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Emergency Medicine

How do I know EM is right for me?

This is the million dollar question. Perhaps you enjoyed certain aspects of all your rotations but can't see yourself as only an internist or a surgeon. Maybe you love procedures and trauma, or conversely, don't like office practice. Emergency Medicine is a broad-based specialty for people who want to know “a little about a lot.” And also be experts at the undifferentiated patient. It requires you to think fast, multi-task, and delegate responsibility. One must form intimate patient relationships quickly and interact effectively with consultants. Many note “lifestyle” as another allure of Emergency Medicine, however, the hours off are only rewarding if you love your hours on, which can be any hour of the year. The ultimate challenge for us all is to find the career that makes us happy at work.  

Emergency Medicine is a young field that is growing quickly in expertise, demand, and popularity. For patients, the ED remains one of the few providers of open access medicine that turns down no patient. For residents, EM training offers a diverse skill set, a controllable lifestyle and the reward of being truly available to all patients.

What are the pros and cons to a career in Emergency Medicine?
Depending on what appeals to you, some of the pros may be cons and vice-versa:

Pros Cons
  1. A fast-paced, exciting environment
  2. Opportunity for procedures
  3. Flexible scheduling
  4. Range of patient acuity and complaints
  5. Minimal patient follow-up
  6. First to evaluate patients
  7. Lots of patient and physician interaction
  8. Increasing fellowship opportunities (critical care, international, 
    ultrasound, pediatric EM, sports medicine, EMS, education, administration)
  9. Increasing research opportunities
 
  1. Shifts are usually non-stop work (little downtime, no “lunch conferences”)
  2. Can be very high stress (high acuity/high patient volumes, and poor patient follow-up)
  3. Shift work (rotating nights/days)
  4. ED is open 24/7, weekends and holidays
  5. Having to make decisions with incomplete information
  6. Potential scrutiny by colleagues in other specialties and pushback for admissions
  7. “Boarding” patients awaiting admission & overcrowding in the ED, especially with psych patients
 


What is involved in an EM residency?

There remains a range of program types/lengths. The majority are PGY1-3, but a number of traditionally academic programs are PGY1-4. All programs offer the same core rotations (required for credentialing): These include increasing ED time with each year of residency, ICU months (MICU, CCU, SICU, or PICU), Anesthesia, Orthopedics, OB/GYN, Pediatric EM, Ultrasound, EMS and Trauma. The goal is to gain exposure to specialties that interact frequently with the ED. Call is limited to off-service months and sick call. The true uniqueness of a program comes in the non-required rotations. Some programs pride themselves in more specialty floor months (usually in PGY1 in the PGY1-4 programs), more ICU months, and rotations in burn units or Toxicology. PGY1-4 programs offer more elective time and many PGY4 years are designed for “mini-fellowships.” Or specialty tracks that you can carve a niche for yourself. All credentialed programs will make you a good doctor. The best program for you will be one that matches your future, personal and career interests and often, more importantly, your personality.

What will be my options when I finish my residency?

As an EM physician, your career will offer a range of options, from a community practice in the suburbs to a small rural ED, to being faculty in a large, urban, university hospital or a mix. There are also a multitude of fellowships to match your interests. Job opportunities still remain fairly abundant in Emergency Medicine, although in certain areas (California, Colorado…), the job market is more competitive. The average salary is $200,000 but varies depending on practice setting and location, it can range up to $400,000 in more rural areas. Academia normally pays a little less but allows opportunity for research, prestige, and teaching. Alternatively, a broad EM training also provides an adequate basis for practicing in general health clinics, on a cruise ship, or as a primary physician with an adventure expedition. International EM is becoming a popular area of interest with residents, and many programs are now offering overseas electives as a result.

What do I look for in an EM program?

