Oct 27, 2010
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Hi Guys -

I'm applying to EM this cycle from medical school in the Midwest. I'm originally from Utah and have a lot of family in Arizona, my wife is from Georgia and has a lot of family in both Carolinas. Unfortunately, while I'm locking down plenty of Midwest interviews, I've been outright rejected at one program and haven't heard from hardly any of the other Western/Southern programs I applied to.


Statistically, I am an above average candidate with 3 solid SLORs and no red flags (ie, I should probably pass any academic screens). Is it possible that I didn't demonstrate a legitimate geographical interest in the South or West and therefore I'm getting screened out in a heavy application year? Is there a classy way for me affirm my definite interest in those geographical areas? In fact, the one program that already rejected me was REALLY high on my list - is there a classy way to make sure they didn't screen me out as a Midwesterner who wouldn't want to live in the Southwest?
 

The White Coat Investor

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I've heard your story before. Several things to consider:

1) There are very few programs out West in comparison. There's 2 more now than when I applied, but they're already very competitive. They can be very picky. There are only a handful of really competitive Midwest programs. The other programs are probably about as good as most of the ones out West, but location counts for a lot when it comes to competitiveness, especially in EM.

2) The programs I interviewed with out West sent out invites later than the Midwestern programs.

3) I applied to 30 programs and got interviews at 28 of them. One of those two who rejected me was in North Carolina. UNC and Carolinas can also afford to be quite picky and still fill their slots with good people.

4) The U of A and UNM are also very competitive (were you talking about one of those?). Great programs in great locations. It helps to know someone to get your foot in the door.

5) I doubt someone is going "This guy wouldn't come out here. He obviously likes the MidWest." My class at the U of A had plenty of Midwesterners, as has the U of U as I recall.

Good luck.

P.S. How's Francisco D'Anconia these days?
 
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OP
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Oct 27, 2010
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I've heard your story before. Several things to consider:

1) There are very few programs out West in comparison....

Good luck.

P.S. How's Francisco D'Anconia these days?
Thank you, I appreciate the response and your consideration.

It was actually Maricopa that shot me down, which I really thought would be in my statistical zone. I guess I just can't think of what might have screened me out so early in the race if it wasn't for location. I've heard some rumors that a humble call with a simple geographical explanation opens door, even doors that have been closed rather than just unanswered. I'm not desperate enough to beg yet....

Francisco, Dagny, and John are all looking more dead every day.
 

The White Coat Investor

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Thank you, I appreciate the response and your consideration.

It was actually Maricopa that shot me down, which I really thought would be in my statistical zone. I guess I just can't think of what might have screened me out so early in the race if it wasn't for location. I've heard some rumors that a humble call with a simple geographical explanation opens door, even doors that have been closed rather than just unanswered. I'm not desperate enough to beg yet....

Francisco, Dagny, and John are all looking more dead every day.
The call can't hurt you now, unless you count losing a couple days and a few hundred dollars to go interview.
 

Pure Anergy

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I don't believe in the geographical legitimacy thing. I'm from the east coast, and I was invited to Maricopa and rejected by another program a two hour drive away from me. I've never lived out west and don't know a soul in Phoenix. They have no evidence that I would move all the way to the other side of the country except that I sent them my app and accepted their invitation to interview. It's really subjective when the programs decide who to interview, so don't drive yourself crazy trying to understand why a specific program invites you or rejects you even though you have good stats. There's not always a rational reason for it, just like there isn't always a rational reason why you like one program better than another equally good program. Sometimes it's just a feeling. As far as calling post-rejection, I don't have an answer to that. I've heard of people doing it, but I already have enough invites and don't plan to try it. If you do it, good luck and hope it works out for you.
 
OP
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looks like my thread is losing steam.....

so here's a shameless bump. I guess I just can't figure out how I was screened out before they got my MSPE, you know? I've received several rejections now (a few in my MidWest region) but at least they have my MSPE and know I only "passed" Psych and Neurology.


