Emergency Medicine FAQ

From time to time (at least three times a year) someone starts a thread asking what the "top" EM programs are. (I confess, one of those threads way back has my name attached to it.) After choosing a specialty, a medical student naturally has a desire to go to a "great" residency so she can get a great education and be a great doctor etc. Nothing wrong with that. The problem comes in when we try to rank something that is inherently unrankable. Now there are many types of schools that are ranked by national news magazines on various factors such as research money, competitiveness of application, etc. The problem with using those rankings is that you, as the applicant, must agree with the method used to make the ranking for that ranking to have any usefulness to you. For 99% of us, that method doesn't apply and so the ranking doesn't apply.

The only solid thing that we could possibly rank EM programs on would be competitiveness. There are basically two numbers that one could use. The first is how many applications that program receives. Clearly a more competitive program receives more applications. However, this information is usually closely guarded and possibly inflated by program directors. Besides, it isn't a very good surrogate for a program's quality. I mean, when you chose what programs to apply to you thought about what.....location and what somebody told you about the program? What makes you think that 1000 other EM applicants know any more than you do? So why use their collective data to justify a ranking? The second number is how far down a rank list the program must go to fill its spots. Clearly a program that didn't fill is likely less competitive than one that did. That does not always hold true as can be seen with a few examples:
1) A program that doesn't interview enough applicants looks less competitive than a program that interviewed 3 times as many applicants to fill the same number of slots.
2) A program that was new or struggling a year ago but has rapidly stepped up.
3) A freaky year where you interviewed too many people who weren't interested in moving to your city. i.e. too many of your applicants treated you as a "back-up" program. Or in other words, you interviewed candidates that had better options elsewhere.
The problem with using this number is that it is even more closely guarded than the number of applications, and I for one am glad it is. If it were public, and a rank list were put out every August using it, programs directors would have great incentive to rank highly those they knew were going to come to their program, rather than those they really wanted. As a result they could say "I only went down to number 12," but the entire purpose of the match would be defeated. Thus for applicants, this number is unattainable.

Since those are the only objective numbers we can use to quantify "Top Programs," and there is no official US News and World Report for EM, we are forced to go off of reputation. Every doctor you talk to will give you a different list for the top programs in the country. Most of the time their opinions are based on how someone once answered the same question to them when they were applying, so take it with a grain of salt, especially if its been a few years since they interviewed. The key is to watch out for programs they tell you not to apply to. Usually that advice is based on concrete knowledge of problems in the program.

After all that, I think it would still be useful to provide applicants with a list of programs whose names are frequently mentioned by faculty members as being great programs.

Programs that all would agree have great reputations (deserved or not) year after year (in no apparent order):

Pittsburgh, Indiana, Hennepin, UCLA-Harbor, UCLA-Olive View, Vanderbilt, UNC, Carolinas, Denver, Cincinnatti.

Programs that seem to frequently crop up on lists of top programs
(in no apparent order)
Arizona, Maricopa, UNM, Cook County, USC, Highland, Christiana, Both programs in Florida (Feel free to edit this with the names Quinn, I know you know them,) Emory, OHSU, UC-Davis, UCSD.

There are people who frequent this website who would add several dozen more programs to that second list. There are tons of "hidden gems" out there. There is a lot of regional variation, and people in different regions have different opinions. (You'll notice my second list has a "Western" slant to it, since that's where I went to medical school, that's where I went to residency, and for the most part, that's where I interviewed.)

A point frequently made in threads addressing this subject is that EM has a much stricter RRC (residency review committee) than a lot of other specialties. What that means is that a much higher percentage of programs are good (as opposed to bad) than most other specialties. The difference between a good EM program and a great EM program is minimal compared to the difference between a good FP program and a bad FP program. In our field, it is difficult to go wrong, and reputation should play a much lower role than other important factors such as fit with residents and faculty, location, curriculum, shift length, 3 year vs 4 year etc.

I think that about sums up the way most of these threads end up, so hopefully this will be useful as a sticky.

 

This info is culled from about 20 posts I made during the 2004 Match season:

How complete does my App need to be for me to apply, and when should I send it in?

Look Here!

Letters of Recommendation

Ok, you can send them anytime but you need to have them all in by the time applications are due. Application deadlines are set by programs.

You can apply as early as the beginning of Sept. with nothing more than your Common Application File (hereafter CAF) also known as your CV. That's right, no letters, no personal statement, nothing. Most programs also want to see your Step 1 score then. Sometimes interviews start being offered with nothing more than these two pieces of information.

I recommend to my 3rd year "Mentees" that they plan on getting 2x as many letters as they need, because you never know when you might get a really great one. Generally speaking you are pushing it to be getting letters in Sept. of your 4th year. I would begin soliciting letters about this time (March) in your 3rd year.

To solicit a letter talk to the prospective letter writer AT THE BEGINNING of the rotation. That let's them know you're interested and for them to pay extra attention/give feedback. Most faculty will be straightforward about how good a letter they can write for you.

At the end of the rotation supply them with an ERAS cover letter and make sure it is signed for waiver (there is some controversy as to whether is is good to waive or not) and filled out where to send the letter to. At some point in your third year someone at your school should tell you what your AAMC ID is, once you have it put it on there too. Otherwise don't worry, the person who handles LOR's at your school will know it.

Once letters are in you have to create them in ERAS (won't open for class of 2005 until July) and then assign them to programs. You can assign different letters to different programs, delete letters from programs, and shift them around. It's very flexible for you to be sure your programs get the best letters you have.

For More . . .

-------------------------------------------------------------------------------
Should I rank them higher so they rank me higher? and other ROL myths.

RANK THEM IN THE ORDER YOU WANT TO GO TO THEM.

If you like #2 more than #3 then don't mess with your list. How they will rank you should have NOTHING to do with your list.

Believe the process.

Be the spoon.

