Thanks for the advice. So if a spot opens up sometime from now until July, how do they fill those (2-4 year) spots? Is it just like a mini scramble... many people apply and then they just let the person who gets it know. Or do they interview you?
I'm going to give you the straight dope, because I went to St. George's, and was a worse candidate than you (as I got no EM interviews my first time around, and couldn't be in the match anyhow as I forgot to take my English test). I did a prelim year in IM at Elmhurst, which was NOT cush - the pathology was GREAT (saw stuff I'll never see again, and 4 patients from Tibet that year), but we had to do clinic, and I only got 1 elective. And 2 1/2 months of day float. I did my month in the Elmhurst ED (which was great) and my elective in the Mt. Sinai ED. Got good letters, was in great with the residents, but didn't get ranked because I was an FMG. Hell, I (as the intern) even tubed a code on the floor, and the critical care resident was a Sinai EM resident, and he said in front of everyone (and there were more than 15 people there) that he could work with me any time, any day of the week.
4 interviews that year, and I still didn't match. I
did, though, successfully scramble into a spot. I think USCDiver was another successful scrambler on SDN that year. I did my time in hell at Duke, and am now gainfully employed as an EM doc.
Bust your butt this year on IM (if you don't find an EM spot), on all rotations, completely kick *** on your EM month, and, if there's another hospital affiliated with yours, try to do an EM elective there - you'll look much better as an intern than as a med student, because you can actually do stuff.
As far as the 2-4 programs, they have until next year to fill spots unfilled now, and there's a lot of things that can go in and out of flux. Keep your eyes open, and don't piss anyone off. And keep at your letter writers, including from your IM PD - you'll need that as one of your letters.
Any other questions, PM me. There are all sorts of quotes and aphorisms (in multiple languages) that all round out to the same thing: ad astra per aspera, vouloir, c'est pouvoir, "You may be whatever you resolve to be" (MG TJ "Stonewall" Jackson), "why is it that people who work the hardest seem to have the best luck?", and so on.
If you want it, work for it. In this case, the race isn't always to the swiftest, but to the one who keeps on running. I'm proof of that.