Navigating Emergency Medicine Without a Home Program

Alexis Moreno-Montes, MSIII
University of Nevada, Reno School of Medicine
EMRA MSC Student Advising Coordinator

The Hidden Challenge

For many students, the path to residency is an easy one. They are likely familiar with the application process for residency from their academic advisor or mentor, they are able to ask their home program’s attending physicians and residents questions about the residency application process, and finally there will probably be someone at their home program who recently participated in the match that they can talk to about their own experiences during the match process. That is not always true for students interested in emergency medicine at institutions without a home EM residency.

I began to realize the way things worked over time. As I went through rotations and had discussions with other colleagues, I began to feel as if I didn’t have the established support system that others experienced. There was no program director down the hallway, or an EM Clerkship Director who has been there before to guide me. The information did exist, but wasn’t given to me.

This experience is more prevalent than you would think. Several new and smaller medical schools, regional schools, and institutions do not house emergency medicine residencies. Students from these schools who realize they want to pursue EM will need to make one thing happen as part of their journey into emergency medicine: self-directed, intentional work on all aspects of the application process.

This is a guide for those students. This is NOT a shortcut, rather, a candid discussion of the difficulties and the skills required when pursuing this type of pathway.

Finding Mentorship Without a Built-In Network

The mentoring aspect of a residency program can be very influential for resident preparation; however, it can also be significantly unequal from institution to institution. Institutions with their own EM programs have abundant mentorship opportunities. Students run into EM residents and attending physicians throughout their day while applying for residency positions and absorbing the knowledge through proximity. Attendings are used to teaching and guiding residents and students. As a result, at institutions without this same type of structure, mentorship has to be actively constructed.

The first step is to find where emergency medicine (EM) physicians practice. It might not be at your academic hospital, but it probably will be somewhere close by. Emergency physicians practice at community hospitals, urgent care centers, affiliate teaching sites, and as part of their job at a trauma center. Some of these physicians are likely interested in mentoring you if you show that you are serious about learning from them. The most important thing to keep in mind when trying to get an EM physician to mentor you is to reach out to them early, and intentionally so, and not to simply ask for a letter of recommendation in September of your application year.

There are organizations that help fill this gap such as the EMRA which was formed to connect emergency medicine residents and their interest groups (EMIG). EMRA has many tools available to students, including an online community, mentorship programs, and student advising resources to help students who do not have support from their "home" program. Conferences, such as the American College of Emergency Physicians (ACEP), provide platforms to meet with EM faculty, residents, and other applicants. These opportunities allow you to make connections that could lead to a mentor, reference, or colleague.

It would help to think intentionally about creating different kinds of mentors; a clinical mentor who has experience with bedside practices, an advising mentor who has experience with the application process and a research mentor if you see academic work as a part of your future. No one individual will be able to do all three roles well and asking someone to will likely create frustration for both parties involved. Building a network as opposed to having only one mentor will allow you to have a more resilient approach to the process.

Being Strategic About Clinical Exposure

Without a home EM residency, clinical exposure in emergency medicine may not come automatically through your school's rotation schedule. That means students often need to seek it out earlier and more deliberately than their peers at other institutions.

If your school has EM elective options available in the first year or two of medical school, take advantage of them. If they do not exist, ask if they would be willing to create one. Many programs will find a way to provide students with the opportunity to explore their interests in emergency medicine whether those opportunities exist formally in the curriculum or not. Informal shadowing shifts in local emergency departments also provides students with a foundation of understanding of the culture and workflow of an emergency department prior to starting their formal rotations. While it may appear unimportant, arriving at an away rotation with a comfort level in an emergency department setting allows you to focus on your performance during the rotation rather than getting accustomed to the environment.

The away rotation deserves special focus. It is also here that we see perhaps the biggest structural disadvantage to date. Students from home EM programs have the opportunity to obtain a SLOE from faculty members who have watched them operate in a familiar environment for years. Typically, along with their home program SLOE, one away rotation will be enough to fill out their application. Unfortunately for students without a home program, this is not an option available to them. As the SLOE must originate from an EM faculty members of a residency program who have seen your clinical skills, most students in this position will require two away rotations to get the letters needed. This is an extra month away from home, in a new city, in a new program where you are starting from zero.

While these additional expenses may seem minor, the financial burden of two away rotations is not small. Away rotations cost money. Housing in a new city (typically during the highest demand months) alone can range anywhere from $1500 to $3000 or more per rotation. When you add transportation, food, applications, etc., plus lost wages from any part-time job, a second away rotation can easily exceed $5000 dollars out of pocket by students without a home program. For students from lower socioeconomic status or students with excessive debt burdens, this is not a minor nuisance. It’s a real roadblock which limits what programs they can afford to apply to and ultimately how many opportunities they can affordably explore.