Any other opinions (thanks to those that already replied)?
 

alwaysaangel

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looks like my thread is losing steam.....

so here's a shameless bump. I guess I just can't figure out how I was screened out before they got my MSPE, you know? I've received several rejections now (a few in my MidWest region) but at least they have my MSPE and know I only "passed" Psych and Neurology.


Any other opinions (thanks to those that already replied)?
You will never know. It is most likely geographical and if you look at the "applicant support" thread you will see that Maricopa dumped a bunch of people on the same day - it wasn't just you.

There was something about everyone (myself included) that they just thought didn't jive with their program and an MSPE wouldn't make any difference. Maybe it was geographical and they didn't belive you really wanted to go their. Maybe it was geographical and they're trying to train EM docs for Arizona and they are only interviewing AZ natives because they want people who will stick around. Maybe they are really heavy on creating community docs and all the people who were rejected said they want to go into Academics.

There is no way to know for sure. You could email them and ask. You could email them and tell them all about how you want to move to AZ and stay forever. It may help, it may not. You will probably never know exactly why you (and dozens of others) were rejected that day. You need to stop dwelling.
 

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looks like my thread is losing steam.....

so here's a shameless bump. I guess I just can't figure out how I was screened out before they got my MSPE, you know? I've received several rejections now (a few in my MidWest region) but at least they have my MSPE and know I only "passed" Psych and Neurology.


Any other opinions (thanks to those that already replied)?
They don't care that you "only passed" psych and neurology. In fact, that might be a bonus!

This isn't med school. They're looking for people they want to work with. It's a job interview. They probably do a brief screen consisting of "Did he get honors in at least one of his EM rotations and did he score at least 220 on the boards?" Then they read your letters and statement and decide if they think you're cool or not. That's it. I mean, if your transcript is full of fails or some other red flag that might be a problem, but for the most part it's EM grades, letters, statement, and board scores. After that, it's ALL about the interview.
 
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Is there any chance your PD knows anyone out there? I've heard of a student at our school in years past who didn't have the best boards score but was really interested in a specific program in that area, PD made a call and vouched for him, he ended up being chief resident eventually. If not, a polite email from you reiterating your interest and asking if there was anything in particular that they thought made you not a good fit for them can't hurt at this point, as others have said. In any event, I doubt the reason was solely geographical. I know a number of people from my midwest school who are interviewing or have matched out there without being from the area originally. Best of luck to you!
 

fergustsi

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They don't care that you "only passed" psych and neurology. In fact, that might be a bonus!

This isn't med school. They're looking for people they want to work with. It's a job interview. They probably do a brief screen consisting of "Did he get honors in at least one of his EM rotations and did he score at least 220 on the boards?" Then they read your letters and statement and decide if they think you're cool or not. That's it. I mean, if your transcript is full of fails or some other red flag that might be a problem, but for the most part it's EM grades, letters, statement, and board scores. After that, it's ALL about the interview.

Regarding honors in EM rotations, i understand the most competitive programs can be picky and say something along the lines of what you said above with screening people out without honors. What about other solid programs? I mean is a HP really that bad?
 

Go Time

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Regarding honors in EM rotations, i understand the most competitive programs can be picky and say something along the lines of what you said above with screening people out without honors. What about other solid programs? I mean is a HP really that bad?
WRT EM rotation grades...my experience is that there is a great degree of luck/randomness/variability involved in what it takes to get honors at different programs and within a program. So, I'd be surprised if the lack of honors or the presence of a pass makes for an invite bust.
 
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The White Coat Investor

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WRT EM rotation grades...my experience is that there is a great degree of luck/randomness/variability involved in what it takes to get honors at different programs and within a program. So, I'd be surprised if the lack of honors or the presence of a pass makes for an invite bust.
Let me ask you this....imagine you're a program director. You have so many applicants you have to put in some kind of academic screen. What would you choose? I'd choose honors in an EM rotation and board scores.
 

