Writing about the ins and outs of successfully going from a clerk to a resident is a potentially massive undertaking, but a necessary one, given the growing competitiveness of Emergency Medicine as a specialty. This brings me to the first question …
Where do I go for advice?
In addition to the medical school administration’s class meetings, there are several sources for this. First, "Getting into a Residency" by Kenneth Iserson is highly recommended. Also, do not overlook the faculty in the department of interest, especially the Program Director and Assistant Program Directors (who else would have better insight on the subject?!), and the faculty dedicated to student education. Make appointments early and frequently. Your adviser will be very helpful.
Ask all of your friends who are upperclassman for advice as well. One thing I did was take the match list and the directory (both available at the Dean’s office) and call every student on the list who matched in my specialty. Don’t be shy; most fourth-years will be on vacation and won’t bother returning your call anyway. The most important rule about advice is to ask as many people as possible, so you don’t get misled by an outlier.
How do I get an adviser?
Go to the department and solicit one early. Find one you like. He or she should make you feel comfortable. You’ll see him or her a lot over the year, and if you don’t feel he or she is approachable at any time for even “unimportant” questions, then keep looking. He or she should be knowledgeable about residencies, and not just your school. If your school does not have a residency in your specialty, get a “virtual” adviser (try saem.org) or find one during an away rotation at a residency-based program.
When you are with your adviser, start by telling him or her about yourself as a candidate and what you are looking for in a program. Be completely candid, or you will not be benefiting from this invaluable resource. Bring drafts of your C.V., Transcripts and Personal Statement to review, and volunteer your test scores. If you want direct advice, ask direct questions, like, “Am I competitive enough for this specialty, or should I be applying to a back-up choice as well.” Finally, your adviser is someone who will probably get to know you better than anyone else in the department, and will therefore be someone you will probably ask for a letter of recommendation. Keep that in mind when you make your choice.
How do I get letters of recommendation?
This is arguably the most important part of your application. Start by asking people with whom you’ve worked and made a good impression, and by asking tactfully: “I would like a letter of recommendation. Do you feel you can write me a strong one?” Emergency Medicine has gone to the ‘Standard Letter of Evaluation’ or ‘SLOE.’ It is a form letter that summarizes your performance on the rotation and compares it to others in your class. There is space for personal comments on it as well.
Generally, three letters are adequate and four are safe. Get two or three in your field, preferable from faculty at an EM residency-based program. This is an important point. Emergency Medicine is a small specialty, and everyone knows everyone else. Community-based EM letters are nice, but it is difficult to interpret “this student would make a great resident” from a place that has never trained a resident. You may get one in another (but not completely unrelated) field, although it should probably be your fourth letter. These should be solicited during or immediately after your rotation, unless you will work with the person again in another rotation. Letters should be from clinicians. If you did research with a Ph.D., that should be your fourth letter.
How do I nail my EM rotations?
- Work hard. Your patients deserve that. Arrive early: If you're not 10 minutes early, you're late. Stay until your patients are taken care of, not when your shift time ends.
- Own your patients. Don't try to impress with how many patients you can see and H&P and yet not follow your patients. You should be the first one to know when labs are back, X-rays are read, consultations are completed, the patient is or isn't feeling better after medication, ready for dispo., etc. Be a manager, not just a reporter. Have a plan. Don't just say the CBC is back; say, "The CBC is back and the WBC is high. The patient's abdominal pain is slightly improved after morphine but he is still tender, so I'd like to get a CT to rule out appy."
- Get good at SOAP format presentations — subjective starting with chief complaint and objective starting with vital signs. Make sure you include a well thought-out DDx (your assessment) including the most life-threatening things first and your plan (including both work-up and treating symptoms — patients want to feel better).
- Be a nice person. Be nice to everyone: faculty, residents, other students, nursing staff, ED techs, housekeeping, cafeteria staff, the program and student coordinators. Everything will get back to us. Have good situational awareness including an understanding of your role on the team. This is an audition for an interview and ultimately for a spot in the residency.ou are writing your own SLOE with every shift.
How do I make my fourth-year schedule?