It's beneficial to name this cost out loud; not to dissuade you from traveling down the path, but to acknowledge that there are genuine costs associated with doing so. Planning such as researching affordable housing options earlier in your academic career, seeking travel scholarships through organizations, and thinking strategically regarding the programs to participate in can significantly decrease the financial burden. However, due to the cost of living, no method exists to completely eliminate the financial burden. Students would do well to take these costs into consideration when they plan their rotations, as opposed to discovering them during the middle of a rotation cycle.

During every clinical experience, the principles are the same: show initiative, ask for procedures, engage actively with the team, and demonstrate that you understand emergency medicine as a collaborative specialty.

Navigating the Application Process Without In-House Guidance

The logistics of applying to emergency medicine can be confusing, even when supported by your institution. In many cases, without that institutional support, the confusion is magnified. What is a SLOE (Structured Letter of Evaluation)? How is it different from a standard letter of recommendation? How many "away" rotations should you complete? And how do you select the "away" rotation sites you will attend? What is the actual time frame in which the applicant timeline begins? These are the types of questions that home-program students typically learn about through a form of osmosis; however, the students at other institutions must seek out these same answers themselves.

Fortunately, the information available to students who are seeking to apply to emergency medicine residency programs has never been as readily available as it is today. EMRA provides application guidelines and advising resources specifically for students who are navigating the application process. Additionally, there are podcasts, such as the EMRA podcast and EM Clerkship, which provide an abundance of information regarding each phase of the application cycle. Many of the residents you will meet during your away rotations have gone through the residency application match process recently. As a result, they may be able to provide you with down-to-earth, practical advice that websites alone cannot convey.

The one resource that you can utilize is the people you meet during your educational journey: specifically, your mentors. Asking a mentor to provide feedback on your personal statement, input on drafts of program-specific responses, or honest feedback regarding your application timeline is not asking for a favor -- it's what they are meant to do. Students that ask their mentors to help them will typically have better written applications than those that attempt to write their own applications without any support from someone who has been in their shoes.

You should also know about the SLOE. The SLOE is the main letter of recommendation used in emergency medicine residency programs and it is created by the faculty at the institutions where you did your away rotations and where you were evaluated clinically. That is why the two-rotation reality I mentioned earlier is not just a scheduling issue, but is a structural requirement for all medical students without a home program. When planning your rotations, keep in mind the quality of the evaluations provided. Smaller cohort sizes, longer shifts, and programs that invest in their students may be able to provide a more meaningful SLOE than high volume rotations where students go through and no one knows anything about them.

Building Your Own Path

It’s worth noting that if you are one of these students, you will develop a unique and useful set of abilities. The ability to proactively network, enter an unfamiliar environment easily, and articulate your strengths to a potential program or mentor without the endorsement of an institution. It is a form of resilience to be able to figure out how to do things independently. All of these are not secondary characteristics to emergency medicine, they’re the very same attributes that the specialty seeks.

Emergency medicine seeks out physicians that can rapidly determine an unfamiliar situation, adjust to the ever-changing circumstances, and operate within an uncertain environment. Students that have developed these same skills through necessity since their second year of medical school are prepared to function in this environment as residents.Students also practice self-advocacy through the process of reaching out cold to an unknown physician to ask for a rotation that was not offered to them, and articulating their ability to begin working immediately after match day. These processes take time to develop and ultimately become comfortable skills. The comfort level that students develop with self-advocacy will remain with them once their match day has concluded.

This is not meant to dissuade one from pursuing a field without a home program. There are certainly students at home programs that have access to a variety of supports, guidance, and opportunities that students at other programs do not. The difference in access is genuine and should be recognized. However, rather than feeling helpless about those differences, we should focus on developing the skills and resources to compensate for those limitations.

Emergency medicine draws those who enjoy ambiguity, those who can navigate in an environment that has not been entirely charted. In many ways, navigating your way into emergency medicine without a home program will be a simulation of the specialty itself. Practicing how to do well under less-than-ideal circumstances and receiving fewer answers.

Students who have success navigating this type of scenario are not the students who had the greatest advantages to begin with. The students who have success navigating through this type of scenario are the students who were candid about what they did not have. The students who were resourceful to obtain what they needed, and the students who were persistent enough to continue down the road even though the route ahead was unclear. Sounds like the blueprint for a good emergency medicine physician.