Subpar EM rotation support group / Anyone have any bad SLOE stories?

[AwayWoeThrowAway]

Edit late November: Interview season is in full swing and I've gotten more invites than I need including to strong names like Emory, Carolinas, Maryland, Michigan, Indiana, Cincy, Highland. My interviewers have told me that my SLOEs are all solid (one went as far as to say "all top third," which I'm happy with). So either my SLOE from this place wasn't as weak as I was worried about, or the rest of my application was enough to make up for it. I wouldn't quite say I was worried for nothing, but at least things seem to have worked out. /edit

Having never read a SLOE before, I'm looking for others' input: What's a bad SLOE look like?

Like... How bad does a SLOE have to be to hurt you? Does it need to explicitly say bad things along the lines of "We have concerns about X's professionalism and performance on this rotation," or is it also pretty bad if it's simply bland and impersonal?

I'm 3 weeks into an Away and feeling like I'm invisible to the attendings and letter-writers here, despite doing the "available, affable, able" thing as well as having Honors and an outstanding eval from another EM rotation. Bracing myself for a big discrepancy between those two SLOEs. The rest of my app is excellent, so I'm trying not to worry, but... Reassurance and/or horror stories from those who have gone through this process would be appreciated. Crossing my fingers for, "I know it's scary, but I got a Pass on my Away and still had no problem getting interviews at places I wanted, it'll be okay!"

Meanwhile, if anyone else is out there on a rotation that isn't going the way they wanted, feel free to PM me or reply here and we can vent.

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[drunken_owl MD]

Who's evaluating you, attendings or residents?

 

[KinesiologyNerd]

I thought this about one of my rotations. Worked with attendings not residents and felt like to most of them I wasn't very impressive. SLOE was a HP, but at the end of the day I was at the pointy end of their rank list.

Moral of the story: you're your worst judge and you're probably doing fine

 

[AwayWoeThrowAway]

Thanks, @KinesiologyNerd ! I hope you're right.

@sdflemin , in a sense, I'm being evaluated by everyone, but I'm working most closely with residents. Why do you ask?

 

[DO3]

Thanks, @KinesiologyNerd ! I hope you're right.

@sdflemin , in a sense, I'm being evaluated by everyone, but I'm working most closely with residents. Why do you ask?

Having never read a SLOE before, I'm looking for others' input: What's a bad SLOE look like?

Like... How bad does a SLOE have to be to hurt you? Does it need to explicitly say bad things along the lines of "We have concerns about X's professionalism and performance on this rotation," or is it also pretty bad if it's simply bland and impersonal?

I'm 3 weeks into an Away and feeling like I'm invisible to the attendings and letter-writers here, despite doing the "available, affable, able" thing as well as having Honors and an outstanding eval from another EM rotation. Bracing myself for a big discrepancy between those two SLOEs. The rest of my app is excellent, so I'm trying not to worry, but... Reassurance and/or horror stories from those who have gone through this process would be appreciated. Crossing my fingers for, "I know it's scary, but I got a Pass on my Away and still had no problem getting interviews at places I wanted, it'll be okay!"

Meanwhile, if anyone else is out there on a rotation that isn't going the way they wanted, feel free to PM me or reply here and we can vent.

If that's how you feel, it's probably not gonna be a program you wanna rank.

 

[AwayWoeThrowAway]

If that's how you feel, it's probably not gonna be a program you wanna rank.

Nah, still interested in the program. Unless you know something I don't.

 

[DO3]

Nah, still interested in the program. Unless you know something I don't.

If you feel invisible to attendings as a student, that should not be a place you rank. I don't have to know which program it is or anything else about it. It's not gonna be a place where you'll wanna be for 3 years.

 

[deleted480308]

If you feel invisible to attendings as a student, that should not be a place you rank. I don't have to know which program it is or anything else about it. It's not gonna be a place where you'll wanna be for 3 years.

Couldn't disagree more. Rank it last if you want, but invisible em resident is still better than "paid attention to scrambled prelim residdent"

 

[AwayWoeThrowAway]

If you feel invisible to attendings as a student, that should not be a place you rank. I don't have to know which program it is or anything else about it. It's not gonna be a place where you'll wanna be for 3 years.

Couldn't disagree more. Rank it last if you want, but invisible em resident is still better than "paid attention to scrambled prelim resident"

There's that, and there's also the part where I've paid attention to how the attendings interact with the residents and the interns, and I've liked what I've seen. My charitable take on it is that the attendings have their hands full with new interns and don't have the bandwidth to also manage students. I'm self-aware enough to know that the student experience isn't the top priority during a shift, after all.