Because of ACGME Residency Review Committee (RRC) requirements, you will get good training wherever you go. The goal is to pick a program that is the right for you. When considering programs, ask yourself if you think you are interested in community or in academics. This can have a significant impact on where you choose to train. Physicians who stay in academics should develop strong skills in teaching, research, and mentorship. Community EM physicians, however, see their own patients and value strong skills in administration and efficiency in moving patients. Many young physicians opt for community practice right out of residency, or a balance of both in a community hospital with an academic affiliation (like Mercy Medical Center). In general, important things to consider are:

1.Patient Volume: You want to see a lot of patients during your training. The idea is to see as much as you can while in training so that surprises afterward are minimal. Residency in Emergency Medicine should not be the time to look for a “cush” program. When you become an attending, you want the confidence that when that patient with heart failure rolls in, you've treated it 1,000 times before.

              Questions to ask yourself and EM programs:

      1. How many patients do they see in the ED annually?
      2. How many patients are residents expected to carry at once?
      3. What types of patients do they NOT see and therefore how much learning is supplemented by simulation?

2. Patient Diversity: Many programs have several different hospitals where you train, often a university hospital and one or two community hospitals. This gives you exposure to a variety of different patient populations, treatment speeds, and styles. As an EM physician, you need confidence in caring for both kids and adults with a wide range of pathology and acuity. At most programs, diversity of adult pathology is not a problem but the amount and level of trauma, pediatrics, and ultrasound can vary.

              Questions to ask yourself and EM programs:

  1. How do they structure their pediatric learning, in a block format or longitudinally integrated shifts throughout the year?
  2. Are there any special populations in the community that the ED serves?
  3. What are the demographics of the patient population in terms of insured vs. uninsured patients?

3. Off Service Months: EM residency requires a good balance. You want a strong ED but you don't want lackluster off-service months. You want to learn EM-relevant skills on every rotation. Although no program is perfect, it is good to find out about the off-service months. Off-service months also provide residents with an opportunity to develop stronger relationships with the consultants of the hospital.

              Questions to ask yourself and EM programs:

  1. Are they high yield rotations?
  2. Are the EM residents well-respected within the institution?
  3. What is expected in the rotation in terms of carrying patients and being on call?

4. County vs. Community vs. Academics: Many hospitals will give you a good mix of each of these environments but some programs consider themselves “purely” county. These are things to talk to the residents at the program about. Most of the time county hospitals are a large safety net, resource filled hospitals that see many uninsured patients. Community programs see a mix, and a lot of academic programs will have a few community or county rotations but the majority will be in the over reigning academic hospital where consultants and complicated patients are the norms.

              Questions to ask yourself and EM programs:

  1. What kind of patient population are you looking to learn from?
  2. Do you haev geographical preferences? For example, urban vs. rural

5. Other Residents: The more specialty departments and residents are in your hospital, the less you may do in the ED. For instance, Orthopedics attendings will happily teach and allow EM residents to reduce fractures if they have no residents, but their residents have priority if the program exists (program dependent). Again, for academic practice, this is less important, but if you practice in the community, you may want to have experienced a wider variety of procedures. The most important thing to consider when looking at residency programs is how it felt when you visited there. Faculty recommendations matter, but the best program according to your advisor may not be the best fit for you.

               Questions to ask yourself and EM programs:

  1. Did you like the residents and faculty?
  2. Is this an area where you could live for 3 to 4 years?
  3. Does the program demonstrate a commitment to resident wellness?

The debate on 3-year v. 4-year programs

The difference between 3 and 4-year programs is that the longer programs allow you more time for electives and to find a niche within EM. Usually, the progression of EM responsibility within the department is more gradual. There are many rumors about the length of EM residencies including:

  1. In order to stay in academics, I have to be in a 4-year program.
  2. Top programs are all 4 years in length.
  3. Residents that train in 4-year programs are better EM physicians than residents coming out of 3-year programs.
  4. Three years of training is insufficient to make one comfortable as an attending.

All are false, but some subtleties do exist:

  1. No, you do not need 4 years to graduate to an academic appointment. Some people call a 4- year program “the $200,000 mistake,” referring to the 4th year as an EM resident.
  2. 2. Some of the best programs remain PGY1-3 (BIDMC, UMaryland, UChicago, Christiana, Temple – to name only a few). One thing to consider, however, is that if you aspire to employment at an institution with a 4 year residency program, they are unlikely to hire you straight out of a 3 year program and probably won't consider you until you have a few more years under your belt, or at least a one year fellowship. Also, with four-year programs, if off-service rotations are well-managed, then you really could acquire a stronger and broader specialty training with a floor-heavy first year.
  3. Four-year programs offer more time for electives, specialization and/or research. However, three-year programs are efficient and equally encompassing of the core requirements.
  4. Keep in mind that official certification for fellowships still requires the true “fellowship” year, whether you trained in 3 or 4 years.

