Emergency Medicine: Everything a Program Director Doesn’t Always Tell You

1. Emergency Medicine:Everything a Program Director Doesn’t Always Tell You Gerad Troutman, MD Texas Tech University Health Sciences Center University Medical Center Emergency Medicine

2. Bio • Originally from Wichita Falls, TX • Texas Tech School of Medicine 2007 – Lubbock Campus • University of Mississippi Emergency Medicine – Jackson, MS – 2011 • Texas College of Emergency Medicine Leadership and Advocacy Fellow - Current • University Medical Center / Texas Tech Health Sciences Center – Current

3. Objectives • Prepare medical students for a successful match in Emergency Medicine • Encourage students to become involved with EMIG, TCEP, and ACEP • Show medical students on what life is like as a private Emergency Medicine Physician

4. Disclaimer • These are my viewpoints from applying to and matching into EM from a medical school without an EM Residency • Little mentorship; had to find much of this out on my own • I was a chief resident last year and thus was closely involved with the application process – interviewing, ranking, etc • I AM NOT associated with an EM Residency Program currently

5. What is Emergency Medicine? • Emergency Medicine is the medical specialty dedicated to the diagnosis and treatment of unforeseen illness or injury. • The practice of emergency medicine includes the initial evaluation, diagnosis, treatment, and disposition of any patient requiring expeditious medical, surgical, or psychiatric care. • Emergency medicine may be practiced in a hospital-based or freestanding emergency department (ED), in an urgent care clinic, in an emergency medical response vehicle or at a disaster site.

6. EM Physician ≠ Triage Nurse! • EM has a well developed body of its own literature • Annals of EM, Journal of EM, etc • Prompt early recognition of disease and immediate start of care allows for better outcomes • Sepsis, MI, Pneumonia, Stroke • Many presenting problems are completely treated by the EM Physician • Many fractures (reduced, splinted), minor trauma – lacerations/MVCs, Other general medical issues

7. EM vs FM • Emergency Medicine has been a boarded specialty for 33 years now; the days of new Family Medicine graduates ‘Working in the ER’ are ending daily. • Isolated parts of the country, VERY low volume/low pay • Fewer and fewer spots every year • If you want to practice Emergency Medicine then you should plan on training in Emergency Medicine

8. Terminology… Get It Right! • ER = Emergency Room or a TV Show. • ED/EC = Emergency Department or Emergency Center • These are the place you will end up working. Even a small hospital has a 2-4 bed ‘EC’. • EM = Emergency Medicine – The practice of Emergency Medicine • We do not practice ER Medicine (?Emergency Room Medicine?) • This terminology may offend someone… lose ER from your vocabulary. • You want to be an EM Physician and wish to work in an ED or EC.

9. Just How Competitive is EM? • Often loosely compared to Radiology, Anesthesia…. • Considered a notch below Derm, Ortho, Plastics, etc • 2012 – ZERO spots post match (1668 filled!)… • Radiology had 40 • Anes had open spots • 2008 – 1399 spots; 29 unfilled spots • NRMP Data is from US Allopathic Graduating Seniors

10. NRMP Data *2011

11. NRMP Data *2011 • Step 1 Mean: 223 • Step 2 Mean: 234

12. NRMP Data *2011 • Publication? Research?

13. NRMP Data *2011 • AOA, Superstar Medical School?

14. How To Match…

15. Pre-Med • EMS? • Nursing? • CEO? • Battlefield? • Focus should be MCAT, college grades, and getting into medical school • Has very little impact on the final match..

16. First Year – Medical School • EMIG or equivalent • Join ACEP, TCEP, EMRA ($55 annually for all 3!) • Shadow in the ED! • Even if just a few hours on an evening after a test • Develop a relationship with a Mentor! • Chief resident, attending you hit off well, etc • Get good grades. • You do not have to be at the top of your class, but at least shoot there and minimally be in the ‘middle of the pack’

17. Second Year – Medical School • Shadow, continue Mentor relationships • Active role in EMIG • Attend state/national EM conferences. • GET INVOLVED! • Good grades (Duh!) • STEP 1, STEP 1, STEP 1, STEP 1 • Uber important… DON’T FAIL!!

