Here's a summary of our EM match advisory meeting..
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Wow, big turnout. Everyone wants to go into Emergency Medicine? That's a lot of you to match. Okay, so this is supposed to be preparation for a career in Emergency Medicine. So you want to be an ER doc? I guess the first thing you should realize is that it's misspelled. It's ED. I work in an Emergency Department. It's not just a single room, and the specialty is actually called Emergency Medicine. So when you talk to someone in Emergency Medicine, or you talk about your career in Emergency Medicine, you don't call it "ER Medicine", you call it Emergency Medicine. I'm not insane about it, but some people have a tendency to go on about it.
So the TV show, which I'm sure you all watch. I've never watched it; I get a good dosing of it every day when I'm at work. Based on what I've heard, the descriptions of it, is it as realistic as the things that I've got drawn up here? No.
Alright, so Emergency Medicine and the Match. First of all, if you start looking through programs (and don't worry, you don't have to go do this tonight; you've got time) you'll get an idea of what's out there on the horizon and get an idea of the landscape. There are different formats for residency training programs in Emergency Medicine. We kind of came along after all of the other specialties were long established already. We started out with most of the programs being four year programs, but some were three year programs. The three year programs said, "We can do it better because we can do it in three years", and the four year programs said, "We crank out a better product". The Federal Government finally decided "enough is enough. If some say three years and some say four years, then we'll pay for three and a half years", so a lot of the programs who were using four years are systematically folding because they can't afford it. Medicaid and the Federal Government pay for a lot of residency training programs: the salaries for the residents. So since folks aren't independently wealthy, they're switching over to a three year format. ___ used to have a four year format. I thought it was a great thing. I know you guys want to be out as quickly as possible, but that's the real scoop. There are 1-4 programs; 2-4 programs, where you do an internship somewhere else and then go into Emergency Medicine; and 1-3 programs. We are now a 1-3 program.
You cannot get boarded without being residency trained in Emergency Medicine. It's kind of weird: you can do Family Medicine, you can do Internal Medicine, you can do Psychiatry, and you can go work in an ED. Many EDs will hire you because you have an MD degree and you have a pulse. That's all that's required. If you're going to be a teaching facilitator, they require board certification. Having said that, there's also a new rogue organization, not the American Board of Medical Examiners, but another side group that is making their own board, so when you say, "Oh yea, I'm boarded", people are getting confused about it. So we have to figure out if it's the real Emergency Medicine or is it the pseudo Emergency Medicine where you do internship, practice on the job, and wiggle your way in.
What are the minimums? There aren't really a whole lot of minimums. You have to go to medical school, you have to finish, and if you match in a 2-4 program, you have to go to internship (in anything). Is everyone clear on the differences between internship and first year residency? I don't see a single hand. You! Okay, thank you for asking. There is no difference. In the old days, internship was basically nothing more than a fifth year of medical school, except you got paid instead of having to pay for it and it counted towards your residency training program. As specialties became more complex, and the body of knowledge required for that specialty became bigger and bigger, most of the specialties started capturing the internship year and saying, "We'll just pull you right into residency". Nowadays all specialties do that, so the first year of residency is synonymous with the word "internship". There is no difference. Good job being honest and asking that question. You have a chance in Emergency Medicine. That's actually not too far off the mark. Every time I ask for a consult in the ED, I'm asking for help. Every time I ask a service to come down and admit the patient, I'm asking for help. The patient is now beyond what I can take care of in the Emergency Department, and I have to have help. The patient has to be admitted to continue care. I ask for help all of the time. All the time. There's no shame in it.
Okay, what sets an applicant apart? Longstanding interest in the specialty is a good thing. That doesn't mean that you have the entire series of "ER" on DVD in your home collection. That does not count as commitment. Maybe some of you have a prior career in EMS. Maybe you were a nurse in Emergency Medicine. Maybe you spent a long time volunteering, and you were working as a clerk in an ED, and then became a tech in the ED. Just a longstanding interest and commitment in the specialty, as opposed to the person who in December on their EM rotation says, "Hey, this is a good thing, I think I'll apply." That's the person that program directors will think, "I wonder if they're going to bail on me six months or a year later when they suddenly decide, ‘I want to do what those guys are doing over there instead of what I'm doing now.'" Program directors don't like that. They don't like holes in their residency program.