There are two important periods in the year: June to August and November to January. The three months of the summer are your power months. These are the last months that go out to residencies on your transcript. This is also the latest you want to get letters. Therefore, this is the time to do rotations that will impress a program. They should be your “big guns”: your specialty rotation, the away elective, the Sub-I. I know this is a popular time for vacation, but if you’re going into a competitive field, you have only these three months to make a final impression. Note that it might be possible to take these critical rotations at the end of your third year, or you might be able to take them in September, October and November as well, but getting a letter onto the ERAS system on time will be difficult to impossible (although the Programs will see the new letter during your interview and ranking, it will not help you to get the interview). The winter months are heavy interview months and should be saved for lighter rotations or vacation time. Before signing up for the course during those blocks, it’s not a bad idea to speak to the course director about taking interview/travel days off.
What electives should I take?
First of all, away electives are popular, and doing a rotation in your specialty at another institution is recommended in order to give programs a sense of perspective. For Emergency Medicine, the median number or rotations is now two, with some doing three. There are three reasons to do them: to do something impressive at a big-name place, to “audition” at a top choice program, or genuine interest. The advantages are obvious: it is an addition to your file and a shot at a letter from someone well known. Potential pitfalls come if you go there and fail to impress. Your top choice program might be more confident that you are the best thing to come along, or that you’re the worst disaster in the history of students! Similarly, you might have a shot at working with Dr. Big Name only once, and it could be the time you dazzle or the time you spill coffee on his or her favorite outfit. If you want to apply for an away elective, apply early through VSAS, applying to 2-3 rotations per block (and immediately canceling if you get a more preferred rotation lined up). The saem.org website is a good resource for a list and descriptions of away rotations in Emergency Medicine.
As far as the rest of your schedule goes, take things that are interesting to you. Take rotations that are related to your field, such as a month in an Intensive Care Unit or on the Trauma Service, as well as things that you are just curious about. Ask the upperclassmen what the most popular rotations were.
Should I do research?
Many programs are impressed with research and even more impressed with publications. If your interest is genuine, you should be able to back it up on your C.V. If you tell a program you love research but there is nothing to support that in your application, they will see through it. Most programs also feel the value of one month of research does not compare to four years of ongoing involvement. If you’re looking to publish, a case write-up is a quick opportunity. If you see an unusual case, do a literature search. If you find minimal references, talk to your attending about submitting a case report. If research is not your thing, and a program asks, tell them you haven’t had the exposure but are interested in exploring it with an open mind.
In general, the best advice I can offer about doing activities to your CV is to be true to your values. We look at your CV to get a feel for your values. If you do activities that speak to your values, it will show on your CV. If you’re a researcher, do research. If you are into helping people who face the most obstacles to getting care, work in a homeless shelter and/or a free clinic (etc). If you love international work, go on medical mission trips. Let the programs decide if you have values in common with their programs. You can’t be all things to all programs, and trying to do a little bit of everything is disingenuous to the program, and more importantly, to yourself (if you wind up matching there).
When should I take the Boards?
Some competitive programs want to see Step II scores when you apply, but most do not. If you got spanked on Step I, you will need to take Step II early to show residencies that you’re really not academically pathetic. This assumes that you will study enough to redeem yourself. If you did “well” (above the national average for candidates applying to your specialty), then you have the option of taking Step II later on and saving your summer for concentrating on your power rotations. Remember that you need to pass Step II in order to graduate (and start residency), so take them no later than December or early January. Programs are nervous about ranking you (in late February) if they haven’t seen you pass Step II yet.
The best way to study for Step II (and all standardized tests) is to do practice questions. It is true that a multiple choice question will never make you a better doctor—I’ve never had an ED patient present a potential diagnosis in a multiple choice format. But like practicing any skill, doing multiple choice questions will get you better at them. They will raise your test score by 10 points.
Step III is beyond the scope of this article. But since advice is free (and worth only that much), take it as early as your state will allow—delaying will only lead to academic amnesia.
Where should I apply?
There are many sources about programs. A list by location and specialty is provided in the NRMP Directory and the ERAS website. Most residencies have websites that are loaded with information. SAEM has an excellent directory with descriptions and links to program home pages on their website (saem.org). Then sit down and read.