How the Match Works for YOU!

The match favors the applicant because it prioritizes your rank list over the programs rank lists. For example:

I interview at 2 hospitals, Mercy and City (sound familiar?). I like Mercy better and rank them #1 and put City #2.

Mercy likes me OK and ranks me 7, they have 8 spots. City LOVED me and they rank me #1.

Now, if the systems were biased towards the programs I would get "pulled" into City even though I don't prefer them because they ranked me higher. THIS DOES NOT HAPPEN.

Instead I go to Mercy, where in fact I am farther down the list, because the system PUTS ME AT THE HIGHEST PROGRAM ON MY LIST THAT HAS A PLACE FOR ME.

If the system was weighted equally it would be much more complicated. The computers would try to put you at a program as high on your list while at the same time trying to fill programs with candidates as high on THEIR lists as possible. Many many more possibilities. THIS ALSO DOES NOT HAPPEN.

More in "Is the Match Fair"

Should you tell the PD they're #1?

RESPONSE:

I.....don't think so. If program X ranks me #5 and program Y ranks me #2, I will go to the program that I rank higher. If I ranked Program X #1 then I will go there over program Y. You cannot have equality in programs because you cannot rank two programs the same so thhere will never be a "tug-of-war" between two programs. One program will always be higher on your ROL than another. That said, you always go to the highest progam you have ranked that has a spot for you. Period.

In this situation spots 1 and 10 are absolutely equal, there is a guarunteed spot for you there if you rank them first. If you rank them last and you have to go that far down your list there will still be a guarunteed spot for you there.

I don't know where this keeps coming from that a program can pull you away from one you have ranked higher by putting your higher on their ROL. It is against the match rules and would in fact be a breach of the match contract with you.

So, again, you cannot be pulled farther down your ROL by program that rank you higher than your #1 choice did. You may wind up at one of those programs by nature of the fact that your #1 filled before they got to you on their ROL, but you didn't get "pulled" down there, that's just the way the system works.

Also, this is a terrible match strategy for PD's and is absolutely not the strategy the PD's I know said they were taking. A PD does not want to get residents who "made a mistake" and ended up matching at a program they don't really like. These will be unhappy troublesome residents who will make the program look bad. The 3 PD's I know all said that they are looking for the best applicants who are excited about coming to their program. So, using this strategy it would be best to rank 1-10 the best applicants you had who were MOST LIKELY to come to your program by desire.

The Thread

See also ROL rank effect

--------------------------------------------------------------

Other Threads of Interest

Location Vs. Strength of Program

EM and Burnout

2004 Interviews and USMLE Step 1 Scores

How competitive is EM?

Why choose EM?

 

Regarding 3 vs 4 year programs, I'll include the link to the Denver program's page on training formats:

http://www.dghems.org/dgwhat4.html

 

also look for the "rules of the road" book for students on the AAEM website, a year or two ago you got free membership to AAEM and the book online just for signing up as a student.

 

Quinn:

Hope the project's going OK. Please don't hesitate to ask for help as needed.

 

This post will address the following common questions:
1) How competitive is EM?
2) How many programs do I need to apply to?
3) How many programs do I need to interview at?
4) How do I pick programs to apply to and interview at?
5) How many letters of recommendation should I obtain?
6) What are the most important things to find out at an interview?

EM is a moderately competitive field. It is more competitive than FP, IM, Peds, Gen Surg, Pathology, and Psychiatry and less competitive than Derm, Ortho, Optho, Plastics. It is approximately as competitive as Rads, Urology, OB/GYN. Approximately 93% of EM applicants secure an EM spot each year. There are usually 20-40 spots left for the scramble, and these all fill within hours. Post-scramble there are no EM openings in the nation.


Hopefully you will have decided on EM prior to August of your senior year. At that point you will need to obtain an EM advisor. The best advisor is someone who has recently been through residency. You can still obtain letters from the big names in the department, but you want the advice of someone who has relatively recently been through the match process and residency. Go over the list of 120-130 programs with your advisor. Ask him or her to point out programs that he or she would recommend not applying to, and also to share information on the programs he or she has firsthand information on. During this month you also want to ask for letters of recommendation. You will need at least 3 (it is expected that at least 2, and likely 3, will be from emergency physicians. 2 of them ought to be from academic physicians.) Also probe your faculty members for programs where they are well known. If you are applying to any of those programs, send a letter from the corresponding faculty member to that program. It is a small community, and it's better to have a good letter from someone the PD has heard of.

Next step, also to be done in August, is to decide how many programs you need to apply to. Here are some rough guidelines.

Student A: Step I 250, EM grade Honors, Student Body President
15-30 programs

Student B: Step I 215, EM grade High Pass, EMIG President
30-40 programs

Student C: Step I 182, EM grade Pass, Golf Handicap 7.
40-50 programs

Remember, up until 30, programs are very cheap to apply to. After that, the price goes up.

Now, also in August, you need to select which programs you are applying to.

Start with 120-130 programs.

Eliminate all programs your advisor warned you about. You now have a list of 115-125 programs.

Next, determine which programs will cause you to lose your significant other if you match at them. Eliminate all these.

1) Are you at your predetermined number of programs to apply to? If so, congratulations, send off your ERAS application. Do you have less than you need to apply to? Consider flowers, chocolates, and long discussions of the importance of support from your S.O. Do you still have too many programs? Continue on down this checklist until you get to the predetermined number.

2) Eliminate all programs in locations YOU aren't willing to live.
3) Determine how you feel about the 3 vs 4 year program question. If you are a 3 year person, eliminate the 4 year programs still on your list.
4) If you made it this far and are still above your predetermined number, congratulations, you're either very open-minded or lying to yourself.
5) Eliminate all locations you can't afford to live in.
6) Determine how new of a program you are willing to go to. If you don't want to go to a program that has been around less than 2,5, or 10 years, eliminate those.
7) At this point, if you still have too many programs, it might be worthwhile to review the curriculum found on the program website. Eliminate programs with more than 1 month of medicine wards, more than 6 months call as first year, or more than 8-12 months of call all together. (With allowances for 4 year programs if they are still on your list.)
8) Eliminate programs based on website design and voodoo.

