EM PD - Ask Me Anything

[gamerEMdoc]

I got asked by one of the administrators if I would be interested in starting up an EM related "ask me anything" thread, and I was thrilled to get the opportunity. I've answered tons of questions over the past year, but thought this would be a good way of trying to condense down the advice to one thread for people looking for advice in the future.

So if anyone has any burning questions about Emergency Medicine as a specialty, balancing life outside of EM, applying to EM, succeeding on your clerkship's, or any other questions that come to mind, feel free to ask away!

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[CliveStaples]

I'll throw one out as an incoming intern.

I've heard the good wisdom about not being too nervous about my knowledge base coming into intern year; just come with a good attitude, ready to learn, ready to work hard. What I'd like to know is what you've noticed that separate the successful interns from the ones that struggle a little more over the course of the year? In particular, are there things about how some interns prepare, work on shift, etc. that some develop over their intern year that you think help them find greater than average success.

 

[Status Sciaticus]

As a prospective applicant, I have a few questions regarding the application cycle.

1. How do you view someone who is in the bottom quartile, but has above average step scores and good SLOEs?
2. Is doing specialty electives such as US, Tox, or Peds EM at other institutions a good way to get your foot in the door to show interest in a particular region? (Basically doing these electives after I've done my actual AI aways).
3. What are some qualities that turn you off of certain applicants during interviews?
4. Does a lack of leadership/volunteering activity come off as a red flag if you have research as your main EC? Received some bad advice saying that leadership positions and volunteering wasn't important once you're actually in med school compared to research activities.

Thanks for doing the AMA!

 

[gamerEMdoc]

Absolutely. The best PGY1's hit the ground running; they aren't passive about learning EM. They embrace things that are difficult, as opposed to those that shy away from things like sicker patients because "I'm not ready" or "there will be plenty of those procedures in the future". And if you start residency and begin a studying plan for the in service exam from the beginning, you will be so far ahead of many in your class. No one runs a marathon by being a couch potato and then trying to train the week beforehand. Yet, I see so many people who say "I want to see how I do the first year without studying to see if I even have to study for boards". Figuring out a way to have a good work/life balance, while still finding time to really embrace learning EM, is key and the sooner you find a good pattern to do this, the better.

In addition, a good bit of it comes down to hand holding. Many PGY1's early on have a hard time breaking out of MS4 mode. They can go take a history, but they want their plans spoon fed to them. Don't be that guy. Embrace that you are a physician now, and that means you have to see your own patients, look stuff up, figure it out, come up with your own plans. The more you embrace the independence, the faster you will get better.

Last, administratively, you have to realize that you are going to have way more responsibilities than you did as a student. Deadlines, deadlines, deadlines. There will be projects to complete, scheduling deadlines to hit, procedures to log, charts to sign, meetings, etc. If you are not an organized person, get organized, quickly. Utilize some type of task list tracker to get organized (I like Wunderlist) as well as the calendar on your phone. Dont be the person the program coordinator is constantly having to track down to get your stuff completed.

 

[gamerEMdoc]

1. How do you view someone who is in the bottom quartile, but has above average step scores and good SLOEs?

I view EM performance (SLOEs) above all other things. And pre-clinical grades (which most schools use for their class rank) are pretty meaningless.

2. Is doing specialty electives such as US, Tox, or Peds EM at other institutions a good way to get your foot in the door to show interest in a particular region? (Basically doing these electives after I've done my actual AI aways).

If you can't do more EM because your school limits you to a certain number of EM rotations, then these rotations can help you get exposure to an EM program (and secure an interview) without actually doing an EM rotation. But don't make the mistake of using one of these rotation as a means of getting a SLOE, those should be preferably from 2 true EM clerkships.

3. What are some qualities that turn you off of certain applicants during interviews?

Ok this is a great great question that I haven't been asked before. Mainly it comes down to personality. Residents have a huge say in who we rank. Fit within the residency is very very important. So if someone goes to the pre-interview dinner and the residents just don't like them, that's a big problem. People that are rude, come across as arogant, etc. That's gonna be an immediate DNR. It sounds intuitive, but I assure you, people shoot themselves in the foot every year. When I was a resident, I remember a guy making sexually explicit comments about the waitress during the dinner. And another guy asking about ways to milk the residency for money by buying books with education money and returning the books to keep the money. You can't make this stuff up.

4. Does a lack of leadership/volunteering activity come off as a red flag if you have research as your main EC? Received some bad advice saying that leadership positions and volunteering wasn't important once you're actually in med school compared to research activities.

Oh I don't know if that was bad advice. Extracurriculars, leadership, research... all that is more icing on the cake of the application. If you have good EM clinical grades and good SLOEs you'll get in somewhere. A lot of extra-curricular stuff is overblown in the application in my opinion. I honestly don't care if you were the treasurer of the student FP interest group your second year of med school. It's just not important. Sure, big time leadership, like national level positions, are impressive, but they are also hard to come by and most people aren't going to have a leadership position like that either.

 

[SamtheWise]

What behaviors do you see residents doing that you really wish you could get them to stop?

Also, just out of curiosity what sorts of things get residents in real deal trouble with program leadership?

 

[gamerEMdoc]

What behaviors do you see residents doing that you really wish you could get them to stop?
Signing notes without proof-reading them. Poor bedside manner (I HATE having to fix someone elses customer service mess when I enter the room). And as above, the general apathy towards residency education, feeling like you will just learn everything passively eventually.

Also, just out of curiosity what sorts of things get residents in real deal trouble with program leadership?
I mean, I can't discuss some of the more boneheaded things I've seen on this forum, but luckily real trouble is quite rare. Most of this is common sense. I'm sure I can come up with 1000 ways of getting fired. Sleep with a patient. Punch as staff member. Harass a nurse. Attempt to cheat on the in-service exam. Missing work to go moonlight elswhere. I mean, there are tons of egregious things you could do that would get you fired, but they are also common sense.