What do I need to do to make myself a competitive candidate?

By the time you read this, your third year is almost complete and a lot of the work has been done! However, one of the most vital parts of your application is still to come: your EM electives. How you perform in these electives is notoriously what residency directors will be scrutinizing. This will be reflected not only by your grades on these rotations but also in the letters of recommendation that you get as a result, the SLOE (Standard Letter of Emergency Medicine). The next most valuable portions of your application are 1) Clinical grades, especially in Internal Medicine and Surgery, 2) Step 1 and 2 scores, and 3) Preclinical grades. Ultimately, EM physicians want a colleague they can LIKE, TRUST, and RESPECT.

The Maryland EM faculty advises interested students to do at least two rotations in EM. Often, this means people do one at UMMC and one at another institution. Away can mean across town (i.e. Mercy) or across the country. True away electives can involve a lot of paperwork and planning as some schools even have different rotation dates than Maryland. Start applying for away electives early! March or April is not too early. Generally, you want to complete your EM electives by the end of October so that your grades and recommendation letters will be available before the application deadlines. Thus, competition for these “key months” (July, August, September) is high. Also, do not be afraid to email the clerkship coordinator to tell them of your interest. Sometimes this will get you a spot and they can pick you out from other people applying for the away.

Many programs use an application called Visiting Student Application Service (VSAS)/Visiting Student Learning Opportunities (VSLO) in order to accept students from other medical schools at their institution. Not every program uses VSAS/VSLO, some have their own unique application that can be found online. Common requirements for away rotation applications:

•    CV/Resume
•    Headshot (found on Medscope)
•    Completed immunization record including titers (AAMC immunization form)
•    Proof of malpractice insurance
•    N95 Fit Testing
•    Proof of personal health insurance
•    BLS card
•    Up-to-date flu shot and PPD

Getting all of this together can take time and should be done early, around February or March if possible. The part of the application that many people struggle with is vaccination and titers. Getting titers done, especially if you have be re-vaccinated because you’re not immune can take months and be a rate limiting step to completing your application.

Doing an away elective does not guarantee you a spot at the program, though it may grant you an interview spot. Conversely, you don't need to do an away elective to get a spot at a program. Importantly, away electives are ideal for YOU to check out a program- either because you think you want to go there because you want to see what's out there, or even because you'll see what you DON'T like. It's important to treat the away rotation as a "month-long interview" with the program as well.

If you aspire to do a residency in an area that is particularly competitive (i.e. California, New York City), an away rotation may show your serious consideration of the program and grant you an invaluable interview. Also if you want to be a competitive bi-coastal applicant, you should do an away on the west coast to show your interest and desire to be anywhere in the country. You will find on the interview trail that a number of residents in a program did do away rotations at that institution, but many did not as well.

While not necessary for your application, consider the rest of the time in your fourth year as preparation for residency. As the majority of residency months are in the ED or ICU, time spent in an ICU can be very helpful to expose yourself to some of the hospital’s sicker patients. These months often provide opportunities for procedures (central lines, LPs, chest tubes, intubations) that are rarely seen, much less performed, during medical school. In addition, these months are a great opportunity for exposure to ventilator management, use of vasopressors and running codes. All of this will come in handy in the emergency department, not only with initial patient stabilization but also when boarding patients bound for the ICU. In addition, UMaryland offers other useful electives, including Emergency Ultrasound, EMS, Trauma Surgery, Trauma Radiology and Primary Care/Emergency Medicine Orthopaedics.