So yeah, not seeing red flags about the program, just wondering how big of a red flag it is for your SLOE to be impersonal or bland or in the middle third or bottom third. Like, maybe PDs know that it's best to be succinct and therefore short bland SLOEs are perfectly fine? Or maybe it's the norm to really give a detailed picture of the applicant, and therefore a bland SLOE is a true red flag?

 

[CajunMedic]

I'm 2 shifts in to my second audition. Already worried about SLOE. Little contact with attendings, they stay in the fishbowl and residents do the work. The Intern on shift is supposed to do the lion's share of picking up patients. No access to EHR to follow patient results, on shift with 2 other students so we're all fighting for the same pool of patients. I seem to catch the ones that I can't work up easily, by the time I'm done, 2 more have come in and been seen.

 

[AwayWoeThrowAway]

I'm 2 shifts in to my second audition. Already worried about SLOE. Little contact with attendings, they stay in the fishbowl and residents do the work. The Intern on shift is supposed to do the lion's share of picking up patients. No access to EHR to follow patient results, on shift with 2 other students so we're all fighting for the same pool of patients. I seem to catch the ones that I can't work up easily, by the time I'm done, 2 more have come in and been seen.

That's so rough! I'm sure it's a hospital policy, rather than a departmental decision, but programs shouldn't be allowed to take visiting students if they can't provide them EHR access. That's a basic necessity. At the very least, they should have to disclose that to students during the away application process.

 

[carbonizedeyesockets]

So yeah, not seeing red flags about the program, just wondering how big of a red flag it is for your SLOE to be impersonal or bland or in the middle third or bottom third. Like, maybe PDs know that it's best to be succinct and therefore short bland SLOEs are perfectly fine? Or maybe it's the norm to really give a detailed picture of the applicant, and therefore a bland SLOE is a true red flag?

There is likely far more being observed of you than you realize. And if it is not required that you work directly with attendings, then the person writing the SLOE likely (hopefully) seeks input from residents, too. You're probably not the only rotator to not have access to the EMR, so they probably understand that it is hard for you to stay on top of results, etc. Much of what is being observed is your interactions with others. Pissing off nurses and residents will hurt you so much more than not being able to recite the Canadian head CT rules or whatever you think you're going to impress the attendings with.

 

[racerwad]

That's so rough! I'm sure it's a hospital policy, rather than a departmental decision, but programs shouldn't be allowed to take visiting students if they can't provide them EHR access. That's a basic necessity. At the very least, they should have to disclose that to students during the away application process.

Why do students need access to the EHR? If students were held to the same standards as interns and residents for charting, SDN would crash from the amount of complaining. It isn't fair to students to expect them to know the ins and outs of any given hospital's charting or what is expected to get full billing, etc. Having access is handy for labs, imaging, etc, and to feel like you are part of the team, but students shouldn't feel like they need to be as productive as the interns and residents in order to be successful at an audition.

Most programs aren't looking for medical students who are basically ready to be senior residents; they are looking for hard working, fun to be around people who demonstrate a willingness to learn.

What I'm trying to say is that students shouldn't feel like the system is against them they have limited access to the ehr, can't order stuff, can't chart, etc. I remember it seemed important to me at the time but I promise it is not.

 

[AwayWoeThrowAway]

Why do students need access to the EHR? ... Having access is handy for labs, imaging, etc, and to feel like you are part of the team, but students shouldn't feel like they need to be as productive as the interns and residents in order to be successful at an audition.

I want to defer to your judgement! The way I've understood it is that showing up, being likable, applying yourself...those are the bare minimum things. It's not about being as productive as a resident, it's about being able to fulfill basic student responsibilities, which does involve following up on results and owning the patients you see, even though you see fewer than a typical resident.

On patients who can't give you much history, being able to see a previously charted medication list and past medical history is helpful. Might not be 100% accurate, but it's a start. The more a student can contribute, the more they'll learn, and the better picture the team has of how that person functions in the workplace.

Rotations where you just shadow or can't stay involved because of structural problems like lack of EHR are frustrating for students who want the chance to do well. Makes us feel like...why are we even here, except to get in the way? What can these people possibly say about us on a SLOE, other than "seems like a nice guy"? Or is a "nice guy" SLOE enough?

I would be completely happy to accept the lamest shadowing rotation in the world if I didn't have to worry about this "make or break you" concept of a SLOE. But since standardized evals are a thing, standardized expectations of students and standardized student responsibilities sure would be nice.

