Zesty Mortdon is a recent medical school graduate who will start his emergency medicine training in July. In part two of this series, he addresses the competitiveness of EM, gives insight into the application process, touches on SLOEs, and gives advice on how to stand out on audition rotations. If you haven’t checked out part one yet, click here: The Med Student’s Guide to Emergency Medicine (Part 1)

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Competitiveness

This is a hard question to gage. I would recommend looking at the NRMP match data. Specifically, look at average board scores and contiguous ranks (how many interviews you need to aim for to have a certain percentage of matching). Those will generally give you the best idea of how competitive EM is and how competitive you are within the applicant pool.

Historically, EM is mid-tier in terms of competitiveness. In very broad strokes, it’s less competitive than derm or ENT, on par with anesthesia and general surgery, and more competitive than FM and IM.

Competitiveness is also largely dependent, as mentioned above, on your away rotations and SLOEs. Killer rotations with solid SLOEs can definitely make up for a lack-luster Step 1 score.

Audition rotations

Unlike other specialties, auditions (also known as acting internships [AI], sub-internships [sub-I], whatever you want to call them) are extremely important for EM. This is mainly because of the need for SLOEs, which are discussed below. But auditions are also important as you get to know if a program is a good fit for you in terms of resident support, faculty set-up, and ED structure (nursing staff, scribes, EMR, dictation help, equipment, etc.)

At a minimum, you need two auditions. This typically includes one rotation at your home institution and another at an outside program. This is assuming your home institution has an EM residency and you can rotate with them before September 1st. If your home institution does not have an EM residency, or you cannot rotate with them before September 1st, you need to rotate at another outside hospital for an audition. This is because you need at least two SLOEs before applications open, and these should come from programs with an EM residency (further discussed below).

I encouraged third years to go on as many auditions as they could afford and mentally handle. These are fantastic opportunities to get to know programs and for them to get to know you. However, they can get expensive as you’re paying double rent and are in a city that may be more expensive. Even more, you have to be on you’re “A game” for all of these rotations. Think of them as month long interviews. One bad shift with a resident or attending can be detrimental. However, expectations are typically geared toward personality and teachability traits more than gross medical knowledge. Be a hard worker, personable, likeable, and willing to learn.

Where you choose to do auditions is a debated topic. Some people will argue you should do them at institutions in which you are extremely interested. Some argue you should do them at programs that write solid SLOEs. Some argue you should do them at a wide variety of hospitals to cover your bases (i.e. one at a big academic level I trauma center, one at a community hospital, one at a DO program if you’re an osteopath, etc.). I was a fan of covering your bases, though I wonder in hindsight if my application would have been stronger had I done rotations only at big centers. I ended up doing a rotation at my home institution (small, non-levelled community center), another at a big level I academic center, one at a medium sized level II community hospital, and my final at a big county/academic, level I program (ended up matching here). I got great exposure to all of the different program types and was well informed for the type of program in which I wanted to train. But I can’t help but wonder if the top tier programs missed my intentions compared to kids who only rotated at huge tertiary centers. While I advocate for my method, I can’t definitively say this is the best way to guarantee you match.

SLOEs

https://www.cordem.org/esloe/

The main utility of audition rotations is to obtain standard letters of evaluation, or SLOEs (pronounced “slow” or “slow-e” depending on who you ask). These letters are standardized letters of recommendation that assess you in comparison to other medical students who rotate through a given hospital. They have general questions, but also have a section that asks how you rank in comparison to other students. The options are top 10%, top 1/3, middle 1/3, and bottom 1/3. It’s important to note that while a top 10% SLOE looks best, a bottom 1/3 SLOE does not necessarily kill your chances. Some programs may even write a glowing review, including how even though you received a bottom percentile SLOE, you would make an excellent physician.

You need at least two SLOEs from programs with a residency. Three SLOEs are ideal, with a fourth letter of recommendation either being a fourth SLOE or an independent letter that is high quality and personal (I prefer the latter here). You need at least one SLOE to be written and submitted by time your application is submitted (mid-September). If you do not have one by this point, most programs will consider your application incomplete and won’t review it (though some will if you contact them and tell them SLOEs are incoming). Most programs are okay with you only having one SLOE in by time applications open and will view your application accordingly. However, it is still technically incomplete as most programs require two SLOEs. Ideally, you should have two SLOEs uploaded by time applications open. I strongly advocate for this plan. I spoke with a EM program director at a big academic center, and he said when he is faced with the task of sorting hundreds and hundreds of applications, he sorts them into three initial categories: complete, incomplete, and definite no. He said it greatly benefits you to be in the complete category, as they will be considered first. And with the pile being so big, he often finds so many quality interview choices that he does not make it all the way through the incomplete pile. This is only one PD’s opinion and style, and plenty of my colleagues matched with only one SLOE in by September. But his program was solid and he had great residents, so this bit of advice has stuck with me.

Make sure to allot enough time for the programs you rotate at to actually write the letter. If you finish your second audition September 10^th, this may not be enough time for your SLOE author to submit. As a rule of thumb, I would recommend finishing your auditions by the end of August at the absolute latest. This will give your last SLOE author about two weeks to submit a SLOE.