Go Time

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Let me ask you this....imagine you're a program director. You have so many applicants you have to put in some kind of academic screen. What would you choose? I'd choose honors in an EM rotation and board scores.
I think it is fairly common for grades to be primarily based upon a handful of subjective attending evaluation where the evaluators only interacted with the student for a couple of patients during one shift...and those evaluations are sometimes not filled out for a couple of weeks after the shift where those interactions took place. The difference between Honors and Pass could also be the result of couple of answers on a multiple choice exam. I think that makes it hard to really know what the difference between Pass and Honors means in terms of predicting future performance as a resident. So if I was a PD looking for talent and potential, I would look at the overall package and not hang my hat on those grades when selecting folks to interview...it doesn't take that much more time.
 

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...it doesn't take that much more time.
How many applicants do you think a particular program director has to look at? Do the numbers.....

~1500 applicants each applying to ~30 programs, 45000 applications total.

Divide that by ~120 programs=45000/120=375 applicants per program. How many overall packages are you going to look at before putting in a screen? Keep in mind that's the average number, the really popular programs might have 3 times that many. They simply CANNOT read the entire package. They MUST put in a screen. The simpler, the better. The only universal screen is board scores. There was a paper a few years ago that listed what PDs really looked at. As I recall, it was board scores, grades in EM rotations, and letters. They don't care what you got in histology. Here's the paper:

http://www.ncbi.nlm.nih.gov/pubmed/10894243

But if you don't have a competitive application, apparently you can just make it up:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201142/

Good luck.
 

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Regarding honors in EM rotations, i understand the most competitive programs can be picky and say something along the lines of what you said above with screening people out without honors. What about other solid programs? I mean is a HP really that bad?
I had a buddy who also had great board scores and comparable overall grades to mine. He got a HP. I got an honors. We both applied to all the programs in the West. I got interviews at all of them. He got interviews at none of them. Maybe it was something else, but I think it made a big difference.
 

alwaysaangel

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Yeah, I would agree at this point getting honors on the EM rotations is important - based on what my mentors have told me and my classmates and my experiences applying so far. In fact, I think on the paper quoted above its like 5th of all the factors which is pretty high.

Is it "unfair" because its subjective? I guess. If you define something that is inherently subjective as unfair. But this isn't school anymore. We are applying for JOBS! And from here on out its going to be subjective. Where you get chosen for residency will be subjective, what you get for a raise (other than the minimum each year) will be subjective, whether or not you're chief resident will be subjective, where you ultimately get hired, etc. etc. etc.

Yes, honors in an EM rotation is subjective: did they like you, were you useful, did they generally think you will be a good EM physician based on their experience with you... But so? Thats what PDs are looking for at this point. Someone who is the EM type of personality who will be a good addition to their program. And having high board scores doesn't make you a good addition to the program. Being personable, useful in the ED, and someone that everyone wants to work with makes you a good resident in the ED.

I've had 3-4 different attendings tell me that on interviews the only thing they're trying to figure out is whether or not you'd be fun to work with at 3am on a Saturday night. Will you increase their energy level or be a dud. Totally subjective. But completely important from their perspective.
 

Go Time

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How many applicants do you think a particular program director has to look at? Do the numbers.....

~1500 applicants each applying to ~30 programs, 45000 applications total.

Divide that by ~120 programs=45000/120=375 applicants per program. How many overall packages are you going to look at before putting in a screen? Keep in mind that's the average number, the really popular programs might have 3 times that many. They simply CANNOT read the entire package. They MUST put in a screen. The simpler, the better. The only universal screen is board scores. There was a paper a few years ago that listed what PDs really looked at. As I recall, it was board scores, grades in EM rotations, and letters. They don't care what you got in histology. Here's the paper:

http://www.ncbi.nlm.nih.gov/pubmed/10894243

But if you don't have a competitive application, apparently you can just make it up:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201142/

Good luck.
I was thinking 500-700 applications per program to review over a 10-12 week period...maybe divided up between a couple people. So, maybe an extra hour per week to scan beyond EM grades and board scores.

The post-interview article you posted has something like 7 different criteria, including "other", whose mean/SD overlap with the generalized use of EM grades (I didn't see a specific use or differentiation of that grade noted).