 

[deleted497653]

I agree that students should have access to EHR. This is from the perspective of a current attending who had students on rotation while a resident. However, I would guess most SLOEs are subjective and based on affability. I haven't written a SLOE or read one so I can't help much. Just make the best of whatever is left of the rotation. You may not even have to use that particular SLOE in the end.

 

[racerwad]

I want to defer to your judgement! The way I've understood it is that showing up, being likable, applying yourself...those are the bare minimum things. It's not about being as productive as a resident, it's about being able to fulfill basic student responsibilities, which does involve following up on results and owning the patients you see, even though you see fewer than a typical resident.

On patients who can't give you much history, being able to see a previously charted medication list and past medical history is helpful. Might not be 100% accurate, but it's a start. The more a student can contribute, the more they'll learn, and the better picture the team has of how that person functions in the workplace.

Rotations where you just shadow or can't stay involved because of structural problems like lack of EHR are frustrating for students who want the chance to do well. Makes us feel like...why are we even here, except to get in the way? What can these people possibly say about us on a SLOE, other than "seems like a nice guy"? Or is a "nice guy" SLOE enough?

I would be completely happy to accept the lamest shadowing rotation in the world if I didn't have to worry about this "make or break you" concept of a SLOE. But since standardized evals are a thing, standardized expectations of students and standardized student responsibilities sure would be nice.

I agree that having access to the EHR makes you feel like you have more control over what can be a murky and subjective process. I argue the point that not having access prevents learning or staying involved. It does prevent you from having new or interesting data to share with the attending and that is super frustrating, but (at least at my place) it is not held against you. Attendings and senior residents get phone calls from different departments about now info before it even is uploaded online, so even if there were relevant findings on the imaging or dimer result, the people you're trying to impress usually already know.

A nice guy SLOE is valuable (if everything else is also present). Many qualified candidates get moved down on our list every year because of their interactions with nursing, other residents, etc. The same is true for folks with red flags on their SLOEs, although we rarely interview these candidates. I ended up matching a place where I didn't get access until the last week.

I get your anxiety as I have also been through it. Now that I've been on the program side of the Match, I promise your attitude and personality are far more valuable than your clerical skills.

 

[Cinclus]

One of my 4th year aways was at a place where everybody successfully got EHR access...except for me. Bugged IT about it every day to no avail. I would let my attendings and residents know at the start of each shift that I didn't have access and couldn't easily follow-up on labs, imaging, etc, and at the end of each shift, they'd be filling out my eval while telling me how I need to follow up on those things more, ugh. I (rather non-confrontationally) brought up my lack of access again when confronted at shift's end about this, and an attending scolded me for being resistant to feedback...which delightfully made it into my letter. My SLOE was pretty bad from this place. Definitely damaged an otherwise good app, seeing as how I was portrayed as a lazy person who was unwilling to learn. Yay. Was actually told by the clerkship director during a feedback session near the rotation's end that I was doing well and had favorable evals. Got blindsided by that SLOE-bomb. I had two others that were fine. Be careful with SLOEs and rotations that don't let you see your evals. Still very grateful to have matched last year. Could've gone very badly for me.

 

[Psai]

One of my 4th year aways was at a place where everybody successfully got EHR access...except for me. Bugged IT about it every day to no avail. I would let my attendings and residents know at the start of each shift that I didn't have access and couldn't easily follow-up on labs, imaging, etc, and at the end of each shift, they'd be filling out my eval while telling me how I need to follow up on those things more, ugh. I (rather non-confrontationally) brought up my lack of access again when confronted at shift's end about this, and an attending scolded me for being resistant to feedback...which delightfully made it into my letter. My SLOE was pretty bad from this place. Definitely damaged an otherwise good app, seeing as how I was portrayed as a lazy person who was unwilling to learn. Yay. Was actually told by the clerkship director during a feedback session near the rotation's end that I was doing well and had favorable evals. Got blindsided by that SLOE-bomb. I had two others that were fine. Be careful with SLOEs and rotations that don't let you see your evals. Still very grateful to have matched last year. Could've gone very badly for me.

That is such bull****

 

[Groove]

Just ask your attending if they mind writing a "strong letter of recommendation". Most attendings will shoot you straight. It's not like we're out to sabotage anyone. Asking for a "strong" letter is the key word.

 

[AwayWoeThrowAway]

Just ask your attending if they mind writing a "strong letter of recommendation". Most attendings will shoot you straight. It's not like we're out to sabotage anyone. Asking for a "strong" letter is the key word.