In that same vein, who should you ask for a SLOE? This will change based on the program but is usually easy. All of these programs realize you need SLOEs in order to apply. The vast majority have a clinic clerkship director or other designated attendings that assume you will need a SLOE, and have a procedure in place to assess you (i.e. you may have to have an attending or resident fill out an evaluation after every shift you work, with all of the evaluations being conglomerated by the SLOE author to compose your letter). Regardless, this should be one of the first questions you ask when you are setting up auditions! In the off chance there is no designated process, you should ask the attending you’ve spent the most high-quality time with for a SLOE. Ideally, this will also be the attending you liked best. These are important, so make this choice carefully if you’re at a rare program that doesn’t have a SLOE-writing process in place.

Switching gears, you can get a SLOE from a hospital without an EM residency program. They have special SLOEs for this situation (see link above). I personally used this as my third SLOE since my home program did not have a residency program. However, the jury is out regarding how these SLOEs are weighted compared to residency SLOEs, and if you are better off asking EM physicians in this situation to write you a traditional letter of recommendation. I got positive feedback in multiple interviews for having three SLOEs (even though one was non-residency) and having a fourth letter from a general surgeon that I really got along with and respected immensely.

How to impress and succeed on EM rotations

The biggest thing to remember when on your AI is that most residents and attendings don’t expect you to know everything. I would argue the main thing they’re looking for is someone they can get along with. You’re going to be working with these folks at 3AM on Christmas Eve. They want someone they like, or at least can tolerate, during these tough days. You can teach medicine. It’s much harder to teach personality.

So to impress and succeed, it’s important to be personable. Be easy to get along with, be teachable, and show willingness to learn. You don’t have to know the differential and work-up for myoclonus. But you have to show the motivation to learn it and be able to work it up when the next patient with myoclonus shows up in a room.

Now there are ways to get some brownie points on these rotations. Anything you can do to free up time for residents will be huge. Know how to suture and how to I&D an abscess without supervision. Follow up with patients after treatment. Someone came in with nausea and was given Zofran? Follow up in a half hour and tell the resident how they’re responding. In that same vein, keep an eye on labs/imaging for each patient and let the resident know of any abnormalities. To do this, try to have access to a computer and EMR. Always ask for feedback after a shift.

One last thing: try and work at least one shift with the program director (PD). Most rotations will work this in for you, but in the event they don’t, it can be extremely useful to work directly with the PD. Putting a face to a name is beneficial. It’s also important to see how the PD manages the residents and how his or her personality mingles with yours. Finally, SLOEs from PDs are phenomenal. For one of my auditions, I asked the PD for a SLOE instead of the designated attendings. This was a gamble. I risked coming off as a student that doesn’t follow protocol or who was bothering a PD to do something another attending was delegated to do. So, I can’t recommend you do this. But if you got along well with the PD and built a solid rapport, it might be worth asking. Just assess your relationship with the PD across the rotation and go from there.

Can I match into family medicine and then pursue EM after that?

Yes.

This is a great question and one many of my classmates considered. American Council of Emergency Physicians (ACEP) puts out an annual compensation report, which includes how many EM jobs are available to FM physicians. As of 2018-2019, jobs open to primary care board certified docs was at 43%.

The catch here is that these jobs will likely be at small, non-levelled, community hospitals. It will be very difficult to find get a job in a big level I trauma center or at a university. It will also be hard to get jobs, no matter the type, in popular cities (i.e. LA, NYC, etc.).

I’m not entirely up to speed on the process of entering EM through primary care. From what I understand, some programs will offer a fellowship-like training period after residency for you to train more in the ED. It’s probably worth checking with someone who pursued EM this route.

Closing thoughts and advice?

My biggest advice is to make judgments from your own experience and not from what you read or hear. I’d rather trust my own experience than that of others, no matter how ubiquitous the thought. Not to say you shouldn’t listen to other’s advice or opinions, but try not to take their experience as definitive truth.

The first step in choosing a specialty does not have to be surgery or non-surgery. Think of other factors that drove you in to medicine. Do you want sick patients? Do you want your own patients? Do you want procedures? Do you want to take call? The list goes on. But again, do not default to the commonly used techniques or opinions. Take a step back and think what works best for you.

Get auditions set up early! You should aim for two SLOEs by time applications open in September. This is vital to your chances of matching. Some may argue you only need one, but I strongly suggest getting two.

When you’re on auditions, its not necessarily about how much you know. It’s more about how you mesh with faculty/residents, how teachable you are, and how much you’re willing to work.

Try to work at least one shift with the program director.

Check NRMP match data to gauge your competitiveness in this field. But remember, a killer audition can immensely improve your chances even if you’re numbers are a bit weak.

While you may have a preference for academic, community, or county residency programs, try to judge where you want to go by how well you fit in with the residents/faculty. Co-residents and faculty that are supportive and good teachers will lead for a better experience than program type.

You can practice in the ED as a family medicine boarded doc. However, your job opportunities may be limited as an attending.

There are plenty of negatives to EM. It’s important to think about what you like the best about a specialty and what you hate the least.

Thank you for reading! I would be happy to answer any additional questions. Also, any feedback would be greatly appreciated.

Resources for medical students

• reddit.com/r/medicalschool
• NRMP match data
• Student Doctor Network – emergency medicine thread
• Cordem.org/esloe
• ACEP’s annual compensation report

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Again, if you haven’t checked out part one, click here: The Med Student’s Guide to Emergency Medicine (Part 1)

For all updates, follow me on Twitter: @JordanSoze