Everyone has different criteria. For some, geography is important. For others, academic vs. community hospitals are key. Some won’t consider a hospital without an Aeromedical transport, or a Transplant center, or a Regional Hansen’s Disease Center or a Level I Trauma Center. People have different learning styles. Some learn better by seeing more patients and managing their own cases autonomously, at which point a large public hospital makes more sense. Those programs require a more self-motivated learner. Other students learn by reading and discussing individual cases in detail. A smaller private hospital might afford the time and support for that type of program. There’s a continuum of teaching (and learning) styles out there. It’s all very personal and you should try to decide what your priorities are. Talk to people.
The competitiveness of Emergency Medicine and the strength of your application should determine the number of applications to send. You should shoot for 10-15 interviews; fewer is too scary and more is too expensive, time consuming and exhausting. I usually recommend applying to 25-40 programs in order to accomplish this.
How do I apply?
Start with the ERAS application. Your personal statement is the hardest part. Do it on a separate page. While you can single-space it, one [ERAS] page is the hard-stop limit if you don’t want to anger the reader. The generic formula is to start with why you chose your specialty. Then talk about all the wonderful things you’ve done in medical school and before. End with your plans for the future, i.e., where do you want your career to go. Remember to try to distinguish yourself (in a positive way—don’t get too creative unless you were an English major in college) from the other 999 applications sitting on the reader’s desk. Anything you feel is important but not represented in the rest of your application belongs here. Have a trusted friend or adviser proofread it.
You need a CV. You will use the ERAS format, so don’t spend time making your draft look “nice.” Include a line with your hobbies and interests; residencies like complete people. Don’t lie or exaggerate anything on your CV—programs are aware of this problem and double check your entries, which we will report to your Deans Office for disciplinary action (on your permanent record). Board scores should be attached to your ERAS application. You will also need a recent photo. Check and double check your application before sending it. Develop an organizational system to keep track of each program. Some use spreadsheets while others make a simple checklist.
The Standardized Video Interview (SVI) is daunting. After each question, take 30 seconds to gather your thoughts, take a deep breath and begin. Dress professionally (it’s an interview) and pay attention to your background (blank white wall preferred, quiet space) and lighting (a window behind you puts you in silhouette—test your camera view before starting the SVI).
When should I apply?
You should write your personal statement and CV during the summer, as they are the most time-consuming and dreaded tasks. Show them to your adviser for editing. Program websites should also be reviewed during the summer with the goal of creating your list for your adviser before ERAS opens (Sept 15).
Solicit letters as early as possible, as they tend to be de-prioritized by the people who write them. As the SLOE has a place for your EM grade and faculty comments, it usually takes a month to turn around the letter after the rotation has ended. Since many residencies won’t look at your file unless it is complete, a tactful nudge is in order. If “Thanks again for writing me a letter” elicits a confession, it is a license for you to remind them. If you check the ERAS system and you still see a delinquent letter, asking “Did you have any trouble with the ERAS system?” may be an appropriate way to remind them again. Don’t start sending daily or weekly emails—it’s inappropriate for a student to nag faculty.
Transcripts are sent with your ERAS application. Request a student copy of your transcript to check for accuracy well before sending them. The Dean’s Letter is the rate-limiting step. It now goes out on Oct. 1. Your application is incomplete without it, so the object is to get all of your other paperwork into the program’s hands before then. I suggest that you consider Oct. 1 an (unofficial) absolute deadline. Stay on your letter writers.
Where should I Interview?
Try not to put yourself in the position of turning down interviews; I ended up ranking second the program I came closest to declining! Try to choose the number of applications carefully and leave yourself time for the interviews. Budget for a ninth semester. I’m not kidding. While people like to clump interviews geographically and take one long trip, many competitive programs can’t offer that kind of flexibility in scheduling. Programs offer more interview slots than they have, so you need to accept an interview offer right away. Even waiting a few days could cost you that spot. Be sure to check your email daily for these few months. You didn’t get this far without being a little ‘type A.’
There are still ways to save money. Booking in advance and staying over a Saturday night (an “excursion fare”) are the cheapest ways to go, but they may not be feasible. Make sure the extra nights in a hotel won’t cost more than a regular ticket. Also, consider allowing extra time for shadowing in the ED, as well as checking out the city. You’ll find this invaluable during rank list time. Student Travel Agency (STA) will save you a lot of cash. Several websites, including orbits.com, cheaptickets.com, expedia.com, travelocity.com, kayak.com and priceline.com are worth looking into. Other options for closer destinations include AMTRAK and driving. Don’t drive more than 90 minutes to two hours on the same day as an interview, or you won’t get there in peak shape.