Diversity. Everyone likes diversity. It's much more interesting, much more fun. They also have a larger base of stuff that they can drawn on when faced with challenge. In Emergency Medicine, the challenge is basically to take care of anything that walks through the door. Everything is fair game, no matter what. Anything that walks through the door is mine to take care of and stabilize until whatever specialty I call on to help me can pick up the care.
Research requirements. Regardless of what you end up going into, 99% of what I'm talking about up here is useful for any specialty. It's not specific to Emergency Medicine. Programs have some kind of research requirement. It's interpreted differently by different places. Most folks have it as, "You will do something of publishable quality." Whether it gets published or not, that's up to the publishers, and no one has any divine knowledge of what motivates them necessarily. [You'll do] something of publishable quality. There are some places that interpret it very loosy goosy. We [also] have journal club, where we work on statistical methods a little bit. If you have had some prior research experience, that just means that the program director is not likely to come after you because you're having a problem doing your research requirement. Like the person who after two years still hasn't finished their research requirement, and you finally have to threaten them: "If you do no submit this in the next six months, then we are not going to allow you to sit for boards, and you will have to repeat a residency someplace. Good luck." We don't like dragging things along like that.
AOA? Do you have to be AOA? No, you don't. It's nice, but it only goes to a handful of folks, and if we relied on that, there would be an even bigger shortage of Emergency Physicians. I wasn't AOA. I didn't get close. I didn't have the grades for it.
Letters of recommendation tips. In Emergency Medicine for 5-6 years now, we have been using a standardized format to try to level the playing field a little bit. Anyone who sits on the panel and goes through all of the applications knows that there's a whole gaming to the system as far as letters goes. Anyone who has ever read military letters knows that they're all glowing, they all walk on water. There's a special way of reading those to kind of tease through it and see the subtleties that are there, otherwise everyone is great and wonderful. But there are good letters and there are not-so-good letters. There's no such thing as a bad letter, per se. So we use a standardized form. It's basically a row of check boxes comparing you to your peers as well as the previous year's class, plus how many letters has the letter writer done in the past, and there's a comments section. I like doing a traditional letter in addition because a few lines is not enough to describe a person. Anyone not in Emergency Medicine will do the plain old traditional letter. You really have to have at least one letter from an Emergency Medicine physician. It doesn't make a whole lot of sense for someone to recommend you to do something other than what they do. Shoot for about four letters of recommendation. I think that's the limit that ERAS will allow you to do. Take a breath. You don't have to ask me for you letter of recommendation yet. There's still time, but you will be asking for that a little further on down the road. If you start shadowing in the ED, and you start bonding with folks as you come in, maybe buddying up to a certain group of attendings, then later on, they can write you a letter of recommendation. They have known you for several years, you have been shadowing in your free time, and they have had multiple discussions with you, this is great. That's a great letter of recommendation, as opposed to a bad one like, "To whom it may concern. I met Suzie Q during her rotation in my specialty and I recommend her for whatever specialty that she chooses." All I can say about that person is "tree killer". What a waste of time. He has no clue who Suzie Q is. "His specialty" and he is recommending her for something else. This is crap, okay? It doesn't say anything bad about her, but he sure did crucify this student in the process because it's a crummy letter. You don't want that. You want this: "I have known this student for multiple years. We've been involved in research together. They've been coming and shadowing. We've had multiple discussions, and I know that they have thought this through very carefully, and they know what they're getting themselves into. I recommend them very highly and know that they're going to do a great job." It'll be a bit longer than that, but those are the big things that you want to see in that letter.
