By Samir P. Desai, M.D., and Rajani Katta, M.D.
Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and
250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them
There are 4,479 total residents training in approximately 150 ACGME-accredited emergency medicine residency training programs. Of these, 85.1% are graduates of U.S. allopathic medical schools, 9.0% are osteopathic graduates, and 5.7% are international medical graduates.1 Osteopathic students may also enter an AOA-approved emergency medicine residency program. In recent years, there have been over 40 such programs.2 Based on recent match statistics, emergency medicine can be considered to be a moderately competitive specialty.
We recently discussed the emergency medicine residency selection process with Dr. Jamie Collings, the Executive Director of Innovative Education and an associate professor in the Department of Emergency Medicine at the Feinberg School of Medicine at Northwestern University. For many years, she served as the program director of the emergency medicine residency program at Northwestern. Over the past fifteen years, she has been heavily involved in advising students interested in pursuing a career in emergency medicine. Dr. Collings earned her medical degree at the Oregon Health & Science University, and then completed her residency at the University of Chicago.
At many medical schools, there is limited exposure to emergency medicine until the fourth year, when students have greater flexibility to participate in an emergency medicine clerkship. In a recent study done at the University of Toronto Medical School, preclinical students were able to participate in an emergency medicine observership experience.3 Researchers found that this experience allowed students to make more informed decisions with respect to emergency medicine as a career. Beyond shadowing, how can students learn more about the specialty prior to rotating through the emergency medicine department?
This is a common problem and one that often isn’t even helped with shadowing. Many students come and watch for a couple of hours during the day and get a very limited view of the specialty. I would recommend some time out of the department talking to several EM physicians. One thing that becomes extremely important to physicians long term is lifestyle. I find a lot of students picking EM for lifestyle reasons only to figure out later that the “lifestyle” may not be for them. 2/3 of the shifts in EM are evenings, nights, and weekends and over time this can become a huge negative when it comes to your spouse and children. Many of us end up working a lot of holidays while the rest of the family is off and you will find it difficult to get to all of your kids activities. On top of that, the older we get the more difficult night shifts are and the longer most of us will need to recover. I think that students should spend time shadowing, but also talking to practicing EM physicians about the good and the bad of the specialty. Also, if you are really interested in EM, make sure you shadow on a Friday or Saturday during the night (a room full of drunk patients may not be what you envision).
Excellence in the EM clerkship is considered a very important factor in the residency selection process. According to Dr. Shahram Lotfipour, director of undergraduate EM education at the University of California Irvine School of Medicine, the EM clerkship “is the only opportunity for students to demonstrate to EM faculty their ability to take directed histories, perform accurate physical examinations, offer concise presentations, as well as be a productive and reliable member of the EM team.”4 Students often wonder what they can do prior to the clerkship that will help them perform at a high level. What suggestions can you offer students in this regard?
I think this starts long before your clerkship in EM. The skills you learn on each core clerkship can be incorporated into your EM rotation. Sometimes a student thinks they want to do EM and they don’t pay enough attention while they are on other rotations. So start early and work hard on every rotation. When it comes to preparing for your EM clerkship there are a few things that may be useful. Try to review the approach to a patient with chest pain, abdominal pain, and difficulty breathing. These are very common complaints and you should start your clerkship with a good differential for a lot of the basic complaints in the ED. I would also recommend a couple of things when you are on rotation. The first is don’t pick up too many new patients when you don’t have the others under control. A lot of students think that it looks good to have several patients at once. This can quickly make the attending and senior resident very unhappy if you have a lot of open loose ends that they have to follow behind and clean up. Better to be totally on top of your few patients than lost with a lot. The next big recommendation is really stay on top of what is pending on your patients. If you have ordered some tests, know when to expect results and check on them frequently. There is nothing worse than finding out something didn’t get ordered or done and you could have helped make it happen. You should be the first to know the results of tests on your patient and the first to know about any delays and why so you can act to prevent any problems.