Okay, so you've sent off your applications on September 1st. Now you will wait around hungrily for interview offers to start rolling in, beginning in October and lasting up until December 10th or so. As they come in, call immediately and schedule an interview. Make a reasonable attempt to schedule similar locations in the same time frame, but realize it is unlikely you will be able to plan it out perfectly.

As you begin to acquire more than 10 interviews, you need to begin considering which ones you are going to turn down. You should interview at 8-15 programs. 8 if you're cavalier, 15 if you're anal. Don't interview at more than 15. It will cost you money to rank more than 15 so what's the point. If you are lucky enough to get more interviews than you want to go on, you will need to do more research prior to going on interviews. Consider the following list of questions to ask yourself:

1) Which 5-6 actually have the possibility of being your number 1?
2) Which ones are geographically close, and chronologically can schedule an interview around the same time as those 5-6?
3) If you still have too many, use the list above to whittle them down.
4) If you still have too many, email residents, peruse the websites, talk to faculty from your school, and get your list down to 8-15.
5) Don't sweat numbers 6-15. The chances you will match at one of those is minimal. For the most part, they are back-up programs. It is likely that you will rank highly, and match at one of your "pre-interview" top 5. Surprises happen, but not very commonly.

A few special considerations:

Couples match: If your S.O. is applying in EM or a similarly highly competitive field, apply to more programs and interview at more programs.

Poor applicant: Someone hosed you with a bad letter and you only got 4 interviews. Go to your interviews, do your best, and make sure you're in town during match week in case you have to scramble. If you are scared things are looking bad for you (such as NO interview invites by the second week of November) consider sending out a few more "desperation applications" via ERAS to programs still accepting applications (be sure to check which ones are.) Also consider calling programs you haven't heard from. The worst they can tell you is no, and at best they'll see your interest and invite you over the phone.

IMG: Realize that many people will see your status as a negative. Plan to apply to and interview at (if possible) more programs than a US Grad.

Late applicant: You decided you want to do EM during your October rotation. It's not too late, but you will need to scramble to get your applications in and your letters off. Consider applying to more programs than the average joe to make up for your late decision.

The surprisingly competitive applicant: OK, you applied to 40 places, and now have 32 interviews scheduled. Be sure to cancel early, there are a lot of less competitive applicants who really want that interview which is your 27th back up.

Now for the interviews.

There are many things you may find out on your interview trip, but the important ones are:

1) Will I really enjoy living here?
2) Will my s.o. really enjoy living here?
3) Do I fit in with the faculty and residents?
4) Do I feel like I will get the education I want here?
5) Will I get the (fill in the blank) experience I am looking for? (Blanks are applicant dependent, and frequently are US, EMS, Peds, Trauma, Research, Procedures etc)
6) How long are shifts, how many will I work a month, is a month here 4 weeks or a full month, how soon after a shift do residents leave, what is the sign-out culture, how many months of call, any problems obeying the 80 hour work week etc?
7) Do I like the program director? Will she go to bat for me? Why is she the program director? etc.
7) Are there any big red flags?

Following the interviews assemble your match list after consulting with your advisor and those you care about. Pay special attention to the order of the top 5. It is unlikely you'll match below there, so don't sweat which program is your number 8 and which is your number 9. Rank them in the order you want to go to them, no matter what you tell anyone, or what anyone tells you. The match works, don't try to game it.

 

This question is commonly posed in this forum, typically by a first or second year medical student, and sometimes by a third or even fourth year medical student. If in the early med school years, the asker is typically attempting to find their field early so they can have a muy bonito application. If asked later, the asker typically has done a few rotations and is feeling the pressure to decide on a specialty. To both types I say this: Take your time, and don't worry. You've got plenty of time to decide. That said, there are a few generalizations that can be made about people who seem to be happy going into EM. EM's strengths are important "categories" to them, and they do not mind EM's weaknesses. So compare yourself to the descriptions below to decide if EM is for you.

Strengths of EM:

1) The EP sees his profession as a job, not a calling. You will notice in your medical school class that there are those who live, eat, and sleep medicine. Those people typically do not go into EM. EPs typically have many outside interests, and are interested in a job that allows them to pursue those interests as well as medicine.
2) EPs love working up undifferentiated complaints. They got upset in their third year medicine rotations when they were told to go down to the ED and work up the guy with the COPD exacerbation. They wondered, "If I already know he has a COPD exacerbation, what's left to work up?"
3) EPs get bored easily. ADHD at its best. You can work something up as long as you like, and then when you get bored with it, you either admit it or refer it to be worked up as an outpatient.
4) EPs think a doctor-patient relationship is what you have when someone gives you a chart with a patient's name on it, not what happens after following someone's hypertension for 10 years.
5) EPs like to do procedures. They think sticking people with needles is fun. They know the truth of the statement, "There is no body cavity which can't be reached with an 18 gauge needle and a good strong arm."
6) EPs aren't afraid to make a decision on limited information.
7) EPs like to work as a team. They don't see nurses and techs as out to get them as you may see in other areas of the hospital. They know what their nurses do outside of the hospital, and nurses call them by their first names.
8) EPs like to multi-task. So many off-service residents never gain an appreciation for emergency medicine until they feel overwhelmed with 5 patients on the board for the first time, and then realize all the EM residents have 10. EPs prefer to work while they're at work.
9) EPs prefer a specialty of breadth to a specialty of depth. They enjoy learning practical information, and using common sense.
10) EPs enjoy being able to take care of people from all walks of life, rich, poor, old, young, smart, stupid, etc, without having to worry about whether they can pay you.
11) EPs typically enjoy a large percentage of their medical school rotations. They often complain about psych rotations, but all think Psychiatry is interesting, just not necessarily something they'd like to do all day. They enjoyed surgery, they enjoyed ICU, they may even have liked OB/GYN. They usually liked internal medicine, but detested rounding for hours and writing 10 page long notes.
12) EPs don't feel a sense of importance when paged to the hospital from their daughter's soccer game. (If you see this one as a weakness, you really don't belong in EM.)

