For one, you keep hearing that the road to EM has a few different and unique requirements. There’s the part where you answer questions in front of a webcam and the recording is then scored by people you never meet (lucky for you, fellow MSC member Jonathan Brewer has already covered how to excel at the SVI). And then there’s the part where you need to do one, if not more, away rotations. And lastly, there is all this talk about a “SLOE”.
WAIT, WHAT PART OF EMERGENCY MEDICINE IS SLOW?
No, not “SLOW”, ”SLOE!”
Introduced in 1997 by the council of EM residency directors (CORD) as a way to better discern EM applicants, SLOE stands for “Standardized Letter of Evaluation”. Well, at first it was actually called the “Standardized Letter of Recommendation” (SLOR), but the need was generally the same. Inundated by the vast array of positive and often subjective narrative letters of recommendation (NLOR), program directors found it difficult to objectively compare applicants. This was not to say that the SLOR did not have its own downsides (which can be researched elsewhere), but after nearly two decades of refinement, the SLOE was born in 2014.1 The takeaway here is that the SLOE is not simply another effusive, flowery letter that only praises EM applicants, but rather it employs a few different metrics to more objectively compare applicants. Consequently a few different studies suggest it is one of the most, if not the most important part of the EM application.2,3 Understanding these components is useful as you start your EM rotations, because in large part, it will be guide by which most EM programs will grade your rotation.
ALRIGHT, LET'S “SLOE”PEN THIS BAD BOY UP
Unfortunately, the 2018 SLOE is only available through the CORD website to SLOE writers. Nonetheless, I was able to get my hands on the 2015-2016 SLOE, which, for all intents and purposes, shall be our guide as we go through the SLOE. As a reminder, the SLOE is often filled out by the EM clerkship director, department, or other EM faculty member; you will not see your SLOE because you should have waived your right to do so.
First off, the SLOE is broken up into four distinct sections: Background Information, Qualifications for EM, Global Assessment, and Written Comments. For the most part they are pretty straightforward once you have the document open, but let’s take a deeper look.
This section begins by defining the nature of contact between the evaluator and the applicant. One tip here to make things easier on the evaluator is to include what number rotation this is for you when sending out the request in ERAS. Of course, upward trends are better than downward ones, which means if your first rotation was not quite your best, the second is the place to show your improvement! The other parts of this section simply ask the grade received by the applicant which is followed by the percent breakdown of grades received by all students on the rotation in the previous year. As you may discern, these percent breakdowns are to ensure grade inflation is curtailed.
Qualifications for EM
This section is a direct comparison between you and all other EM applicants, broken up into seven qualities. I will not waste your time here with the individual qualities, which can be gleaned through the actual SLOE, but would like to discuss the three options available to evaluate each quality.
In general, the format here is broken down into the following:
● Top ⅓ (Above peers/Outstanding)
● Middle ⅓ (At level of peers/Excellent)
● Lower ⅓ (Below level of peers/Good)
As natural born perfectionists, we would understandably all like to be in the “Top ⅓” category, however given the way the SLOE is formatted, sometimes it is simply not possible. Fortunately, the CORD website offers the following: “Each year the pool of candidates applying to emergency medicine is very competitive. As such, applicants “at the level of peers (middle 1/3)” should be viewed as a positive evaluation and “below the level of peers (lower 1/3)” also describes a candidate who will likely match.”4
Perhaps the most objective section, the “Global Assessment” poses two crucial questions. The first is the applicant recommendation ranking compared to applicants in the previous year. Here, the applicant can be defined as one of the following:
● Top 10%
● Top ⅓
● Middle ⅓
● Lower ⅓
Within this section the evaluator must also define how many of each category designations were given in the last year, again to curtail inflation.
The second question asks where the applicant resides on this institution’s rank list. The aforementioned designations are once again used with the addition of a new category: “Unlikely to be on our rank list”.
The last section is similar to a NLOR in that it is written in narrative format, but specifically prompts three qualities: areas that will require attention, areas of weakness from the SLOE, and relevant non-cognitive attributes. Many EM rotations contain a “comments” section on their shift evaluations. Here is usually where they will come into play.
OKAY, “SLOE” DOWN, WHAT DOES THIS ALL MEAN?
All in all, an understanding of the components of the SLOE is an important part of the framework for doing well on your EM rotations. Because the SLOE is meant to be used to more objectively differentiate EM candidates, it contains language that may be discouraging to some applicants. Nonetheless, the CORD website provides at least some relief through the thick of it all. That being said, as many people will tell you along the way, all you can do is try your best! Good luck!
1. Martin, D. and McNamara, R. (2018). The CORD Standardized Letter of Evaluation: Have We Achieved Perfection or Just a Better Understanding of Our Limitations? Journal of Graduate Medical Education.
2. Breyer, M., Sadosty, A. and Biros, M. (2018). Factors Affecting Candidate Placement on an Emergency Medicine Residency Program's Rank Order List. Western Journal of Emergency Medicine.
3. Love JN, e. (2018). Council of Emergency Medicine Residency Directors' standardized letter of recommendation: the program director's perspective. - PubMed - NCBI.