EM Match Advice: The EM Rotation, ERAS, and Am I Competitive?

EM Match Advice: The EM Rotation, ERAS, and Am I Competitive?


Today launches a series of Google Hangout videos, which was created and expertly facilitated by Dr. Michael Gisondi (@MikeGisondi) from Northwestern. In this series, he recruited an amazing panel of program directors from around the country, who have kindly volunteered their time to share their insights and expertise. In these videos, you get a sense of each panelist’s personalities while they outdo each other with behind-the-scenes advice and stories, which would normally be shared only at the institutional level. Our videocasts are a unique must-see for medical students interested in and applying into Emergency Medicine (EM). Keep a look out for more videos in the future!

The EM Rotation

Dr. Gisondi facilitates a great discussion about the EM clerkship rotation featuring esteemed residency program directors Dr. Lainie Yarris (Oregon Health Sciences University), Dr. Maria Moreira (Denver Health), and Dr. Jan Schoenberger (LAC-USC), with the occasional outburst/question by Dr. Michelle Lin (UCSF-SFGH).


Electronic Residency Application Service (ERAS)

Dr. Gisondi (Northwestern) facilitates a great discussion featuring star residency program directors Dr. Gene Hern (Highland-Alameda), Dr. Laura Hopson (Univ of Michigan), and Dr. Josh Broder (Duke), with an occasional question by Dr. Michelle Lin (UCSF-SFGH).


Mirror Mirror on the Wall: Am I Competitive?

Dr. Gisondi (Northwestern) kicks off a great conversation and debate about knowing how competitive you are, as an applicant. This panel features star residency program directors Dr. Andrew Perron (Maine Medical Center), Dr. Madonna Fernandez (Harbor-UCLA), and Dr. Kevin Biese (UNC Chapel Hill), with comments by Dr. Michelle Lin (UCSF-SFGH).


Watch the other EM Match Advice series videos!

Michelle Lin, MD
ALiEM Editor-in-Chief
Academy Endowed Chair of EM Education
Professor of Clinical Emergency Medicine
University of California, San Francisco
Michelle Lin, MD
Michelle Lin, MD

Latest posts by Michelle Lin, MD (see all)

Michael Gisondi, MD

Michael Gisondi, MD

Associate Professor and Vice Chair of Education
Department of Emergency Medicine
Stanford University
Editor, ALiEM EM Match Advice series
  • Sean Slack

    Thank You, this is really great!!

    • Glad you enjoy these, Sean. Mike’s idea for this video series has gotten lots of great feedback. Makes me wonder why we didn’t do this sooner. Thanks for commenting.

  • SR

    Thanks for the great videos. Any thoughts on whether you need 3 LORs in by the time ERAS opens? I was recommended to submit SLOEs only, and my third SLOE will likely be submitted around mid-October. Will I experience difficulties getting interviews as a result? Thanks.

    • Hi SR: Great question. I sent your question on to others, but here’s my opinion as an advisor–

      I generally recommend that 3 LORs be in by late September (before the Oct 1’s release of the Dean’s letter). This is when the GO sign waves, and all the PD’s and APD’s blaze through the applications. Ideally that is 1 non-SLOE LOR (research, core rotation, project mentor) plus 2 SLOEs. If you have only 1 SLOE by then, I’d look for 2 non-SLOE’s + 1 SLOE. Hope this makes sense.

      Bottom line – have 3 LOR’s ready to go. Add the additional SLOE(s) as they come in.

      Looking forward to hearing what others think.

  • Michael Gisondi

    Hi SR,

    I’m glad you enjoyed the Hangouts.

    I totally agree with Michelle on this one. No matter what a program lists as the “deadline to apply”, the effective deadline for you is October 1st — the day the MSPE is released. Some students will have otherwise complete applications by that date.

    Most programs require at least 3 LORs to have a complete application. Some of these programs will require a minimum of one SLOE, some will require 2 SLOEs. I’m not aware of any programs that have an absolute requirement for 3 or 4 SLOEs.

    My preference is at least one SLOE from every EM clerkship in the MS4 year — and preferably a “Department SLOE”, when available. Most students only do 1 or 2 EM rotations as an MS4, so I really only expect to see that many SLOEs. The third letter can be from any clinical service attending or research mentor that knows you well.

