EM-Bound Medical Students: EM Clerkship and Away Elective

David Gordon, MD
Associate Program Director
Duke University

Sree Natesan, MD
Associate Program Director
Duke Emergency Medicine

Originally published in June 2023 EM Bound newsletter

Doing well on your sub-I will remain key to obtaining a strong SLOE as well as showing your passion for Emergency Medicine. Here are some top tips for rocking it!

Show up ready to shine: Showing your passion for EM means being engaged and enthusiastic. Your eagerness and ability to help out your team can help you shine.

  • Show up on time: Be sure to be at least 5-10 minutes early so you end up at the right place at the right time. Showing up late can create a bad impression that may linger despite your best intentions to correct this. View yourself as what you are- an integral member of the team.
  • Make yourself indispensable: Helping the residents with tasks can elevate your status on the team. Whether it’s following up on labs/imaging, calling consults, updating the patient/family, or calling nursing homes/families for collateral information, think of innovative ways to help out with patient care. Your residents will love you for it!
  • Be prepared: Show up well-rested and ready to perform. Read ahead of time (check out our Bridge to EM Curriculum if you are looking for a place to start). Ensure your success by having your bag packed and ready for your first day (see all the essentials that you will need below).

Illustration by Dr. Moises Gallegos

  • Present like a pro: Clear and concise patient presentations are key to showcasing your medical knowledge and clinical reasoning skills. In each patient encounter, use the differential diagnosis as your guide for organization and content. Always know your patients’ vital signs and make it clear when you are concerned for the presence of a serious condition… or grab your supervisor right away if you think the patient requires immediate attention! By the end of the presentation, your listener should have a good feel for “what do you think is going on?” and “what do you want to do?” Before starting your sub-I become familiar with the differential diagnosis for common complaints and the presentation style for emergency medicine.
  • Top chief complaints (Education Video: Patient Presentations in Emergency Medicine):
    • Abdominal pain
    • Altered mental status
    • Back pain
    • Chest pain
    • Fever
    • Headache
    • Musculoskeletal injury, trauma, and wound care
    • Nausea and vomiting
    • Shortness of breath
    • Sore throat
  • Know your procedures: The best way to be allowed to do procedures is by knowing the process. When your team is doing a procedure, you can chime in on landmarks and the steps to demonstrate that you know the drill. This will help you earn their confidence and give you more opportunities to do procedures during your Sub-I.


EMRA- Patient Presentations in 3 minutes
Education Video: Effective Consultation in Emergency Medicine
CORE EM: Procedure Videos
SAEM: EM Clerkship Primer
EMRA: Crush your Clerkships

W. Gannon Sungar, DO
Denver Health

Michael Gottlieb, MD, RDMS
Rush University

Originally published in May 2023 EM Bound newsletter

The opportunity to complete at least one away rotation is exciting for both students and educators. While exciting, these away rotations can also be stressful for students who find themselves in a new environment with a short duration of time to make a positive impression. In fact, multiple studies have shown that performance on an EM rotation is one of the most important factors considered by EM program directors in resident selection. Given the importance of performing your best on these rotations, how do you succeed? Or just as important, how do you NOT fail?

Below we provide a list of Dos and Don’ts for ensuring your success on your EM rotations. These words of advice have been compiled over years of experience working with rotating medical students, feedback from the ALIEM Chief Resident Incubator, and surveys from senior residents and faculty. While some of these tips may seem simple or even obvious, every year across the country students still fall victim to the pitfalls and fail to capitalize on the opportunity to truly differentiate themselves. Heed this advice to maximize your rotation.