 

[LostinLift]

When do you need to have 2 SLOEs uploaded in order to receive a chance at a "first wave" interview?

What separates top 10% from top 1/3rd? Specific examples would be appreciated How can you practice and improve in these areas?

How much does geography factor into your decision to invite? Say you're on the west coast, do an away in the midwest, will the east coast be less likely to invite you? To the extent that you can say from experience.

Best ways to prepare for your EM rotation after core rotations but before EM?

How good does it look to do a rotation later in the season solely or mostly to audition at a program, providing the student is well liked, works hard, and does well overall. How high up generally do you place these people?

Roughly what is the percentage of home + away rotating students that are interviewed out of the total number of interviews?

Related to the above 2 questions, where do home + away rotators generally end up on your rank list. What are some things away rotators do that will move them up or drop them down the rank list?

 

[gamerEMdoc]

When do you need to have 2 SLOEs uploaded in order to receive a chance at a "first wave" interview?
Get the first SLOE in by mid-september. Most programs will extend interviews with one SLOE, knowing that you'll be able to get a second by mid-interview season. I'd definitely want to get a second in by the end of October, and I'd email programs that you'd already interviewed at to let them know that a second SLOE was uploaded to add to your application.

How much does geography factor into your decision to invite? Say you're on the west coast, do an away in the midwest, will the east coast be less likely to invite you? To the extent that you can say from experience.
Geography really matters. We have a filter that looks at schools withing a certain geographic distance that tries to target people we think would prefer to stay in our geographic area. We certainly interview people outside of that filter, but it is helpful to try to target people that will look to match at your program. Once people are in for interviews, looking where they are from, where they went to college, etc. All that helps you predict their genuine interest in your program. As a community EM program in a smaller city, you know you are more likely to match someone in state, or someone who went to college in a smaller town vs someone who went to med school and college in NYC. I've always believed the number one predictor of how students make up their match list is geography. Its not that way for everyone, but it plays a sizable role in most applicants lists.

Best ways to prepare for your EM rotation after core rotations but before EM?
Know what you are getting into (I'll re-post some general tips I posted in another thread in a second about how to look good after I finish answering the other questions). The best thing you can do ahead of time is come up with solid differentials and plans for common ED complaints. A good quick free resource is the Clerkship Directors in EM website (M4 Curriculum) and read over their "approach to" sections for how to think like an EM doc about the most common chief complaints you'll see. So many students come out of the room, report a decent history, and can't reliably come up with a solid differential diagnosis or reasonable plan. It's ok to be wrong, but you need to show that you have thought about the problem and can come up with a reasonable plan on your own. Many students just aren't there when they first start, and if you are, you'll be ahead of the game.

How good does it look to do a rotation later in the season solely or mostly to audition at a program, providing the student is well liked, works hard, and does well overall. How high up generally do you place these people?
The highest ranked people almost always rotated with us. Not always, but usually. After-all, first hand experience with someone who does really well can't be overstated.

Roughly what is the percentage of home + away rotating students vs. other students interviewed?
Well my perspective on this is coming from a community EM program. We have about 30 students rotate in the first 5-6 months of the year who are EM interested. We interviewed about 85 this year for 8 spots. I'd say its going to be about 1/3 of the total interviews going to people that rotated most years.

Related to the above 2 questions, where do home + away rotators generally end up on your rank list. What are some things away rotators do that will move them up or drop them down the rank list?
Because I'm at a community EM program, they are all technically away rotators. We're affiliated with a med school as a clinical campus, but that's not the same as being a home University based EM program at a medical school. In terms of what people do to move up and down the list, it comes down to mainly two things. First EM performance (SLOEs and how you do on your clerkship). Then personality and how you fit in with the residents and attendings. If you fit in well with the team, and are good clinically, you'll be ranked highly.

 

[gamerEMdoc]

Here's a re-post as promised from another thread where I posted some little things that can make or break you on your EM clerkship. When I initially wrote these, I wrote them off the top of my head, I'm sure there are more things, but this was what came to mind at the time when I was asked about "how to get a good SLOE"

1. Show up 10 min early to every shift. If you are late, even once, and someone writes about that on your SLOE (I see this several times a year reading applications), it looks AWEFUL!
2. Don't be hard to schedule. If the chief residents make the students schedule, and you have a ton of requests and are a headache, I guarantee you that chief resident will tell EVERYONE about it
3. At the beginning of the shift, find out who you are working with. Are you assigned to a resident or attending. Introduce yourself, and ask them how they'd like you to approach the shift. Some might want you picking up charts anytime. Others may prefer to hand you charts. Everyone has a different workflow.
4. If you work with a resident, do anything you can to help them. I can't stress this enough. Residents probably have more say in boosting people up, and dropping people down, the rank list than some attendings. PD's don't want drama. They don't want to deal with residents who don't get along. And residency is tough. So if you can do little things that help the residents, I promise you, they will lobby for you.
5. Don't ever lie. If someone asks you a question like "does the patient have any vomiting" and you didn't ask, say you didn't ask. Don't say "no" and hope you are right. Because if you get caught in one lie, noone will forget it.
6. Be courteous and nice to the nurses and ancillary staff at all times.
7. There is too much focus for students on seeing more patients. Its great if you can see 10-12 patients a shift, but if all you are doing is an H+P and never following up on anything, never rechecking anyone, and never updating the person you are working with, then you are basically creating more work.
8. Understand that sometimes, you may get pushed aside. The ED can be busy and chaotic. Sometimes, an attending/resident may just not have time for you to pick up another case with them. They are often carrying a huge patient load. Don't be offended or take it personal. Offer to help out in anyway you can.
9. Read and follow up on your cases. If you see something interesting, it would be crazy impressive to see the attending a week later and tell them "remember that patient with delirium the other night? I looked him up, and it turns out they found..."
10. Don't just followup labs/xrays. Anyone can do that. Students shine when they followup on the patient's themselves. I promise you, if you go back and see a patient and catch something that wasn't caught before (patients do change over time), they will be VERY impressed
11. Lastly, time yourself in the room. Strive to eventually be able to get out of the room in 10 min or less. Thats not going to be feasible when you start, but it eventually needs to happen. You'll learn what is essential to ask and what isn't. You're job isn't to do a medicine H+P. It's to do an ED note. Focus on high yield questions about the chief complaint, don't get tied down in the ROS and not flesh out why the patient is actually here. There will be patient's that make this hard to do, but getting out of the room faster is essential for you to impress residents and staff.