    In sum, my advice is 3 LORs uploaded in ERAS by September 30th, at least one of which is a SLOE.

    Best of luck!

    • SR

      Thanks for the great advice. In emphasizing the SLOE, it somehow never came up that I should still have 3 LORs in by October 1. Luckily, I still have time to get another LOR. Glad this video series came out this week, otherwise I would have been in some major trouble. Thanks again.

  • Scott

    Hi Dr. Lin… I am applying this year as a non-tradional applicant, being a DO and a flight surgeon in the US Navy having graduated from medical school in 2010. I was wondering if you had any recommendations/advice for those of us in these non-traditional situations, specifically in terms of our letters of recommendation and focus on post-medical school experience? Thanks for the great videos… VERY helpful!

    • Hi Scott: Great question. I’m not an expert on advising DO’s since there’s a unique set of issues to deal with (taking the USMLE’s in addition to your COMLEX so that PD’s can compare apples-to-apples, knowing which programs are DO-friendly and unfriendly– sorry no such list exists). You probably already know this but here’s a list of the DO-residency programs in EM:


      I would poll more people to get their advice on this. I’ll send out emails to my DO colleagues to see if they have advice here in this blog. I’m assuming you are not planning on doing any clinical rotations this academic year, and so you won’t have a recent SLOE? Hopefully you have kept in contact with an EM person to get a SLOE recommendation letter — these are key. The down side is it won’t be recent, but hopefully your active service as a flight surgeon makes up for it. Hard to say how differently PD’s will take that — as a plus or minus.

      Hope that helps a bit. Best of luck!

    • Michael Gisondi


      You are definitely in an uncommon situation — a very small percentage of our applicants are returning from military service obligations and most are allopathic graduates.

      In general, graduates from osteopathic and international medical schools tend to be more successful in the match when they have portions of their application that are the same as those of US allopathic seniors — the same boards (e.g., USMLE rather than only COMLEX), the same letters of recommendation (e.g., SLOEs from clerkship rotations at institutions that sponsor an allopathic EM residency program), etc. This allows the “apples to apples” comparison by allopathic EM program directors, as Dr. Lin points out. You may not be able to control those parts of your application while fulfilling your military service, however, and the program directors will understand this. For instance, I would not expect to see a SLOE from someone still in active duty — how would you get a SLOE while working at a military hospital abroad?… obviously you can’t, so hopefully the selection committees will take that into consideration.

      Your military service will be a great equalizer though. While only a small percentage of our applicants are returning from active duty, we are still familiar enough with service obligations to know what unique skill sets you bring to the table. Some of your letters of recommendation can/should be written by supervisors who are able to describe your strengths and work ethic, as demonstrated in your current role. The personal statement is also an important opportunity for you to highlight the work you have accomplished and the lessons learned.

      Thank you for your service to our country. I hope that it brings you success in the match.


  • Stefan

    Dear Dr. Lin and Dr. Gisondi,

    Thank you very much for your efforts providing a very honest and pertinent information source for medical students planning to become an emergency physician. I enjoyed all of your hangout-sessions.

    At this point I would like to ask, since I know how important clinical clerkships are as regards the applying for a residency program – could you provide any information where to go as an international medical student? It is quite hard to find any universities that offer clerkships for non-US students, most of them even explicitly exclude them from their clerkship programs.

    Thus I hope you could give any tips where to apply und I am looking
    forward to your reply, thanks again.

    • Hi Stefan: Yes, it indeed is tough to find out such information. If you do a quick google, I found this: http://electives.us/unilistims.html

      Not sure how current it is, but it’ll be worth looking at individual institutions. You might also look at the more official resource, posted by the AAMC at: https://services.aamc.org/eec/students/

      Best of luck!

    • Michael Gisondi


      In her response, Dr. Lin offers great resources to start the process of finding a US allopathic school for a visiting clerkship. I know that the emphasis we placed on this as important strategy is easier said than done. I’m surprised that there are not more resources available for international students interested in US rotations.

