A newsletter for medical students pursuing a career in Emergency Medicine

July 2020

Reminder: It’s the start of the academic year as the doors of the ED open to new talent of our sub-Is and interns. Often with the vast array of resources, it’s hard to know where to start to help you bridge any gaps that may exist in your medical knowledge. Bridge to EM is designed to help you through this 8-week guide to provide structured preparation that is free for students. It contains vetted up-to-date information to help you shine on your ED rotation.


July 1st signals an end of another year of training and also the beginning for thousands of just-graduated medical students starting their intern year. It’s a celebration and reminder of a fresh start.

So, for the sub-I’s out there, how can you prepare for your EM rotation? Dr. Moises Gallegos will be sharing some tips on adapting to virtual clerkships. For the EM bound candidates, we will give you updates as reflected in the “Consensus Statement on the 2020-2021 Residency Application Process for US Medical Students Planning Careers in Emergency Medicine in the Main Residency Match,” including the non-EM SLOE, what that’s about, and how you’re going to obtain them. Hint: you need your advisors to help guide you throughout this process. Given the ever-changing landscape of the application cycle due to COVID19 restrictions, having advisors is essential for your success.

Beyond the application, it is also important to excel in your EM rotation, as only one eSLOE will be accepted for the 2020-2021 residency application cycle. How can you prepare for success? Let’s use the eSLOE as a roadmap to help you develop a game plan.

  • Show up: Be on time, prepared, and ready to work. We understand that you are still a medical student. You don’t have to know everything. What we want to see is you are able to receive and apply feedback and how well you work with others.
  • Commitment to EM: There’s nothing like a 3 a.m. ice-breaker than a medical student sharing her passion for hyperbaric medicine or a project you’ve been working on to utilize an electronic medical record in the free clinic you’re leading. Not clear about your passion yet? This is a great time to be inspired and ask your attending about their passions. However, be ready to talk about YOUR commitment to EM. Signpost this as opportunities arise.
  • Work hard: An important area in the eSLOE is your ability to work hard and assume responsibility. Can we trust you to execute the tasks as discussed? Clarify if you are not sure what the tasks are. Read up about procedures you’re about to do. Several just-in-time training is available at ALiEM (https://www.aliem.com/just-in-time-training/) . Say something if you are not comfortable doing procedures. This requires humility, an honest self-reflection, and a willingness to learn. I’m reminded of Brené Brown’s, “Don’t shrink. Don’t puff up. Stand your sacred ground.”
  • When in doubt, SPIT it out: SPIT refers to formulating differential diagnoses in an EM-friendly fashion: Serious, Probable, Interesting, Treatable diagnoses. Incorporate your treatment plan in the Treatable diagnoses. Pro tip: use the “interesting diagnosis” to share a quick 1-minute talk on the topic for fellow rotators, residents, and your faculty. Ask for feedback afterward. Make it EM bite-size: what I need to know, how can I miss this, and key features/pitfalls. In short, we want to know your “ability to develop and justify an appropriate differential and a cohesive treatment plan.”
  • Be kind, and be helpful: We are looking for med students who will be able to work in teams… Our team. Emergency Medicine can be chaotic and requires adaptability to challenging uncertainties. The best way to handle this is to not do it alone; hence, we love kindred spirits who we can get along, collaborate, and even share a laugh with.
  • Be kind to your patients: You know we must really care a lot about compassion if you see “be kind” written twice. This is part of the art of medicine. Developing rapport with your patients is key to success, on your sub-I and in your career in EM.
  • Look things up: Utilize your resources. This includes beyond googling and your pocket EM book, your fellow medical students, residents, nurses, and other staff. How much guidance (and work) you will need during residency is something your eSLOE writer will be evaluating. Do your best with the above, and this part should be easy.

Now that you know what is in an eSLOE, you have a better strategy on how you will perform in your only EM rotation this year, as well as how you will tackle the challenges of this year’s academic recruitment cycle. For more tips, check out the ALiEM EM Match Advice podcast series. Good luck!


Adapting to Virtual Clerkships

As the academic year kicks off, the continuation of remote learning due to COVID-19 is changing the medical student transition to clerkships. Although various states are relaxing shelter-in-place orders, medical schools and hospitals continue with heightened precautions in patient-care settings and restrictions on in-person instruction for the safety of patients, healthcare providers, and trainees. Virtual clerkships, either entirely or in part, will be commonplace as the pandemic persists.

Accepting the less-than-ideal situation, it is also important to recognize that with any challenge comes the opportunity for growth. Adapting to virtual clerkships will be a dynamic process as we all continue to learn best practices. Here are some tips for making the most of learning during virtual aspects of clinical rotations.