  • Do Perfect Your Presentations. You can be certain that you will be presenting every patient you see to someone who will likely be evaluating you. Studies have shown that the majority of a supervisor’s impression of a student is linked to how well that student gives a medical presentation. Stick to the script and present it in an organized and consistent manner. Highlight pertinent positives and negatives to craft your differential diagnosis during your presentation. Know all the necessary details, but process the information and only present what you feel is relevant. Take some time prior to your rotation to practice your presentation skills.
  • Do Commit. In addition to providing a thoughtful and organized presentation, push yourself to commit to a plan for each patient. Again, you are not expected to always be right, but an assessment and plan, even a bad one, helps your supervisor to understand your thought process and identify potential learning opportunities. Avoid trying to guess what your attending or senior residents might be thinking, and instead, consider asking yourself “What would I do for this patient if I were all by myself?” Not only will you impress them with your willingness to commit to a plan, but your learning will also be accelerated.
  • Do Take Initiative. Being proactive on your rotation not only demonstrates situational awareness, which is a critical skill in emergency medicine, but often puts you in a position to be more involved in activities within the emergency department. Spend some extra time in the department early in your rotation to familiarize yourself with common supplies and gain an understanding of the flow in the department. Gather the equipment you need for a procedure on your own, and look for ways to make yourself useful without being pushy. Demonstrating your ability to identify and meet the needs of the department further exemplifies your ability to be a team player.
  • Do Have A Goal. Prior to your rotation, consider your strengths, weaknesses, and opportunities for growth. Asking for help or direction in a certain area of your practice is not an admission of incompetence, but quite the opposite, as it shows insight into your own education and a commitment to lifelong learning. Define a goal for each shift and for the rotation as a whole to direct your learning efforts and guide supervisors on areas to focus on. This will result in stronger and more specific evaluations as well as maximize your benefit from the rotation.


  • Don’t Be Late. Arriving late to a shift demonstrates a lack of respect for your patients who are waiting to be seen and for your colleagues who are waiting to go home. In short, it is unacceptable. Don’t let the thousands of hours of work you have put into your medical education suffer because you show up ten minutes late to a shift. Consider doing a trial run of your commute prior to starting your shifts to ensure there will be no missteps and consider arriving to shifts a little early to allow an ample time cushion prior to your shift time.
  • Don’t Lie. Reading this, you may say to yourself, “I would never lie”, but the temptation may present itself – and given the stakes of these rotations, it may be stronger than ever before. Don’t do it. Whatever element of the history or exam that you fabricate will be immediately revealed when your supervisor evaluates the patient themselves. More importantly, even a simple lie calls into question your trustworthiness and integrity and invalidates all of the other work that you are doing. As a rotating medical student, we don’t expect you to know everything, but we do expect you to be honest and to have a growth mindset, which requires a willingness to acknowledge and reveal your deficiencies so that you may improve.
  • Don’t Be a Jerk. Again, this seems like simple advice, but recognize that you have the potential to be evaluated by everyone with whom you come in contact during your rotation. As such, don’t put your best foot forward for your attending to only then be disrespectful to the clerkship coordinator. Be prompt and professional in all of your interactions and communications. Be collaborative in how you interact with other students. Remember, EM is a team sport and it is critical to your success to be able to interact collegially with a broad group of people.
  • Don’t Forget Why You Are There. While it is easy to think that the goal of your EM sub-internship is to impress faculty members to cement your place on a program’s rank list, remember that first and foremost you are there to take excellent care of your patients and to learn. Too often students waste their time on shift trying to make ultimately meaningless connections with faculty members or residents. If you really want to impress, devote yourself to spending that extra time with your patients, following up on results, communicating the plan, and ensuring their comfort – this will not go unnoticed and is the heart of why we all went into this field.

Lastly, remember that an “audition” rotation is just as much a program auditioning for you as the other way around. Reflect on your experience and think about what kind of learning environment you need to thrive. Your sub-internships are an amazing opportunity to see how emergency medicine is practiced at different institutions. Embrace every learning opportunity and it will build a strong foundation for your residency training.

The above is based on an ALIEM Article entitled 8 Tips on How to Succeed in Your EM Sub-Internship. Also check out this great infographic from #EMOttowa and their 12 Tips for Success.

Benjamin Karkunle, MD
Assistant Professor
McGovern Medical School at UTHealth, Houston TX
Originally published in July 2023 EM Bound newsletter

As medical students auditioning in EM departments this application cycle, you are facing a different experience than before. You may be limited in what patients you’re allowed to see. You may feel as though you are shadowing instead of contributing to the team. We are all frustrated by the COVID-19 reality. Don’t forget that your attendings and residents want you to gain real knowledge and skills from these months and they want to set you up to succeed despite the challenges.