 

[750335]

What made your most memorable interviewees stand out?

 

[gamerEMdoc]

What made your most memorable interviewees stand out?
The best interviews always make me laugh honestly. I like trying to find people I can relate to. You have to spend 3 years training someone, working with them as part of your team. You already know how they are clinically (sloes) and knowledge wise (boards). All that's left is really, do I want to spend three years training this person. My interviews tend to be pretty laid back for this reason, and more focused on interests outside of medicine, unless someone has something glaring to discuss in their application.

The other standout people are the people who just love EM. You can see it. Their eyes light up when they start talking about some Tox rotation they are getting to do, or an US elective, etc. Sometimes, people just have a different level of passion for EM, and it can shine through in the interview. There's probably a handful a year that you just know are going to be absolute all stars and just a joy to help train based on their personality alone.

 

[green lantern]

What resources would you recommend students to use while on auditions or before away rotations. Particularly interested in Podcasts, or good apps that are useful?

Sent from my SM-G386T using SDN mobile

 

[8741empls]

Thank you for taking the time to do this, and everything else you do on this forum! It certainly doesn't got unappreciated.

Regarding what you said about people who love EM. How does pre-medical school experience in the emergency department (direct patient care) relate to that same idea? Does long term exposure reflect a level of commitment to/passion for emergency medicine in an application? Does knowing from the beginning that EM was the job for you appear as tunnel vision?

Additionally, I see people listing "non-traditional student" as something that sets them apart on the ROL thread. How does non-traditional look from a program perspective? I've seen/heard it discussed both positively (more mature, dependable, life experiences that allow for higher degree of empathy, etc.) and negatively (families are potential risk for distraction). Or is it a factor at all?

 

[jd989898]

Have you ever had an MD/PhD applicant? What are your thoughts about MD/PhDs applying to EM?

 

[surely]

Thanks for doing this! Here's a question I've been curious about:

Applicants on the Rank Order List threads often say they had a really tough time choosing between programs 3 through 8 on their ROL, because they liked the programs roughly equally. Do PDs have a similar issue deciding an order for applicants on the program's ROL? For instance, are you infatuated with students 1-20, then equally excited about students 21-50, then less enthused about students 51-75, then not ranking the last 10?

 

[nonamesleft]

Thank you for doing this AMA!
What factors would enable an applicant to make a better informed decision on their ROL? Do you have advice on how to look for red flags in a program? I think interview days have limited exposure to the group dynamics. Beyond looking at facilities and judging if you can get along well with the people that you do get to interact with, how can an interviewee get a better sense of how the patient management team (doctors, residents, nurses, etc) gets along with one another? (for both within the ED as well as with other services)

 

[gamerEMdoc]

Just got off my 12 hour provider in triage shift... whew... lets get to some questions.

 

[gamerEMdoc]

What resources would you recommend students to use while on auditions or before away rotations. Particularly interested in Podcasts, or good apps that are useful?

Sent from my SM-G386T using SDN mobile

I like PalmEM as a quick app to look up quick facts in personally. Lots of good info in a cheap little app.
The EMRA antibiotics guide is quite useful for many students/residents
I've always like EM secrets as a quick read if you are just looking for something to study off shift to learn more about EM facts
And for just general knowledge of workups and common diagnoses, the CDEM website isn't bad, and its free. They have MS3 curricula, MS4 curricula, and peds EM. These are the people that write the SAEM CDEM exam that many rotations use as an "unofficial shelf exam" at the end of the rotation. The website is: CDEM Curriculum

 

[gamerEMdoc]

Thank you for taking the time to do this, and everything else you do on this forum! It certainly doesn't got unappreciated.

Regarding what you said about people who love EM. How does pre-medical school experience in the emergency department (direct patient care) relate to that same idea? Does long term exposure reflect a level of commitment to/passion for emergency medicine in an application? Does knowing from the beginning that EM was the job for you appear as tunnel vision?

Additionally, I see people listing "non-traditional student" as something that sets them apart on the ROL thread. How does non-traditional look from a program perspective? I've seen/heard it discussed both positively (more mature, dependable, life experiences that allow for higher degree of empathy, etc.) and negatively (families are potential risk for distraction). Or is it a factor at all?

I think personal experience in patient care is always a nice bonus to see on an application. People who are former scribes or ED techs just know their way around the ED better, and often just appear more clinically advanced than students without those experiences, especially in the very early months of the 4th year clerkships before everyone has gotten 1-2 months under their belt. And life experience in general is helpful. I'm not sure you can quantify it. But it definitely is an added bonus on an application. It doesn't have to be healthcare. I love seeing that someone was a waiter/waitress, worked as a front desk receptionist somewhere, etc. Medicine is a service industry, and like it or not, patient satisfaction is really important. And no one, and I mean no one, seems to get that concept more than people who worked a service industry job like the restaurant business. Again, lets not all go out and take a year off to become a waiter somewhere, lol. I'm just saying, it is a nice little added bonus on an application, but either way probably isn't going to make or break it.