      My institution is one of those schools that limits access to student rotations to a short list of global partners: http://www.feinberg.northwestern.edu/education/visiting-students/global-partners.html

      Perhaps your dean can offer a list of US schools that participate in similar partnerships with your school?

      Good luck,
      Mike Gisondi

  • West Coaster

    Thanks for these videos, they are SUPER helpful! I have a unique situation though, and though you addressed it in your “red flag” portion of the “Mirror Mirror” video, I just wanted to hear any advice you might have specific to my situation.

    To make a long story short, I carried over some really poor study techniques from undergraduate studies into medical school (I attend an MD school on the west coast). I had never really struggled in school, so I wasn’t really aware anything need changing. I ended up failing two classes in 2nd year by a few points, and was required to repeat. I made major changes, figured out what works, then have done really well ever since. I went on strong into clinical rotations, honoring several, including my EM rotation. I also did well enough in a second year class, I tutored new 2nd year students during my 3rd year. I also was able to pass Step 1 and Step 2 on my first try without any difficulty. I have several other extra-curricular activities, including leadership and a short story I published in a compilation.

    My goal is to be an excellent EM physician, not to get my first choice residency, so without sounding too desperate, I’ll go anywhere. I’m hoping that my experience will be seen a positive reflection of character rather than display a risky applicant. I have considered other specialties, but nothing compares to the experiences I’ve had in the ED, good or bad. Now, I have been told by several advisors to “apply broadly.” How many programs should I be aiming for so that I am applying broadly? And do I have a chance of matching somewhere? Thanks for any advice, and again for the fantastic videos!

    • Interesting question. So many factors to weigh in-

      1. Quality of your Dean’s letter explaining your 2nd year hiccup as eloquently as you just did. Quality of your personal statement explaining this also. Quality of at least one of your letters explaining this. What is important is a consistent and strong message.

      2. Your performance on your EM audition rotation(s).

      It’s great that honored some of your core 3rd year rotations and your home EM rotation. That’ll go a long way. Hard to say how much program directors individually will respond to more “risky” applicants, despite all the other supporting factors. Honestly if you were to look at this from the PD perspective, if I found two exactly equal applicants with one red flag vs zero red flags, it would make sense to go with the safer choice on paper. So with that in mind, I would indeed apply broadly. Assuming you get honors in your 2nd EM rotation and great letters, I would recommend start thinking with 30 applications, adding 15 for the 2nd year hiccup, and then subtract about 10 for all the great things you’ve accomplished thus far. That’d be about 35 programs to apply to. You can always overapply and then cancel interviews once they start rolling in. You’ll want to interview and rank at least 13-15 programs.

      Caveat – this is just by gestalt sense talking. Definitely get more opinions. My crystal ball is not perfect. Good luck, and thanks for sharing your story. It’s tough to deal with, but I’m sure you can conquer this speed bump in what I’m sure will be an amazing career in EM.

      • West Coaster

        Thank you for the thoughtful insight, it is very helpful! I will try to apply to slightly more programs than the average I’m hearing, just to be on the safe side. In the mean time I’ll keep working hard and do my best to ensure I am getting all I can out of my EM rotations. Thanks again!

    • Michael Gisondi

      West Coaster,

      Dr. Lin is spot-on in recommending that your challenges in the MSII year need to be addressed by you (personal statement), your dean (mspe), and most importantly by your EM advisors in their SLOEs. You would do well to have EM clerkship and/or residency leadership at your school help your application by offering a similar perspective on your abilities as to what you will describe in your personal statement.

      I’m going to disagree with Dr. Lin in numbers of applications. When your advisor says “apply broadly” that is code for “send out at least twice as many applications as everyone else – and avoid major cities like LA, SF, Chicago, NY and Boston.” You need to be as conservative as possible right now.

      It’s clear that EM is your passion and I applaud you for going after your best fit specialty. That being said, if you had to repeat a year of medical school you need to be very thoughtful about the process: solicit lots of opinions from EM advisors, apply broadly as defined above, and have a realistic back-up plan for this match cycle in case it doesn’t go your way this year.

      Best of luck,

  • RG

    Thank you so much for these wonderful videos and insight! I’m wondering whether it makes a difference if we have 3 vs 4 letters? I currently have 2 SLOEs and 1 LOR; I think all are pretty good. I’m debating if I should get a fourth letter or not.

