The First Pulse Check: How to set yourself up for success in EM residency

“Are you ok?” My wife asked as I flopped onto the bed, which was still just a mattress on the floor. I (KL) had just finished my first shift as a resident and was overwhelmed. We still had furniture to buy, boxes to unpack, and countless things to repair. The house we were so excited to move into had not lived up to our expectations when we saw it for the first time in person. Despite all the housework we had to do, I felt paralyzed by the incompetence I felt on my first shift. The mountain between myself and some semblance of a doctor seemed insurmountable. I had been told about 15 different resources by 15 different residents since Match Day and had no idea how to start learning. Plus, my wife and I had just moved 1,000 miles away to a place where we had no community and no family.

Depending on where you match, you may be dealing with some, all, or even more challenges and issues as those described above. While nothing can fully prepare you for your first day of residency, consider us your big brothers/sister who can share tips and tricks that we have learned, heard, and gleaned along the way.

Preparing for residency requires a lot more than just brushing up on Tintinalli’s. Some medical knowledge is a pre-requisite, but it is by no means enough to help you make it through residency with your personality, relationships, and your soul in one piece. You can start preparing mentally, personally, and interpersonally for what will likely be one of the hardest (and best) jobs of your life.

This guide, while not comprehensive, hopes to spark your thinking about major points you should consider between Match Day and your first shift as a doctor.

First things first… Celebrate!

You made it! Regardless of where on your list you landed, you are on your way to learning and honing your craft. It is now time to start taking care of real patients who are going to call YOU doctor. While some things on this list need to be started soon after Match Day, don’t forget to slow down and smell the roses- make sure those trips or family visits are planned and reflect on your current journey and next steps forward.

Prepare to Move

While the academic year begins on or around July 1st, it’s important to note that you will have responsibilities as early as late May with your residency program. All programs will have at least one week of orientation prior to July 1. If you are planning a big trip or vacation, then make sure you know when you are expected to be on campus. Give yourself 3-4 weeks prior to your orientation start date to move so that you will have time to get unpacked, explore the area, and, most importantly, meet and bond with your new co-residents before you get busy and disperse around the hospital.

Prepare a New Place to Live

Should you rent or buy?

While all of us are in different financial and family situations, perhaps the most important thing to consider when answering this question is: What are your plans after residency? Most financial planners will tell you that you should own a home for at least 5 years for the value increase to offset things like closing and realtor costs [1]. This is important given EM residencies are all 3 or 4 years.

Questions to ask yourself include:

• Am I planning on fellowship?
• Is it a competitive fellowship, or a fellowship not offered by my program?
• Is this somewhere I want to live after residency AND a place with a reasonable job market?

If you feel confident that you will be in a location for the long run, then buying a home might be the right decision for you. If you plan to buy, then finding a realtor should be one of the first things on your list. Purchasing a house is a very lengthy process, on average around 44 days [2], so you should be prepared to sign a contract within a month or so of Match Day. Keep in mind, you can also use a realtor to help with renting, often at no cost to you, but they won’t always be as quick or responsive as with clients looking to buy, as their financial return is much lower than for purchasers.

Another thing you can do is ask graduating residents about homes or apartments to rent as they move out, which may make the transition and finding a vetted location easier.

Pro tip: If your significant other works from home or will spend a lot of time at home, save both of your sanities and ensure you have enough space so you can sleep after a night shift while they work.

Prepare Your Finances

Congratulations! You’re about to be RICH (er). While it’s true that MAKING money is a lot better than PAYING money to be in the hospital, there are some worthwhile financial questions to consider prior to starting residency. Most importantly, make sure you have a plan for how you are managing your loans. While the loan landscape is constantly shifting, the AAMC provides a good starting point to think through your options [3].

Additionally, keep in mind how many expenses are associated with moving and starting residency. Depending on your contract, you will potentially be responsible for two rents while in limbo, a security deposit, applying for your medical license, in addition to the usual living expenses. Just because your orientation starts in June, you should not anticipate receiving your first paycheck in June. Often orientation pay is included in your first paycheck of the academic year and may not come until mid or late July. Also, in order to make a budget and understand what you can afford, you will need to know how much of your income will be taken out in taxes and benefits before it hits your bank account.

Now is a great time to level up your adulting and your budgeting skills. There are plenty of budgeting apps available [4]. Honeydue, is a favorite for author KL.

