EM, letters from core or rigorous rotations such as ICU, surgery, or internal medicine may be better to choose from than an easy elective. A 4th letter could be considered if you have a mentor or a PI in a research project you have been involved with. Dr. Avegno warns that letter writers outside the specialty with big titles are not very impressive in EM. This differs from some other specialties. Sometimes medical school deans don't recognize this uniqueness in EM and may accidentally mislead students. .8) Anything else regarding the application process that you see as important, but has not been discussed here?
As an open-ended question, I expected to get a variety of responses. Interestingly, without suggestion, all but 2 respondents chose this opportunity to discuss the personal statement. The personal statement is sometimes reviewed to "make sure you're not a weirdo or too eccentric," but overall it will not play a large role in determining whether you get an interview at a program. (That is, unless you've been pre-determined to be a weirdo.) Your personal statement "shouldn't be a resume in paragraph form." "Be creative and make sure someone proof reads it to assure the grammar is accurate." "Write about something that can't be found elsewhere in your application. You want the first paragraph to grab the reader's attention without being too cheesy." Importantly, "never write anything negative about another facility, another specialty, or a patient. Keep it all positive." The personal statement may play its biggest role during the interview where the interviewer is looking for things to talk about. Some interviewers have a very standardized interview and always ask the same questions, however others are looking to make personal connections and a personal statement can help augment that. Finally the personal statement provides the opportunity to address any weaknesses in your application. The 2 other opened ended responses come from Dr. Lin and Dr. Avegno. Dr. Lin recommends scheduling lighter months during interview season. Try to do an outpatient month or use a vacation to free up time during the interview trail. Try not to get call months because you don't want to be exhausted on your interview. Dr. Avegno re-emphasizes the importance of turning your application in early and to avoid hiding any weaknesses in your application because they will be seen. Be ready to talk about your weaknesses in your application. Interview Process 1) I understand there are different types of EM programs that could be loosely divided into 3 styles: community, county, and academic. Do you agree? Also tell me about what types of students thrive at your style of program.
Unfortunately this is not a black and white issue. Some don't agree with that statement because programs "come in all different cultures and flavors"-- that it's too limiting to categorize programs. Another points out that "all are academic because all programs guarantee the same number of academic hours as mandated by the RRC." That being said, others agree with the statement but only "in broad strokes" or "roughly agree with the 3 different types. Of course there is some overlap but that is my starting foundation." "Many places have features of more than one categorization. There are very few pure county or pure academic programs, and most programs combine all three." Dr. Wald points out that It may be easier and more appropriate to categorize the institution instead of the program. Institutions in big inner city environments are classically high volume with limited resources, have lots of trauma, and have a greater proportion of indigent population. This type of institution is sometimes categorized as 'County.' Community institutions tend to focus on clinical training and might not place as heavy an emphasis on research. Their prime objective is to train phenomenal EM doctors who can work just about anywhere in the US. Academic institutions place more emphasis on research, academics, and publishing on a national level, but may not be the best setting for those who have no interest in research. Dr. Ander brings out a good point. "Don't worry about the type of programs all that much. You may think you are a county type resident, but in the interview process you may find out that you will really thrive in the community program. So when applying, don't put your blinders on too early in the process." Dr. Fix echoes the same thing and suggests doing an away rotation at a program that is dissimilar than yours to explore what would be a good fit for you. "If your school is an academic institution, then try to do an away at a county program. Then go with your gut regarding what place you click with best. That is way more important than county, community or academic categorization." In short, "Every residency program has a different focus and slightly different training. Figure out what their strengths are and if it matches up with what you want then go with it. It doesn't really matter in the end, you're going to get great training." --Dr. Lin 2) What are common mistakes/misperceptions that applicants make in evaluating themselves and programs? Are there things that are commonly missed during the application/interview process?
