EMRA and CORD Student Advising Guide, 2023

Ch. 8 - Apply Smarter Not Harder: Understand Your Competitiveness

So how competitive am I?

Every applicant has their strengths and weaknesses, and the vast majority of applicants fall into a competitive category. While we can never replace an EM-specific advisor who is familiar with your application’s strengths and weaknesses, we will use survey and analytical data from the NRMP and residency program leadership to help you better assess your level of competitiveness. We would encourage you to perform your own assessment and share it with an EM advisor. Don’t have an EM advisor? Feel free to sign up for one! Just request an advisor by sending your contact information to distanceadvising@cordjobboard.com.

What is (and isn't) competitiveness in the EM Match?

Competitiveness is your ability to successfully match into an EM residency, which is related to the likelihood of obtaining enough interviews to match. When we discuss competitiveness, we usually do so in reference to a successful match into an EM residency program, which is not necessarily the same as matching into the residency program you most prefer. Most of the data we use helps us to understand how populations of students successfully match into any EM residency program. It is important to know competitiveness is not a contest between you and other applicants; rather it is a propensity for you to match successfully in EM overall.

Competitiveness is multifactorial and influenced by intangible and tangible factors. Intangible factors might include common interests shared between you and the program or a sense of feeling that you will fit in a program. We often lack sufficient data to quantify a “fit” for a program based on candidate preferences, but you will determine program fit as you evaluate and interview with programs. Tangible factors may include grades, board scores, class rank, letters of recommendation, research publications, and other such measures and can be quantified based on nationally available data. However, please remember that numbers don’t tell your whole story or a complete story of a program. Assessing your competitiveness is an important milestone on your journey to residency. In addition to the elements described above, your ultimate success in the Match is greatly affected by your application strategy and your sense of fit within particular programs, both of which can be best assessed by you and your EM-specific advisor.

The elephant in the room: How does the number of applicants to EM overall influence my competitiveness?

In the 2021-2022 and 2022-2023 NRMP Match cycles, we saw declining numbers of EM applicants, after having seen growth among applications for many years. We have also seen the number of available EM residency positions continue to increase. Even if math isn’t your strong suit, it’s easy to recognize that fewer applicants and more available positions likely means less overall competition. Even as these variables change, we can still assume that PDs are looking for a certain caliber of applicants. We can also still assume that applicants will develop at least one, but probably a few, preferred programs. The numbers and advice shared here are derived from data and evidence, including post-Match data from the 2021-2022 NRMP Match. If the data changes, advising patterns will also change. The advice presented here is based on data as current as possible, and though we may see shifting trends in the numbers of applicants and programs, the general advice given here should largely be appropriate and applicable for the next few years. In this edition, competitiveness is described with ranges, which will likely still be appropriate for the next few years as well.

What is the difference between being nationally, regionally, or locally competitive?

As mentioned, local or specific program competitiveness is difficult or even impossible to predict. Your competitiveness within a specific locality or program may center on personal relationships, familiarity with a program, or nuanced qualifications, in addition to more standardized qualifications such as national board scores and letters of recommendation. Moreover, individual programs will emphasize different application components (eg, an eSLOE from a neighboring or known program may have more weight than your board scores) that might change how competitive you are within that location. Ask your academic advisor for insight into particular programs. It’s also important to ask PDs what is important in their program. Program websites and the EMRA Match database also offer insights into each program’s emphasis.

Regional competitiveness might be influenced by relationships but may also be influenced by a rotation or eSLOE generated from a rotation within that same region. Program leaders place substantial influence upon letters and evaluators with which they are familiar — in a 2014 PD survey, 97% of respondents agreed that “knowing the person who wrote the SLOR [now known as the eSLOE] increases its value to my decision-making.”¹ While some programs within a region share some of the same preferences or priorities when selecting candidates, not all do, thus making regional competitiveness also challenging to predict.²

National competitiveness is a broader concept but easier to quantify in terms of common residency application components, including grades, board scores, class rank, and letters of recommendation. National data on competitiveness presented in this chapter represent data that historically have predicted a successful match into EM and the preferences and consensus opinion of those individuals who are involved in allocating interviews and generating rank lists at EM residency programs.