Prepare to Get Plugged into Your New Community

Undoubtedly one of the things you considered when you made your rank list was the location you would be traveling to and the things you could do there. Whether you find yourself in the Smoky Mountains, Miami Beach, or downtown New York City, you’ve chosen a place that will allow you to pursue new or old hobbies. Make a list of hobbies and activities that have helped you de-stress in medical school and learn how they can best be applied to your new area so that you have a prepared plan to unwind before the stress even hits.

Early on is a good time to also get plugged in with medical and community services that you might need. Waiting to try to find a primary care physician (PCP) when you are about to run out of your daily prescriptions, or when you have an acute medical need, is not a good idea. Find one and have a visit early, so that you can make sure you have access to someone who can refill your medications, see you when you are sick, or place referrals when you need them. Doctors are notoriously bad patients. Don’t let that be you. Follow the advice you will find yourself doling out almost every shift, and get plugged in with a PCP.

Your needs and interests will vary, but a good starter list of services and communities you may want to explore and get plugged in with include:

• PCP (this can take several months, so get started early) [5]
• Therapist
• Dentist/orthodontist for you and any family members
• Gym
• Coffee shop
• Church or other religious
• Community or activity group, such as hiking or running groups

Prepare Your Friends and Family

You’ve worked hard in med school, but as much as we hate to say it, residency is when things actually start to get tough. It’s important to let your family, non-medical friends, or significant other know what to expect. For example, walk through your schedule with your significant other so that they know when you will be in the hospital. Make sure you have a shared calendar and that they can see your shifts. Discuss how you will manage sleep when you are post-call. Explain the importance of day-time sleep on night shifts and figure out what you can do to make it quiet, dark, and uninterrupted. This will take the support of your significant other or family. Let family and friends know that given the time commitment of residency that it’s helpful to know in advance as possible about events like weddings, group trips, family events, and that you may have limited availability and flexibility depending on the times of the year and your workload.

Prepare to Do Your Paperwork on Time

Don’t be the resident who causes trouble. For starters, pay attention to your email, and do your paperwork on time. Don’t make them email you reminders or hound you to get basic things done. Seemingly simple things like this could keep you from getting future positions like being a chief resident, or even getting hired later, if you have a reputation for being late or unreliable with basic things.

Prepare Your Calendar

More than other jobs, even more than other medical specialties, your calendar will now control your life. Your schedule will have very little consistency, and you will need to constantly be checking to recall when your shifts begin and end. Our program, for example, has shifts beginning at 0700, 0900, 1200, 1300, 1500, 1700, 1900, and 2300. These shifts are any combination of 8, 9, 10, and 12 hours long and could be at one of four different hospitals. Find out what calendar system works best for you and get good at using it.

Additionally, get an early understanding of what time you have guaranteed off.

• Do you get a golden weekend every month?
• How many weeks of vacation can you request?
• Are there any off-service rotations you can anticipate having the weekend off?

These are all important questions to have answers to when it comes to planning things like weddings. Depending on how your schedule works you may have to take one of your vacation weeks to ensure you can make it to important events like weddings. You will undoubtedly receive a text from one of the current residents shortly after match day, these are great questions to ask them about.

One of the “hidden curriculum” items is to understand the culture around requests and shifts. This information won’t be written in any of your policy guidebooks, but it has to do with the culture of work. Is the culture that you arrive 10 minutes early and take sign out then? Or does sign out start right on the hour? Is the culture to sign out any active patients, or to try to complete most of the dispositions before signout? Is the culture to try to swap shifts when you need it, or to do whatever possible to set your schedule up from the start. These types of things are norms that you can ask about and also observe the upper-level residents to see how they function.

The start of residency is a great opportunity to learn how to automate EVERYTHING. Rent, utilities, and credit card payments should not be part of your cognitive burden. Anything that cannot be automated needs a reminder (i.e., take the trash out). Working a schedule of nights, weekends, and holidays means that while the rest of the world knows Sunday as the day after Saturday, you just know it as a day you work or don’t. This can make it difficult to remember scheduled weekly events like trash pickup.

Prepare to Embrace the EM Community

Since you have matched in EM, that will become a core part of your identity as a physician. However, you will come to find out there is a whole world of alphabet soup and niches/interests to explore in our broad world of EM. There are many ways to get involved and explore both at a national level as well as locally in your residency that will help “fill your cup” for the non-shift parallel to practice that gets you excited!

Starting with alphabet soup, know the big organizations and see if you want to get involved.