In regards to evaluating themselves, students don't always have a great handle on how competitive they are. Some students can overvalue their own competitiveness resulting in under applying and not getting enough interviews. You should start evaluating how competitive you are as early spring of the 3rd year when making your 4th year schedule. (See questions 4-6 in the Application Process to find an approach to this.) Additionally, sometimes students with a background in EMS or PA, may over judge their competence and their clinical skills, and it can come off as arrogant if one is not careful. Another pitfall occurs when students don't think about what their goals are, and if they will be happy moving to another city. Internal reflection and being honest with yourself will help you find clarity in where you will be happy and what program you will fit into best. In regards to assessing programs, realize that programs will blow their own horn about their relative strengths. As a student this can be difficult to decipher. For example many programs claim that all their residents receive “Ultrasound Certification.” Dr. Cooney brings out the point that there is no true ultrasound certification. ACEP has put together guidelines about how to train residents, but being "ultrasound certified" can be a bit over-rated. Some programs state that they certify their residents in ultrasound, when it doesn't mean all that much when you get out into practice. The better question to ask is "What kind of ultrasound education am I going to get here?" Dr. Lin finds that students focus too much on the 3 year vs. 4 year programs. Many programs that were once 4 year programs have shifted to a 3 year format. Something to consider, however, is that training is a lifelong process. She believes it shouldn't make that big of a difference if you go to a 3 year program or a 4 year one. She recommends that you look at the bigger picture and where you want your next academic home to be. Focus more on the people and the program, rather than the length of training. As a final point here, try not to listen to rumors about programs and take information on student forums with a grain of salt. In the process of applying, there is something to be said about the competitiveness of programs in desirable geographic locations. While it doesn’t mean the programs are better, recognize that you may have to apply more broadly if you are dead set on matching on the west coast or in ski country. For example, very competitive students in the northeast can find difficulties getting interviews at programs on the west coast. Those programs are challenging to get into and often times students may not recognize the impact this can have. A couple people mentioned tidbits about interviews. First, make sure you have questions. It makes you look interested and well informed. Even if an interviewer answers all your questions, you can ask the next interviewer the same question because you may get different answers. If you don’t ask questions it makes you look uninterested. Second, programs want to know why you are interviewing at their program, so if you don't know much about the program (and don't have questions) then they're going to think you are just filling out your interview schedule. Third, when answering questions during the interview, stop and think about your answers from the interviewers perspective. For example, when you get asked "Why are you going into EM?" if the answer always involves activities outside of work, then you may need to think about that again. From a faculty standpoint you'll be seen as a flight risk. Make sure you view things from a residency director's standpoint when answering questions. While it may be true that you enjoy activities outside of work, it shouldn't be the primary reason why you want to do EM. Additionally, don't be rude to the residency coordinator, over email, over the phone, in person, EVER. They can definitely close the door shut if you're thinking about ranking a program. .3) Is there anything medical students seem to focus too much on that in reality isn’t that important with the whole match process?
Some advised that students can be overly concerned about the personal statement. It can be a challenge to figure out what to put in your personal statement. Recognize that anything you put in your personal statement is fair game for the interview, so don't put anything in there you don't want to talk about. However, the personal statement can also explain any delay in training or academic deficiencies that will be noticed in your application. It’s also a chance to show a glimpse of your personality. Personal statements often don’t really improve an application, however it can occasionally hurt an application. One adviser states "You want to be average and not noticed in this category. Not too weird, and don't go over one page." (See question 8 in Application for more comments on the personal statement.) In regards to assessing programs, understand that there is no true ultrasound certification. ACEP has put together guidelines about how to train residents, but being "ultrasound certified" doesn't mean all that much out in practice. Some programs are stating that they certify their residents in ultrasound, but perhaps the better question to ask is "What kind of ultrasound education am I going to get here?" Several felt that students focused on trauma too much. They worry about how much trauma they see and how the traumas are run. Most all hospitals will train you well in trauma. The differences between programs will lie in the amount of trauma that you see. In the places that see 20-30 traumas per day, realize that you may not learn trauma better--you're going to learn high volume trauma better. Trauma evaluation and management is often simpler than much of the medicine done in the rest of the ED. The bulk of trauma is ATLS, ABCs and knowing when to transfuse, and when to rush to the OR. However, if you know you want to work in a level one trauma center when you get out of residency, then maybe you should be looking to go a level 1 trauma center for training. If you want to be a well rounded EM physician then every place is going to get you the trauma experience that you need. Students also seem to needlessly focus on the pediatrics experience, the number of procedures (central lines,chest tubes, etc), the number of in house calls and many of those things don't make much of a difference in the big picture. The important thing is that students get an overall feeling about whether they fit into a place or not. You will get good training anywhere. It makes more sense to focus on the fit. If you like where you work you will become more invested and therefore get more out of your experience. It's seems pretty common for students to let programs know that they are interested in their program shortly before rank lists are finalized. Dr. Lin commented on this and doesn't think that it makes that big of a difference in how you are ranked. Even with that said, she still recommends that you 'play the game' and let them know you think highly of them. Importantly, if you tell a program that you are ranking them number one on your rank list, then make sure it’s the truth. And don't tell more than one program that. "Programs talk. EM is a small community." 4) What are qualities that programs look for when interviewing students?