ERAS Applications, Filters, and Your Competitiveness

Your ability to match closely correlates with the likelihood of obtaining enough interviews to match. Residency programs need to find ways to sort through the large number of applications they receive each year. One way they do this is by applying screening filters to help determine which files to review further for an interview offer. In a 2022 PD survey, approximately 30% of applications were rejected based on a standardized screen.³

The 2022 USMLE Step 1 and COMLEX Level 1 transition to a pass/fail examination coincides with an overall trend away from using Step 1/Level 1 as a measure for evaluating candidates for residency. Of note, before the transition to pass/fail, NRMP PD survey data indicated that 100% of PDs utilized USMLE Step 1 scores to determine whether to grant an interview, with nearly 50% just requiring a pass.³ This suggests that going forward, many programs will use a failed Step 1/Level 1 score as a screening tool.

With this Step 1/Level 1 transition, USMLE Step 2 score targets have become more relevant. Nearly a quarter of PDs indicate a required target Step 2 score in selecting candidates for interviews, with an additional 47% citing a preferred score. An additional 26% required only a passing score. Thus, nearly all PDs in some way utilize a USMLE Step 2 score for evaluating candidates for interviews (Figures 8.1 and 8.2).³ It is important to have a USMLE Step 2 score for entering the NRMP Match process and to increase your competitiveness in EM. Data in the 2021 NRMP PD Survey indicates a moderately high relative importance of USMLE Step 2 scores (3.8/5) compared to Step 1 scores (3.5/5); however, the USMLE Step 2 scores still rank lower in importance when compared to the MSPE, performance in the EM clerkship, and several other factors (Figures 8.3 and 8.4).⁴

Beyond Filtering

It is worth noting the AAMC, NRMP, and ERAS all support holistic application review and have developed tools for such review. More and more programs are adopting and developing holistic review processes to increase diversity, identify promising applicants, improve program alignment, and support an institutional mission. A holistic review of applications includes elements of both academic and personal characteristics, which are not so easily filtered.

A selection of important academic and personal characteristics are shown in Figures 8.3 and 8.4, respectively. Notably, Letters of Recommendation in the Specialty (eSLOE in EM), Diversity Characteristics, and Commitment to the Specialty are among the most frequently cited elements. Concerning the relative importance of various personal characteristics, the eSLOE again stands out as very important — along with a few other factors, including performing an away rotation, completing an away rotation in a PD’s department, professionalism and ethics, and the absence of any NRMP Match violations.⁶

Among programs citing holistic review approaches, the most common and most important elements of this review included an applicant’s attributes, interests, interpersonal skills, ethics, professionalism, and personal experiences. Applicant geographic preferences were cited as a relatively important factor, but only 48% of the time.³

Student Engagement with Programs

The COVID-19 pandemic brought many waves of change to the world and to EM residency applications, not the least of which has been the increased use of virtual opportunities for applicants to engage with residency programs and for programs to offer information to applicants. In 2022, a majority of programs relied upon and perceived a benefit from their websites, social media platforms, and virtual “open houses” as means to engage with applicants.³ Though it is not clear if these behaviors increase competitiveness, some programs view this engagement as a proxy for interest in their program, which may help with matching at a particular program. Interested students are encouraged to use these resources to assess how their values, needs, and perceptions align with programs.

Which factors are most influential in increasing candidate competitiveness?

There are differences between the factors that will help you garner an interview and the factors that affect your position on a residency program’s rank list.⁶ Important factors influencing an interview offer are presented in Figures 8.3 and 8.4, while Figure 8.5 highlights selected factors that influence rank position by PDs. The eSLOE and related factors (such as grades in your EM clerkships and EM rotation performances) are highly influential in both interview offer and ranking.^3,6-8 It is important to recognize some of the other factors that affect your chances of an interview offer may not be as influential on your final position on a program’s rank list. After you get your foot in the door, interpersonal skills and interactions with individuals during your interview are the most influential components in ranking.^3,6

The eSLOE seems to hold a lot of influence, but I can’t read it.  How do I evaluate the competitiveness of my eSLOE?

eSLOEs are routinely rated highly in terms of impact in selecting candidates for interviews.^4,8,10 However, candidates usually forgo the right to read the letters. It would be improper to ask a letter writer or a program to disclose the information on the eSLOE or to specifically ask where a candidate is likely to be ranked. Therefore, we recommend asking the letter writer for a full evaluation at the end of the rotation, including your grade, and asking how that grade and your overall performance compare to others who have rotated within the last year. We also recommend asking the letter writer about the anticipated level of support for their candidacy, as this approach maintains professional integrity but also informs the candidate of his/her/their anticipated competitiveness.