Weaknesses of EM
1) EPs don't mind being criticized. They are the whipping-boy of the hospital because there is someone in the hospital who is better at nearly every individual thing that they do. Those are the people they admit their patients to. So of course those people are going to see their mistakes.
2) EPs don't mind treating drug addicts, street people, drug-seekers, uninsured patients, psychiatric patients, criminals, trauma victims, child abuse victims etc (sometimes all in the same person.) Many rotators in EM profess a dislike of treating these patients.
3) EPs don't mind working nights, weekends, and holidays when it means that they work three 4-day weeks a month.
4) EPs eat faster than any other specialty. I thought I was pretty good until I saw an attending inhale a sandwich while walking between the nursing station and the trauma bay.
5) EPs don't take it personally when they are sued. They realize it is about money, not ability.
6) EPs don't mind not being "the expert." They don't get tired of family and friends constantly asking, "I know you work in the ER, but what are you going to specialize in when you get burned out." They aren't intimidated by the fact that PAs and NPs work in EDs.

Hope this is helpful.

 

CV Questions

1) If they were medicine related then maybe yes, otherwise definitely no. Undergraduate, no.

2) No, your CV is about finding a position in Medicine, unless they were on the history of medicine then keep things in your CV medicially related.

UNLESS they help show that you are a well rounded person. Which brings us to ---

3) Yes, but keep it short unless you had some type of leadership position. I put in some stuff about leadership positions I had at church and in a medicine-related charity. I had 1 short paragraph that listed my other hobbies (dogs, music production, etc.)

BTW ERAS walks you through this whole process including the hobbies thing, and that's the only CV any PD will ever see except maybe your letter writers or for early match.

The Thread

-----------------------------------------------------------------

What's with the Dean's Letter?

The Dean's letter is a summary of your medical school performance. It typically sums up your year 1-2 performance in a paragraph and has a paragraph about your extracurriculars, the rest is taken from your year 3 evals. PD's just want to see that you're not a psychopath and that you did well on rotations. There are apparently "code words" that appear in Dean's letters that let them know this stuff.

Unless your school is very different you usually don't have much input into the dean's letter. We were only able to review ours for errors after a brief interview to see if there was anything about us that should be included that wasn't in the file. The Dean's letter really only serves to do 3 things, the two I already mentioned and give a class rank of sorts. Again - code words here. Mine said that I was "Highly recommended" which was code for "he is in the middle 50% of his class."

The Thread

 

I am a Foreign Medical Graduate, and matched this year (2004) into Emergency Medicine. I thought it would be a good idea if I could give some tips, based on my experiences. This is intended for IMGs (People coming from Medical Schools, not in the US, but accredited and recognised by most, if not all, residency programs) and FMGs (People coming from Medical Schools, not in the US, and not accredited or recognised by residency programs. I belong to the latter.)

1. Board scores: They mean the most I think. You need to have really good (and I mean REALLY good) board scores to have your application even considered by the programs all over the country. In my experience, both Step 1 and 2 scores count equally.

2. US experience: You should have done atleast 1 clinical rotation in the US at a good Medical School with a average to above average residency program. This is VERY important, as in most cases, the Letters of Recommendation are generated from these very rotations. Ideally, you should have about 3-6 months of US experience, and some of those months should be in Emergency Medicine. It gives the PDs an idea, that you are dedicated to EM. Other specialties would be fine as well, but EM counts the most.

3. LORs: LORs coming from US physicians are again EXTREMELY important. You have to understand that everyone applying for EM has stunning LORs. And you are competing with US grads... so everything goes against you. You need to prove to the PD that there are US physicians who believe that you are as good (or even better) than any US grad. LORs coming from big names in EM are a big plus. And it goes without saying that getting an outstanding SLOR is also of utmost importance.

4. Research: Having research always shows your academic side. Its good to have some EM research publications if possible, or research in any specialty would do. Research gives your application the "edge" over other competing FMGs or IMGs. Publications are not necessary, and even unpublished research would help, as long as you have something to show for it.

5. Visas: As sad as it may be, it changes your application completely. As strong as your application may be, if you require a visa (J1, H1B etc.) from the institution, that tends to place your application right at the bottom of the pile. I know there is'nt much you can do about it, but it is something to keep in mind. Have a Green card or being a US citizen helps a lot, even if your application is'nt that great. So for all those who have visa issues, remember... your application overall has to be just amazing, for PDs to look at it and give you a chance to prove yourself.

6. Personal Statement: Try to show your dedication. Show that you want to bring a change to the field of EM to your home country, or anywhere else in the world. PDs like that a lot. It shows that you are not just into EM for the money or the work hours or the lifestyle. So the trick is to be clear in your intentions, while not going beyond and being unrealistic.

I hope I have covered everything I could think of. Just my 2 cents. PM me if I can be of any help... I would be more than glad to help.
- samdaman

 

This thread has valuable information and is a great resource. Great job, everybody!

I put all of my advice at http://www.geocities.com/andy_kahn_em/
(hope it helps).
The most useful info can be found in the sections entitled "3rd year" and "4th year." It covers the things I did to match into EM. The "links" page has several sites that are useful for gathering info on the field as well as the applications process.