Many programs want to see your commitment to the field of emergency medicine, so consider joining emergency medicine organizations. These include ACEP (American College of Emergency Physicians) and associated EMRA (Emergency Medicine Resident’s Association), SAEM (Society for Academic Emergency Medicine) and AAEM (American Academy of Emergency Medicine). Membership in these organizations comes with a variety of resources useful to medical students, and most are free if you are a student. Learn more about EM, get resources to help with your EM rotations and application process, and expose yourself to different facets of EM through various FOAMed (podcasts like EM:Rap, blogs like ALIEM.com or EmCrit.org).

Of utmost importance, find an EM advisor to guide you through the process and start early. EM physicians value each other's recommendations THE MOST. Case in point, only EM requires a SLOE from academic EM-only physicians. Dr. Bond, the residency director here at Maryland and Dr. Mattu, the former program director and now vice chairman are both very open to advising students. Many other faculty are also willing to serve as mentors. They will be honest with you in your status as a candidate, how many programs to apply to, etc. Try to get as much information as you can from people in the field - residents, attendings, etc…

Check out this great resource for information straight from EM residency directors.

The Specifics about the Standardized Video Interview

1. The AAMC’s Standardized Video Interview was made mandatory for all emergency medicine applicants for the 2017-2018 application cycle. If you are planning to apply to emergency medicine (or are even still slightly considering applying to EM during the summer before your application cycle), you must complete this to be considered for a position in emergency medicine. When you log into your ERAS, check the box on your dashboard indicating that you will be applying to emergency medicine for an e-mail with instructions on how to record your SVI. If you check this option and complete the SVI, this does not bind you to applying to emergency medicine.

2. Before you read further, first, don’t sweat it! This is still a very new concept in the world of emergency medicine and there is not yet enough data for program directors to know what to do with yet. However, even though this should not be something you are losing sleep over, you should also not wait until the last minute to complete this. It is required and there are no exceptions to the deadline.

3. Per the AAMC, the purpose of the SVI is to expand the pool of applicants that programs choose to interview beyond only those with high board scores or clinical grades. You will be assessed on two ACGME competencies: knowledge of professional behaviors and interpersonal/communication skills.

4. Take time to read over the SVI instructions and guidelines on the AAMC website. In short, you will get 6  prompts, must record your less-than-3-minute response immediately following each question, and you are ultimately scored by trained third party raters. Those scores will be transmitted to the emergency medicine programs to which you apply. Some quick tips: Dress for an interview (at least with a suit jacket and nice shirt). Record in a place that is quiet, distraction free and with reliable internet. Prepare for this with the practice questions on the AAMC’s website and think about ~8-10 clinical scenarios that have challenged you in some way or taught you something you will not forget. Lastly, practice by recording yourself and don’t forget to ask for some help from EM program leadership or OSA if interviews are not your forte!

4.5 A couple of months after completing the SVI you will receive an Unofficial Score Report from AAMC. The score report will contain a score as well as a percentile rank. Again, it is not clear how program directors are using this information and whether this information is used consistently during the application process.

In terms of the ERAS application, a few tips:

  1. Submit your application EARLY: Even if incomplete (you may be awaiting your last SLOE and definitely the Dean's letter, which is transmitted on Nov. 1st for all students), some EM programs will start sending interview invitations in late September and early October. Begin your personal statement early (summer) so you are not stressing about it at the last minute. Also, have several people in EM (faculty, residents, etc.) review your personal statement before submitting it.
  2. Letters of recommendation- Ask early and often: The most important part of your application are your SLOEs (standardized letter of evaluation). These are unique to emergency medicine, and should only be completed by a board-certified EM physician familiar with filling our SLOEs. EM residency programs put utmost weight in the SLOEs that they get from other EM faculty. Try to work with potential letter writers for at least 2-3 shifts so that they will know you better. Letters from titled faculty (clerkship director, residency director, etc.) are valuable; however, do not underestimate the value of a letter from another EM faculty member (i.e. a mentor) who knows you very well. In general, you will need at least 2 letters from EMERGENCY MEDICINE faculty from Maryland and 1 letter from the away rotation you complete. You should plan to get a SLOE from every institution you do an away EM rotation at, generally filled out by the medical student EM director at that institution. It can be a red flag for programs to see that a program you did a rotation at did not write you a letter. Great letters from physicians in other fields are good, but may not be necessarily required but this varies depending on who you talk to. Give letter writers a few weeks to submit their letters and follow up early. DO NOT wait until the day before the deadline to track down letters. You may need to hassle your letter writers unfortunately.
  3. Discuss your list of programs with someone: Dr. Bond , Dr. Mattu , or whoever you go to for advice, can help you decide on which programs to apply to, how many, etc. It is a good idea to ask more than one person for advice as you will find that faculty members with different training experiences will offer differing opinions. There is no ranking system of EM residency programs, and you will find that many schools with names traditionally well-known at the university and/or graduate level do not necessarily have “top” EM programs. This is why it is very important to talk to someone about the list of programs you plan to apply to in order to find out if you have a good mixture of “reach” and “safety” programs. This is not a process you want to attempt on your own.

