Consensus Statement on the 2021-2022 Emergency Medicine Residency Application Cycle Part I: Emergency Medicine Rotations and Letters

Consensus Statement on the 2021-2022 Emergency Medicine Residency Application Cycle
Part I: Emergency Medicine Rotations and Letters

March 26, 2021

On January 25, 2021, the Coalition for Physician Accountability (CoPA) released guidelines regarding away rotations for students participating in the upcoming residency application cycle in light of the ongoing COVID-19 pandemic. The primary recommendations were:

1. No away rotations before 8/1/2021, except for students with a specialty interest they are unable to pursue at their home institutions
2. Tentative resumption of away rotations after 8/1/2021, with a limit of one such rotation per student

As a field that relies heavily on away rotations, Emergency Medicine (EM) is uniquely affected by these recommendations. The purpose of this statement is to affirm conceptual support for the CoPA guidelines, and to describe the specifics of how they should be operationalized in EM to optimize equity and consistency in the residency application process. An additional intent is to recognize these rotations as valuable finite resources and assure they are available to the majority of applicants. In light of the continually changing landscape of the pandemic, this statement will be re-evaluated as new information becomes available, and will be revised if needed in May 2021. These guidelines apply to the Main Residency Match and do not apply to students who have a contractual obligation to the military or are applying to the military match.

In an effort to promote safety, fairness, and equity in the EM residency application process, we strongly recommend the following principles be followed:

1. The timelines outlined by CoPA for away rotations should be followed by all institutions offering EM rotations. With the COVID-19 vaccine becoming more widely available, many EM educators have voiced frustration over what they perceive to be needlessly restrictive recommendations. However, it is extremely probable that a majority of medical schools will abide by the CoPA guidelines. Students at these institutions would be placed at an unfair disadvantage relative to their peers at schools that choose not to abide by the guidelines. In the interest of fairness, we strongly encourage that no away rotations in EM be offered prior to August 1, 2021, except for students lacking access to EM at their home institution, as stipulated in the CoPA document.
2. EM residency applications should include a maximum of two electronic Standardized Letters of Evaluation (eSLOEs). An eSLOE is a letter written by a faculty member at an institution that hosts a residency program in EM, using the prescribed eSLOE format and is considered the “gold standard” of EM letters. eSLOEs are obtained through completion of a senior-level in-person clinical rotation in EM rotation at an institution with an EM residency, and are typically authored by a consortium of EM faculty involved in both medical student and residency education. The two eSLOE limit is designed to promote equity and comply with CoPA guidelines prohibiting unnecessary away rotations. Away rotations will be a highly limited resource this year, and should be distributed among the largest possible number of students. However, it should be recognized that in rare cases there may be valid reasons why students may have more than two eSLOEs. When this is the case, the reason for the anomaly should be clearly explained in the student’s residency application.
3. The mechanism by which students receive their two eSLOEs will vary according to individual circumstances. Most students will receive one eSLOE from a “home” EM rotation at their own institution, and a second eSLOE from an away rotation completed after August 1, 2021 in accordance with CoPA guidelines. However, some medical schools are affiliated with multiple EM residency programs, in which case students may have two home eSLOEs, with one coming from each program site. Some medical schools are not affiliated with any EM residency programs, in which case students may have two away eSLOEs, as a home eSLOE is not an option for them.
4. Students without access to an EM rotation at their home institution should be considered and prioritized for these limited away rotation spots. These students have been particularly disadvantaged by the pandemic, as they must do away rotations in order to complete their residency applications. Away rotation applications from students should clearly and honestly describe whether they have access to a home rotation. We encourage EM clerkship directors to be mindful of the supply and demand for rotations to ensure equitable allocation of available spots, and to consider the student's need for an EM rotation in addition to their qualifications and competitiveness. It should be noted that students without home EM rotations are permitted to complete rotations prior to August 1, 2021 as stipulated in the CoPA guidelines.
5. We strongly encourage EM leaders to forge partnerships with medical schools in their regions that do not host EM residency programs, with the goal of providing a “home” for students who would otherwise lack access to home rotations. This will require active advocacy on the part of EM educators, who may need to seek out contacts at other local institutions and negotiate with their own leadership to accommodate these students.
6. Away rotations should not be required or expected for this application year for students with access to a “home” rotation. It is likely that there will be some students who are not able to complete away rotations, as the time frame for these rotations is very short, and COVID-related travel restrictions vary by state and region. Program directors should view applications with single eSLOEs as being complete, and should consider them equivalent to applications with 2 eSLOEs. Program directors should also recognize that the August 1 start date for away rotations means that students may be completing these rotations late, and thus submitting eSLOEs after the traditional deadline. Program directors are encouraged to consider these late eSLOEs in their application review process to the greatest extent possible. As second eSLOEs often provide critical information about students’ growth over time, these letters may strengthen the residency application and provide a competitive advantage over students who have only one eSLOE. It is therefore essential for the EM education community to consciously consider the inequities faced by students in accessing away rotations, and recognize that requiring away rotations has the potential to exacerbate these inequities.
7. The intent of these recommendations is to assure they are available to the majority of applicants. We will monitor rotation capacity closely, and modify these recommendations if rotation supply and demand do not align as expected.
8. Vaccination status should not be used as a determinant of rotation eligibility. Student access to vaccination varies considerably both regionally and by institution. In addition, students may have contraindications to vaccination or other reasons why they choose not to receive the vaccine. It is important that we refrain from discriminating against students based on vaccination.
9. Students should follow all institutional, local, state, and federal guidelines in planning their rotations. Educational leaders should neither encourage nor allow students to travel or participate in away rotations in violation of any applicable public health guideline. Additionally, students should be encouraged to avoid high-risk situations, such as staying in group housing with other students or residents. Even among vaccinated individuals, these practices increase the risk of students spreading COVID-19, and for unvaccinated individuals they create an obvious safety hazard.