 

[gamerEMdoc]

Have you ever had an MD/PhD applicant? What are your thoughts about MD/PhDs applying to EM?

MD/PhD's generally are (at least I'm assuming) going to be attracted to more academic University based places with huge research resources. I doubt many community EM programs get a ton of MudPhuds applying. I certainly wouldn't hold it against people, and I appreciate it when I see research on someones application, but I think in general, people with heavy research interest naturally gravitate to research heavy centers.

 

[gamerEMdoc]

Thanks for doing this! Here's a question I've been curious about:

Applicants on the Rank Order List threads often say they had a really tough time choosing between programs 3 through 8 on their ROL, because they liked the programs roughly equally. Do PDs have a similar issue deciding an order for applicants on the program's ROL? For instance, are you infatuated with students 1-20, then equally excited about students 21-50, then less enthused about students 51-75, then not ranking the last 10?

Look, I could talk for hours on rank lists. Its literally my favorite part of GME. I love trying to figure it out, deciding where to put people where, trying to find diamonds in the rough. It's my version of the NFL draft. I spend almost all year working on it. So excuse me while I geek out for a second here below...

Here's what we do. I score every application based on a scoring rubric that I adapted from the place I went to residency, but then changed quite a bit over the years. It adds a score for various parts of the application, and then a weighted multiplier that is dependent on the importance (to us) of that part of the application. So for instance, SLOEs have a weighted multipliers much more significant than preclinical grades (obviously). I score the applications for each week, and then there is a final interview score that gets added to calculate a total candidate score. That seems complicated, but it really is not. What it does is, it allows us to quickly order our rank list from 1-90 based on a score that tries to objectively (as much as possible) take the entirety of the applicant, and put them in some sort of order. That's where we start as a base. Then we meet with all the residents and faculty and discuss the list towards the end of the interview season. We discuss each persons application as we go down the list. Residents/Faculty give their input as to whether they'd move people up, down, or DNR them altogether. We then take all this input, and then the PD and I sit down and we re-order the list based on all the feedback we've gotten.

Again, that sounds complex. And it is, a little. But I've found that it really does give you a pretty good stratification of the rank list, because as you alluded to, a large portion of the people run together.

So back to your original question... how hard is it to rank the middle group... the answer is, its pretty tough. There are always some big time outliers at the top of the list and at the bottom of the list. But in the end, many programs match a good portion of their match list in that top 1/3 - mid 1/3 grouping. So honestly, even though the candidates all seem to run together there, thats where we actually spend the most of our time debating where to rank people. The scoring system definitely helps stratify them, but still, lots of debate goes into it. Because that's the decision that really matters; that grouping. If you usually go down to say #30 on your list (obviously this varies every year), then it doesn't really matter who you rank #15 vs #20. It irrelevant, they'll all match if they rank you highly enough. But it does matter who you rank #30 and beyond and in which order, because that's likely where your cutoff will be. This is one of the biggest reasons I use a scoring system to help stratify this grouping.

 

[Doctor_Strange]

As an incoming OMS-I at LECOM-SH, I am interested in the world of ACGME EM post 2020 merger. What are your general thoughts? Net benefit for DOs? Zero-sum benefit? My assessment is that while some MDs will be taking up spots in previous AOA EM residencies, with the merger I expect (hope) that ACGME residencies around the country will begin accepting a more noticeable amount of DOs than previously thus essentially offsetting those MDs entering the previous AOA EM residencies. I suppose my question is grounded in perceptions more than anything.

Also, could you talk about when or how you knew EM was right for you? I have worked as a ED scribe for 6 months, shadowed a EM doc beforehand, and even occasionally read articles in AAEM. I read these forums often trying to gain a mature and broad understanding of the field and I believe I like the field, but part of me also believes I may not have the personality for EM.

Finally, outside the importance of good board scores and pre-clinical grades, what additional activities could one do, say in the summer following OMS-I, that could help focus their CV towards EM? Research? Volunteering at a free clinic? I know you alluded to the relative insignificance of, say, being a secretary for a club, so what would stand out, or at least, what has stood out to you in your evaluation of applicants? I know I should be focusing on just getting a handle of med school, but I thought there's no harm in planning/ thinking ahead

Thank you for your time and insight!

 

[gamerEMdoc]

Thank you for doing this AMA!
What factors would enable an applicant to make a better informed decision on their ROL? Do you have advice on how to look for red flags in a program? I think interview days have limited exposure to the group dynamics. Beyond looking at facilities and judging if you can get along well with the people that you do get to interact with, how can an interviewee get a better sense of how the patient management team (doctors, residents, nurses, etc) gets along with one another? (for both within the ED as well as with other services)

I personally think talking to the residents (at dinner, lunch, in between interviews, or when you are rotating somewhere) is probably hands down the most important thing you can do. Residents don't usually have much of a filter, and you'll find out all the positives/negatives you want from them. Mainly though, you can tell by how they interact with eachother the mood of the program. You want to go where there is a cohesive group that gets along and has fun together. Residency is hard, its stressful, but its also one of the best times of your life in a weird way. At least it was for me, and that experience was one that put me on the path to be a perpetually working in a residency program as a career. So first and foremost, make the dinners if you can, and talk to as many residents as you can. More importantly, when you are a student somewhere, watch how the residents interact with eachother, and how they interact with the attendings.

As for things like "red flags". I mean, I'm not sure what qualifies as a "red flag" if a program is accredited and isn't on probation. There will be positives and negatives to any program, but in the end, if you go to an accreditted program that isn't at risk of shutting down, you're going to graduate in 3-4 years and will be able to go work wherever you want, as recruiters will be pounding down your door to hire you. The name of where you train is not going to matter at all if you plan on just going out and working in the community. If you want to do academics when you finish, prestige certainly helps at places that are prestigous, but in the end, community EM programs are littered with faculty that trained at community EM programs. So if you just want to work in a residency, you'll get a job. If you want to work at Hopkins, you may need to go somewhere prestigious.

