I would take the same approach, but you may hear differently from others. The desirable EM places have seen their number of applications increase dramatically in the past 6-7 years. In 2010 the average # of apps submitted per applicant was 27, but increased to 48.6 in the 2017 cycle (and going up by roughly 10% every year). This means that applications to desirable programs have roughly doubled and they can be very picky in whom they select to interview. Also, most of these programs don't have time to go through all of the applicants, so they try to eliminate students with their Step 1 score, geography, red flags, etc. Therefore, I would take the same approach.
I was planning on applying broadly, so this is refreshing to hear. Everyone wants to do EM in the desirable places - I want to be board eligible with ABEM. Send me to the middle of nowhere if that's what it takes, I understand it's competitive in general.
Do you think the red flag I am describing is a kiss of death for my match in EM? I like to think that having strong scores, strong SLOES may help mitigate the issue somewhat, but I could also be foolishly reassuring myself..
Allow me to add the full run-down of my application here:
Undergraduate: Ivy League
Graduate School: Master of Science, Physiology
Business School: Master of Business Administration (5 year MD/MBA)
Medical School: Top 40
Research: Summer research fellowship in transplantation medicine, Pedi EM poster at state medical conference.
Quartile Rank: 2nd Quartile
3rd Year Grades: mostly mid-80's, no clerkship failures
Step 1: 247
Step 2: N/A
SLOES = I will have two SLOEs when I submit ERAS
Other: Interesting personal story - enrolled in medical school while battling cancer, championed over it - fully in remission.
Business school research: emphasis on new venture feasibility in establishing free-standing EDs, operations management of trauma centers, the profitability of new ventures in privately owned (hospital corporation) urgent care centers.
Assistant (volunteer) instructor for ACLS course
Developed a point of care ultrasound curriculum, proposal for new course denied (but something interesting to bring with me to a residency program, I think, esp. if residency program doesn't offer student elective in it)