The Interview

You’ve gotten the interview! Now what? In terms of planning, Nov-Dec and the first part of Jan are the busiest times for EM interviews. If possible, give yourself time off or a lighter elective that will accommodate frequent absences. Few programs will provide hotel rooms, but budget for both accommodations and travel as this is far from guaranteed. Most programs will have an optional dinner or casual meeting the night before the interview to get to know more about the program and meet the residents in a less intimidating atmosphere. Generally only residents and applicants are present at these events, so take advantage of the time to ask candid questions about the program from the residents that are living it every day. Though it is not required, many programs have residents report on any favorite or not so favorite encounters during the dinner, so keep this in mind.

Take the time to prepare for each interview. It is best to go into your interview day knowing at least the basics of the program. Try not to ask too many questions that can be simply answered by looking at the program’s website. In addition, anticipate the most common questions and have a prepared answer to them. It is important to show that you know what you’re getting into, so do your homework about recent news and controversial topics in EM and feel comfortable talking about them intelligently.

The interview day is generally relaxed, starting with a light breakfast and presentation by the program director introducing you to the program. You will then have 3-5 interviews with faculty and/or residents. They usually last 15-20 minutes. This is the program’s opportunity to get to know you and see if they would like you at their program. It takes only a few minutes to get a feel for someone’s personality. Very rarely will you get a tough or curveball question, but if you don’t just take a breath and give your best answer.

The interview day is not only for the program to interview you, but for you to interview the program. Make sure to get all your questions answered (at the appropriate times) and get a real feel for the program, including the residents and leadership. Some important questions to consider:

  1. Is there graded responsibility for residents?
  2. What is role of EM residents in trauma care? Who directs resuscitations?
  3. What is the ED’s relationship like with other services?
  4. What is a typical day like in the ED?
  5. What is the relationship between the residents and attending?
  6. What are the career paths of recent graduates?
  7. How important is resident wellness to the program?
  8. Where do the residents live and is it affordable?

Make sure to ask about things that are important to you. If you are interested in a fellowship down the road, consider whether the program has fellowship opportunities or graduates residents who have gone onto a fellowship. If you have a family, feel free to ask about housing, schools, and job opportunities in the area. Also ask about job placement, especially if you see yourself in one area in the future.

The interview season is long and you may be going to multiple interviews per week. It’s hard to remember your impression of programs and even harder to recall them months later when you are trying put together a rank list. Many people keep an ongoing spreadsheet of program statistics and other take different approaches including writing down a couple of paragraphs about each program after interviews. This will help you remember what you did and did not like about each program months later to create an informed rank list.

Make sure to thank your interviewers after the interview day, either by email or snail mail. Consider thanking the residency coordinator as well, since they are most likely your main contact throughout this process and make sure your interview day runs smoothly.

What are some of the top programs in EM?

Unlike many of the other fields out there, Emergency Medicine has no specific ranking system. Because of the RRC, the vast majority of residencies will offer you the potential to become an excellent physician. A better question would be to ask yourself what you want out of a program. Location also plays a role in many people's choice of program. What some may consider one of the “best” programs in the country may be the worst for you and your particular situation. Ask around and get as much information as you can from as many people.

Fourth year is fun, so make sure to enjoy it. Enjoy the interview trail and the people you meet. Ultimately, you will all be colleagues in the same field! Good Luck!

For more information, please contact: Richa Manglorkar

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Last Revision: February 13, 2019