In the end most peoples rank lists come down to a mix trying to combine which programs you liked with where you want to live geographically. People that like smaller cities/towns gravitate to programs in smaller towns. People that like big cities gravitate to big cities. It's pretty predictable. After taking geography into affect, I really think its just a gut decision about the likability of the faculty and the residents honestly. I mean, I know people come up with all kinds of positives/negatives lists and all to compare the programs, but I think in the end, most people just make a gut decision. At least that's what I did.

 

[gamerEMdoc]

As an incoming OMS-I at LECOM-SH, I am interested in the world of ACGME EM post 2020 merger. What are your general thoughts? Net benefit for DOs? Zero-sum benefit? My assessment is that while some MDs will be taking up spots in previous AOA EM residencies, with the merger I expect (hope) that ACGME residencies around the country will begin accepting a more noticeable amount of DOs than previously thus essentially offsetting those MDs entering the previous AOA EM residencies. I suppose my question is grounded in perceptions more than anything.

Also, could you talk about when or how you knew EM was right for you? I have worked as a ED scribe for 6 months, shadowed a EM doc beforehand, and even occasionally read articles in AAEM. I read these forums often trying to gain a mature and broad understanding of the field and I believe I like the field, but part of me also believes I may not have the personality for EM.

Finally, outside the importance of good board scores and pre-clinical grades, what additional activities could one do, say in the summer following OMS-I, that could help focus their CV towards EM? Research? Volunteering at a free clinic? I know you alluded to the relative insignificance of, say, being a secretary for a club, so what would stand out, or at least, what has stood out to you in your evaluation of applicants? I know I should be focusing on just getting a handle of med school, but I thought there's no harm in planning/ thinking ahead

Thank you for your time and insight!

God I wish I knew the answer to the merger question. I don't, because no one does. But I can speculate. I don't think it will make it easier, nor harder, for DO's to match in EM. I don't think programs that were traditionally DO programs are suddenly just going to start abandoning DO candidates. I just don't believe that's going to happen. Will some of those spots go to MD's? Sure. But I still think you will see very heavy DO #'s in the classes of those programs.

I do think the merger helps DO's by eliminating the AOA match. I can tell you, without a doubt, the two match systems hurts candidates, because it pigeon holes them into trying to choose between what they see as more of a sure thing vs potentially programs they may like better on the other side. It hurt some candidates this year on our rank list. I know several candidates that told me they wanted to go ACGME and would love to match at my program, but were too scared to do so because of their limited # of ACGME interviews. They played it safe and matched AOA, and I don't blame them at all. But I also know where they were on my list and several people easily would have matched who went AOA instead. In the end it benefits students by allowing them to rank their programs top to bottom, without having to make an artificial division to decide whether or not they want to play it safer in one match, vs go to the ACGME match where they may like the programs better (the 3 year draw is powerful).

As for EM being right for me. I fell into it. I had a random elective in my third year, and EM was assigned to me. I had always thought I was going to do something general, so I thought FP would be perfect. I thought FP docs were jack of all trade generalists. Then I rotated in FP and realized I was going to see mostly HTN and DM followups. I hated it. So at that point I was lost mid way through 3rd year. I rotated in Medicine, but didn't want to only see adults and really didn't enjoy rounding. I couldn't see myself specializing in one narrow field like cardiology or anything. I absolutely loved procedures, but equally hated being in the operating room for hours at a time. So basically, I was lost and had this random EM rotation. I was one shift in when I realized this was what I was looking for. In medicine, outside of teaching, my favorite thing that keeps me interested is the undifferentiated case. I love the mystery. I love trying to puzzle things together. Tough cases are awesome too me, I enjoy trying to figure them out. And nowadays, most diagnoses and workups are made and finalized in the ED. You don't usually work through cases over days on the IM floor trying to figure it out most times. The ED gives IM the answer, and then IM manages it. We have all the resources at our fingertips to rapidly evaluate cases and try to get to the bottom of them as fast as possible. Which is awesome to someone who loves the game of the mystery. That's what hooked me.

Oh yeah, and I like staying up all night. And toxicology. And critical care. And the team environment. And how informal everyone always is. And the fact that every once in awhile, you legitimately will save someones life in an instant. Doesn't happen often, but when something bad happens and you do something that rapidly saves their life and they survive, I promise you, this is a gateway drug that will keep you coming back to the ED over and over seeing abd pain after abd pain... just for one chance to do something heroic again.

And lastly, what to do after year 1. I got married and went to the Bahamas. Screw medicine man. LOL. First year was tough, and I think its important to recharge. After second year, you're going to be cramming for step 1 in your little time off. So if you get time off, take some time off. Hell, I'd rather here a story on the interview trail about someone scaling a mountain somewhere than talk about them gunning to do some research project in their two months of free time they got in all of medical school anyways. But if you feel like you must do something I think a medical mission trip is useful. It looks good on an application, allows you to actually get some hands on practice, do something good, and still see the world and have some fun. I think that's a nice compromise. But do whatever you want. There is no cookie cutter way into matching into EM, but there sure is a cookie cutter way into driving yourself crazy by working too hard. So at least consider taking some time off if you got it.

 

[EmergDoc2B]

What's your top 5 (or 10) EM CC interns need to become extremely familiar with and perhaps brush up on before intern year gets under way.
Yes, this is a prestudy question and I will, if needed take my lashings willingly.

Thank you!

 

[RockFlag&Eagle]

I am an M4 but have fielded this question from my school's M3s a couple times: do programs get upset with students who decline their acceptance for an away month? This is assuming they do it respectfully and ASAP. I'm specifically wondering if that would hurt you a few months later when interview offers start coming out or if the programs don't even keep track of that.
Thanks for all your insight on SDN, it is been very helpful for me throughout the year.