18. Third Year – Medical School • Do well in all rotations; keep an open mind to reinforce that you really ‘like a little about everything’ • Develop some thick skin; you will be told by many rotations “Don’t do EM!!” • I think they generally are just jealous of our lifestyle!! • Meet with your Mentor to discuss Step scores, grades, etc and plans for the application cycle. • Look into away rotations; start deciding where you are going to apply

19. Away Rotations • Tap into regional bias • Born/raised/educated in TX… Why should Florida even consider you? Doing an away in Georgia shows you have genuine interest in the SE… etc • Prove yourself, overcome the borderline step score • Know with confidence if the program is a ‘good fit for you’

20. Away Rotations – Setting Up • I think everyone should do at least one away rotation. It allows you to see another program and perhaps a different part of the US. • If you school DOES NOT have an EM Residency, it is IMPERATIVE you do an away rotation in academic EM. • More than two away rotations is probably wasteful • If you insist, make that third rotation Tox, EMS, Wilderness, etc.. Still ask to work ‘a few shifts with the Program Director’ • Contact schools during mid winter/early spring to setup rotations. • August/September/October are PRIME months

21. Away Rotations – Application? • Most places are a very brief applications; essentially prove you are indeed a medical student with EM interest • Some places have extensive application process including score evaluation, LOR, phone interview, etc

22. Away Rotations – How to Shine • From the moment you arrive in XYZ, you should act like you are on a constant interview • Show up early and stay late • Be nice to the Residency Coordinator and Nurses • Be attentive to a patient being too sick for you to see on your own • Only carry 1 to 2 patients MAX. • Offer to all residents on the shift to Suture, I&D, assist with other procedures. • Do not expect to intubate someone, place chest tube, or other more complex procedures… they might happen, but don’t be upset if they don’t offer these to you. Be along side regardless and learn about the procedure

23. Away Rotations – Shining On… • Go to resident lectures; even if its your day off! • Be nice to the Residency Coordinator and Nurses • Ask someone about Journal Club.. Most places have these monthly.. Ask if you can go to it! • If invited to breakfast, dinner, drinks, etc by the residents… GO!!! Be cool, don’t drink too much, have fun. Interact. • Be nice to the Residency Coordinator and Nurses • Make CERTAIN you have some shifts with the Program Director/Assistant PDs/Chairmen.

24. Away Rotation – Finishing Up • MEET with the program director. • ASK for a SLOR • If you really ‘hit it off’ with any particular attending, do not be afraid to ask if they can write you a “GOOD Letter of Rec” • Don’t ask a chief resident for a LOR • Be nice to the Residency Coordinator and Nurses • SEND thank you cards – PD, Coordinator, any Attending or even Chiefs that you hit it off well with, and globally to the whole department

25. Personal Viewpoints • My PD consistently asked our charge nurses “What did you think of XYZ student.” • I also assure you that a poor relation with the Residency Coordinator can affect you negatively. • ALWAYS get a SLOR from your away rotations; unless you just did a hideous job, always include them in your application. • HANG OUT with residents if invited. • I invited a visiting student out with us one night and he said he had other plans. That makes you appear rather disinterested… • NEVER try to have more than 2 patients at a time.

26. Fourth Year – Medical School • Arrange easy rotations during the ‘interview season’ so that travel for interviews are not a big issue. • Take some easy electives at the end of the year that will help you later (Ophthalmology, OB Ultrasound, Dermatology, etc)… Leave the cardiology, ICU, butt kicking services for residency. • Apply to an appropriate number of programs

27. Personal Statement • Probably the most stressful part for students but honestly probably matters the least • A good middle of the road PS is probably best.. Standing out on this is not always a good thing, and standing out ‘positively’ is difficult to attain. • Refrain from ‘being out there’ on the PS… Just stick to the basics – Your interest in EM and why you think you would be good at it • Have an English professor or equivalent proofread it!!

28. Letters of Rec • SLOR – Standard Letter of Rec • Distributed by CORD • MUST have at least one of these on your file • Google ‘SLOR’ and review the document • Obtain a couple more ‘regular’ letters of rec. • EM attending • Surgery Attending • Medicine, etc • Schedule a meeting with someone you hit it off well with and ask “Can you write me a GOOD letter of recommendation” – Make certain they know your aspirations of EM, provide them with a CV – Write “Application to Emergency Medicine” at the top of your CV.

29. ERAS!! • July 1 – Opens to applicants • Start working on the application, PS, sLOR, etc • September 15 – Submission of Application! • AN EARLY APPLICATION IS THE SINGLE EASIEST THING YOU CAN DO TO INCREASE YOU CHANCES OF A SUCCESFUL MATCH!!!! • October 1 – MSPEs (i.e. Deans Letter) Released

30. ERAS Costs • Apply to 30 EM programs = $305 • Apply to 50 EM programs = $805

31. Facebook / Twitter / etc • CLEAN it up but don’t have to delete it • Facebook can hurt or help you • “A life” outside of medicine depicted on an unlocked FB page gives some true positive insight • Drunken pictures, frat parties, cursing in posts, inappropriate pictures, etc certainly CAN hinder your application • You are a professional now; ACT LIKE ONE • I would be willing to bet that 50% or greater of interviewed applicants get their name searched for on facebook. We did on most of our applicants.