-ak

 

This last year 96% of those who wanted to match in EM, did match in EM. The previous 3 years it has been 93%. In comparison, family practice's number was 98%, derm's number was 51%, ortho's was 84%, optho was 82%. These numbers are all pilfered from:
http://medicine.wustl.edu/~residenc...pec/byspec.html

The other statistics published by the national organizations are useless with regard to competitiveness, but this one at least, has relevance.

 

Ahhh the top EM program thread. This subject seems to pop up every 4 months or so. I'm not gonna give a list of my own. Desperado's summary above gives a pretty comprehensive discussion of the complexities of ranking EM programs. However, I think it is helpful for any student considering EM for a profession to have a good survey of the opinions out there. Here is a list of memorable threads posted over the last couple years with several "top program" lists included.

From 6/2002 : 2 lists

From 12/2002 : 2 lists

From 3/2003 : 3 lists

From 4/2004 : 1 list with lots of debate

And of course Desperado's list a few posts above

Again, you can see from these threads that there is always plenty of controversy about the programs considered the "best". But I think there are definately general trends and programs that are universally considered great. Hope this helps.

 

This next information doesn't necessarily pertain to EM alone, but DOES pertain to anyone who starts out in a different type of specialty and then wants to switch to EM. The government limits the amount of money that it will reimburse residency programs for a given resident, which is based on something called your initial residency period. Given that EM is still a somewhat competitive specialty, some programs use previous residency experience to screen out potential applicants.

The following is from a 1997 pamphlet put out by the AAMC, and the info is still acurate to the best of my knowledge. I have boldfaced the most relevant areas...

 

Medicare Payments for Graduate Medical Education: What Every Medical Student, Resident, and Advisor Needs to Know


In nearly every area of your life, the choices you make today will have a direct impact on options available to you in the future. The same is true for your medical education. The more you know, the better position you are in to make clear and informed decisions - decisions that should not be entered into blindly.

The Association of American Medical Colleges (AAMC) developed this brochure to help medical students, residents, and advisors understand Medicare rules related to graduate medical education. After reading it, you will be in a better position to assess the impact of decisions about your future.

1. What are Medicare and Medicaid?

Medicare is a federally administered health insurance program for people 65 or older and certain disabled people. Part A of Medicare pays for inpatient hospital services, skilled nursing facility care, home health, and hospice care. Part B pays for physicians? services, outpatient hospital services, durable medical equipment, and a number of other medical services and supplies that are not covered by Part A. Medicare payments for graduate medical education are made under Part A. The Medicare program is different from the Medicaid program. Medicaid is a health insurance program for low income families jointly financed by the federal government and each state. The Health Care Financing Administration, known as HCFA, is the federal agency that administers the Medicare program and the federal portion of Medicaid.


2. Does Medicare have a role in Graduate Medical Education?

Yes. Medicare estimates its payments to hospitals for costs related to graduate physician training at about $6.5 billion in federal fiscal year 1996. Medicare payments for graduate medical education (GME) may have a direct impact on you. Medicaid also pays hospitals for GME in some states, but that topic is outside the scope of this brochure.


3. Why is it important for a medical student to understand how Medicare pays hospitals for graduate medical education?

The way in which Medicare pays hospitals for medical education may limit some residents? opportunities to switch from one specialty to another. Hospitals receive payment for patient care services from many different payers, such as insurance companies, health maintenance organizations, and Medicare. In some states, the Medicaid program also provides payment for graduate medical education and some state laws require private payers to support medical education training. However, since Medicare is the largest single insurance program providing explicit support for graduate medical education, the impact of Medicare requirements is often of paramount concern to hospitals.


4. What do I need to know about the way in which
Medicare pays hospitals?

Every hospital that trains residents in an approved residency program is entitled to receive Medicare?s direct graduate medical education payment, also known as DGME. The amount of the DGME payment varies for each hospital. It is based on an amount known as the ?hospital specific per resident amount,? which, according to law, was determined by HCFA for each teaching hospital in the 1980?s and periodically up-dated by an inflation factor. It covers the direct costs of training residents, such as residents? salaries, teaching physicians? salaries, and related overhead expenses. For each hospital receiving a DGME payment, Medicare pays a portion of the hospital specific per resident amount. For a hospital to calculate its current Medicare DGME payment, it must do the following:

a. Count the number of residents according to the law and regulations (This will be very important to you, so we will discuss this in more detail below)

b. Multiply the number of residents by the hospital specific per resident amount.

c. Multiply the product in #2 above by Medicare?s share of the hospital?s inpatient days (called the Medicare patient load). Here?s an example:

University Hospital has 400 residents (assumed at 1.0 full time equivalent (FTE) each).

Its updated hospital specific per resident amount for 1997 is $60,000.

30 percent of its inpatient days are attributed to Medicare beneficiaries.

Medicare will pay University Hospital $7,200,000 for direct medical education ([400 x 60,000] x .30).

NOTE: As of October 1,1997, Congress has placed limits on the number of residents a hospital or other provider may count for purposes of the DGME payment. Except for a few combined residency programs, the counting rules for residents described below remain unchanged.


5. Does Medicare cover any other costs related to medical education?

Teaching hospitals also receive an indirect medical education (IME) adjustment from Medicare. Medicare provides the IME adjustment to teaching hospitals to recognize their higher cost of inpatient care when compared to non-teaching hospitals. The IME adjustment is an additional payment for each Medicare inpatient stay. Among other factors, the IME adjustment is based on the ratio of interns and residents to beds. Residents may be counted for the IME adjustment if they are working in the inpatient or the outpatient department of the hospital, or in a non-hospital setting if certain conditions are met. Exempt hospitals (such as psychiatric, rehabilitation, and children?s hospitals) are paid based on their costs, including IME costs, so for them payment for IME is not an explicit adjustment to Medicare?s payment rate.

(cont.)