    • 3 letters are sufficient, although I must say that I’ve seen a 4-letter set as the more common package. If you have great 3 letters, that should be fine. It’s diminishing returns with a fourth.

      That being said, if it’s a great SLOE from a different site, or a letter from a completely different facet of your med school training years (e.g. mentor on a longitudinal project/ research >1 yr), you might considering adding a fourth. You want as many references from very different perspectives. Just having a core letter writer from 3rd yr rotations won’t matter as much. Good luck.

      • RG

        Thank you for the advice!

    • Michael Gisondi


      Three LORs (especially with two SLOEs) makes a complete application in my mind. If your two SLOEs are from different institutions, even better.

      Remember, we PDs will want to see a grade and SLOE from each EM clerkship before we rank you – even if that means a fourth letter coming to us later in the season.

      Have your three LORs uploaded in ERAS by Sept 30th if you are able.

      Have fun on the interview trail!

  • HR

    Thank you for supplying such great advice. We all really appreciate the help during this (somewhat stressful!) time.

    I have a follow-up question to some of the SLOE / letter of recommendation questions already asked. I’m coming from a somewhat unusual 4 year MD/MPH program. Due to some complexities with my schedule, I wasn’t able to schedule externships to start until late September. This means that, although I have a non-SLOE letter of recommendation from my EM Clerkship Director at my home institution (which doesn’t have an ER residency and therefore he was unable to do a SLOE), I won’t have any SLOEs available until near the end of October. My current plan is to upload my three non-SLOE letters of recommendation — two from non-EM physicians who I worked closely with during my third year, and one from my EM Clerkship Director — next week, and then add in my SLOE from my first externship as soon as it is available. I believe I will also be able to get a SLOE from my second externship, but it won’t be complete until mid-November and I wouldn’t actually be able to upload it to ERAS as a fifth letter, of course.

    Do you think I’ll still be able to receive some interview invitations despite my lack of SLOEs initially, as long as the rest of my application is strong?

    Thank you in advance for your advice!

    • I think the application readers will be able to tell pretty quickly about your situation — that you have a home EM rotation letter (which happens to be not in SLOE form). Assuming a still otherwise strong application, I think you should be fine. Regardless, there’s really nothing you can do about it anyway. I’d have your application into ERAS with the 3 non-SLOE letters by Oct 1. Then upload the SLOE(s) s they come in. You can remind the programs that there’s a new SLOE when you go to their interviews.

      • HR

        Thank you very much for your advice! That sounds like a solid plan, and I will definitely put it into action.

        Take care.

  • Anon

    Hi, Any advice on scheduling interviews for someone applying as a couple? I have a situation where I am applying in EM and I was advised by my home school advisors that if I was applying on my own I wouldn’t need to apply to more than 10-15 programs. However, my significant other is a bit of a shakier applicant for various reasons. To give us the best shot at couples matching, I feel like I should be applying to 40+ programs to open up more geographies/programs for my SO to get interviews in case she doesn’t get interviews at places near my top 10 or 15. The part that scares me about his approach is considering what I will do if I suddenly have 25 or 30 interview invites. The interviews that are most important to me are those that have programs nearby that will give interviews to my SO, but if programs are slow giving her an interview, I may not know this info and from what I hear you have to schedule interviews immediately. I may be just counting my chickens before they hatch, but if I were to get a lot of interviews, and its was unclear where my SO was going to get her interviews still, what is my strategy? How do I triage? – Thanks for any help!

    • Tough call. These scenarios are so case-by-case that it’s hard for me to weigh in. Would go with your gut instinct. Wish I could be of more help. Just remember that you can cancel up to within 2 weeks of interviews, if needed — that’s generally accepted as ok etiquette.

  • BG

    How about detailed advice for IMGs? More specifically, Caribbean medical school students who are extremely interested and dedicated to EM? Could someone discuss the factors regarding their competitiveness?

    • Sorry not really my area of expertise beyond the fact that is increasingly difficult for IMGs to match in EM annually. You might look at previous year’s match trends and look at programs who have matched IMG applicants. Good luck.