  • Learning Community: Remember that distanced learning does not need to mean learning in isolation. Create “study groups” with classmates on the rotation.
    • Accountability Buddies: Staying on track with readings and modules will be that much more important in asynchronous clerkships. Check-in with a classmate periodically and keep each other accountable.
    • Shared Cases: You will undoubtedly have fewer patient encounters as a result of Telehealth and PPE sparing protocols. There is learning to be had through the hearing of patients your classmates have seen. Help each other work through them as if you were seeing the patient primarily. This will be good practice for Oral Boards style exams.
  • Virtual Patients: It will be very important to make the most of practice cases, whether on paper, on screen, or in a simulation room.
    • Simulation: Look beyond the mannequin. Several online repositories of “simulated” cases can be used to practice clinical decision making through common emergency medicine presentations (links below).
  • Deliberate Learning: The educational theory of deliberate practice calls for purposeful repetition of skills with the intent of improving specific deficiencies through planning and assessment. By running over in your mind the cases that you’ve seen, you can revisit areas of discomfort and focus your learning. These mental representations can be useful when in-person training is not possible. Be deliberate with your time and efforts. What will you do differently next time? How do you prepare for that next time?
  • Pace Yourself: You may be reading, watching videos, and on conference calls instead of running around the ED, but fatigue will be real. Work through assigned material at a reasonable pace. Getting through the material is different than getting the material.
  • Patient Logs: In addition to keeping track of a patient log to satisfy course requirements, jot down chief complaints, procedures, diagnoses that you wish you had seen more of. You can augment these areas with your self-guided studies. Also consider asking the clerkship director for any curated alternative experiences they may be able to provide.


  1. AMA: Online learning during COVID-19: Tips to help med students succeed
  2. AMA: Medical education COVID-19 resource guide
  3. BMJ: The Deliberate Practice Mindset
  4. MedEdPortal: COVID-19 Virtual Learning
  5. EMRA: Virtual Learning and Medical Student Clerkships


As our nation continues to open up and many states feel the increase in COVID-19 cases, it is even more important than ever to stay abreast of this disease and ways to protect yourselves and your community. As students are now returning to rotations, it is prudent to be systematic in donning and doffing your PPE. Check out our archived EM Bound newsletters for COVID-19 information, as well as links to important websites and videos.

Here’s the link to ARCHIVED newsletters.


Emergency Medicine Application Letters of Recommendation:
2020 Version

Cullen B. Hegarty, MD
Program Director
HealthPartners Institute/Regions Hospital Emergency Medicine Residency Program
Co-chair of the CORD SLOE Committee

Sharon Bord, MD
Co-Director Undergraduate Medical Education
The Johns Hopkins School of Medicine Department of Emergency Medicine
Co-chair of the CORD SLOE Committee

Hey Emergency Medicine Applicants—it’s July, and most application cycles are the same as the year before, and the year before, so it’s easy for us to explain the process to students and easy for students to learn the process as so many students have done before them.

But it’s July 2020, and things are very different this year (in so many ways). To help you out with the confusing application season of 2020, we have got some information on Letters of Recommendation (LORs) that we hope will help you with your application process!

To start, let’s give you the quickest history of LORs in EM. Over 20 years ago, all letters were what we call narrative LORs. Think of a one-page word document, that looks similar from person to person, and unfortunately is easy for the letter writer to use for multiple students with a name change here, update pronouns there, and a few key statements about the student. Very generic, hard to highlight strengths, and even harder to reflect opportunities for growth. Not super helpful.

EM was the first specialty to create our own letter, and now many specialties have jumped on board with them! Our letter was originally called the SLOR: Standardized Letter of Recommendation. In the past 10 years we’ve changed the name to be the SLOE: Standardized Letter of Evaluation, as the letter is part a recommendation and part an evaluation of your performance on a rotation. Recently we created an electronic portal for the letters to be created and saved in, so the letter is now called the eSLOE for electronic Standardized Letter of Evaluation. The eSLOE is written by faculty at academic EM residency programs.

Fast Facts

  • Why is the eSLOE so important? Over the years of the SLOR, then the SLOE, and now the eSLOE is consistently rated as one of the most important parts of a student’s application to EM by the program directors in EM.
  • Variants of the SLOE: Given the success of the SLOE, over the past 5 years we have created a few variants of the letter. View all SLOE versions.
  • SLOE for non-academic EM faculty: This is a letter designed to be written by an emergency physician who works at a hospital not affiliated with an EM residency program. Examples of this letter from the Midwest would include the University of North Dakota and the University of South Dakota – both schools have EM rotations, but neither has their own EM residency.
  • SLOE from an EM subspecialty rotation: This is a letter designed to be written by an emergency physician whom you worked with during an Ultrasound, EMS, Peds EM, or Toxicology rotation.
  • O-SLOE: This is NEW for 2020. Off-service Standardized Letter of Evaluation. Given all of the changes to medical student rotations, and therefore to the EM application process, we have created this letter to be used for all of your non-EM letter writers to use (examples: Surgery, Medicine, Pediatrics, etc.). For the O-SLOE, we recommend having someone write the letter who knows you well, more than someone who is well known, and we are truly open to reading this letter from any clinical rotation that you have done. There is not one key off-service rotation that leads to a better letter than any other.