Minimum board scores? There's no magic number. Having said that, there are program directors that will apply filters through the Electronic Residency Application Service and say, "I'm not going to take anyone under" whatever number, at least on the first wave of acceptances for interviews. The process works where you send in your application, they kind of ruminate over it, and then they get back to you and say, "Yep. We like what we see here preliminarily. We'd like you to come for an interview." Then you go to an interview, and then you submit a match list, they submit a match list, magic happens in a computer, and then on Match Day those results are released. People find out where they're going to be, and programs find out who they're going to get. You saw that overview already? From somebody? Just making sure we're internally consistent, right? Alright, average is around 220, it's good, it's the middle of the pile. We'll take some folks that are a little bit lower. We like, obviously, to take folks who are higher, but higher is not always better. Sometimes, if it's the application of extraordinarily bright people who knock the top off of the board scores, but who have the social skills of a rock. The letters of recommendation will sometimes say, "This person has frequent run-ins with the faculty and staff", and one letter after the next says that. Why do we want this person? This person would be a great resident in someone else's program. They can be someone else's problem child. Those are some of the things we look for because three years is a long time for us to be unhappy, and also when you're looking at a program, three years is long time for you to be unhappy. Especially in the wrong career choice, so you want to think that through well.
GPA? Again, no magic number. There are things that we like to look for. An A-B student is great. An occasional C, yea, it happens to everybody every once in a while. No problem, you know it happens, been there done that, and learned a lesson from it. We like to see an upward trend. A consistent low GPA is a red flag for us. There's a huge body of knowledge that goes into Emergency Medicine. You've got to be able to read, and you've got to be able to comprehend the material, process it, and apply it. There's just no way around that. If there are problems and glitches, we need some good explanation for it, not an excuse. "Oh, well that person didn't like him, so they gave him a bad grade." No. It's all about earning your grades. You get what you earn. If there're problems, if there's a death in the family, and it's cataclysmic emotionally, that's certainly justifiable. Your letter writers can address that for you, so you don't even necessarily have to go there or even allude to it in your personal statement. Remember the personal statement that you had to write for medical school? You get to do another one for residency. And if there are academic issues or blips or blemishes, then you'll probably have to do something else to recover from that. You'll need to get involved in a research project, or do an elective in that specialty someplace else to show them what you're made of, to prove to them that you're more than just the grades.
I tried making this smaller, but I did not succeed, and I apologize for the busy-ness. Nationally, there are 141 programs, and just under 1500 spots. Last year in the match, 11 of those programs didn't fill all of their spots, so most programs fill them. There were 1300 seniors applying. There are other applicants, as you can tell by the difference, so there were a lot of other folks also applying for Emergency Medicine spots. Those are folks who have done a year someplace else, and then decide, "I want to go to Emergency Medicine". Sometimes they're military applicants, and there's also the foreign folks who apply through the match. And then there's the folks who apply outside the match; after the scramble is all done, then they open the playing field for all of the other folks that didn't go through the match. They can start getting the bits and pieces that are still left over. Matches. Here: 1146 of those 1400 were filled right off the bat in the match by the seniors, and 1459 of the 1472 were filled in the match [i.e. before the scramble], so there's not a whole lot of empty spots left over as you can tell. 80% went to seniors, 99.1% of spots filled, so there's not much left over. That's important for me when I'm sitting on scramble day trying to find somebody a home in Emergency Medicine for someone who didn't match for some bizarre reason. We've been very lucky. We have a very very high success rate in the scramble. Last year I pulled a new rabbit out of my hat. I matched someone who never went to their first interview. Don't do that! Okay? Don't do that, but I got one of the few Emergency Medicine spots that were still out there. It was a very bizarre sequence of events, and a very outstanding student. It was actually my idea to try.
