Author: Ash Rider, MD, Highland Emergency Medicine R4, on behalf of the Advising Students Committee in Emergency Medicine (ASC-EM)
Congratulations! You have chosen the best specialty, filled with incredible individuals and a rewarding career. No matter where you end up for training, you will graduate an ED doc prepared to handle anything, and that is SO special. The question in front of you—where do you go to meet that end?
You just interviewed at many different training programs, perhaps all over the country. You’ve chatted with hundreds of residents and given your most heartfelt responses in interview after interview. You’ve sat in airports for hours and spent more money than you’d like to admit on travel costs. Hopefully along the way you enjoyed visiting new cities or catching up with friends you haven’t seen in years. It was fast-paced and exhausting while you were at it, but now the more challenging task is at hand: the process of reflecting back on your experiences and crafting your rank list. I write this as a fellow trainee with the hope it helps you shift through your thoughts and impressions on which programs are your “best fits.” Part of that process is defining your own fit, as well as personal and professional priorities in the next 3 to 4 years. If you are having any difficulty in creating the layers of your rank list, I hope that answering these simple 3 Reflection Questions (3RQ) will shed some light on where you will best flourish as an emergency medicine resident.
RQ #1: Where do you want to be?
Are you someone who prefers to be near your family and longstanding friends? What would it be like for months to years without having these people near you? If that is not a future you can envision, then look no further–you’re meant to stay put, so emphasize programs locally. For those who have a partner who is obligated to a particular city, this is also an easy question to answer. Perhaps you’ve built a strong professional community locally that provides many opportunities during residency and beyond. These are some of many reasons why a nearby program may be important to you.
If you are not committed to a particular place, is there somewhere NEW you’ve always wanted to live? I would argue that residency is one of the best opportunities to try living somewhere different. You will be instantly blessed with a group of friends who share a similar mindset, and will cherish becoming close with your class during intern year.
If you are committed to going somewhere new, think about the difference in personalities between the East and the West Coast, the Midwest and the South. With each, consider the varied experience in weather and access to things you enjoy. If you’ve never lived in the Midwest or East Coast, just know that might be new to you to scrape ice off a windshield in -10 degree weather while snowing. If you can’t live without mountains or skiing, going to Texas may not be your best fit. Love the ocean, an avid surfer? Maybe an inland state doesn’t match your profile. Do you adore the changes in seasons, fall, and later snowfall? California’s temperate climate may not keep you entertained.
Down to the nitty gritty within an area—do you need to be in a city? How big? Houston and NYC are both big cities, but the living and commuting experience is quite different. Or do you prefer a rural experience because that is the setting in which you anticipate working some day?
Most likely, many graduates from your program will stay in the area for jobs afterwards. Your alumni network connections will be important for your career after residency. If you left Maryland when you were 18 but plan on moving back to raise a family, residency might be a good springboard for building professional relationships. Asking yourself where is a good first question, but is often the easiest to answer. Ready for more?
RQ#2: What about your clinical experience matters to you?
There are many elements to consider. While it is true that all residency programs provide excellent emergency training, each program is distinct with unique strengths.
Take a look at the curriculum. How many off-service rotations would you do, and when in your training do they occur? If you are invested in Women’s Health, having more than 1 week of OBGYN will be important. If you are critical-care bound, is there adequate ICU exposure and will you be the senior resident in the ICU? Is there enough longitudinal pediatric exposure for you to see manifestations of illness in any season? If you are planning on working at a community site without orthopedic, ENT, or plastic surgery support, do you have ample opportunity to rotate on these services, spend elective time in specialty clinics, and practice in clinical settings without heavy support from these subspecialties? Likewise, if you foresee yourself doing a fellowship in administration, global health, EMS, wilderness, or sports medicine, is there flexibility to pursue these electives? Are there faculty mentors or recent grads to guide you in projects related to your interests? If a fellowship, a particular work setting, or a career trajectory are important to you, take a look at the recent alumni and ask yourself if they mirror the type of practicing physician you want to be.