32. Step 2 ? • When should I take Step 2? • Individualized question to discuss with your mentor, but generally… • If you did better than average on Step 1, its not so important to get done early • If you did below average on Step 1, Step 2 is your chance to shine. MOST people do better on Step 2… but DON’T BLOW IT • A borderline Step 1 score followed by a lower Step 2 score (or fail) is a potential Kiss of Death

33. Number of Programs? • Assuming no failed classes, middle of the road class placement or higher, good SLORs… • Step 1> 220 – Your in great shape! Safe applying to 20-30 programs • Step 1 200-220 – Very ‘Matchable’, best apply to 30-50 programs • Step 1 <200 – Going to take some work, but still have a good chance if no other bad marks. Step 2 early with improved score. Apply to 50+

34. Kisses of Death • Failed class, Failed year • Failed Step • FMG/IMG • If you fit any of these, I would consider applying to essentially every EM program in the country. • AWAY rotations are utmost importance; pick wisely and BE A ROCKSTAR.

35. How many interviews? • Your goal should be at least 10-12 interviews • Make sure to hit a place or two that is ‘off the beaten path’ even if you are a stellar applicant.

36. Interviews.. • Accept all you get at first… once you are hitting the 10-15 mark, start shifting through and cancelling as needed • CANCEL EARLY and politely • NEVER just ‘not show up’ – KISS OF DEATH • Early airfare, consider priceline.com for rooms or a room block the program offers. Some programs offer to stay with a resident.

37. Interview Day • ALWAYS do everything you can to make any evening before dinner/party or lunch/drinks. • These are a way for you to really mingle and see how you fit • Professional Dress is obvious • BE NICE to EVERYONE you meet. Be very nice to the residency coordinator and any residents that give you tours, etc. • Calm and collected as possible. • ASK SOME QUESTIONS at the end of each interview • Even if you ask the same thing to everyone!!

38. Actual Interview • Usually 3-5 total – 15 to 20 minutes each • Typically include the Program Director or combo of Assistant PDs, often other attendings in the department, occasionally the chair, and typically a resident (usually a chief). • Rather laid back; more of a ‘get to know you’ session and determine if you fit well into their program

39. Thank You Cards? • I’ve heard both ways… • Personally I did not send any… I would guesstimate that less than half the people we interviewed sent them and I honestly do not think that any of the ‘cards’ changed anyone's rankability • *ALWAYS send thank you cards if you did an away rotation!*

40. EM Program Competitiveness • Almost a direct correlation with how popular the place is to live • Just because a program is ‘competitive’ I am hesitant to say it is ‘better’. EM is very different from IM. • Look at a map.. If the program is in a place that is a popular place, much to do, etc etc…chances are that program is going to be more competitive than the program located in a town you have not even heard of.

41. ERAS/PDWS – Post Interviews… • So… you have interviewed. What do the programs do know? • There are >100 programs and probably >100 ways they go about it…. • ERAS has a computer program called “Program Directors Workshop” which is what programs use to look at, evaluate, and eventually rank applicants!

42. PDWS

43. Interview Ranking by the Program… • Programs customize how this is done; typically a linear ‘score’ that is put into the program. • PDWS is very customizable. • Essentially, at the end of the interview season, a rank list is produced based on a composite score. I would guess that every program meets multiple times and ‘changes the list’ slight based on other preferences….. Making a final list submitted to NRMP.

44. Interview Ranking by the Applicant • What is important? • Rotations, feel of the department, resident camaraderie, pay, Moonlighting, etc • Location, happiness, remember its only 3 or 4 years! • Talk to your family/loved ones and rank based on your shared feelings of ‘happiness’. You will unlikely be as successful if your spouse is not happy. • Don’t get hung up on ‘Program X better than Program Y’. A RRC Accredited program will get you to your end goal…A Board Eligible Emergency Physician.

45. Rank Lists… • Do not try to ‘beat the rank’... • List programs in order of where you want to go • Do not Rank a program ONLY if you feel like you would rather NOT MATCH than go to that program… • MAKE SURE TO CERTIFY YOUR ROL!!!

46. Post Interview… • Emails, Phone Calls  To Applicant • Some programs do, some don’t. No need to ‘freak out’ just because you may not have received a phone call or email, etc. Again, this is done at very random… • Emails, Phone Calls  To the Program • I have not heard a clear answer; I’ve heard PDs say its unimportant to them, yet there is much speculation that it could help you notch up a list? • If you contact a program, BE TRUTHFUL!! If you tell XYZ they are your number 1, then they need to really be.. otherwise an “I ranked you highly” should suffice…

47. Get Involved… • Join your schools Emergency Medicine Interest Group, Texas College of Emergency Physicians, and American College of Emergency Physicians. • ACEP Scientific Assembly (Denver this year) • ACEP Leadership & Advocacy – Washington DC

48. Questions? • Feel free to contact me: Gerad Troutman, MD • TroutMD@gmail.com • Feel free to add me on Facebook