Okay, how many spots are there here in 2005, and going to the left to 2009. The number of spots each year continues to grow. There're a few more programs opening each year, so Emergency Medicine is continuing to expand, not contract. Those PGY2 programs, those 2-4 programs, those are the dwindling ones; like I told you, the Federal Government is pulling back the funding, so they've gone from 44 down to a fraction of that, so less and less of those programs. What was the point of this? The point was that Emergency Medicine is becoming more popular. The percentage of students applying to Emergency Medicine is increasing, as are the number of slots. It's popular. I'd say "naturally" because of Emergency Medicine: it's great. Is there anything else that I haven't said here? Oh, typically the folks that I'm sitting down and scrambling for are folks that changed their career choice fairly late in the game. Generally, if they sat down with the advisor long in advance and have gotten their application together, we look for the weaknesses that are there and have done stuff to bolster that. Slow and steady makes the race. You can't show up on the day before interview season starts, and you're filling out your application, and say "Oh, there's a problem here". You can't correct it at that point. This is all over the long haul, which is why we're having these meetings here early. So start early to get them all set.
Okay, requirements. Do your Emergency Medicine month here at ___. I repeat: do your Emergency Medicine month here at ___. We're the ones who are going to be advising you. Also don't forget to do your Emergency month here at ___. If you have done your rotation somewhere else and you need a letter of recommendation, I can't help you because I don't know you. Again, do your Emergency Medicine month here at ___. You can still do one someplace else. A lot of times I get the question, "Should I do another one someplace else, and how many should I do?" My answer, which is my favorite answer for a lot of questions, is it depends. Those who know me and have worked with me know that that's my standard answer: it depends. It's a double edged sword. You may go someplace because there're some blemishes, and you're there to kick butt and show them what you're made of. You better do a good job, because they know exactly what they're going to get if they match you. If you go to that rotation and show up late and tend to hand off patients and not follow through on patients, they're going to say, "No way." You have pretty much done yourself in, and you're not going to get a good letter of recommendation from them either. Now if you happen to be AOA, walk on water, or brilliant and medicine is your fourth career, and you want to go check and see if a particular school is as good as you heard it was, well you might want to go check it out. I've had some students who were very brilliant and thought, "I don't want to go to that place and come back and think, ‘That was horrible. There's no way I'm going to rank that place. That was not anything like I thought it was going to be.'" That's fine.
Regarding shadowing, you can shadow with any attending in the Emergency Department that you want to. Anytime: we're open 24/7, 365. So if you want to come shadow during your break, that's fine. During holidays, that's fine. If you have some time in evening, and you're just tired of looking at books and want to get away and want to get away for a few hours, come shadow in the ED. That's fine. Nothing says you have to come in for X amount of time. If two hours is what you've got, it's your nickel. Come check us out. You're there to learn and find out if it's something that you're interested in. And you may decide once you're down there, "Hey, I've seen a lot of surgical patients, and those are really cool. I really like the surgical patients." You may decide that surgery is what's for you. Or you like all the psych patients, and you start to get more involved, and decide you want to go into Psychiatry. If you come shadow in the ED and decide you want to go into Psychiatry, I call that a win because we helped you pick out what your niche is. We see such a big diversity of stuff, so even if you're like, "Ummmm, maybe Emergency Medicine, but I kinda think I should do something else." That's fine. The ED is a good place to scope out those other things. We're not insulted by that. If you want to use us to pick out some other specialties, that's okay. We're big kids.
So what should you do? I've said it a couple times, but just relax. You've still got time. But start early thinking about these things. Don't waste away your summer. As far as things that are most important in your application, you'll find that getting so many points or reaching a certain level in your online video game is not one of the things that gets you credit in your residency application. It's all about beginning with the finish in mind. We do the same thing in Emergency Medicine: it's all about preparation. Like over here on the left, Dr. [?] is getting ready for trauma patients coming in, and then we go from 0 to 60 in two seconds. We're prepared for it. It's not really very chaotic, at least for us, because we were ready for it. We knew what was coming, we kind of knew what to expect, and we were prepared for all of the contingencies.