How many SLOEs do I need to be competitive? Do more of them make me more competitive?

Depending on some predetermined factors, most candidates in the range of competitive to very competitive will be advised to do two EM rotations at an institution with an EM residency program, and candidates in the less competitive range will be advised to do two or three. It is generally expected to obtain an eSLOE from each of your EM rotations.

Unfortunately, some individuals get advised to do as many EM rotations as possible. However, more does not necessarily translate to better. Performing at a high level consistently on three, four, or five EM rotations takes a lot of effort and stamina. Expectations for each subsequent EM rotation are likely to be very high, as you will be expected to have accumulated a lot of experience at that point. There is also a point of diminishing returns for students beyond their second EM rotation. Third, fourth, or fifth EM rotations tend to receive lower evaluations, compared to first or second EM rotations.⁹ In addition, EM is a community that attempts to support its members, and when you elect to perform four or five clerkship rotations, you selfishly keep others from participating, violating the community-centered principle. Program directors look for these patterns and recognize these behaviors. It is not uncommon for PDs to question candidates who complete more than three rotations. For all of these reasons, we advise students that there is never a reason to do four or more EM rotations.

Does the timing of my eSLOEs influence my competitiveness?

While it is ideal that two eSLOEs are present in your ERAS application at the time of submission, many programs recognize you cannot always complete two EM rotations and obtain two eSLOEs by mid-September. EMRA Match identifies programs willing to offer an interview with zero, one, or two eSLOEs; use this data if you will not have a second eSLOE available by the time of interview offers (October). If you obtain an eSLOE after submitting your application, email programs or message them in ERAS to make them aware that an additional eSLOE is uploaded and ready for review. Refer to Chapter 5: Applying for Away Rotations for further data concerning the timing of your rotations to obtain SLOEs.

How do board scores affect my competitiveness?

Board scores, like eSLOEs, provide another objective comparative parameter. As already discussed, many programs will not interview applicants with a failed USMLE Step 1 or Step 2 score.^4,8,12 The transition of USMLE Step 1 and COMLEX Level 1 to pass/fail has eliminated the numerical predictive value of these tests. Data from NRMP PD surveys indicate any failure of these tests is used for application screening and is an indicator of being less competitive.3,6 When numerical scores are available, each program has different cut-offs for what they consider to be competitive. Ultimately, the decision to grant an interview is multifactorial, and scores alone may not guarantee nor prohibit an interview.

How important is USMLE Step 2?

Recent data indicates 95% of PDs desire a USMLE Step 2 score to offer an interview.³ Only 5% of PDs do not consider Step 2 in their decision to offer interviews. Thus, your safest bet is to complete Step 2 in time for your score to be released by mid-September.

What is a good score on USMLE Step 2 for applying to EM?

• Marginally Competitive: < 220 (including any failed USMLE Step 2 attempt)
• Less Competitive: 220–239
• Competitive Candidates: 240–259
• Very Competitive Candidates: > 260

How important are my preclinical and clinical grades?

While basic sciences grades have been ranked lower in terms of importance to residency programs, performance in required third-year clerkships is cited as being heavily valued in multiple studies.^3,6,8

Emergency medicine rotation grades have been cited as very important to PDs year after year.^3,6,8 However, students and PDs are aware that a grade alone does not translate directly into a certain level of competitiveness. Schools vary widely in terms of grade distribution (percentage of honors vs. high pass vs. pass grades). So, while a pass grade generally equates to lower competitiveness, this may not be the case on a pass/fail rotation or a rotation with a very high percentage of pass grades. Likewise, an honors grade generally equates to higher competitiveness, but this may not be the case if the majority of students at an institution obtain an honors rating on that rotation. Grade distributions are conveyed to PDs through eSLOEs and the MSPE.

For both non-EM and EM clerkships, an upward progression of grades through rotations will be well-received and a downward progression may be more poorly received.

How important are extracurricular activities?

Extracurricular activities are a good way to show yourself as an individual and display what mattered enough for you to volunteer your time. Interestingly, PDs tend to weigh extra-curricular activities more heavily than research activities for both interview selection and ranking.³ This often comes up during interviews, so be ready to discuss anything you are listing on your ERAS application. Leadership roles and involvement in medical school administration or interest groups can convey your dedication and work ethic. Focus on extracurricular activities that demonstrate leadership, commitment, and hard work.