  • PA

    In regards to competitiveness, how much does prior experience in emergency medicine and related fields count for? I am an osteopathic medical student on the eastern side of the country. Prior to entering medical school, I practiced as a physician assistant in a rural Pennsylvania emergency department, and prior to that, I was a paramedic. I am still heavily involved in EMS as a pre-hospital physician assistant. Do programs look favorably on prior experience?

    • Great question. I think it’s on more positive data point on your application, although in my opinion, it’s a very minor positive point. It probably won’t be the vote-swinger. I think most programs have had really great and really poor experiences with applicants with previous medical-related careers, based on anecdotes I’ve heard – in the end, it’ll depend on the rest of your application package. Good luck!

    • Michael Gisondi


      While you probably will be somewhat ahead of your peers on day 1 of internship because of your past clinical experience, it is not such an advantage to the program that they will favor that credential over everything else. All other things being equal, perhaps. Your experiences should serve you well during interviews though, as faculty may ask you several questions along the line of “give me an example of a patient interaction that…” Previous healthcare experience will come in handy with those interview questions, if not in the larger match process too. Good luck!


  • Guest

    Another big thanks for these videos. I’m an applicant (US allopathic senior) this year and things haven’t quite panned out. My question is if an applicant doesn’t match this cycle, what are some ways they could spend their time next year that might help their re-application from a PD’s perspective? Unfortunately I did not have a back up plan such as applying to prelim or transitional yr prgms from the start–my advisor thought my metrics were competitive, with no red flags that I know of… but without a home program it’s difficult to get inside feedback on my application in its entirety. Applied to 30 programs at first and received 2 invites from those (declinations from many including the only ones I have regional ties to), and then applied to 55 total with a total of 5 invites now (Dec 4). This is why I think my prospects are grim! Thanks again for your time. I’ll be sure to update this post with my match outcome.

    • Sorry to hear about your experiences thus far this year. As depressing as it may be, I think it’s wise to think of a backup plan now. As for your interim-year plans, I’d recommend something longitudinal rather than smaller 1-3 mo projects. Ideally if you can get into a program with a graduate degree, that’d be a bonus! … or a 1-year research fellowship at an institution with an EM residency program. Then next year, I’d have someone look over your application again. I share your frustration about not knowing why things turned out the way they did. Good luck.

    • Michael Gisondi

      I echo Michelle’s sentiment of frustration. This can be a very unpredictable process and I am sorry to hear of the added stress for you during this process. It is really difficult to do any one thing that makes you that much more competitive. I like the idea of a graduate degree program, but make sure it is something you authentically want and it is of practical use in your career. You will be trading away a year of patient contact, so make sure that the degree is relevant. Prelim years keep your skills up and offer lots of educational opportunity, however they don’t make you more competitive than the superstars of next year. Should you need choose to interview at a few, pick places (1) that are at an institution with an EM residency that is not ultra-competitive (2) that offer an EM month or elective month that can be scheduled in the first month or two, such that you can demonstrate your skills to the local program and get another recent SLOE. There are lots of institutions that meet those criteria, you just need to do your homework before choosing where to interview or SOAP to.

      Michelle and I briefly discussed another installment in late February on the topic, “What do I do if I don’t match and want to reapply to EM?” Students, is there interest for this, or would it only add to the stress?

      • CY

        Dr. Lin and Dr. Gisondi,

        This may be late, but I think a video on “what to do if you don’t match and want to reapply to EM” would be very helpful. I for one, would love to hear what you all have to say. As someone who didn’t match last year, had no backup plan, and no EM residency program/advisor at my home institution, I remember scouring the web looking for answers during the weeks after match day, calling anyone I thought could help.

        After not matching, some of the big questions I had were:
        1. Where do I stand now?? I understand this will be different on a case by case basis but is there a % match rate for REAPPLICANTS to EM? Or more generally, are the chances of matching into EM as a reapplicant: decent, low, unlikely, dismal?
        2. What, if anything, can I do between April to September (when the next ERAS applications due), to bolster my application/CV and improve my chances of matching next year?
        3. What’s the best way to spend the off year, Prelim IM/Surgery vs. research vs. getting another degree (MBA, MPH, etc)? Is one of these viewed more favorably than the others? A side question to this is about doing a prelim year. Occasionally, I would hear that doing a prelim year and reapplying was a bad idea, because it eats up 1 year of our GME funding. Is this true?
        3. How are EM reapplicants viewed by programs in general? Do programs filter you out because you’re a reapplicant? Are reapplicants separated out to be reviewed after the main pool of US allopathic 4th years?