First, realize that interview season is a tremendous amount of work for residency programs. In order to maximize efficiency they often have a structured interview process; i.e. it may not be a free form as it appears. Different programs are looking for different things in their applicants. Further the things they are looking for can change over time. This can make it near impossible to try to predict what programs are looking for. For example, among several different interviews, one interview may be more focused on evaluating personality, another focused on medical knowledge, and the third interview evaluating professional qualities. Some mentioned looking for leadership qualities, and others look for people with a positive outlook. You can try to game the system but you are probably best served by just being yourself. During the interviews the programs are looking to evaluate you personality and whether you would fit in well with the program. Programs recognize that well fit residents are happy residents, and happy residents get more out of residency. Cited examples are: Do they have a good sense of humor? What are their personal qualities? Do you match who you seem to be on paper? What is their personality? Are they fun? Will they be a good ambassador for the program? Do I enjoy talking to this person? Do I want to work with this person for the next 3-4 years? Are they teachable? They frequently ask themselves would I want to spend a busy night shift with this person? Dr. Wald perhaps summed it up best in his “elevator test”:
5) Does it make me look good to come back for a second look?
The general consensus is that second looks should be done if it helps solidify the applicant’s opinion of a program. However, it’s generally felt from the interviews that a second look will typically not change where you are on a programs rank list. Programs will already have made their decision about you from when you interviewed. Additionally, second looks can cost a significant amount of time and money for likely no improvement in rank. The only thing it definitely does is reassure the program director that you are interested in the program. There are definitely reasons to do second looks but they should be done for you, not to impress the program. Some uncommon circumstances are likely to make a second look beneficial. If you are couples matching, doing a rotation in the same city, or if you find yourself back in the city for another interview then it may not hurt to get a second look. You may see the program on a regular day, rather than the show that can be put on for the interview. Additionally, Dr. Ander states that "if you live in the same city as a program, and if you’re interested, then go knock on their door and say ‘Hi’.” Second looks can help you see what goes on behind the curtain and what the department is like when there is not a big group of interviewees. If you do want to have a second look, or spend some time in the ED for a couple hours, then make sure to let the program coordinator know ahead of time. Dr. Wald is a stronger advocate for second looks and shared an idea that works well from a money and time efficiency standpoint. “I generally recommend second looks, or ‘pre-looks’”. If you fly into the city the day before the interview, it would be a good idea to hang out in the department for a few hours before going to the night social. Second looks are definitely a good idea. It allows the applicant to see how people interact in the ED. However the applicant must realize that they are still on their interview. Realize that they may get asked clinical questions if in the ED.” 6) If I have concerns about a program (attrition rates, concerns about it being malignant, etc), does bringing up questions to the PD/residents hurt my chances of matching? Also, what should I be really concerned about and what doesn’t matter that much?
If you have concerns about a program, first make sure the information is correct from multiple sources. Don’t ask questions about vague rumors. If you hear a rumor about a program, weigh that against clear information that is out there. Dr. Ander believes, “Honest programs should be honest during orientation on the interview day." You may hit on touchy subjects so, when you bring it up, you want to be very gentle in your approach. One way to approach it is to ask around the question instead of asking it directly. Actual suggestions for this approach were:
Bringing it up with the residents at the social may be a bit easier to do than during an interview. However, if you are going to be direct, be careful and make sure your information is correct. With that being said Drs Heitz, Lin, and Cooney feel that if you ask it in the right way during an interview, it can show that you are paying attention, interested in the program, and have done some background research. It also gives the faculty the change to let students know what they are doing to fix any issues. You just want to make sure that you appear respectful. It is likely better to bring it up one on one, rather than in public. A couple people mentioned that you probably want to avoid the word “malignant” as that is a very ….malignant word. The way any direct questioning will be interpreted partly depends on the personality of the interviewer; some may feel threatened, while others may appreciate the chance to answer your concerns. To address the second question. What should I be really concerned about? The following are things worth considering. Some are obvious red flags, others are just things that may need a bit more investigating. Some signs of instability might include:
Hopefully this helps you find a way to approach your concerns. If this could impact the next 3-4 years of your life then you really do want to get to the bottom of it one way or another. Also, consider bringing up any concerns/rumors with your mentor before openly bringing them up to a program. Keep your eyes and ears open when you interview and pay attention to how people interact with each other. Luckily all this gloom is rare in our specialty.
7) What advice do you give students as they prepare for the interview process?
