Authors:
Andrew Langille DO1, Christina Hornack DO2, Dhimitri Nikolla DO3

Positions/Affiliations:
1ACOEP-RSO Secretary, EM Resident, UT Nashville, Nashville, TN

2ACOEP-RSO President, EM Resident, Adena Regional Medical Center, Chillicothe, OH

3ACOEP RSAC Chair, EM Attending, AHN Saint Vincent, Erie, PA

Introduction

The COVID-19 pandemic has led to many challenges for all learners in medical education, but orphan program medical students face some additional obstacles. Here are some tips for applying emergency medicine (EM) during the pandemic!

Do ONE audition rotation and obtain ONE Standard Letter of Evaluation (SLOE).

Away rotations are either discouraged or limited for most students due to the COVID-19 pandemic; therefore, most institutions must reserve rotation spots for all their affiliated medical students. This limits the available spots for orphan program students who need to travel to do a rotation in their chosen specialty.1 To ensure that all students applying to EM residency get the opportunity to audition at an EM residency program and obtain a SLOE, EM applicants should limit themselves to only one audition rotation and obtain only one SLOE.2 Despite these efforts, some EM applicants may not be able audition and obtain a SLOE from an EM residency program; therefore, CORD has created multiple SLOE options:3

  • eSLOE for academic EM Faculty
  • SLOE for non-academic EM Faculty
  • SLOE from an EM sub-specialty rotation
  • O-SLOE or Off-service SLOE for non-EM letter writers

Choose letter writers who can vouch for your clinical skills and character.

Most EM residency programs have an internal process for completing SLOEs, and you have no control over who completes the form. However, you can choose who fills out your other letters of evaluation, and you should choose a physician who can vouch for your clinical work and character. Your application can speak for itself with regard to your scholarly accomplishments, but the right letter writer can provide valuable insight into your bedside manner, work ethic, adaptability, interpersonal skills, and personality. These are often considered just as or more important than your scholarly work when deciding whether you would be the right fit for a given program. Lastly, we recommend waiving your right to see the SLOE; this will maximize the perceived authenticity of the letter.4

Beef up your application.

Given the travel limitations, EM residency programs will need to rely more heavily on other aspects of your application. EM specific research/scholarly work, advocacy, or leadership positions in national/local EM organizations show great commitment to our specialty, but most of these opportunities are likely outside the time window of most current EM applicants. However, there are several last-minute ways to beef up your application including:

  • Publish a case report or brief review article in The Fast Track.
  • Present a poster at a national conference.
  • Attend an EM conference (most will be virtual this year!).
  • Join and contribute to an ACOEP Committee or other EM organization.

Supplement your clinical education.

Emergency department (ED) volumes have declined by about half during the pandemic and many medical students have been pulled off clinical rotations due to safety concerns.5,6 The ACOEP-RSO website has a myriad of EM educational resources you should check out!7 But, for students who need to review the basics, we recommend the EM Clerkship Podcast, and for students who need a deeper dive before intern year starts, we recommend the ALiEM Bridge to Emergency Medicine program.

Crush your one audition rotation.

Pandemic or not, you want to crush your audition rotation. However, now you can’t wing it and learn as you go. Here are some practical tips to having a successful audition rotation:

  1. Show up 15-minutes early and be ready to go!
  2. Take no more than 10-minutes to gather a concise history and physical examination.8
  3. If the patient has unstable vital signs or may need an immediate test/intervention, get your resident/attending right away. If you are a medical student with prior clinical experience (ie. paramedic, physician assistant, etc.), you may already have the skills to manage that patient, but remember in the ED your role in that patient’s overall care is to be their medical student. Alert your resident/attending so that they can do their jobs and you all can function as a team to deliver the best care possible to that patient.
  4. Present the patient in less than 3-minutes.9
  5. Have a list of (at least) three diagnoses – the must not miss diagnosis, another important one to consider, and the most likely explanation.
  6. Have a plan. It doesn’t need to be perfect or complete yet, but show your resident/attending that you are moving past the ‘Reporter’ stage of your learning onto the ‘Interpreter’ and/or ‘Manager’ stages (RIME Model).10
  7. Never, ever, ever lie. If you forget to examine a body area or ask about a pertinent positive/negative, admit to it and offer to go back and do it. It is ok to miss or not know something; this is a learning environment. It is not ok to lie about it.
  8. Follow up on test results (ie. labs, imaging, etc.) and interpret them yourself!11
  9. Provide a disposition. Patients can’t stay in the ED forever; they can be discharged, admitted, observed, or transferred.
  10. Learning is facilitated by clinical context. Write down a few ‘learning pearls’ from each shift and read/listen/view additional material on the topics when you get home from your shift. If a resident/attending briefly reviews a topic with you or asks you a question, they usually expect you to read further and may ask you about it on the next shift.
  11. Feedback can be correct or incorrect and can be delivered in a manner that is helpful or not helpful. Remember to be professional when accepting feedback. Don’t dismiss any feedback without significant consideration. And, if you are unsure whether the feedback was accurate, consider consulting with your advisor or mentor. Thanks for the Feedback: The Science and Art of Receiving Feedback Well is a great book to learn more about feedback.12
  12. Ask for feedback and consciously incorporate it into your practice, especially if you are working with the same attending/resident who provided you with the feedback.
  13. If your resident/attending sends you home a little early, this is not a red flag. They likely want to catch up on documentation and do not want to waste your time. If they send you home halfway through the shift, this may be a red flag; consider contacting them by email and politely asking for feedback on ways to improve. Either way, you are dismissed! Nobody wants you lurking in a corner of the ED with nothing to do!
  14. Have a small collection on-shift resources handy including MDCalc, WikEM, and UpToDate. The Chief Complaint Emergency Medical Handbook is a great book to learn the evaluation and management of those “can’t miss” diagnoses.13
  15. Have fun, have a good attitude, don’t complain, try to be positive, be helpful, and be grateful that you have this opportunity to do an audition rotation while some may not due to the pandemic!

Conclusion

We hope these tips help provide some guidance applying EM during the COVID-19 pandemic. However, this list is not comprehensive, so if you need any further guidance, assistance, or mentorship, please contact us at the ACOEP-RSO!

References

  1. Orphan Applicant Emergency Medicine Applying Guide. CORD Advising Students Committee in EM (ASC-EM). https://www.cordem.org/globalassets/files/student-resources/applying-guide—orphan.pdf. Accessed 2020-06-20.
  2. Consensus Statement on the 2020-2021 Residency Application Process for US Medical Students Planning Careers in Emergency Medicine in the Main Residency Match. https://www.saem.org/docs/default-source/saem-documents/2020-res-app-consensus-statement-v2.pdf?sfvrsn=359201fd_2. Published 2020. Accessed 2020-06-20.
  3. SLOE FAQ Medical Students. Council of Residency Directors in Emergency Medicine (CORD). Published 2020. Accessed 2020-06-20.
  4. Garmel GM, Grover CA, Quinn A, et al. Letters of Recommendation. J Emerg Med. 2019;57(3):405-410.
  5. Wong L, Hawkins J, Langness S, Murrell K, Iris P, Sammann A. Where Are All the Patients? Addressing Covid-19 Fear to Encourage Sick Patients to Seek Emergency Care [review-article]. NEJM Catalyst. 2020. doi:CAT.20.0193. Accessed 2020-05-14.
  6. Lou N. Med Students Face Unsure Future During Pandemic. MedPage Today. https://www.medpagetoday.com/infectiousdisease/covid19/86059. Published 2020. Updated 2020-04-20 18:15:00. Accessed 2020-06-20.
  7. Educational Resources. ACOEP-Resident Student Organization. https://www.acoep-rso.org/education-events/educational-resources/. Published 2020. Accessed 2020-06-20.
  8. Wald DA, Ander DS, Fisher J, Lin M, Manthey DE. Performing a Complaint-Directed History and Physical Examination. In: Emergency Medical Clerkship Primer: A Manual for Medical Students. Clerkship Directors in Emergency Medicine; 2011:31-38.
  9. Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme. Acad Emerg Med. 2008;15(7):683-687.
  10. Sepdham D, Julka M, Hofmann L, Dobbie A. Using the RIME model for learner assessment and feedback. Fam Med. 2007;39(3):161-163.
  11. Introduction to Radiology an online interactive tutorial. University of Virginia Health System Department of Radiology & Medical Imaging. https://www.med-ed.virginia.edu/courses/rad/. Accessed 2020-06-22.
  12. Stone D, Heen S. Thanks for the Feedback: The Science and Art of Receiving Feedback Well. New York, NY: Penguin Books; 2015.
  13. Feier C. The Chief Complaint Emergency Medical Handbook. Hermosa Beach, CA: 5150 Publishing; 2014.