What about when it's a group SLOE put together by the PD, the assistant PDs, and the clerkship director based on all of your evaluations? They don't review your evals until the rotation is over, so there's no opportunity to really ask this. And since not submitting a SLOE is a red flag, the only possible information to come out of this conversation is the knowledge that you may need to apply more broadly than you were expecting.

If you're at some program where the SLOE is written by an individual attending, I guess you could ask around until you find someone who enthusiastically promises you a good SLOE. I think those programs are rare.

 

[SamtheWise]

Unfortunately it's a game and you have to play it. The only advice I can give is residents and nurses often have way more input than you would think, so you'll be surprised by which particular interactions end up having a large effect on your SLOE.

 

[deleted480308]

What about when it's a group SLOE put together by the PD, the assistant PDs, and the clerkship director based on all of your evaluations? They don't review your evals until the rotation is over, so there's no opportunity to really ask this. And since not submitting a SLOE is a red flag, the only possible information to come out of this conversation is the knowledge that you may need to apply more broadly than you were expecting.

If you're at some program where the SLOE is written by an individual attending, I guess you could ask around until you find someone who enthusiastically promises you a good SLOE. I think those programs are rare.

My home program promised auditioning students they will get a verbal conversation if the sloe would be negative before anything is uploaded so the candidate can decide if they want it. They have told candidates before the letter wouldn't be good.

 

[AwayWoeThrowAway]

My home program promised auditioning students they will get a verbal conversation if the sloe would be negative before anything is uploaded so the candidate can decide if they want it. They have told candidates before the letter wouldn't be good.

That's a very kind thing for them to do. It does introduce an additional element of unfairness and de-standardization if some students get to essentially pre-screen their SLOEs while others don't, though. Maybe CORD should address this by making it an absolute requirement that all SLOEs be sent to all programs. Or making it a requirement that negative comments be disclosed to all students with a signed acknowledgement from the student...but that of course runs contrary to the benefit of applicants waiving their right to view their letter, so it won't happen.

All I can do is wait to get a grade from my worrisome rotation and make an appointment to talk to the course director to ask for feedback and directly ask if he/she thinks I should be concerned about my SLOE. It pains me to do that because I don't want to get on the program's bad side by coming off as needy or pushy. I know it's an unattractive look.

This process is not fun but most of us survive and match. Trying to stay positive. When the worries pile up, reminding myself that applying to 80+ programs is surprisingly affordable, if a bit manic.

 

[Siggis_is_good]

As a long time lurker, and 4th year currently applying, I have a question (primarily geared toward anyone who regularly authors or reads SLOEs). Why are we as applicants not allowed to see our SLOEs?

I know my clinical grades and USMLE, but EM is unique in that the most important part of our application and marker of competitiveness is a pretty big unknown. A SLOE isn't a typical recommendation letter, instead, it represents your "real" sub-I grade and evaluation (basically a MSPE for EM and we get to read our actual MSPEs!). Despite all the variation in sub-I grades and grading schemes across programs (Honors/Pass/Fail, Honors/HP/P/F, just Pass/Fail?), we all get a real standardized and hidden bottom line "grade" at the end of the day (top 10%, top 1/3, middle 1/3, and bottom 1/3). I'm not sure why we have to have the smoke and mirrors and mind games of trying to translate our sub-I grade and comments into how strong our SLOE is. It just adds more stress to what is already a pretty stressful processes.

The way I see it, if a program is super transparent, and your sub-I grade/feedback perfectly and clearly correlates with your SLOE, then great! You have literally gained no new information by reading your SLOE. If there's a pretty big discrepancy, that's a pretty big red flag, likely reflecting poorly on the education leadership in that program (If you really thought a student was bad, isn't the goal of education is to give them honest feedback so that they can improve?). I don't see what positive incentive keeping SLOEs secret has. Would programs really write them differently if they knew applicants could read them?

The only possible "pro" toward keeping SLOEs hidden that I can think of is the "Where would you rank this applicant?" question, which is a slightly different question from the global assessment, and someone could argue that reading it constitutes a match violation (since no one is forced to say where they would rank someone... despite all the games played during the interview season). Then again, isn't this just the "objective" answer to the "How competitive do you think I am question?" that we are all encouraged to ask our PDs? I fully admit that, selfishly, it feels like really useful information to have as an applicant.

I'm genuinely curious what SLOE writers/readers think. Maybe all EM sub-I's can at least switch to a standardized grading (top 10%, top 1/3, middle 1/3, and bottom 1/3) so that anxious applicants that keep hearing how EM is getting more and more competitive can have at least a little more concrete knowledge in what is a very nebulous and anxiety provoking process.