 

[SamtheWise]

What is your opinion on programs contacting students post-interview? Second looks?

In sort of that same vein, do programs really care how far they go down their rank list? From your description of your program's rank list assembly it doesn't sound like you take into account an applicant's likelihood to match with you.

 

[CCmetal94]

I'm an incoming OMS-1. The school I'm attending has two MD schools (and two ACGME EM programs) in the same city. I've wanted to do EM for a long time. Would it behoove me to reach out to these MD EM programs at any point during my pre-clinical years? Find a mentor? If so, what is the best way to go about doing this?

 

[EMGui2017]

What's your top 5 (or 10) EM CC interns need to become extremely familiar with and perhaps brush up on before intern year gets under way.
Yes, this is a prestudy question and I will, if needed take my lashings willingly.

Thank you!

Seconded this question. I am trying (read: failing) to prestudy effectively with my 4th year brain and I feel like I need some direction to make it more worthwhile. I am assuming that a solid review book (case files, EM Secrets) that we used for aways might be a good starting point. Is there another resource you would recommend incoming interns use in addition?

Thank you for doing this!

Also @RockFlag&Eagle for what it's worth I will be starting in June at a program which I turned down an away rotation at. I know N=1 and I did it respectfully/promptly (conflict of schedules) but even then my advisor told me I would not get an interview there.

 

[RockFlag&Eagle]

Seconded this question. I am trying (read: failing) to prestudy effectively with my 4th year brain and I feel like I need some direction to make it more worthwhile. I am assuming that a solid review book (case files, EM Secrets) that we used for aways might be a good starting point. Is there another resource you would recommend incoming interns use in addition?

Thank you for doing this!

Also @RockFlag&Eagle for what it's worth I will be starting in June at a program which I turned down an away rotation at. I know N=1 and I did it respectfully/promptly (conflict of schedules) but even then my advisor told me I would not get an interview there.

I'm glad to hear that. I did not get interviews at the two I declined even though I think I was competitive for those programs. I assumed it was just coincidental but hard to know with such a small sample size. Thanks!

 

[gamerEMdoc]

What's your top 5 (or 10) EM CC interns need to become extremely familiar with and perhaps brush up on before intern year gets under way.
Yes, this is a prestudy question and I will, if needed take my lashings willingly.

Thank you!

Obviously... know your cardiac arrest algorithms. Then in terms of chief complaints, develop an approach (ddx, workup algorith, common treatments) for:

Chest pain
Abdominal pain
Elderly generalized weakness or AMS
Fever/Sepsis in an old person
Fever in a child > 3 mo old
Fever in a neonate
HA
SOB
Trauma (elderly falls, minor MVCs, etc)
Toxic ingestion

That's going to cover like 90% of your cases.

 

[gamerEMdoc]

I am an M4 but have fielded this question from my school's M3s a couple times: do programs get upset with students who decline their acceptance for an away month? This is assuming they do it respectfully and ASAP. I'm specifically wondering if that would hurt you a few months later when interview offers start coming out or if the programs don't even keep track of that.
Thanks for all your insight on SDN, it is been very helpful for me throughout the year.

Well, I'm not sure I can speak for all programs. Honestly, I don't even know who does or does not accept the rotations. Our program coordinator handles that, so honestly, I'd never know if someone was offered a rotation and declined. Now if you are rude about it, or cancel the last second, I can see the program coordinator making us aware of that, but other than that, I can't see it ever being a big deal. I'm sure there are programs out there that could be petty about it, but I bet most wouldn't care (at least I'd hope not).

 

[gamerEMdoc]

What is your opinion on programs contacting students post-interview? Second looks?

In sort of that same vein, do programs really care how far they go down their rank list? From your description of your program's rank list assembly it doesn't sound like you take into account an applicant's likelihood to match with you.

I appreciate the followup honestly when there is true genuine interest, but it doesn't factor into the decision where to rank people. Programs should rank people in the order they want the candidates, and candidates should rank the programs in order of where they want to go. They shouldn't factor in likelihood of matching into the decision. That's not how the match works. Besides, students lie to you all the time (seems like every year I hear "I'm ranking you #1 from a highly ranked candidate who ends up matching elsewhere). If you start changing your list based on people telling you they are going to rank you high, then it just encourages more people to lie. Rank them how you want them. That's my philosophy. Now, I'm not saying a students interest in your program never helps. Because obviously, you want the people that eventually match at your institution to like it there and be enthusiastic about matching there. Its just, you don't go moving people way up the list based on some comment that they are going to rank you high.

That all being said, I'm not opposed to post-match communication. You just have to take it for what it is. Its not going to help someone or hurt someone, but I also don't think its wrong to let the highly ranked students (or programs) know where they stand.

 

[gamerEMdoc]

I'm an incoming OMS-1. The school I'm attending has two MD schools (and two ACGME EM programs) in the same city. I've wanted to do EM for a long time. Would it behoove me to reach out to these MD EM programs at any point during my pre-clinical years? Find a mentor? If so, what is the best way to go about doing this?

Probably a bit early in your first year. If your school has an EM interest group, I'd get active there. I'd seek out a good mentor at the end of 2nd or beginning of the third year. In terms of finding a good local mentor, ask the residents at the programs who they'd choose, or ask students from your school that rotated there. Every site is at least going to have a clerkship director, and I'm sure they'd be happy to answer your questions.

 

[gamerEMdoc]

Seconded this question. I am trying (read: failing) to prestudy effectively with my 4th year brain and I feel like I need some direction to make it more worthwhile. I am assuming that a solid review book (case files, EM Secrets) that we used for aways might be a good starting point. Is there another resource you would recommend incoming interns use in addition?

Thank you for doing this!