        Just wanted to share some of the thoughts I had during that crazy time. And
        thank you so much for these videos! They’ve been enlightening and very helpful.

        • Great questions and tough scenario. There is no simple answer. The best way is to find a local advisor who knows your case and advise from there. A video is too generic to meet your needs.

        • Taku Taira

          I would like to add my 2 cents on this one.
          – I have never the opportunity to assist a student who did not match so have no first hand knowledge of the scramble or now the SOAP. Having said that, if you think that you might not match it is important that you are already in contact with your dean of student affairs. That person and their office will have the most knowledge and experience with non-matching students. They generally will work with an EM person to assist with the scramble.

          – With regards to the your % question… this is truly a case by case situation. I have seen applicants that I am sure will never match in EM, then there are those who have a single flaw who have a legitimate chance, and others who applied poorly.

          – Which brings me to your next question what to do. I think that this starts with an honest appraisal by someone who is willing to give you (brutally) honest feedback about your application. 1: Is it feasible with your record to match into EM 2: What is the major thing that is holding you back from matching in EM… this second question is almost as important as the first one. I review and interview people in your situation on a yearly basis. The time you spend in-between should focus on what is holding you back…

          – If it was your step scores then take step 3 and put your heart and soul into it

          – if it was your performance on your EM rotation first find out what your deficit was, work on it then find another one

          – Where you a late convert and there is a question about your commitment… then do some more EM specific things.

          – The answer is rarely do more research… the lack of research is rarely what holds applicants back. For most of us it is a longitudinal commitment to research and accomplishments in research that catch our attention. We are usually acutely aware of research for the purposes of padding your CV. HOwever if you defer graduation and take time off to do a year of research in something you really care about. (bench, public health, advocacy) or some outreach/volunteer then you are talking about somethign that can substantially improve your application.

          – With regards to what to do in your next academic year. I am not sure that any specific sepcialty/transitional year is going to substantially change your application… Whatever you do try to enter somewhere where you can do rotations in the ED early on, ideally somewhere with an EM residency. I would be proactive about gaining more EM experience as an intern and the oh so important SLOE. Contact the department early about your interests and be take advantage of any opportunity to be involved. Even if that means volunteering, scribing, etc.

          – Most places will initially look at your application on its own merits. When it comes down to brass tacks, there are some places that will not take you/rank you because of GME funding. ie. you go into IM you have GME funding for 3 years. You then transfer to EM after your 1st year. You now have only 2 years of funding to cover you for the 3 years and the GME office has to eat that… now it becomes an institutionally dependent question and less about the program at that point. I have had a resident who completed an entire residency and another who switched after a year.

          – Now the thing that you may not know about is that there are positions that open up throughout the academic year. Every once in a while a PGY1 or 2 spot opens up. The only way to really stay on top of this is to be in contact with someone who is on the CORD list-serve… it seems like that is the first place where is comes up. SO stay in touch with you med-school advisor and make sure they know that you are still looking.

          Hope this helps

          • CY

            Thank you for taking the time to answer and explain all my questions. It helps a ton!

  • Roadrunner

    In your EM Rotation video you discuss Honors vs. High Pass. How do PDs view a mere Pass?

    • Michael Gisondi

      Good question — with a less than straight-forward answer. How does “it depends” sound? The grade is important, but only in the context of the grade distribution of your school. For instance, if 40% of students receive Honors and 50% receive High Pass, then a Pass would be a concerning grade. Conversely, schools who only give 10% Honors and 20% HP do their students with a Pass a great service — obviously many great future emergency physicians will post only a Pass at that school.

      Hope that helps. And good luck!

  • Kira

    Thanks for the phenomenal videos! MS3 here from a DO school that offers no clinical advising. You mentioned SAEM offering e-advising, but I’m struggling to find this anywhere (I’m also not currently a member?). Any other resources for finding an advisor?