• American College of Emergency Physicians (ACEP): Emergency medicine’s primary professional organization- ACEP publishes practice guidelines, covers breaking news related to EM, advocates for EM physicians nationally and at the state level, and provides high quality conferences and education.
• Emergency Medicine Resident Association (EMRA): Run by EM residents and for EM residents- EMRA publishes on-shift clinical books, publishes resident perspective articles, advocates for residents to other organizations, and houses multiple interest committees from education, POCUS, Critical Care, EMS, and more.
• Council of Residency Directors in Emergency Medicine (CORD): EM’s education-focused organization involving pre-clinical educators, clerkship directors, residency faculty, program directors, fellows, and involved residents
• Society of Academic Emergency Medicine (SAEM): Organization focused on advancing EM research and education including department chairs, researchers, faculty, residents, and more. Includes Residents and Medical Students (RAMS) board which is the resident specific sub-organization of SAEM.
• American Board of Emergency Medicine (ABEM): The governing organization that creates and oversees the board certification process for EM physicians
• Accreditation Council for Graduate Medical Education (ACGME): The organization that sets the standards and requirements that a resident of any specialty must meet to graduate as well as standards for a program to meet to be accredited. They govern multiple specialties, but you will hear about them a lot in coming years due to EM program requirement changes.

Additionally, you will see your faculty wear different hats from EMS director, Emergency Ultrasound Director, ED Operations team, Toxicology expert, nocturnist, research PI, and so much more.

Ask for mentorship, but understand mentorship is a two-way street. Mentors and advisors prefer residents who are both invested but also self-motivated to move projects forward or complete tasks. This is also a great way to get plugged into communities that interest you, such as simulation or global health. Ask early, because although individual ED shifts feel long, time otherwise flies in residency. Graduating with an area of expertise and a community for your niche can help you be more successful and satisfied with your career in the long run.

Prepare Your Knowledge

Every intern will arrive with different levels of knowledge, procedural experience, and soft skills. Multiple landmark educational studies have shown learners universally suffer knowledge attrition during large breaks, a phenomenon termed “summer learning loss” because of its origins in research surrounding primary school [6]. Students who continue to engage with content minimize this knowledge loss, build more knowledge, and perform better [6].

You can turn the time between Match Day and the start of intern year from a “summer learning loss” time to period of continued learning. Fortunately, you do not have to navigate this time on your own. There is an ALiEM curriculum, sponsored by EMRA, specifically designed to help prepare medical students for the start of intern year in EM, called Bridge to EM [7]. The curriculum is excellent, self-paced, and free. It maps out a multi-week program that guides you through the best educational resources that are not purely textbooks. It includes core content areas of EM knowledge, POCUS, soft skills for interns, and image interpretation in small bites during the weekdays with intentional spaced repetition to help you recall the knowledge better. The goal of this program is to help you feel more prepared when you walk into the ED on day 1.

Once you start intern year, the C3 series from EM:RAP is a great podcast to help you learn approaches to chief complaints and presentations. 98%+ of residency programs provide EMRA membership for their residents, and EMRA members can access EM:RAP for free.

Lastly, we recommend waiting to invest in question banks until you get to your program. Educational question banks and tools such as PEER, EMCoach, Rosh, and more are often provided by your program. As with any big test, the yearly In Training Exam (ITE) that you will take each February rewards consistent daily studying as opposed to cramming.

Prepare Yourself: Check Your Own Pulse First

There is a saying in Medicine that when there is a patient who is coding or who has vital signs that make you sweat, that you should check your own pulse first. Take stock of yourself. Make sure you are not spiraling out of control mentally or physically, so that you can perform at your best and take care of the patient. Similarly, now that you are about to start residency, it is a good time to get into the habit of checking your own pulse. That could be through more structured methods, such as counseling, therapy, coaching, journaling, or writing down your thoughts regularly. It could be a semi-structured approach, like checking in with yourself as you drive to work each day. Find small habits that you can start and maintain that will help you grow your own personal awareness, resilience, and strength.

Welcome to the specialty!

You’ve got this.

References

1. Cahill E. How Long Should you Live in a House Before Selling. Experian, Jan 2023.
2. McMillin, Petry, and Moore. How long does it take to buy a house. Bankrate, Nov 2024.
3. Loan Management Options. American Association of Medical Colleges.
4. McMullen L. The Best Budget Apps for 2025. Nerdwallet, Jan 2025.
5. Consumer Reports. How to get in to see primary care physicians and specialists quickly. The Washington Post, Oct 2023.
6. Quinn and Polikoff. Summer learning loss: What is it, and what can we do about it? Brookings Research, Sept 2017.
7. Bridge to Emergency Medicine curriculum. Academic Life in Emergency Medicine, May 2024.