 

6. How does all of this affect me?

Residents working in all areas of the hospital complex may be included in a hospital?s FTE count for the DGME payment. A hospital may also include residents working in non-hospital sites in its FTE count if the site is part of the resident?s educational program and there is a written agreement that the hospital will continue to pay the resident?s salary for training time spent outside of the hospital. When Medicare counts the number of residents for determining a hospital?s DGME payment, each full-time intern and resident is counted as 1 .O FTE during what is called an initial residency period. After the initial residency period, a full-time resident can be counted only as a 0.5 FTE for Medicare?s DGME payment.


7. What is considered an initial residency period, and when does it begin?

The initial residency period is the minimum number of years in which a resident is eligible for specialty certification. It is based on the minimum accredited length listed for each specialty in the Graduate Medical Education Directory (sometimes called the Green Book), published by the American Medical Association (AMA). The initial residency period is determined at the time the resident first enters a training program and does not change, even if the resident later changes specialties. For this reason, it is very important that you understand that the residency program in which you begin training determines the number of years in which Medicare will make full direct graduate medical education payment to the hospital for your training. The Medicare program has published a list of specialties and initial residency periods, which may be found in the Appendix. Except for geriatrics and preventive medicine, all subspecialty training is beyond the initial residency period, and each FTE is counted as a 0.5 FTE. If you started your residency training before July 1, 1995, your initial residency period is counted differently. It is the minimum number of years required to be eligible for board certification plus one year. Regardless of when your training begins the initial residency period may not exceed 5 years.

Here?s an example for a resident who began her training after July 1, 1995:

Dr Smith begins an internal medicine residency. Internal medicine has an initial residency period of three years. Dr. Smith soon realizes she?d rather do a surgery residency (which has a five year initial residency period) and would like to begin training the following year. However, even if Dr. Smith is accepted into a surgery program, her initial residency period remains 3 years. e would be counted as 1.O FTE during her first and second year of the surgery residency and 0.5 FTE during her third, fourth, and fifth years, The hospital will be paid less for her last three years of training than for other surgery residents who are still in their initial residency period.


8. I intend to train in a specialty that requires me to complete a prerequisite year in another specialty. How will this affect my initial residency period limitation?

Some specialties require a year or more of generalized training in a specialty other than the one in which you are seeking board certification. Since the law requires that the initial residency period be determined at the time a resident enters a training program, your initial residency period will be based on the specialty that you begin training in even if you ultimately intend to train in another specialty. For instance, if you begin training in internal medicine your initial residency period is 3 years even if you intend to train in another specialty which requires a total of 4 years of training, such as anesthesiology. In this example, you will be weighted as a 0.5 FTE for your fourth year of training. Some programs, however, are accredited as transitional year programs. Typically, transitional year programs can be used to meet the required year of generalized training. HCFA has said that it will count training in a transitional year program as an additional year beyond the initial residency period at a full FTE if the resident has chosen a career specialty that requires as a prerequisite an entry year of fundamental clinical education. Continuing with the earlier example, if you complete the transitional year and then do 4 years of training where a total of 5 years of training is required, you can be counted as a full FTE for up to 5 years of total training. If there is not a requirement of a year of basic clinical training and you desire to complete a transitional year program because you desire a broader base of clinical experience, the transitional year will count against your initial residency period and could result in you being counted as a 0.5 FTE for the final year of subsequent clinical training.

(cont.)

 

9. I completed a year of clinical training after medical school, and now I am fulfilling a military commitment. How does the initial residency period limit affect me?

Many medical students who have military commitments are required to complete 1 year of post-medical school training in an accredited program before entering the military. If you are in your first residency program after graduation from medical school or have not exceeded the limits of an initial residency period in another specialty, you will be counted as
a 1.0 FTE during the required year of training prior to entering the military. If you subsequently leave the military and enter a residency program, the year of training previously completed will count toward that resident?s initial residency period. If the residency year completed prior to entering the military was in a specific specialty, such as internal medicine, your initial residency period will be based on that program-even though you left the program to complete a military commitment. If the training prior to entering the military was in a transitional or preliminary year program, then the initial residency period will be based on the specialty in which the resident resumes training. Any training in a residency program operated by the military that may be counted towards board certification also counts toward the initial residency period.


10. Does training time for which Medicare does not pay count against my initial residency period limitation?

Yes. It does not matter whether or not Medicare makes any payment towards your training. All training time that counts towards certification in a specialty is counted against your initial residency period for purposes of determining Medicare?s DGME payment. So even if you completed a residency program that Medicare did not support, any training which you may wish to do later will be considered to be beyond the initial residency period, and you will be counted as a 0.5 FTE for purposes of determining Medicare?s DGME payment.


11. I plan to begin a combined residency training program. What is my initial residency period?

The answer depends on the type of combined program in which you will be training. If each of the individual programs that makes up the combined program is a primary care specialty, such as internal medicine-pediatrics, then you will count as a 1.0 FTE-for the minimum number of years required for board eligibility for the longer of the two programs, plus for one additional year. Congress has defined primary care to mean general internal medicine, general pediatrics, family practice, geriatrics, preventive medicine, and osteopathic general practice. Congress also has determined that this rule applies to a combined program that includes an obstetrics and gynecology program. For example, if you enter a combined internal medicine-family practice program, both of which require 3 years for board eligibility, you will be counted as a 1.0 FTE for 4 years - the 3 years required for internal medicine or pediatrics, plus one year. For any additional years of training in an approved program, you will be counted as a 0.5 FTE. If you enter a combined program in which one of the two programs is not a primary care program, such as internal medicine-emergency medicine, then the rules are different. HCFA determines the initial residency period based on the longer of the two composite programs. In the internal medicine-emergency medicine example, HCFA stated last year that since the initial residency period for each program taken separately is 3 years, the initial residency period for combined internal medicine/emergency medicine programs is 3 years. You will be counted as 0.5 FTE for the fourth year of the combined internal medicine-emergency medicine program.

