applying for an emergency medicine residency!

Okay first of all - YAY congratulations on getting to this point. It's not an easy decision but picking emergency medicine... you're stepping into an amazing community, with wonderful people, exciting cases, incredibly special moments with patients, and a front seat view of what's happening in the world.

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WHERE DO I APPLY?

Everyone said this to me, and it's true: you can get great training anywhere. Emergency medicine is unlike a lot of other fields. There is no clear ranking of what's "the best" program. Which is maddening when you're trying to figure out where you want to apply but really encouraging when you start to interview and imagine your life in these places. I'll walk you through some of the ways to think about programs, but really you need to find what the best fit for your values and your career aspirations and your life outside of the hospital.

There are three types of hospitals. SAEM has an excellent map that you can filter by type.

Academic hospitals tend to be referral centers and get super complicated patients, they've got all the specialties and consultants you can think of! Often, the emergency medicine doctors are not "running" the hospital, but you're surrounded by brilliant colleagues in other fields who can teach you so much. These hospitals are closely affiliated with medical schools and research institutions which gives you access to the all the resources, funding, mentorship. If you're at an academic hospital in a city with a lot of other hospitals, you might see a lower volume of patients.

Community hospitals are where most emergency physicians end up working after they finish training. There's a wide range of patient populations, volume, and acuity, but these tend to have fewer consultants so the ED will do a lot of procedures and processing. 

County hospitals tend to have a high-volume, high-acuity patient population, and they tend to have the trauma centers too. These are usually public hospitals with a strong mission to take care of a historically underserved community. They usually aren't the most efficient systems and they don't always have the resources they should. Every major city has one big county hospital (at least), and many are affiliated with an academic institution/academic hospital.

Another branch point is how many years you want to train. A three year program at a high-volume site is plenty to get the skills needed for your career, and it means that you're making an attending salary one year early. If you want to do a fellowship, check to see if the residency is able to place graduates at the fellowships you're interested in (some four year programs are reluctant to take fellows from three year program). A four year program might have more time for electives and research, and you might need that fourth year to round out your skills if your program doesn't get a high volume of patients. Generally people seem to agree that 3.5 is the perfect amount of time for an EM residency.

Think about shift length. I only rotated at sub-internships that did eight hour shifts and the residents seemed pretty biased towards them (which makes sense because that's part of why they picked the program). I would assume that eights mean nine-ten hours in the department and twelves might mean like thirteen-fourteen, plus you've got factor in your commute. So eights are nice because you get a little chunk of the day to yourself outside of the shift, but if you do twelves then you do fewer total shifts during the month. People's preferences vary widely. One resident recommended that I make my own twelve hour shift by shadowing 1.5 shifts - give it a try to see how you feel. Some programs do a mix; I've heard that twelves on the weekends can be nice because it frees you up to get a golden weekend (2 days off in a row!) every so often. For programs that do a LOT of shifts, it's fair to expect a shift reduction with each progressive year. Make sure you write down shift lengths, shifts per/month, shift reductions for each place you interview at.

A HUGE part of your list is going to be location location location. I feel like it's one of THE biggest factors in what your list looks like. Do you want to live in a city or in the suburbs? What part of the country do you wanna be in? Where is your support system at and how close do you need to be to them? For most EM programs, you will have time outside of the hospital and you need to find places that you want to be, places that you can live a life that recharges and renews you and keeps your cup full. That being said... keep an open mind! Apply broadly, let yourself be surprised by the interview trail.

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INTERVIEW ADVICE:

My friend Natalia and I compiled a list of virtual interview advice that can be found here. It's geared towards medical school interviews but still has some helpful chunks. The biggest difference I noticed between med school interviews + residency interviews is time - I had 30-60 minutes per conversation when I interviewed for medical school. For residency, my interviews were usually 15 minutes (12-20 was the general range) but EM cares a lot about first impressions / has a short attention span I guess LOL.

Emergency programs are often looking for "fit" - which is vague and intangible and sometimes problematic based on the heuristic they're using. If you wanna do your research, ask if you can be put in touch with residents before your interview day and ask them what kind of intern thrives at their program. Some of thee programs known for autonomy want to see that you're independent/a self-starter/know when to ask for help. Some programs that have an urban safety net hospital want to see a strong commitment to equity. It's hard to know really what programs are looking for but you'll hear people talking about ~fit~ so think about what parts of your application/personality/values connects with this program's mission and what they seem to emphasize.

Also do future you a favor and take notes/keep a spreadsheet - you're going to see a massive amount of information and it's all gonna blur together unless you find a way to stay organized.

During the cycle, I kept a running list of questions I might want to ask programs during one of the MANY opportunities to ask questions:

Logistics:

• What is signout culture like? How late do people spend after your shift? (lol most residents are gonna tell you "it depends based on the person" but still worth asking)
• Some places might have scribes or dragon/dictation to help with note-writing which is usually what keeps people after shift - but don't assume they will especially if you're interviewing at a county program
• What is relationship like with nurses?
• Is there 24 hour social work?

Curriculum:

• What's your favorite off-service rotation? (if you ask directly what the relationship with consultants is like, most ppl will vaguely tell you its good, except one interview said they didn't get along with GEN SURG lol and that is bad vibes since y'all will split the trauma cases)
• How does trauma work at this program? (some places do blocks, some longitudinal; some programs run all the traumas, some alternate with surgery; some places get all the airways and some alternate with anesthesia)
• Is there a shift reduction every year? How many shifts per month + how long is each shift?
• If there’s a fourth year of residency – ask what the fourth year is FOR? Make sure you're getting something from the fourth year instead of just being cheap labor for the hospital lol

Jobs:

• Is there a list of where graduates end up working / doing fellowship?
• Where do residents moonlight at? 

Extracurricular:

• What’s a side project you've worked on residency?
• Is there a list of publications in the last year from residents + faculty?

Wellness:

• What's the backup coverage system look like?
• How do days off/vacation work?
• Can you tell us about a specific time the program/program director supported you/went to bat for you?
• Is there a residents union?
• Do residents get free parking or food?
• A fun light question --> what's your favorite cafeteria food? 

General:

• What makes someone like you love this program?/why have you stayed?
• How did this program compare to the other top programs on your list? (Tends to get more specific answers then why did you pick your program, to which everyone answers “the people!!”)
• What kind of resident thrives here / fits in?
• What’s the best advice you have for a new intern? 

Some places had anonymous question forms which was great for the "tough" questions. That being said, even if they don't... ask those hard questions that might change your management. 

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RANKING & WAITING

This was the hardest part! Interviews have wrapped up and the virtual season made it really hard to differentiate programs or imagine myself in new places. My advice is to have a few absolutes and then go with your gut. There are a few things you know in your heart you cannot compromise on - for me, it was gritty county hospital, a commitment to social justice, warm weather... and then organize your list based on the vibes. 

It feels like we put so much build up into this process, when your residency experience is so much more based on you than it is your program. The truth is that emergency medicine is getting more competitive every year and there are a lot of factors outside of your control. It's hard not knowing what your life will look like for the next 3-4 years... but keep an open mind and an open heart, try to trust the process because emergency medicine will bring all kinds of adventure, growth, and wonder to your life no matter where you go.

xoxo