What do they ask on interviews?
Questions you should be ready to answer include why you chose this field, what are you looking for in a program, what are your future career plans, what do you do in your spare time, what sets you apart from other applicants, and what case was a particularly tough, stressful or good learning experience for you.
Be prepared to discuss any questions raised by your Dean’s letter or Transcript. Don’t make excuses. Explain the situation and finish by saying that you think you’ve matured from the experience. By the way, never disrespect your school. Someone who complains about his or her school will complain about his or her residency later. Remember, your school’s patient population and variety of pathology offered you tremendous clinical training while you gained great patient management skills. You chose to come here.
What questions should I ask?
Interviews are an important time to evaluate a program. Be candid about how finding a good “fit” for both of you is what will make a successful residency match. Tailor your questions to your needs as well as your specialty. Also, certain questions are good to ask Residency Directors while others are not. Use some common sense.
In the end, your greatest source of information will be the residents. Are they happy? Do they look tired? Be wary of a program that doesn’t let you spend time alone with the residents (plural). Also keep in mind that most program directors meet with the residents after you leave and add their comments to your file. A friend of mine didn’t rank at a program because of a back-handed comment she made at lunch about living in Detroit. You are never “off the record.” Do not underestimate the input of the residency coordinator. He or she can “DNR” your application depending on the way you treat him or her in person or over the phone. Being polite, professional, warm and persistent with the program coordinator can get you that last-minute open interview spot as well.
Some valuable questions have included: what is the strength of this program, where do residents go afterwards (academics? community? fellowships?), how many faculty are there (ratio to residents), what is your relationship with other departments, describe your orientation program, what percentage of your residents are U.S. graduates, is there research in your area of interest here (will you have a mentor), is conference time protected, what teaching opportunities will you have, do the faculty use their protected time for teaching and are they evaluated by the residents or students, how responsive have the program directors been to resident input (and cite a recent example), etc.
Questions for residents include all the above plus: what is the program’s weak link, how is the bedside teaching, do you have time to read, how are the off-service rotations, are you happy, would you recommend this program to your best friend (pay attention to the answer; a “yeah” is different from a “YES!”), do the residents go out together as a group, how is living in this city, etc.
Certain questions are important but on soft ground. These include questions about call schedule, night float, ancillary services, antagonistic nurses and salary. Fortunately, many of these are answered on the program’s website. Be sure to read it the night before (and pay attention during the morning presentation), as asking questions that have already been addressed there makes you look uninterested.
One final tip: my basic rule of interviewing is that people like to talk about themselves, so ask open questions that allow them to go on about the parts of the program they’re proud of. Hopefully, the warm fuzzy feeling this gives them will carry over when they’re evaluating you. But don’t just sit there either. You want to make an impression. Be yourself, as there’s no use fooling each other now and being miserable because of it for the next few years.
Try to leave yourself some additional time to ask if you can observe in the Emergency Department for several hours, either the day before your interview or immediately afterwards. It will give you a better sense of the program and will also give you an additional opportunity to talk to other people. Furthermore, it gives the impression that you’re interested in going there.
By the way, follow up with a thank-you letter to each of your interviewers. Get the correct spelling of people's names before you leave. This should be brief but should also mention a specific point in your conversation so it seems personalized. Asking for a “second look” visit goes a long way in impressing a program.
Is there a strategy to the rank order list?
NO!!! Don’t get sucked into game playing and don’t put huge weight on programs’ promises to rank you high if you rank them. Rank ALL the programs you’d prefer to working in McDonald's for a year (or scrambling for after the match). Not doing this is the express ticket to not matching. And rank them in order of preference — PERIOD. Even if you have “no chance” of getting into your top choice, rank it first anyway. That’s why it’s called a top choice. Your rank list should be a “wish list.” The computer algorithm is student [not program] driven — it’s designed so it can’t hurt you.
Keep a running draft rank list as you go on your interviews. And take notes as you’re traveling home from each place. It will help you a lot in February. Finally, read your rank list out loud to a trusted friend, explaining your reasoning for where each program is ranked, before submitting it.