12. Which training programs does Medicare support?

Hospitals are entitled to count all residents who are participating in approved educational activities. Typically this means programs which are accredited by the Accreditation Council on Graduate Medical Education and included in the AMA?s Green Book. Medicare also includes programs not included in the Green Book, but for which an American Board of Medical Specialties organization issues a certificate.

13. I have already begun training in a 3 year program and want to switch to a longer program. What do I do now?

It is important for both you and the program director to fully understand the financial implications of Medicare?s initial residency-period limitation to the institution. The precise financial impact of a resident beyond the initial residency period will differ for each hospital and depends on the hospital-specific per-resident amount and on the percentage of inpatient days in each hospital attributable to Medicare. Let?s look at a sample teaching hospital in 1996:

Sample hospital specific per resident amount $65,000
Average Medicare patient load: 30%
Medicare per resident payment: $19,750
Potential annual loss for a 0.5FTE resident: $9,875

The rules regarding the initial residency period apply only to the hospital's Medicare DGME payment. Residents participating in an accredited training program are counted as 1.0 FTE for the IME adjustment when they are beyond the initial residency period. For most hospitals, Medicare's IME adjustment far exceeds Medicare's DGME payment. So, as a percentage of the hospital?s total Medicare medical education payment, the financial impact of a resident beyond the initial residency period may be small. The impact will also be more or less for any institution, depending on its per resident amount and percentage of Medicare inpatient days. For instance, pediatric hospitals typically have few or no Medicare patents. If a hospital has no Medicare inpatient days, the hospital will be unaffected by your participation in a training program. Similarly, hospitals payment for your training time beyond the initial residency period will be less if the hospital's per resident amount is very low. In short, both you and the residency director should fully consider the financial impact on the hospital before making any decisions that would affect your future career.

If you have any questions, please contact Ivy Baer at the Association of American Medical Colleges, at 202-828-0490, or [email protected].

 

There are EM toxicology rotations (I know there is one here at Dallas/UT Southwestern) that should be pretty relevant. I enjoyed the EM Ultrasound elective at UC-Irvine. I believe there are EM Research electives at certain places. My wife did the Pedi EM rotation at Kosair's Children's Hospital when we were in Louisville, KY and she learned a lot. You might look into seeing if anybody has an EMS type rotation although I am not really familiar w/ anything like that. I think any rotation where you get to spend more time w/ the EM faculty and residents may be helpful in having more exposure the program, especially if you can go to conferences and interact w/ everybody. I used most of my electives and options to do EM b/c I loved travelling and working in the ED (did EM at Parkland in Dallas, did "elective" in EM at Louisville, did "acting internship" in EM at Sacramento, and did EM Ultrasound in Orange County as mentioned earlier at UC-Irvine. see http://geocities.com/andy_kahn_em/MS4.html for more details on those places during my time there."

 

Are you thinking of posting a thread asking the Emergency Medicine (EM) Forum community for opinions about your chances of getting into an EM residency? If you are then thank you for coming to this FAQ first. Hopefully this information will help and you will reconsider your post.

If you have come here after posting and got a bunch of replies about someone named Fatty McFattypants that’s just the forum regulars saying that you should check out the FAQ and use the search feature to see if your question has already been answered. You will find that many of your questions have been thoroughly answered and some, such as the “What are my chances?” question have been beaten to death. The best way to get the most out of the SDN EM forum is to ask specific questions with a narrow focus. If your question is too broad you just will not get the responses you are looking for. For example you will get much better responses if you ask a question such as “What’s the difference between Program A and Program B?” rather than the dreaded “What’s the best residency?”

While the posters on the EM Forum tend to provide good quality information and advice there is no way that anyone here can assess your competitiveness in the Match and what your chances really are. We don’t know all of your information and circumstances. If we do know everything about you then you have posted too much personal information about yourself on the internet which is unwise. It is also unlikely that anyone will read all of a post long enough to comprehensively explain your application. Even if we knew all about you we still have no idea what the upcoming Match will be like as it changes every year. EM may be more or less competitive in the next Match. You also need to treat anything you read on the forums with the degree of skepticism appropriate for an anonymous internet bulletin board.

So what are your chances?

Most of what goes into making you competitive for a residency (any residency, not just EM) is common sense. Things that help your competitiveness include:
-Strong letters of recommendation (in SLOR format if the writer is EM faculty, info at http://www.cordem.org/slor.htm )
-High Board Scores
-Good clinical grades
-Publications
-Research
-Good interview skills
-Pre-clinical grades
-Dedication to EM (EMRA http://www.emra.org, AAEMRSA http://www.aaemrsa.org/index.php, volunteering, etc.)
-Related experience (EMT, ER tech, etc.)
-Special circumstances (experience in other fields, MBA, anything that sets you apart)

Things that hurt your competitiveness include:
-Low or failed boards
-Low clinical grades or failed clerkships
-Poor letters of recommendation
-Interviewing poorly
-Low pre-clinical grades or failed courses
-IMG/FMG status*
-DO degree*
*Please note that I am referring to the American, allopathic match. I am absolutely not putting down any of these physicians. However the reality is that there are programs that will not consider these applicants or give them a lower standing which puts them at a disadvantage. Just like everything else this disadvantage changes in its impact each year.

Your chances as an applicant depend on your ability to maximize the things that help you and minimize the things that hurt you. If you have failed a clerkship or bombed a board exam will it be impossible to get into an EM residency? No. But for every negative you will have to shine in some other area. Do you have to have research or publications? Absolutely not. Do they help? Sure. Will they overcome a negative like a failed exam? Maybe. That depends on the program, the rest of your application, the year, the Program Director’s mood that day and many other variables.