Now that you know a little bit about the letter options in EM, let’s talk about letters specific to the 2020 application cycle. Given the effects of COVID-19, most students going into EM this year will only have the chance to complete one emergency medicine rotation. With that in mind, here is how we would approach getting 4 letters into your ERAS application:

  • 1 eSLOE: This should ideally be a departmental letter from where you rotated.
  • 2-3 other letters: Some combination of a SLOE from a non-academic rotation, SLOEs from EM subspecialty rotations, and/or O-SLOEs from your off-service rotation. What combination you will have of these letters depends on what clinical rotations you have done so far. We can picture a common application this year will have either one SLOE from a non-academic rotation or one SLOE from an EM sub-specialty rotation and 2 additional O-SLOEs.
  • 1 possible letter from a research mentor (or someone who knows you well outside of the clinical area). These individuals should write a regular letter of recommendation for you.

Here are some FAQs and additional resources. You can also read more on the CORD website for even more information.


July 1st is here. While med students still follow the university calendar, residency training across the country officially starts on July 1st. There’s a lot of energy surrounding this date–it marks the leveling up for physicians-in-training across the country.

Three suggested Twitter accounts to follow today:

Here are some Twitter hashtags that will continue to help you with your journey:

  1. #EMBound
  2. #WomenInMedicine
  3. #FOAMcc

You can engage with us at @ALiEMteam. We’d love to hear how you are doing!



Advice for Sub-Is in the COVID-19 Era

Being a sub-I during a time where social distancing, increasing rates of COVID-19 with its myriad of clinical presentations, and the need to conserve PPE can add further stress to an already challenging time. Here is some advice from some APD’s and faculty across the country to help guide you on your way.

Applying to EM during this pandemic adds an extra layer of uncertainty and trepidation. Know that you’re not alone in this. Be kind to yourself. While you will never have complete control of things, you have the ability to control how you let things affect you. Be kind to others. Everyone, including the program leadership and staff, is trying hard to figure this out with you. How you treat yourself and others, especially during these stressful times, will carry over on your future in Emergency Medicine–a field full of exciting, stressful, unpredictable uncertainties. We look forward to embarking on this journey with you.

Al’ai Alvarez MD, Assistant Residency Program Director, Stanford Emergency Medicine

We see you working hard and trying to show your passion, talent, interest, and skills. We can’t imagine the pressure you must feel with the ever-changing environment, requirements, and now the ability to get only one SLOE. Please know we are rooting for you and want you to be successful! Be yourself, be authentic, and know you will and are doing amazing things (like being a med student in the midst of a global pandemic!). Try your best and know in the end, it will be enough. Excited to see where your path leads and I know you have a beautiful future ahead of you!

Sree Natesan MD, Assistant Residency Program Director, Duke Emergency Medicine

As medical students, you will want to put your best selves forward and ensure those 15-20 mins of face time with a program count. Practicing this new format with your colleagues is one of the ways to make sure this part of the process paints you in the best light. Remember that we are all a part of this new process, learning and evolving, with you. As long as you stay focused and use all the tools that got you to this point, you will get to where you want to be!

Andrew Restivo MD, Associate Residency Program Director, Jacobi-Montefiore-Einstein Emergency Medicine

Know that we are in this together. Know that we recognize the uncertainty you face and share the concerns you hold. Know that this pandemic has called upon all of us to be flexible, creative, and resilient. But be assured that we have your back. It’s what we as emergency physicians do. Take good care of yourself. Be true to yourself. Let your interests guide you. Some things will be different, but what remains the same is that we look forward to getting to know you and welcoming you to the EM family.

David Gordon MD, Associate Program Director, Undergraduate Education Director, Duke Emergency Medicine

Albert Einstein said, “in the midst of every crisis, lies great opportunity.” I like to use these multiple crises affecting our country to think creatively. What could be done better today and tomorrow that would never have previously been acceptable because of ingrained culture? As a medical student, think about how YOU would have approached these obstacles and constraints in education today? We at ALiEM would love to hear.

Michelle Lin MD, ALiEM Founder, University of California, San Francisco


  1. SheMD: Letters of Recommendation during COVID
  2. Twitter Thread: RUBrave Enough


The 3 most popular clinical blog posts in March 2020 were the following:


  • Editor-in-Chief: Sree Natesan, MD (Duke University)
  • Top News Section Editor: Al’ai Alvarez, MD (Stanford University)
  • SpotLight Section Editor: Moises Gallegos, MD MPH (Stanford University)
  • Clerkship Section Editor: David Gordon MD (Duke University)
  • Medical Student Liaison: Bryn Dhir (Johns Hopkins University)
  • Chief Advisor: Michelle Lin, MD (University of California, San Francisco)
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at https://t.co/50EapJORCa Bio: https://t.co/7v7cgJqNEn
Michelle Lin, MD