A newsletter for medical students pursuing a career in emergency medicine

July 2021

Letter from the Editor:

Each July, the door opens to welcome interns into the world of Emergency Medicine. Apprehension and anxiety reign as roles are transitioned. For our #EMBound students, although this may seem so far off, I can assure you the time goes faster than you think! Whether you are a first-year med student learning about EM, or a fourth-year Sub-I hoping to rock your rotation-- know you have the talent, passion, and skills to make your dreams come true and we are here to help you on your journey to becoming #EMBound.

We also hope you can help us grow in our journey to serve you and consider filling out the short feedback survey at the end of this newsletter. Happy learning!

--Sree Natesan MD, EM Bound Editor-in-Chief

TOP NEWS

Reminder: 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. If you are looking to brush up on knowledge, or get a glimpse of what this specialty entails, check out this awesome resource!

The Have to/Want to Perspective and Other Ways of Doing More Than Surviving Your Clerkship

Al'ai Alvarez, MD

Director of Well-Being

Stanford Emergency Medicine

July 1st is here! Congratulations! It’s a momentous time of the year. Welcome!

"Accept that you are imperfect and always will be. Your quest is not to perfect yourself, but to better your imperfect self."—Eric Greitens in Resilience

This quote reminds me of the growth mindset and our role in bettering ourselves. It also normalizes that while there may be unrealistic expectations of always doing well in medical school, we also acknowledge that challenges are part of your training. We don’t expect you to know everything, nor do we expect you to show up to your clerkship able to do every EM procedure. In fact, as a faculty member, I still find myself not knowing exactly what my patients have. And that’s ok. Our job as emergency physicians is to think of the worst things, emergencies, and to anticipate how we would address this or the next best steps to help our patients. It is not our job to provide final diagnoses--this is often just a bonus.

With that, I recently learned this perspective from one of our med students: think of yourself as a tourist. As a tourist, you're not expected to know the lay of the land. Be curious. Even if you think you already know what’s going on with your patient, stay open-minded and see how else you can improve their visit in the ED-- through diagnostics, through procedures, or simply by acknowledging their suffering and being there for them.

Another perspective is the difference between having to versus wanting to do something. For example, “I have to do a neuro exam” is very different from “I want to do a neuro exam.” As the pendulum swings to the "I want to" narrative, you'll realize you'll be a lot more motivated, and tasks become less of a chore. So, we ask that you try your best. At the same time, take care of yourself. Find moments when you can recharge. Hydrate. Eat. Take that bathroom break. Breathe.

"Real achievement doesn’t happen overnight. At the end of each day, ask yourself whether you were better than the day before." —Daniel H. Pink in Drive: The Surprising Truth About What Motivates Us.

Lastly, be on the edge. Push yourself when you're on shift to be a little uncomfortable. Being too comfortable does not allow for growth; being too uncomfortable can be dangerous or paralyzing. The edge is the most productive place to be. Small changes make a difference. I do not doubt that starting your new clerkship will push you to be on this edge. It's hard to know sometimes if what you're feeling is an appropriate amount of challenge or if it's too much. Ask around. Talk to your colleagues and friends. Talk to your mentor or your clerkship director. You don't have to go through this alone.

SPOTLIGHT

Re-framing the “July Effect”

Moises Gallegos MD MPH

Clerkship Director

Stanford Emergency Medicine

These next few weeks mark milestone transitions for medical students entering residency. Similarly, pre-clinical students are entering their first clerkships. This transition in medical education is something highlighted every year as a “changing of the guard” for the healthcare workforce in some ways. With this change comes a whirlwind of emotions- excitement wrapped in nostalgia, anticipation encased in anxiousness, and eagerness marked with caution.

We’ve all heard the joking statement that you should avoid getting sick in July. This jab plays on the idea that inefficiencies in the provision of medical care result from new trainees taking on new roles. What I would encourage you to focus on instead, is that in an academic medical center, teaching and training are built into the practice of medicine, and patient safety is always at the core of supervision.

What do the studies actually show?

The data goes back and forth: Small studies have demonstrated changes in practice patterns, such as medication prescribing and hospital stays, but few have demonstrated clinically relevant impacts on patient outcomes.
Subgroups of patients may experience impacts in care: Large and multi-institutional studies show a negligible effect on most outcomes for the general patient population, but trends towards negative outcomes do materialize when doing subgroup analysis.

Some groups of patients that have been shown to experience increases in morbidity and mortality are cardiac patients, such as those requiring percutaneous intervention, and specialized surgery patients, such as those receiving cerebrospinal fluid shunts.

Academic centers perform better: When comparing teaching hospitals to non-teaching hospitals, patient outcomes across the board are better. While the July Effect may be real in some cases, patients receive better care all-around at academic centers.

What does this mean for me?

You’re not the only one in a new environment: If you are a core student or a sub-intern in the month of July, recognize that you’ll be working next to residents taking on new roles themselves.
Oversight is multi-layered: Program leadership and attendings are ready to support your clinical development while ensuring patient safety. Academic medical centers rely on the naturally existing levels of oversight: nursing staff, senior residents, attendings.

What can I do?

Recognize limitations and knowledge gaps: Accept any moments of “I’m not sure” or “ I don’t know” as opportunities to learn and grow.
Seek out clarification often: Ask for assistance or clarification of a task early. Don’t waste time and energy on small things. Save that for bigger tasks. Don’t know how to place a consult, ask for help and take notes for next time.
If something doesn’t seem right, bring it up: You spend a lot of time with patients, so if you notice that something doesn’t add up with medications, with results, or with the patient’s clinical course-- bring it up to your team. Whether it was something to be concerned about in the end or not, you’ll learn from that discussion.