The best way to help your chances is to do your best in medical school and on your tests. If you know you do poorly on standardized tests take a preparation course. Do not spread yourself too thin by devoting time to research, EMRA, coat-tailing etc. at the expense of your grades and boards. Grades and boards are the foundation of your application.

Find yourself a mentor at your school. Pick an Emergency Physician (EP) you respect and ask if they will help you reach your goal. You will eventually be asking your mentor and other EPs in the department for letters of recommendation so start early building contacts. If an EP refuses or just directs you elsewhere do not get discouraged. These people are busy and you are better off finding a different mentor than having someone accept and turn out to be unable to give you enough time. I think that getting a good mentor is one of the most important things a student can do. It is best done early (e.g. second year or early third year) because you want to build a relationship with your mentor.

Get involved with your school’s EM interest group and/or EMRA or AAEMRSA (web sites above). Those organizations will help you decide if you truly want to go EM and they will help you stay up on current hot topics in EM. That will be a big help at your interviews. Belonging to these groups also shows your dedication to EM and lets you fill in blanks on your application.

You should also increase your chances by using the Match to your advantage. You should take an honest look at your application, preferably with your mentor. Apply to more programs if your application is weak. Interview at as many programs as you can afford. Rank every program at which you would be willing to do your residency. Take your realistic assessment of your application into account when deciding what you will be willing to accept.

Here is the sad truth that no anxious medical student wants to hear: There is nothing you can do that will absolutely guarantee that you will match. All you can do is your best. Remember that most people come out of the Match happy. Good luck.

 

Quinn and I have come up with this thread to serve as the FAQ for the frequent and perpetually unanswerable “What Are My Chances?” posts. We are trying to provide some insight to anxious, novice SDNers as to why it is impossible to tell them what their chances really are.

This thread is to serve as a FAQ so it would be appreciated if we could limit posting to veteran SDNers who have been through the process, i.e. residents and attendings. We would like posts to stick to advising students how to assess their chances and better their chances of getting an EM residency. Please keep the tone of the posts to that of an advisor helping students.

Thanks

 

Excellent thread and well stated. I'm ready to wear the advisor hat if anyone has some serious questions not answered by the above thread. I promise I will not lash out the dreaded Fatty McFattypants unless it is truly warranted.

Also, to add to the above, nothing can help your chances of matching more than getting to know the residents you rotate with on a fairly memorable (professional but personal) level. Having interviewed and talked with applicants to my program, nothing is more important to a program than attracting residents who will mesh with the group and fit in with minimal effort. For this reason, it is nearly impossible to adequately answer your match capability on an anonymous forum, as stated above.

If you get an interview, your application is good enough to match. Period. Programs will not waste your time (or theirs) otherwise. If you are a boob during your interview, you likely will not match there. If you worked well with the residents and the attendings, your chances are pretty good.

Receiving an interview from a program you rotated with is by no means a guarantee that you will match (or even rank highly) at that program. Often times these interviews are customary. Consider them good practice and nothing more. If you want to go to that program and you are a good fit, it will show throughout the month you rotate there. The interview is a formality. If you don't match there, it isn't the end of the world - things work out.

Remember back to medical school, and how you felt when you took the MCAT, and filled out your applications, and you constantly asked yourself if you were good enough to get in? Well, you were good enough, and you still are. Your odds of getting into an EM residency are actually better than getting into medical school. Your work is done now, and there is no academic acheivement that you can do during your 4th year of medical school to significantly alter your destiny in the match. Sure - a few extra points on step II might mean someone ranks you a couple of slots higher in the end of the season on their match list, but in the end, it will not alter your outcome. Focus on being a "people person" and interacting with people again - a talent we all at one point had and may have lost somewhere between Gross Anatomy and Surgical rotations. This is emergency medicine, and this is the "intangible" quality that cannot be predicted, scored, written, or quantified. This is the person behind the photograph on the table of the rank list meeting each program has. Your personality will be what makes people say "that guy was such a jerk, rank him number 100" or "She was incredible and everyone loved to work with her, we cannot lose her."

Everone in medicine can learn emergency medicine and do well. It takes a confident, friendly personality to be a good emergency physician. This is the trait that will best predict your match.

Good luck. Please feel free to PM me with questions...

 

I was recently asked by a user about the possibility of creating a generic account for people to use to post residency reviews anonymously. SDN administration has decided not to do this. There are several valid reasons behind this decision. This kind of account has been abused in the past on other SDN (not EM) forums. The posters anonymity can also be preserved by PMing the review to a mod (that would be me) and having them post it. Since the user would have to PM the mod for the account password the level of anonymity of that procedure is the same as it would be for a generic account. Finally SDN would like to encourage users to post residency reviews on the Residency Interview Feedback page. The Residency Interview Feedback page is anonymous.

So please use the Residency Interview Feedback page. If you want something posted on the EM forum and you want it to be anonymous PM me and I’ll post it for you.

Happy interviewing,

docB

PS- I've posted this note in the relevent threads. I'll sticky this announcement for a few weeks then merge it into the FAQ. If anyone has any questions please feel free to respond in this thread (we don't want policy discussions in the review threads) or PM me.

 

This FAQ is missing some important topics as it stands now. To fix this I'm going to start adding some new posts addressing these topics. However these posts will be in the form of links to new threads about these topics. The reason for this is that the bueaty of SDN is in its community of users. It is my hope that the linked threads will come to incorporate input from many users as well as be continually updated by the community.

I also ran across this old thread which has some good posts on EM in general, EM procedures and a lot of good links (compiled by RxnMan) to relevent SDN threads.

http://forums.studentdoctor.net/showthread.php?t=544397&highlight=community+academic

 

Schedules in EM

 

EM Pay, Compensation, Billing and Benefits

 

EM Employment and Independent Contractor

 

The EMTALA Information Thread

 

I am unsticking this thread as we have the new 2010 FAQ which links to all of these posts by subject (props to RxnMan for the 2010 FAQ!).