You can greatly improve your performance on your interview just by being prepared. Before your interview, make sure you know yourself and know the program you will be interviewing with. Anything on your CV (which you made several months prior) is fair game for the interview. Be able to state your role in the activities that you listed on your CV. Specifically mentioned by Dr. Wald, “If you were involved in research be able to clearly state your role and what the outcomes were in the research project.” Get to know the program by looking at their website and know what their residency has to offer in regards to strengths, faculty, and curriculum. Make a point to remember the names and faces of the program director, associate program directors, and program coordinators because chances are really good you will be interacting with them. Dr’s Wald and Fix have a couple of other suggestions that may give you more depth as a candidate. Dr. Wald states that one could consider doing PubMed searches on publications by the faculty to get to know more about them before the interview. Dr. Fix mentions that if the program has a fellowship that you are sincerely interested in, then contact the program early to see if the fellowship director will be available to meet. During the interview, Dr. Heitz stresses the importance of asking questions. “Always have a question; it doesn’t matter if you already asked that question to someone else. You may get a different answer from a different people. If you don’t have any questions it makes you look disinterested. Have a couple standard questions ready to go to incase you don’t develop any specific questions.” Additionally, know how you will answer commonly asked questions. Dr. Wald mentions EMRA's Residency Interview Guide which is an extensive list covering 200 questions commonly asked during interview, as well as questions for you to ask everyone on your interview day. AAEM's Rules of the Road for Medical Students is also a great resource that has a chapter in it covering the interview process. (AAEM student members have direct access or you can buy the publication off Amazon.) Also, during the interview sessions, be prepared to answer to any academic deficiencies. A few programs may do group interviews. Dr. Lin provides some advice if you find yourself in that situation. “If you have a group interview try not to hog up all the time talking. You don’t want to be seen as the gunner. Actively listen to others around you. It’s meant to be more of a conversation. Remember they may be assessing if you over talk people and how you do in a group setting.” Recognize that every interaction with the program is part of the interview. Dr. Fix stresses that it is important to be nice to everyone. “Be nice to the program coordinator. Be nice to the janitor. And when you are on tour be respectful to others. Also, don’t belittle others at the social.” Dr. Cooney parallels the same idea stating that “students forget that the social the night before is part of the interview process as well. Don’t get intoxicated. Everything you do with the program is part of the interview.” If you are sincerely interested in a program then some suggested writing thank you cards to let them know you’re interested. Dr. Fix stated that there is a wide range of opinions about thank you cards. You can send a short email or write a card through the postal service. She feels written cards through the postal service are probably better, however, not everyone shares these views. Realize that these thank you letters will likely not get you any higher on their rank list. If you do choose to write thank you letters then write about something specific that was discussed during the interview and only a few lines are needed. Shortly before rank lists are due, it’s generally acceptable to let programs know you will rank them highly if that is the case, but some warned against telling a program they will be ranked number one on your list, even if that is the case. Match 1) What part of the match process do you feel is the most confusing for medical students and how do you help them understand it? Also, any misconceptions you repeatedly see?
Two main responses came from this question. First students seem to have a hard time figuring out how competitive they are and how many programs to apply to. If you are perplexed by these same questions, find comfort in knowing that it bothers many other applicants too. These issues are addressed in more detail in the Application Process questions 1-4. Don’t shy away from taking a long hard honest look at yourself. The second thing students struggle with most is figuring out how to make their rank list. While there are no clear answers, some sage advice can be found in the next question. 2) How do you guide students in making a rank list?
Interviewees acknowledged that this is probably the most difficult aspect to address:
Making the final decision about where to rank programs is one of the hardest parts about the match process. I can’t give you any hard and fast rules because there aren’t any. The ranking of programs is so individualized that it’s hard to give broad advice. Those among us with OCD make large spreadsheets meticulously calculating how to rank programs, but many others just go with their gut. Dr. Cooney states that you really have to take a step back and ask yourself what program you enjoyed the most and make it number one. Dr. Wald warns to not change your rank list based on feedback (or courting) that you may have gotten from a program. Rank programs based on where you want to be and don’t try to game the system because it is designed to favor the applicant. Many mentioned the importance of taking notes about programs before leaving the city. The interview trail becomes long and confusing and you won’t remember details as well as you think you will. Reference these notes when considering your rank list. For example: What did you like? What didn’t you like? What was different about this program than others? Did you get any weird vibes from the program? Dr. Wald brings up the challenge of couples matching. He states that when someone is couples matching they need to figure out the competitiveness of the applicants together (a chain is only as strong as its weakest link). There are so many hidden variables that it can be almost impossible to understand the process. Focus on what you can control: people who couples match generally need to apply much broader than others. Before submitting your rank list ask yourselves whether it’s more important to be together or to be in the program(s) of your choice.
Post Match 1) What should I be reading to get me ready for my first year?
As I'm finishing up my senior project and read through these questions again, I'm reminded of how great the responses were to this question. Here I leave everyone with their quoted individual responses to show off the wonderful spirits of these incredible leaders in emergency medicine. It's nice to know the leaders in emergency medicine really are human too. Just like us...although medical school training does all it can to beat the life out of us.
Still have questions that remain unanswered? Of course you do! This was never intended to replace EM mentors, but hopefully this gets you started. Now that you have some of the bases covered, go talk to your advisor or get one at SAEMs E-Advisor! I hope this was helpful, and if you're interested, check out the Purpose and Tributes pages to understand the driving force behind all this. |
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