Residency is in part about your training, but is more importantly about the patients. Your job is to learn, provide excellent patient care, and advocate when necessary. Ask yourself, what is the patient population like at the hospital? Is it diverse enough for you? Insured or uninsured? Do you see the entire spectrum of ages? Will you have the opportunity to take care of critically ill, stroke, STEMI, and trauma patients and be in a role where you’ll be taking a high level of responsibility? Moreover, is the residency program at just one site or do you have the opportunity to explore different practices patterns within emergency medicine? A breakdown that includes county, academic, and community settings is ideal. The VA, Kaiser, and military hospitals are other potential settings, while a children’s hospital is a must for every EM trainee. The thoughtful inclusion of multiple institutions is something that will pay dividends when you graduate, by not only priming you to adapt to multiple settings but also to inform your future career.
Finally, in a gestalt sense, where would you not need convincing of the excellent clinical experience? Ultimately residency is about becoming the best physician that you can be. Are grads prepared to work in any setting after 3-4 years of training? You only get to be a trainee for a finite period of time, and while we are all life-long learners, you want to graduate feeling prepared to handle anything that comes your way.
RQ #3 – What residency personality did you jive with?
This is the hardest to put into words. Everyone in EM is awesome, right? It might be the most important of the 3RQ, as it is directly related to your happiness and feeling of connection with a group of people. Each program might attract a slightly different personality. Who stands out?
Think back to the socials and mixers throughout the year. Where did you laugh, have the most fun or feel the most “at home” with the residents? Where did you have the most stimulating conversations? How did residents interact with each other? Those people will be your seniors, teachers, and lifelong friends. Culture is perpetuated.
In their free time, do residents seem to enjoy hanging out with each other and do they have the schedule flexibility to do so? Ask about the projects and research that residents and attendings are involved in. Are they excited about it or are they begrudgingly completing a scholarly requirement? Do they leave the type of legacy that you care about? From critical care to social emergency medicine, there is a breath of areas of interest and intellectual pursuits, but particular programs may attract individuals aligned with their areas of excellence, or have the resources to better support certain types of projects.
How about the interview day? What were your conversations about? Did the interviewers take interest in you? The questions you were asked might in part reflect values that the program holds dear, so think back to those conversations that struck a chord. Did the residency leadership seem present and fully committed to the program? Leadership is everything, so be sure the program directors prioritize the residents and are personally invested in each individual’s success.
After the interviews, did you stay for conference or spend time in the ED? Was conference engaging and relevant? Did residents and faculty seem like they value that protected time to learn, or did it strike you as a chore? If there were M&M presentations by residents, did the audience support the speaker or attack their actions? Did the learning objectives seem to challenge and push listeners in a new way? The point here is to identify the culture of education. An intellectually curious group invested in being excellent clinicians is going to propel you into being a great ED doc.
On shift in the ED, how much autonomy do the residents have over their patients? You want more independence than handholding, but the right amount of oversight. Are senior residents pushed to see many patients per hour and are they thinking about flow, or is that left for the attending? In codes or airway management, how often does the attending take over? What about handoffs? Sign-out should not be a dumping ground for unfinished tasks punted to the next provider. Within reason, a good sign out reflects respect for your fellow ED colleague. Also think about how the residents interact with each other on shift, with the nursing staff, and with their attendings. Is there a general sense of camaraderie or is the structure hierarchal?
Finally, and most importantly, how do the residents treat their patients? On one side of the spectrum is shot gunned orders and 30 seconds of face time with no bedside manner. On the other is compassionate and through, yet efficient physician who treats every patient with the utmost respect, addresses all needs, and practices evidence-based medicine. The culture needs to hold patient care and quality of training in the highest esteem.
Every applicant approaches his or her rank list differently. Some kept a running rank list while interviewing, others created a spreadsheet of objective data, and some are going simply off a gut feeling. No matter what your approach, if there is some doubt about the order of your residency programs, ask yourself what is important to you, and use this framework of the 3RQ. If you’ve gotten this far in this blog post, and still feel that this is abstract, consider this strategy: Rate each program out of 10. Use your totals to help you with the final rank list. Rate each of these 3RQ questions out of 3, and then leave the final 1 point for overall “I would be thrilled to open up this envelope on match day.” It will come soon enough. Best of luck and welcome to EM!