Gerad Troutman, MD Texas Tech University Health Sciences Center University Medical Center Emergency Medicine.

Gerad Troutman, MD

Texas Tech University Health Sciences Center

University Medical Center

Emergency Medicine

Emergency Medicine:Everything a Program

Director Doesn’t Always Tell You

Originally from Wichita Falls, TXTexas Tech School of Medicine 2007 –

Lubbock CampusUniversity of Mississippi Emergency

Medicine – Jackson, MS – 2011Texas College of Emergency Medicine

Leadership and Advocacy Fellow - CurrentUniversity Medical Center / Texas Tech

Health Sciences Center – Current

Bio

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

Objectives

These are my viewpoints from applying to and matching into EM from a medical school without an EM ResidencyLittle mentorship; had to find much of this out

on my ownI 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

Disclaimer

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.

What is Emergency Medicine?

EM has a well developed body of its own literatureAnnals of EM, Journal of EM, etc

Prompt early recognition of disease and immediate start of care allows for better outcomesSepsis, MI, Pneumonia, Stroke

Many presenting problems are completely treated by the EM PhysicianMany fractures (reduced, splinted), minor

trauma – lacerations/MVCs, Other general medical issues

EM Physician ≠ Triage Nurse!

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 payFewer and fewer spots every year

If you want to practice Emergency Medicine then you should plan on training in Emergency Medicine

EM vs FM

ER = Emergency Room or a TV Show. ED/EC = Emergency Department or Emergency

CenterThese 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 MedicineWe 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.

Terminology… Get It Right!

Often loosely compared to Radiology, Anesthesia….

Considered a notch below Derm, Ortho, Plastics, etc

2012 – ZERO spots post match (1668 filled!)…Radiology had 40Anes had open spots

2008 – 1399 spots; 29 unfilled spots

NRMP Data is from US Allopathic Graduating Seniors

Just How Competitive is EM?

NRMP Data *2011

Step 1 Mean: 223Step 2 Mean: 234

NRMP Data *2011

Publication? Research?

NRMP Data *2011

AOA, Superstar Medical School?

NRMP Data *2011

How To Match…

EMS?Nursing?CEO?Battlefield?Focus should be MCAT, college grades, and

getting into medical school

Has very little impact on the final match..

Pre-Med

EMIG or equivalentJoin 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’

First Year – Medical School

Shadow, continue Mentor relationshipsActive role in EMIGAttend state/national EM conferences.

GET INVOLVED!

Good grades (Duh!)

STEP 1, STEP 1, STEP 1, STEP 1Uber important… DON’T FAIL!!

Second 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

Third Year – Medical School

Tap into regional biasBorn/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’

Away Rotations

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

Away Rotations – Setting Up

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

Away Rotations – Application?

From the moment you arrive in XYZ, you should act like you are on a constant interview

Show up early and stay lateBe nice to the Residency Coordinator and NursesBe attentive to a patient being too sick for you to see on

your ownOnly 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

Away Rotations – How to Shine

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.

Away Rotations – Shining On…

MEET with the program director.ASK for a SLORIf 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

Away Rotation – Finishing Up

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.

Personal Viewpoints

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

Fourth Year – Medical School

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!!

Personal Statement

SLOR – Standard Letter of RecDistributed by CORDMUST have at least one of these on your fileGoogle ‘SLOR’ and review the document

Obtain a couple more ‘regular’ letters of rec.EM attendingSurgery AttendingMedicine, etcSchedule 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.

Letters of Rec

July 1 – Opens to applicantsStart 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

ERAS!!

Apply to 30 EM programs = $305Apply to 50 EM programs = $805

ERAS Costs

CLEAN it up but don’t have to delete itFacebook can hurt or help you“A life” outside of medicine depicted on an unlocked

FB page gives some true positive insightDrunken 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.

Facebook / Twitter / etc

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 ITA borderline Step 1 score followed by a lower

Step 2 score (or fail) is a potential Kiss of Death

Step 2 ?

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 programsStep 1 200-220 – Very ‘Matchable’, best apply

to 30-50 programsStep 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+

Number of Programs?

Failed class, Failed yearFailed StepFMG/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.

Kisses of Death

Your goal should be at least 10-12 interviewsMake sure to hit a place or two that is ‘off the

beaten path’ even if you are a stellar applicant.

How many interviews?

Accept all you get at first… once you are hitting the 10-15 mark, start shifting through and cancelling as neededCANCEL EARLY and politelyNEVER 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.

Interviews..

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 fitProfessional Dress is obviousBE 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

interviewEven if you ask the same thing to everyone!!

Interview Day

Usually 3-5 total – 15 to 20 minutes eachTypically 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

Actual Interview

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!*

Thank You Cards?

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.

EM Program Competitiveness

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!

ERAS/PDWS – Post Interviews…

PDWS

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.

Interview Ranking by the Program…

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.

Interview Ranking by the Applicant

Do not try to ‘beat the rank’...List programs in order of where you want to goDo 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!!!

Rank Lists…

Emails, Phone Calls To ApplicantSome 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 ProgramI 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…

Post Interview…

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

Get Involved…

Feel free to contact me: Gerad Troutman, MD

[email protected] Feel free to add me on Facebook

Questions?