Also @RockFlag&Eagle for what it's worth I will be starting in June at a program which I turned down an away rotation at. I know N=1 and I did it respectfully/promptly (conflict of schedules) but even then my advisor told me I would not get an interview there.

I had a student cancel their rotation a day before it started this year. Still interviewed and ranked them. Sometimes its worth actually giving people the benefit of the doubt if they have a good reason.

 

[EmergDoc2B]

Obviously... know your cardiac arrest algorithms. Then in terms of chief complaints, develop an approach (ddx, workup algorith, common treatments) for:

Chest pain
Abdominal pain
Elderly generalized weakness or AMS
Fever/Sepsis in an old person
Fever in a child > 3 mo old
Fever in a neonate
HA
SOB
Trauma (elderly falls, minor MVCs, etc)
Toxic ingestion

That's going to cover like 90% of your cases.

Thank you very much!

 

[Apollyon]

Ask you anything... Fight 100 duck sized horses, or one horse sized duck?

(Hat tip to Reddit)

 

[gamerEMdoc]

100 duck sized horses, obviously. I dont like birds, and an enormous horse sized duck would be a nightmare.

 

[Status Sciaticus]

what video games do you play? And how many hours per week do you play them?

 

[gamerEMdoc]

what video games do you play? And how many hours per week do you play them?

I'll play almost anything. I have an Xbox One, PS4, and gaming PC, but I stick mostly to consoles. I really like action RPGs and some sports games. I play Madden and MLB the Show all year long, and then will play almost every big gaming release.

I just beat Horizon Zero Dawn, it was one of my favorite games of all time. Ranks up there with The Last of Us and the first Bioshock. Playing Mass Effect Andromeda now but may quit because its boring the hell out of me. Also playing the last Hitman game intermittently.

As for the # of hours... does "a lot" count? If I had to guess, I'd say I average about 20 hours a week, but it depends. I don't game on days I work. If I'm off for a long stretch, I game a ton more. And in the winter, I game a crazy amount because I'm not golfing on my days off. I try to stay on a night schedule on my days off, so I usually stay up until 3am or so. Its not uncommon for me to get lost in a game and play from like 8pm to 3am.

But I still workout at least an hour a day, and I rarely if ever watch TV other than when I'm running on the treadmill. So gaming is my main entertainment diversion, so I like to think its not THAT unhealthy of an obsession.

 

[kenjixshadow]

1) Who is your Game of Throne favorite character?
2) What is your favorite workout?
3) I'm a boring person with limited of hobbies. How should I approach/prepare for an EM interview?

 

[750335]

Is there any advantage to fellowships in EM? I mean, I assume an EM physician can treat kids so what is the advantage of a Pediatric EM fellowship for example? Or any of the other fellowships? Are they equally competitive or is one head and shoulders above the rest? Do they/some of them also mean better pay?

How many hours a week do the residents work and how intense will you say residency generally is? How many hours a week did you work right after residency (assuming you can pick your own number of hours now)?

Any advice for when and how to pick aways? Also as an attending, is it possible to exclusively work at night? Finally, I know you mentioned interviewing about 85-90 students but how many apply generally?

Thank you

 

[gamerEMdoc]

1) Who is your Game of Throne favorite character?

Read all the books and love the series (but the books more). By far and away my favorite characters are Tyrion, Littlefinger, and Aria.

2) What is your favorite workout?

Running on a treadmill and Yoga (DDP yoga in particular)

3) I'm a boring person with limited of hobbies. How should I approach/prepare for an EM interview?

Get some hobbies. You will be asked about them. My interviews routinely delve into discussing Game of Thrones, Walking Dead, Batman, podcasts, running, etc. And if someone brings up video games, the interview always runs over. Otherwise, you want to have be able to have a good answer for common questions. I mean, it never fails but every year someone struggles to answer "why do you want to do EM". Common questions like what are your strengths, weaknesses, what do you want in a program, what do you perceive as the negatives of EM, tell me about a case that you found ethically challenging. I'd have answers for those. You'll probably be asked the same questions over and over as you go on interviews.

 

[green lantern]

What's your average for golf? I am a double bogey average golfer for only getting to play a Handful of times a season.

Sent from my SM-G386T using SDN mobile

 

[gamerEMdoc]

Is there any advantage to fellowships in EM? I mean, I assume an EM can treat kids so what is the advantage of a Pediatric EM fellowship for example? Or any of the other fellowships? Are they equally competitive or is one head and shoulders above the rest? Do they/some of them also mean better pay?

Fellowships in EM generally are strictly a means of boosting your academic credentials. I know thats a generalization, but for the most part, its true. They aren't going to get you paid more for the most part. And if you don't want to do academics and just want to work out in the community, you can still be an EMS director without a fellowship. So there is little reason to do EM fellowships outside of academic pursuits. From a pay standpoint, its a bad financial bargain, especially Peds EM, which makes less money than regular EM and is a several year fellowship. That's why 95% of Peds EM docs are Pediatricians not EM docs.

I don't want to come across as being against fellowships, its just you have to want to do them for the right reasons. They aren't competitive at all in EM, just because most people want to just graduate and work.

How many hours a week do the residents work and how intense will you say residency generally is? How many hours a week did you work right after residency (assuming you can pick your own number of hours now)?

For full time non-academic EM, I think you'll see most full time ED docs coming in around 30 hours/week or so on average. A little more if they want to make more obviously.
For ACGME, core physician faculty are not supposed to work more than 28 hours/week clinically on average throughout the year. That number is 24/week for an APD.
Those are obviously clinical hours where the faculty are actually on shift. That's not accounting for any education stuff, meeetings, etc.
Residents in EM are capped at 60 hours/week, although at least in my program, no one averages anywhere near that. Most of our residents are working 40-45 hours a week in the ED clinically.
Residency is intense at times, and not terrible at other times.

Any advice for when and how to pick aways?

