Authors: Liza Smith, MD; Emily Hillman, MD; Jamie Hess, MD; Seth Kelly, MD; Katelyn Harris, MD; Alexis Pelletier-Bui, MD; and Adam Kellogg, MD on behalf of the CORD Advising Students Committee in EM (ASC-EM)

This applying guide is intended for students interested in applying to emergency medicine (EM) but who have had academic struggles, professionalism concerns, or other potential red flags that may affect their ability to match. A printable version of this guide can be found here.

General Overview
Each year there are more applicants for emergency medicine (EM) residency training than available positions. Predicting which applicants are unlikely to find a match is an ongoing challenge in EM advising. The at-risk applicant is one who, for a variety of reasons, may fall into the less competitive end of the applicant pool and may not be able to have a successful match in EM. This concern is often due to a red flag in his/her application. When the term “red flag” is used in medicine, it indicates a warning sign suggesting more serious pathology, such as the red flags for spinal cord compression in back pain. This terminology has been adopted by application reviewers to refer to signs in an application that raise concerns about an applicant.

Knowing if you are an applicant who will raise red flags in the mind of a program director (PD) is really important for planning your application strategy. If you do have one or more of these warning signs, you are at risk of not matching in EM. You will need to do everything you can to minimize the impact on your application and be proactive about considering a non-EM backup application strategy. Finding an EM position after an unsuccessful match is very unlikely. The best alternative training opportunities, including those that allow for re-application to EM, are going to be those planned in advance of the match with a parallel application to another specialty.

“Red flags” tend to fall into one of three categories: academic struggles, professionalism concerns, and unexplained gaps in the CV. These are not all weighted equally, but any one of them can negatively impact your chance of matching.

Academic Struggles

1. Failure of the USMLE or COMLEX exam
Residency programs are evaluated on the rate at which their graduates pass the boards when they finish residency. It has been demonstrated for many specialties, including EM, that not passing the USMLE or COMLEX is a strong predictor of struggling to pass later exams.(1,2) This correlation leads program directors to worry about applicants who struggle on these types of knowledge assessments. In a survey of EM education faculty conducted by this committee, approximately half of programs will not consider an applicant who failed USMLE step 1, however almost all do consider applicants with below average scores.(3)

What to do? If you have failed a portion of the USMLE or COMLEX, it is critical to retake and pass as soon as possible. These marathon testing scenarios are challenging. In addition to continuing to bolster your knowledge base, taking a course in test-taking strategy can be extremely helpful for many students. In addition, students who perform poorly on or fail USMLE Step 1 should plan to take Step 2 CK early in order to have scores available when submitting the ERAS application in mid-September. An improved performance on Step 2, even just raising your score to average, will reassure programs and increase the likelihood of an interview.3 Failing USMLE Step 1 almost always warrants a nonEM backup plan, though below average scores do not. Because USMLE scores are often used as a filter for programs when reviewing applications, students with below average scores will need to be strategic in selecting programs that are less likely to screen out their applications based on this factor alone (see Figure 1).

2. Failure of a preclinical course or repeating a preclinical year
Failing a pre-clinical course or repeating a year of study typically indicates a struggle with accumulating a strong knowledge base and translating it into testing scenarios. Approximately 70 percent of programs will ‘rarely or never’ (<3 applicants/year) interview an applicant with a preclinical course failure on their transcript or MSPE.(3) However, the impact of a successfully remediated course that does not appear as a failure on the final transcript is less clear.

What to do? Successfully retaking a course is absolutely necessary to mitigate any concerns. If a failing grade will remain on the transcript, a non-EM backup plan must be considered.

3. Failure of a clerkship
Failing a clerkship or other clinical experience is even more worrisome than failing a preclinical course. These can be deal breakers to a program director due to concerns over potential professionalism issues. Nearly all programs reported ‘rarely or never’ interviewing applicants with a clinical course failure.(3,4) Again, the impact is less clear for a remediated course that no longer appears as a failure on a transcript or MSPE.
What to do? In addition to successfully repeating the clerkship, the circumstances around the failure need to be explained in the personal statement and/or MSPE and a non-EM backup plan should be pursued.

4. Negative feedback on the Medical Student Performance Evaluation (MSPE; Dean’s Letter)
The MSPE usually includes feedback given on your clerkship evaluations and occasionally can include constructive feedback that paints the applicant in a negative light, such as lack of interest, multiple absences or consistent tardiness, not paying attention, etc. When such constructive feedback is present in the MSPE, it is a source of concern for programs.
What to do? It is important to fully review your MSPE so you can address it in your personal statement and take ownership of any potentially negative feedback. The impact of the presence of negative feedback on your application varies by the situation and your ability to explain it. If negative comments are associated with a failed or repeated clerkship, a non-EM backup plan should be strongly considered.