Here's a more recent, non-peer reviewed, survey which has an interview selection section:

http://www.nrmp.org/data/programresultsbyspecialty2010v3.pdf

The last survey didn't have a similar combined "other", and neither had "combined academic performance" as options...both of which are the two I've been led to believe are the best forecasters of resident performance/potential.

One thing I'd place in "other" would be something that makes me think the applicant would be good to work with. Another would be geographic ties. Knowing how EM grades can be determined and distributed, it appears that they can be kind of a crap-shoot beyond failure or marginal. Maybe compared to your friend you had more good "other" vibe coming through?
 
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Pure Anergy

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How many applicants do you think a particular program director has to look at? Do the numbers.....

~1500 applicants each applying to ~30 programs, 45000 applications total.

Divide that by ~120 programs=45000/120=375 applicants per program. How many overall packages are you going to look at before putting in a screen? Keep in mind that's the average number, the really popular programs might have 3 times that many. They simply CANNOT read the entire package. They MUST put in a screen. The simpler, the better. The only universal screen is board scores. There was a paper a few years ago that listed what PDs really looked at. As I recall, it was board scores, grades in EM rotations, and letters. They don't care what you got in histology. Here's the paper:

http://www.ncbi.nlm.nih.gov/pubmed/10894243

But if you don't have a competitive application, apparently you can just make it up:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201142/

Good luck.
That second article is crazy. It's stupid to make up stuff anyway, but especially things like make up having a degree or what author they were on a paper. That's so easy to verify.

Since I helped the mod make the new residency reviews sticky, I know that there are 155 allo programs listed on the ACGME website, plus at least three others not listed there (VA Tech, SUNY Downstate, and now UW, which reminds me that I should add it to the sticky). But yeah, you have a good point.

Since we're all going on personal experience anyway, I still say that there is no such thing as geographical legitimacy. I've gotten a bunch of invites to west coast programs in states that I've never even visited, let alone have connections to them. But a few east coast programs rejected me or haven't gotten back to me yet. I can't explain how programs decide who to invite, so I'm not even going to try.
 

Go Time

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Yeah, I would agree at this point getting honors on the EM rotations is important - based on what my mentors have told me and my classmates and my experiences applying so far. In fact, I think on the paper quoted above its like 5th of all the factors which is pretty high.

Is it "unfair" because its subjective? I guess. If you define something that is inherently subjective as unfair. But this isn't school anymore. We are applying for JOBS! And from here on out its going to be subjective. Where you get chosen for residency will be subjective, what you get for a raise (other than the minimum each year) will be subjective, whether or not you're chief resident will be subjective, where you ultimately get hired, etc. etc. etc.

Yes, honors in an EM rotation is subjective: did they like you, were you useful, did they generally think you will be a good EM physician based on their experience with you... But so? Thats what PDs are looking for at this point. Someone who is the EM type of personality who will be a good addition to their program. And having high board scores doesn't make you a good addition to the program. Being personable, useful in the ED, and someone that everyone wants to work with makes you a good resident in the ED.

I've had 3-4 different attendings tell me that on interviews the only thing they're trying to figure out is whether or not you'd be fun to work with at 3am on a Saturday night. Will you increase their energy level or be a dud. Totally subjective. But completely important from their perspective.
Just some thoughts...

I think subjectiveness is fair, but I also think it is challenging for an individual to evaluate someone in a way that forecasts residency performance based on a couple patient interactions during one shift. My experience is that when evaluators don't really know a student that well, the default is to place them in the middle of the pack...and the better they know a student, the better the eval (as a general trend). The difference between honors and pass may have more to do with accumulating face time with individual evaluators (perhaps a function of how specific clerkships are structured) than clinical performance or likability.

On the subject of geographic subjectiveness, I think that a student who has obvious ties to a certain region in their application could very possibly be the subject of interview invite pause at distant programs...especially if other applicants from that region/school have a track record of not showing up for interviews or ranking a program high enough to match.
 
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In the meantime, I've had several very reliable confirmations that a regional bias DOES exist. I got the distinct impression that it wasn't the first or most important part of the screen, but in a year when applications are way up.... every little bit matters.