The same things that made you successful in third-year rotations will keep you successful today! Many things can go on the ‘what makes a student successful’ list, but let me guide you in my favorite – point of care ultrasound.

Here are some tips to make you stand out as an ultraFUNographer:

  • Bring the ultrasound into the room with you during your first encounter: Nothing ensures neglecting a quick, sensitive scan like having to leave the room to get the machine. Abdominal pain, chest pain, dyspnea, and back pain are chief complaints that should get an ultrasound in the room, every time. They won’t always get a scan, but if you have to go out to get the machine, they may not get it at all!
  • Learn how your department enters patient data into their machines: It may be as simple as putting the patient’s MRN in the Patient ID field, but it may not be. This can allow you to shine in helping your team set up for the exam.
  • Have the machine set up, cleaned, and ready to go: Doing these initial steps (especially if your resident or attending is following close behind) and the clean-up steps can really help your team out.
  • Know what pathologies can be quickly screened for using point of care ultrasound: If your patient is complaining of upper abdominal pain, have your right upper quadrant images ready to show your attending to rule out biliary pathology. If it’s lower abdominal pain, quickly rule out urinary retention. Even if your images were not great, you’re showing your appropriate thought process. Practice being versed in which exams can be used for which chief complaint is key to sharing your medical knowledge and thought-process.
  • Verify the end: Don’t end your exam once you are done scanning- your resident or attending may want to add a few more images if they weren’t convinced. Please don’t take this as a sign that you aren’t trusted, it’s our job to assess the patients too! Ask questions and show engagement in interpreting the results your team gets to help you learn and contribute to the diagnosis.
  • Clean up: Once you are done scanning, clean the machine and offer the patient a towel to clean themselves. In COVID-19 times, cleanliness is more important than ever.

For most of you, we know that this is your first month in the department. We don’t expect you to be perfect. We do expect you to work hard, to help the team however you can, and to follow through on tasks. Showing us that you can acquire and interpret ultrasound images, or even that you can facilitate us getting these done, will go a long way.


David Gordon, MD
Associate Program Director
Duke University
Originally published in March 2022 EM Bound newsletter

Let me begin by wishing graduating 4th years the best of luck as Match Week nears. I hope each of you gets one of your top choices, but just know every program has unique and great things to offer. Wherever you end up, the friendships you make with your fellow residents will be what you remember and cherish the most.

For rising 4th years who are gearing up for away rotations, one of the confusing aspects of applying can be the variability across institutions. There can be differences in application systems, deadlines, and vaccination forms. Here, I would like to discuss the different types of letters you might be asked to provide.

  1. Letter of Good Standing: This typically refers to a generic letter that verifies you are actively enrolled at your medical school along with your anticipated date of graduation. Basically, it affirms you are a real medical student who is on the right path. Your medical school’s Office of the Registrar will likely be the source for these letters.
  2. Letter of Recommendation: Some programs may ask for a faculty letter that advocates for you on a more personal level. You can talk to your local EM clerkship director or advisor about who best to provide this letter. Since you haven’t done your fourth year EM rotation yet, the ability to comment on your clinical abilities may be limited. This letter will primarily confirm your interest and commitment to emergency medicine. It can, however, be helpful to provide your letter writer with a general sense about your performance in medical school to date along with special interests you may have (e.g., research, education, community service). Have a CV on hand.
  3. Letter of Interest: This comes from you and is your opportunity to convince your reader that you are sincere in your desire to do an away rotation at their program, as opposed to randomly sending out applications. The reasons can vary but may include wanting to experience a different training environment than your home school, being drawn to a program’s area of expertise, or wanting to be near family. The more specific and personal the letter, the more convincing you will be. Programs have limited space for visiting students, so are looking for those who seem like a good fit and are genuinely interested.

In like a lion and out like a lamb, March is upon us. Wherever you are in the process, may you have smooth sailing and calm waters ahead


David Gordon, MD

David Gordon, MD

Section Editor, ALiEM Medical Student Home Page
Associate Program Director
Duke University
David Gordon, MD

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