Emergency medicine has a plethora of professional organizations, including the Society of Academic Emergency Medicine (SAEM), American College of Emergency Physicians (ACEP), American Academy of Emergency Medicine (AAEM), American College of Osteopathic Emergency Physicians (AACOEP), and Emergency Medicine Residents’ Association (EMRA). Which of these organizations do you recommend students join, and how should they make the most of the membership benefits?
I think the important part of this question is how you get the most out of member benefits. As a medical student many of the aspects aren’t that relevant. What I would suggest is trying to understand what the important issues with each organization are. What are their target issues? What is their focus? Who belongs and why? When it comes time to interview for residency you should have a reasonable understanding of the major issues in EM and what the specialty is trying to do about them so you can have an educated conversation. Each organization has a different focus and personally I don’t believe that belonging to one in particular really helps your application, but hopefully it will help your understanding of the specialty.
Of the total number of residents training in allopathic programs, 9.0% are osteopathic graduates. For osteopathic medical students interested in training at an allopathic residency program, a difficult issue is whether to take the USMLE in addition to the COMLEX examination. Do allopathic EM residency program directors prefer that osteopathic students take the USMLE? If so, is Step 1 sufficient or should students plan to take both the step 1 and 2 exams?
I think it is important for osteopathic students to take both Step 1 and Step 2 of the USMLE if they plan to apply to an allopathic residency program. Most programs understand what those scores mean and it really is the only way we have to objectively compare knowledge across the board.
EM residency programs place great importance on letters of recommendation, particularly letters written by well-known EM faculty, such as the program director, clerkship director, or chairman. In a survey of program directors, letters of recommendation were ranked fourth in importance, behind only the emergency medicine rotation grade, interview, and other clinical grades.5 However, with the way shifts are assigned to rotating students, students may have little or no direct clinical contact with these particular faculty members. What can students do to gain exposure to key individuals in the department?
I think this is a really important issue and should come into play when you decide where you will rotate. I can tell you that after 10 years of reading letters of recommendation some are going to help a lot and others not so much. Many programs have departmental letters or specifically set students up with a mentor and this is my favorite approach. Students get a letter that is written by a small group of faculty who write a lot of letters and who tend to do a better job of “ranking” students. They also tend to ensure that the people writing the letters really understand what areas to focus on and have a lot to compare to. What I mean by this is that they don’t give everyone a top ranking and therefore the letter becomes more meaningful. There are some programs out there where every letter looks about the same and it is of no use to me—I can’t tell which students are really good and which ones didn’t make anyone mad in the few hours of contact they had with them. You don’t have to have the best letter out there to be successful in the match, but you should have one that provides some insights into your strengths and even weaknesses and one that really reflects an understanding of how you might do as a resident. I think the reason it is fourth is that not every letter does this. I can tell that a good letter from the right person can be the number one factor in ranking an applicant for many of us. I can also say that the best letter ever from a brand new graduate, a community physician without an EM residency, or someone who writes that same letter for everyone is meaningless to me.
Matching successfully obviously requires that the student first be invited for an interview. Residency programs have different screening criteria, but many programs look at a combination of quantitative (i.e. USMLE scores) and qualitative information (i.e. letters of recommendation, personal statement, common application form). Of the application components, only the personal statement and common application form are completely under the control of the applicant. What recommendations can you provide to help applicants create personal statements and common application forms that would be attractive to programs?
One of the things I hate most when reading a personal statement is when the student spends the whole time telling me why they like EM. I hate this because they all sound the same and they really don’t tell me much. I recommend to students that they write their personal statement from the perspective of a job applicant (sometimes the students forget that this is what they are). Sit down and think about your strengths and how they will fit into EM and then start writing. Your personal statement should tell me about your experiences and accomplishments and how they will make you a successful EM physician. For instance, leadership positions taught you how to work with a variety of people and successfully accomplish your goals. This is extremely important in EM because you will be leading a team in the department and these skills are invaluable. When it comes to the common application form my advice is pretty similar. Don’t just list what your accomplishments, tell me a little about your role and involvement. On the other side of things, this should also be where you address any red flags in your file. This may be your only chance to tell the review committee your side of the story. Be direct, accept responsibility for your actions and most of all tell us what you have learned from the experience. No one is perfect, and the most important part about failure is what you learned and what you will do to prevent it in the future.