You want to target the top places you want to go in my opinion. Afterall, most people do wind up matching at a place they were. Most students rank places they are more familiar with higher, and most programs rank students that rotated with them higher. I'm not saying rotating somewhere is a guaranteed high rank spot, you have to do well when you rotate there. But if all else is equal in the application, programs are going to rank the person they know over the person they don't.

Also as an attending, is it possible to exclusively work at night?

Yes. And you wont have any problem having someone give them all to you! I'm a night time person, naturally, I usually would go to bed around 2am or 3am. I absolutely hate mornings. I work all late evening shifts, with my shifts ending at 3am. But I also throw a few 10p-7a's in there. But you will NEVER see me there in the AM unless I have a meeting or I'm at residency conference.

Finally, I know you mentioned interviewing about 85-90 students but how many apply generally?

Several hundred. I think this year it was in the 500 range. It's variable year to year.

 

[gamerEMdoc]

What's your average for golf? I am a double bogey average golfer for only getting to play a Handful of times a season.

I'm typically about a bogey golfer. Mid 80's to mid 90's on any given round. I used to play (terribly) in the summer when I was in college, but stopped. Then I never played in med school or residency. I picked it up again after nearly a 12 year hiatus when I was in my last year in the military just trying to try another hobby as a stress reliever. I was about a double bogey golfer when I started again. About five years later I've at least gotten respectable. Doubt I'll ever get pretty good, just because I'm a head case out there on the course!

 

[RainbowOtterz]

I wanted to first thank you for all of the support for the community. You are a cornerstone of this forum and consistently provide good advice. You are a mentor not only to your program and residents but also to the EM community as a whole.

A bit about me to frame my questions, I am a surgical prelim/intern who had the misfortune of not matching last year. I was able to SOAP into a strong and well respected gen surg program and was subsequently supported by the EM department(4 year, very well respected program) and the Surgery Department. This year has been a whirlwind reapplying and delving into the surgical world. I would say I am a significantly stronger person and clinician after this year. Fortunately, I matched into a three year program in the Southwest that I am extremely excited about!! I could not be happier!

What advice do you have specifically for a resident who has already completed an intern year a different specialty? I know I am rusty on some amount of the Internal Medicine aspect of Medicine. How do you suggest that I push myself to further my education and performance since I am intern version 2.0? Plan is to start a reading schedule at the beginning of the year and start ROSH questions fairly early. Anything specific on or off of shift? I hopefully looking at fellowship/academics in the future and any advice for that?

Again, thank you for all of your contributions on this forum and in advance for the advice.

 

[gamerEMdoc]

I wanted to first thank you for all of the support within the community. You are a cornerstone of this forum and consistently provide good advice. You are a mentor not only to your program and residents but also to the EM community as a whole.

Look. I already got a "sticky" for this thread today. My ego can't take much more praise.

A bit. I am a surgical prelim/intern who had the misfortune of not matching last year. I was able to SOAP into a very strong and well respected gen surg program and was subsequently supported by the EM department(4 year, very well respected program) and the Surgery Department. This year has been a whirlwind reapplying and delving into the surgical world. I would say I am a significantly stronger person and clinician after this year. Fortunately, I matched into a three year program in the Southwest that I am extremely excited about!! I could not be happier!

Seriously, congratulations. I matched someone who did exactly what you did this past year, surgery prelim year. Grueling year, and very impressive to put in that amount of work. Well done, and congrats on the match.

What advice do you have specifically for a resident who has already completed an intern year a different specialty? I know I am rusty on some amount of the Internal Medicine aspect of Medicine. How do you suggest that I push myself to further my education and performance since I am intern version 2.0? Plan is to start a reading schedule at the beginning of the year and start ROSH questions fairly early. Anything specific on or off of shift? I hopefully looking at fellowship/academics in the future and any advice for that?

Re: starting in EM, you are going to be way more advanced than your co-interns. I wouldn't worry about it. But I think its always good advice for everyone to start a study plan early. Getting into good habits is imperitive. Once you get in the habit of "I'll study next year..." it's hard to break out of that until its almost too late.
Re: academics, I'd talk to your PD early about it. Get involved with interviewing if your program allows. Get on committees where you can. Do research. Its not rocket science. If you want to be facutly at a big name residency, you may have to go the fellowship route. But if you want to be faculty at a community EM academic site, you certainly will not have to do a fellowship.

Again, thank you for all of your contributions on this forum and in advance for the advice.

Sincerely, you are welcome.

 

[Status Sciaticus]

I'll play almost anything. I have an Xbox One, PS4, and gaming PC, but I stick mostly to consoles. I really like action RPGs and some sports games. I play Madden and MLB the Show all year long, and then will play almost every big gaming release.

I just beat Horizon Zero Dawn, it was one of my favorite games of all time. Ranks up there with The Last of Us and the first Bioshock. Playing Mass Effect Andromeda now but may quit because its boring the hell out of me. Also playing the last Hitman game intermittently.

As for the # of hours... does "a lot" count? If I had to guess, I'd say I average about 20 hours a week, but it depends. I don't game on days I work. If I'm off for a long stretch, I game a ton more. And in the winter, I game a crazy amount because I'm not golfing on my days off. I try to stay on a night schedule on my days off, so I usually stay up until 3am or so. Its not uncommon for me to get lost in a game and play from like 8pm to 3am.

But I still workout at least an hour a day, and I rarely if ever watch TV other than when I'm running on the treadmill. So gaming is my main entertainment diversion, so I like to think its not THAT unhealthy of an obsession.

Yea I spent a week playing it through. ME 1> ME3> ME2 > MEa.
Last of Us is by far a top 10 of all time along with bioshock 1 and bioshock infinite.

Too bad youre not into FPS like Battlefield 1, Destiny, or Overwatch. But if you are, send me your PSN.