Resources:

July Effect? Maybe not.- Emily Hughes

COVID-19 UPDATES

Its been over a year since the pandemic has been in full effect, transforming our lives in a multitude of ways. As cities and states open up, and vaccinations become more widely available, share your knowledge and expertise in how to remain safe to your community. This will be the last nod to COVID in our #EMBound Newsletter but please check out our archived EM Bound newsletters from April-December for COVID-19 information, as well as links to important websites and videos. Stay safe!

Here's the link to ARCHIVED newsletters.

CLERKSHIP LIFE &
RESIDENCY APPLICATION SEASON

Emergency Medicine Application

Letters of Recommendation: 2021 version!

Cullen B. Hegarty, M.D.

HealthPartners Institute/Regions Hospital Emergency Medicine Residency Program

Co-chair of the CORD/CDEM SLOE Committee

Sharon Bord, MD

The Johns Hopkins School of Medicine Department of Emergency Medicine

Co-chair of the CORD/CDEM SLOE Committee

Hey Emergency Medicine Applicant-- it’s July 2021, and student rotations and applications will more closely resemble a standard application season this year (YEAH!). Here are some helpful things to know about EM letters heading into the September ERAS application opening.

First, we will start by giving you a little background. Emergency Medicine was the first specialty to create our own EM-specific letter, and now many other specialties such as orthopedics and dermatology have jumped on board with this concept! 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 partly a recommendation and partly 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. Oftentimes, these letters are authored by a group of faculty, rather than an individual faculty member.

Why is the eSLOE so important? Over the years of the SLOR, then the SLOE, and now the eSLOE, it has been consistently rated as one of the most important parts of a student's application to EM by the program directors in EM.

Given the success of the SLOE, over the past 5 years, we have created a few variants of the letter. All of these versions are located here: https://www.cordem.org/resources/residency-management/sloe/?epsremainingpath=/resources/residency-management/sloe/

SLOE for non-academic EM faculty: This is a letter designed to be written by an Emergency Physician that 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 sub-specialty rotation: This is a letter designed to be written by an Emergency Physician that you worked with during an Ultrasound, EMS, Peds EM, toxicology, or other EM sub-specialty rotation.
O-SLOE: Off-service Standardized Letter of Evaluation. This letter can be used for all of your non-EM letter writers to use (ex: Surgery, Medicine, Pediatrics, etc.). For this letter, we recommend having someone write the letter that knows you well, more than someone that is well known, and we are truly open to reading this letter from any clinical rotation that you have done.

Now that you know a little bit about the letter options in EM, let’s talk about letters specific to the 2021 application cycle. Here are some basic recommendations on how to approach getting 3-4 letters for your ERAS application:

1-2 eSLOEs: This should ideally be a group or departmental letter from where you rotated. Our hope for this year is that most students will be able to complete a visiting or away rotation and in turn can get two eSLOEs into their file! If you are only able to get one eSLOE due to lack of a home rotation or the inability to complete a visiting rotation that is OK too!
2-3 other letters: This should include some combination of a SLOE from a non-academic rotation, SLOEs from EM sub-specialty rotations, and/or O-SLOEs from your off-service rotation. Instead of an O-SLOE, a standard narrative letter of recommendation could be used as well. What combination you will have of these letters will depend on what clinical rotations you have done so far and where you think you can get your strongest letters from.
1 possible letter from a research mentor or someone who knows you well outside of the clinical area: These individuals should write a regular narrative letter of recommendation for you.

FAQs:

What should I do if I have already asked my non-EM letter writers to write a letter for me?
- Don’t worry about it—if they can use the O-SLOE format, great, but if they have already written the letter let them use whatever format they prefer!
What should I do if I am re-applying to EM and only have 1 eSLOEs from last year I can use again?
- If you are re-applying to EM, feel free to use your eSLOE from last year. You may want to add a new letter if you are currently in a preliminary program (from the Program Director). That will be a valuable addition to your application.

For any other questions you may have for this application season, we recommend you find an EM advisor at your school to connect with. If your school doesn’t have an EM advisor, reach out to any EM residency program and we’d be happy to help you out! Feel free to reach out directly to Cullen or Sharon as well with LOR questions: [email protected] or [email protected]. Best of luck with your applications in 2021!

DRESS TO IMPRESS:

Arm yourself with Clinical Tools

We are excited to introduce a new section of our newsletter which will share a decision tool, infographic jammed packed with pearls, or share clinical pearls to help you shine on your EM rotation. Below is our Essentials for your first ED shift created by our very talented Dr. Moises Gallegos.

EXPAND YOUR
SOCIAL MEDIA HORIZONS

It’s July! Here are some great follows to help you with your new rotations. We also want to take this opportunity to honor Dr. Paul Auerbach, who started the Wilderness Medical Society and the field of Wilderness Emergency Medicine. Here is an example of the breadth and scope of emergency medicine and truly the specialty that cares for anyone, anywhere and anytime.

#POCUS

EM MATCH ADVICE PODCAST

Welcome to the new academic year! The EM Match Advice series of podcasts are for senior EM medical students, co-hosted by Dr. Michael Gisondi and Dr. Michelle Lin. Check it out for some great tips to help you shine on your rotation.