In describing his experiences as an emergency medicine residency applicant, Dr. David Guttman, now an emergency medicine physician practicing in Arizona, wrote that “I feel that you can only know a program by being in the ED. Shadowing the residents or, better yet, spending a month working in the ED, was critical for me.”6 Since the interview day does not always allow students sufficient time in the emergency department, how do programs view requests to spend extra time in the emergency department, either just before or after the interview, or even later as a “second look?”
I think this varies a lot depending on the program and you should talk to an individual program about it. Most programs will have a clear policy and you should know what that is and most importantly follow it. It can be a huge negative if a program tells you to call the coordinator and set it up and instead you just show up in the department (it happens and it looks really bad). Personally, I don’t think you will get a real flavor of a program with a couple of hours around an interview day. Most applicants end up shadowing during the day and getting a very different feel for the department. For instance, if you come to my ED at 10am on a Wednesday in January you might think things are slow, that everyone is insured, that no one waits to be seen, and that the residents don’t manage very many patients at once. Contrast that with a night shift in July when there are 30 people in the waiting room, half the patients are intoxicated, no one seems to be insured, there are traumas nonstop and the residents are running around with no time to sit down (this can happen in Chicago, but most don’t want to visit the ED on Friday at 3am). I think the best view of a residency program often comes from the residents themselves. Most residents will be completely honest about their program and will tell you what they like and don’t like (they don’t want unhappy interns in their program). Also ask where else they looked and what some of their other top choices were and why. Same thing for the places they didn’t like and why. If they were looking for the same things as you then this may be the right place for you. I would also ask about the recent graduates—where did they go and what are they doing? This is going to be your best insight into whether a program can prepare you for the job you want—have they done it before for other residents.
In your article “The Residency Interview,” available at the Society of Academic Emergency Medicine website, you provide a number of recommendations to help applicants prepare for the interview.7 Among your recommendations is to have a Top 5 Plan, consisting of five key things that you want a program to know about you. As applicants examine their background, accomplishments, and strengths, how can they decide which things would be of most interest to interviewers?
Again, this goes back to remembering that this is a job interview. Think about the qualities that make a successful resident and emergency physician and try to highlight those when you interview. You would be amazed at how many students focus entirely on figuring out if a program is right for them and forget that there is a clear element of “selling yourself” that is needed.
1Brotherton S, Etzel S. Graduate medical education, 2007-2008. JAMA 2008; 300 (10): 1228 – 1243.
2Freeman E, Lischka T. Osteopathic graduate medical education. J Am Osteopath Assoc 2009; 135-145, 196-198.
3Penciner R. Emergency medicine preclerkship observerships: evaluation of a structured experience. CJEM 2009; 11(3): 235-239.
4Lotfipour S, Luu R, Hayden S, Vaca F, Hoonpongsimanont W, Langdorf. Becoming an emergency medicine resident: a practical guide for medical students. J Emerg Med 2008; 35(3): 339-344.
5Crane J, Ferraro C. Selection criteria for emergency medicine residency applicants. Acad Emerg Med. 2000; 7: 54-60.
6Guttman D. A medical student’s perspective: selecting the best emergency medicine residency program. J Emerg Med 2005; 28(1): 105-106.
7Collings J. The Residency Interview. Available at http://www.saem.org/SAEMDNN/Portals/0/AnnualMeeting09/MedStdSymp09/MSS_CollingsTheInterview2009SAEM.pdf. Accessed on April 22, 2010.