Advice for EM Applicants: Planning Your Fourth-Year Schedule

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EM rotations: When, where, and how many?

For third-year medical students planning to specialize in emergency medicine, preparing a fourth-year schedule can be a daunting task – especially if you don’t know where to turn for advice. We hope that by sharing our experiences, you will be well on your way to securing your top-choice residency spot.

Do them early; do them where you want to become a resident. This is the best, most concise advice we can offer; however, there may be a few caveats, depending upon your individual situation.

What months should I rotate? If possible, you’ll want at least two SLOEs (Standardized Letters of Evaluation) uploaded to ERAS by October 1 – the day that MSPEs/dean’s letters are released. To learn more about the SLOE, please visit the Council of Emergency Medicine Residency Directors (CORD) website at www.cordem.org. The sooner you have these letters of evaluation posted, the sooner your application is considered complete, and the sooner programs will offer you interviews. Keep in mind that some clerkship directors may be faster than others in finalizing letters of evaluation, so the earlier you can complete your EM rotations, the better. Rotations at popular programs can fill up quickly, so get them arranged as soon as possible to have more control over your schedule.

How many EM rotations should I do?
The only right answer for this question is: As many as you think you need to be competitive. That said, we feel that two is sufficient, unless you know that your board scores or overall application are a bit weaker than you’d like. If your school only allows two or three EM rotations, but you want more EM exposure, consider rotations in emergency medicine subspecialty areas such as ultrasound, toxicology, wilderness medicine, research, ED-based critical care, and more. Some students say that by their third EM sub-internship, they began to feel bored because their responsibilities have not advanced and they’re doing the same sort of work-ups as they did in their first two away-rotations with the same limitations. An emergency medicine subspecialty rotation will feel new and exciting, while giving you a chance to check out another program. If you do decide to embark on a third EM rotation, asking questions ahead of time can be important. Find out the acuity level of the patients you will be seeing; whether or not you will be the primary caregiver for patients; and whether you will be staffing patients with faculty, residents, or both.

Do I have to do a home rotation?
Many medical schools have required emergency rotations, while others do not. If your school has an EM rotation – especially if it is affiliated with a residency program – some will advise that you have to rotate there, even if it is not a required clerkship. However, if you’re limited in the number of EM rotations that you can complete and are not interested in becoming a resident at your home program, you’re not obligated – but there are at least two major drawbacks to consider.

The first is lack of an advocate. By not doing a home rotation, you may be missing out on the opportunity to find an advisor who can help you navigate the application process and use their connections within the EM community to help you secure interviews or end up near the top of another program’s rank list.

The second problem is related to an outside program’s expectations of their rotators; they may not know if you are on your first rotation, and this could potentially make it more difficult to obtain a favorable evaluation if your presentation skills and knowledge of the evaluation and management of common chief complaints are not as polished as they could be.

Where (else) should I rotate?
If, so far, you’ve only trained in a community setting, check out an academic or county program – and vice versa. Each of these settings provides a unique set of pros and cons. When it comes to making the best residency choice, you’ll be thankful to know what each of them have to offer.

Applicants looking to apply nationally or within certain regions of the country should also seek to rotate at programs where their SLOEs will be written by faculty with regional or national recognition. Some program directors have seen so many SLOEs from faculty at nearby or well-known institutions that, for better or for worse, they are able to read between the lines and decipher exactly what type of applicant they are dealing with. “Regionalizing” your approach can make a difference in whether or not you will be invited to interview at certain programs.

The double-edged sword analogy
Some people may warn you that away rotations are a double-edged sword that could potentially hurt your chances of matching in a program if you don’t perform well there. However, it’s a risk worth taking since you might discover that a program isn’t the best fit for you. If you are a strong applicant with stellar scores and letters of recommendation, there is a component of diminishing marginal returns that you must consider if rotating at competitive sites.

How do I find away rotations?
Many, but not all, rotations can be found on VSAS (the Visiting Student Applicant Service, offered by the AAMC; more information is available at www.aamc.org/students/medstudents/vsas). Other means of finding rotation opportunities include web searches and the SAEM Clerkship Directory (www.saem.org/membership/services/clerkship-directory). An honest, critical advisor or mentor may also be able to provide valuable input.


Other Scheduling Considerations

When should I take Step 2?
The importance of your Step 2 CK score may vary from program to program, but unless you feel that you underperformed on Step 1 and need to prove yourself with Step 2 CK, your EM rotations should be the first priority when planning your fourth-year schedule. If you underperformed on Step 1, it’s essential that you study hard for Step 2, show a marked improvement in your scores, and have these scores posted to ERAS by the time residency programs can begin logging in to view applicants. Unless you feel that you under-performed on Step 1 and need to prove yourself with Step 2 CK, your EM rotations should be the first priority when planning your fourth-year schedule.

Osteopathic students interested in applying to ACGME residency programs must carefully consider when to complete USMLE Step 2. If you took USMLE Step 1 and COMLEX Level 1 and did well on both, you may be able to wait; however, the key is to remove as many potential concerns about your application to increase your chances of getting an interview. Give the ACGME program directors what they want – a USMLE Step 2 score.

As for Step 2 CS, many students complete this during spring break of their third year and pass without any problems. The sooner you can get this hurdle out of the way, the sooner you can focus on everything else that goes into making an outstanding EM applicant.

What months should I plan for interviews? Each medical school has its own policies on how time off for interviews is handled. Some programs will begin interviewing in late October, and a fair number continue through January, but November and December seem to be the peak times for interview dates.

An alternative to taking time off for interviews is to schedule a more flexible rotation during this time period, such as a reading month, computer-based asynchronous courses, self-directed research or other projects, or other opportunities to earn credit without having to be in clinic. Don’t be shy (but do be polite) about asking course coordinators what the typical duty hours are for a rotation and the possibility of options for making up missed time. It is best to do this well in advance.

What about national conferences? Attending conferences is a fantastic way to meet movers and shakers in the field of emergency medicine. The SAEM Annual Meeting in May, ACEP Scientific Assembly in October, and EMRA’s Medical Student Symposia have programming tracks for medical students and feature residency fairs with program directors, clerkship directors, and chief residents from across the country. If you can fit one or both of these conferences into your schedule, they are highly recommended. EMRA offers travel scholarships to help defray costs for students (www.emra.org/awards). It’s nice to walk into your interviews having already met key players at the program.

Zach Jarou, MD
Zach Jarou is a resident physician at Denver Health Medical Center and the Department of Emergency Medicine at the University of Colorado School of Medicine. He is the 2016-2017 President-Elect of the Emergency Medicine Residents' Association. He has previously served as EMRA's Membership Development Coordinator and as a member of ACEP's National-Chapter Relations Committee, as well as the Chair and Web-Tech Coordinator of the EMRA Medical Student Council and Vice Chair of EMRA's Editorial Committee.
Zach Jarou, MD
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