[He brings up a summary slide with major factors in the application] Points and levels are not on here. You kind of break things apart. Grades in your first two years are important. Grades in your second two years—we consider those separately—including your Emergency Medicine rotation grade. The dean's letter, which gives us the overview of what has been going on in medical school. Your Step 1 and Step 2 scores. You'll hear later on that you're encouraged to get Step 2 out of the way before you finish the application process. Research and publications: good stuff if it happens to be there. If not, it's not the end of the world, but hopefully there's some other things to diversify you a little bit more. Long standing interest. Awards and achievements: honor society, boy scout, eagle scout, whatever. Leadership roles. That doesn't have to necessarily be in medical school. We don't care if you're involved in rotary club or you're in charge of the soup kitchen down at the Salvation Army. Just get out and do something to diversify yourself. It makes you a better person. It rounds you out better all around. There's that personal statement, and your letters of recommendation that I've alluded to already. And after all of that: the interview.
It's not just Emergency Medicine. There are lots of subspecialties. I'm at the point now where Emergency Medicine is a stepping stone to all of the other cool things that I like doing. Wilderness Medicine, International Medicine, Event Medicine. I like practicing outside the four walls of the ED. Wouldn't you guys like to do that? We do that. These are all actual things that are boardable subspecialties in Emergency Medicine. There're other areas that are areas of expertise in Emergency Medicine. It's a stepping stone for all kinds of cool things. Cool to me, at least. We got some folks on our staff, faculty and residents, who are trained police. They will go out there and catch bad guys. They will also shoot at bad guys, and then go take care of them.
Research. Anything that walks through the door is fair game, so you can do research on anything you want to. It's all fair stuff. There are a number of organizations in Emergency Medicine [He is referencing a slide with a list of organizations]. There's a student affiliate of the Emergency Medicine Residency Association, which is part of the American College of Emergency Physicians. I think ___ also has a student representative, but I'm not sure who that is for Emergency Medicine right now. We also have a resident representative. There are Emergency Medicine interest groups. I don't know if our EM student folks are in here at the moment, but they're probably going to schedule a meeting. We've been doing that through the first part of the year, and we'll finish up the second part of the year with monthly meetings. There's usually some pizza, and we'll talk about something interesting or do something interesting in the form of some kind of workshop. If you want to get involved, stick your nose into it, hang around us and see if your personality fits. Specialties have personalities.
I'm going to have to finish up here, so observe and do something outside [of school]. Shadow, research project, go travel, do something to make yourself a better applicant. Don't just sit at home and watch TV or play games. Oh, and this is important. Even if it ends up not being Emergency Medicine that is your final career choice, you want to make sure that you don't put on blinders. I changed my specialty choices a few times during medical school. That's fine. You can change it in residency later on, because I started out in surgery. Keep in mind that something better may be coming along, and don't get so focused in on something that you miss a good opportunity for something that fits you even better. Leave yourself open to the possibility of change.
If you want to do EMS, if you think you're interested in pre-hospital care and you want to do ambulance ride-alongs, that's fine. We can arrange for you to fly in the helicopter, if that something that seems cool to you. There's stiff competition for that stuff, and you have to be patient. We can't get you on there tomorrow, but maybe in a few weeks or something like that. Just do something more than study. Book nerds are fine, but book nerds don't do well in the chaotic environment of the ED. You can't sit there and be thinking and processing all of this stuff before you make your first move. You have to do a little leap of faith, use some intuition, and do other things. An unconscious patient comes in, he's not breathing, and his heart has stopped. I'm not going to sit there and order some lab tests. He's not breathing! His heart has stopped! I've got to do stuff and figure out afterward what's going on. There's a good bit of leap of faith in this stuff, and at the same time you're being bombarded with information. Here are the vital signs, look at the blood pressure, look at the heart rate, here's what his EKG looks like, here's the family history, plus the EMT had some problems with medication, and here's what we did in the field already, we're having issues finding IV access, and we can't get him intubated. All of that stuff is coming in at the same time and you have to sort through it and be able to do it. You may be all right if you have ten minutes to go get a cup of coffee and get all of the answers, but that's ten minutes that you don't have at the beside. Not everyone processes the same way. That's not meant to be mean or a slur in anyway; people are different. People are different, and we have to find out niche.