Professionalism Concerns

1. Academic Misconduct

Academic dishonesty speaks to the character of the applicant and raises concerns about how the applicant will meet the legal, ethical, and professional obligations of a physician. All programs report ‘rarely or never’ interviewing candidates with a history of academic misconduct.3
What to do? If you have been involved in proceedings related to academic misconduct during your medical school tenure but are still on track to graduate, you must have convinced your school that there was a misunderstanding or that you have been rehabilitated. You can certainly try to restate your case for application reviewers in your personal statement, but in a specialty as competitive as EM, it is unlikely you will be offered enough interviews to match. If you move forward with applying to EM, a non-EM backup strategy must also be pursued.

2. Misdemeanor or felony history

There are two types of people in the world: those who learn from their mistakes and those who don’t. For instance, if your response is to blame others, make excuses, and continue to make the same mistakes, your past is likely to drag your application down. Approximately 70 percent of programs ‘rarely or never’ interview candidates with legal trouble on their record, such as DUI or drug possession.(3)
What to do? Take some time to truly reflect on your experience, identify how you could have handled the situation in a differently, and be able to articulate what you learned from it. ERAS has a text box where applicants provide narrative comments regarding a misdemeanor or felony. If you accept responsibility, take ownership of your mistakes, and can demonstrate making conscious changes for the better, some program directors may look past this blemish. A non-EM backup plan should be considered.

3. Unexplained gaps in your CV

If you have taken time off during medical school or if there are long periods of time unaccounted for on your CV, these gaps need to be addressed in your application. PDs may become concerned if an applicant demonstrates a history of not being able to complete a curriculum or course requirements in the usual time provided. Approximately 75 percent of programs ‘rarely or never’ interview candidates with unexplained gaps in their CV. (3)
What to do? There can be good reasons these gaps happen, and you are best off explaining up front in your personal statement or MSPE. Do not rely on the hope that they go unnoticed or that you can get away without explanation. If you leave these gaps to the imaginations of applicant reviewers, they will assume academic struggle or a professionalism issue.

The Best Defense is a Good Offense

In 2016, the AAMC recommended a new format of the MSPE with the goal of offering a more accurate and objective summary of student performance. The new format more directly compares your performance with your peers and highlights adverse parts of your application, such as professionalism deficiencies. For more information, visit this website.

Most advisors recommend addressing red flags in your personal statement. This is the first place that someone reviewing your application is going to look for an explanation. If they do not find one, there is little incentive for them to go any further in considering you for an interview.

You should explain mitigating circumstances that led to your failure of a USMLE or COMLEX exam, or failure of a clerkship, but be careful not to make excuses. In other words: Take responsibility for what happened. Describe the steps you have taken to remedy the issue and how you emerged from these challenges better prepared for a career in EM.

Have an advisor review your personal statement and give feedback. They should be a useful resource with insight on how your explanation will be interpreted. Things happen, life is complicated, and reviewers can understand this—if you give them the chance.

Applicants need to recognize the limitations of any of these strategies for managing red flags. Every effort should be made to explain the circumstances to better inform the application reviewer. However, many times the application will not be reviewed because of the use of ERAS filters by programs. The table below shows the results of a survey of EM residency program directors on the use of filters. (4)

Resources such as EMRA Match can be helpful in determining which programs are likely to use some of these filters. Looking for programs that report considering applicants with Step 1 failures or that acknowledge using certain Step 1 cutoffs can help an applicant target his/her applications to programs that are more likely to fully consider their application. For other red flags, it is hard to predict how programs will react. These applicants are best served with a broader application strategy and early, proactive discussions with their advisor about a non-EM backup plan.

Key Points

1. What does it mean to have red flags in your application?
“Red flags” refer to signs in an application that raise concerns about an applicant. They tend to fall into three categories:

• Academic struggle (such as failing the USMLE or repeating a preclinical course or year)
• Professionalism concerns (such as academic misconduct or having a misdemeanor/felony history)
• Unexplained gaps on your CV

2. How should I address a red flag?
It may be tempting to hope it will go unnoticed by all of the experienced reviewers who will be looking at your application. In almost all cases, it is a good idea to use your personal statement as a vehicle to address any red flag by explaining what you have learned and how you have grown from the associated experience. Early, proactive discussions with an advisor familiar with EM residency applications and having a non-EM parallel plan or backup plan is invariably a good idea. The need for a backup/parallel planning depends on the red flag present and on how effectively it can be addressed and mitigated. Using resources such as EMRA Match can help an applicant be strategic about targeting programs that are more likely to be open to considering their application.

References

1. Caffery T, Jones G, Musso M. Predicting Initial ABEM Board Passage Rates Using USMLE Scores. West J Emerg Med. 2016;17(4.1).
2. Harmouche E, Goyal N, Pinawin A, Nagarwala J, Bhat R. USMLE Scores Predict Success in ABEM Initial Certification: A Multicenter Study. West J Emerg Med. 2017 Apr;18(3):544-549
3. 3. Council of Emergency Medicine Residency Directors Advising Students Committee in Emergency Medicine. (2018). [CORD ASC-EM Advising Addenda Study]. Unpublished raw data.
4. 4. Jarou Z, Kellogg A. Diagnosing the Match: Trends in the Applicant Selection Process. EM Resident. 2018. (Accessed May 25, 2018 at https://www.emra.org/emresident/article/diagnosing-the-match-trends-in-theapplicant-selection-process/)