How many volunteer experiences should I have?

Volunteer experiences are not overly influential in determining your competitiveness.⁶ However, they are tracked in ERAS, and PDs tend to cite them as having moderate influence, with about 60% of PDs citing them as useful in selecting candidates to interview. The type of volunteerism, commitment to volunteerism, or leadership in these activities likely outweighs the number of volunteer activities.

How important are work experiences when applying to EM?

Generally, EM-related endeavors help your application. Examples of these may include work as a scribe in an ED, work as an EMT or paramedic, or other work in the health care field. Prior jobs incorporating multi-tasking and customer service skills, such as waiting tables, may also be viewed as helpful. Prior work experience is not weighted as heavily as other factors when inviting applicants for interviews or selecting candidates for ranking.⁶ Most candidates who successfully match into EM have at least one or more work experiences listed, with an average of 3.4 work experiences.¹³

How important is research when applying to EM?

The amount of research experience is not generally very influential in determining the competitiveness of a candidate.^6,8 This will vary from program to program. Programs with prominent research efforts may emphasize research. Four-year residency programs also place a greater emphasis on research and publications compared to three-year programs.⁸ It is important to note that most candidates who successfully match into EM have at least two research experiences, and an average of three, though not all of this research pertains to EM.^6,13

What criteria might significantly change my level of competitiveness?

• Academic struggles, such as failing Step 1/Level 1 or Step 2, or failure of a preclinical course or clerkship
• Unexplained gaps in medical education or unexplained intervals in the CV
• Professionalism issues, including academic misconduct
• Criminal convictions, including felonies or misdemeanors

So, how competitive am I?

The following competitiveness-based recommendations take into consideration the data cited thus far. Please remember the following recommendations are general guidelines and should never replace advice from an experienced EMspecific advisor who is familiar with you and your application’s strengths and weaknesses.

Further, we highly recommend the use of data-driven resources to guide your sense of competitiveness. Such resources include the AAMC’s Residency Explorer tool and Texas STAR, which can help candidates determine relative competitiveness for an individual program. Unless a student is overwhelmingly competitive in all categories, it is incredibly difficult to determine if they are competitive for all programs. Competitiveness at each program will be determined by the culture and characteristics of that program. For example, program A may be a university-based program, in a desirable urban setting, with many resources, a “prestigious name,” and extensive research funding and productivity. Program A may emphasize high board scores and research experience, and they might only consider applicants from select medical schools. Program B may be community-based, either suburban or rural, emphasize diversity, wellness, and community service, and may therefore more heavily weight service, volunteerism, and a background that supports a candidate’s ability to integrate into the culture of the program. Neither program is better nor worse, but each has different attributes and strengths, for which they will try to select ideal candidates. Very few medical students will be ideal candidates at both programs, and that’s perfectly fine — because each program offers something unique and different. For this reason, it’s very hard to say that a student is universally competitive. However, for ease of understanding, we will attempt to break down aspects of competitiveness that students may use to help assess their status.

The following recommendations for the number of applications are considerably lower than the average number of applications per applicant to EM (55 according to AAMC’s 2023 preliminary data)¹⁴ and represent an area where applying strategically rather than in larger numbers will have a better return on investment.

Marginally Competitive

Your application will have some of the following criteria but likely will not overlap that of any other category:

• USMLE Step 1/COMLEX Level 1: Failure¹³
• USMLE Step 2: < 220 or failure¹³
• Only one EM rotation with no higher than a passing grade*
• No eSLOEs or an eSLOE that is not supportive
• Little or no exposure to EM in extracurricular projects or interest groups
• Presence of a red flag: academic struggle (failed Step 1 or Step 2, failure of a pre-clinical course or clerkship), gaps in medical education or CV, professionalism issues, academic misconduct, criminal convictions, etc.

How this affects your application strategy:

• While USMLE/COMLEX scores alone are not an indicator of suitability for EM, a failure or below-average scores combined with other factors such as an absence of an eSLOE or unsupportive eSLOE means you are at risk.
• You may not be well-suited for a residency in EM or may have to overcome significant obstacles. You should consider a search for alternative plans by applying to a different residency type altogether, but you may consider a parallel plan if you strongly desire (simultaneously apply to both EM and a different residency type as a backup/alternate).
• You may be tempted to apply to as many rotations and residency programs as possible. However, the return on this time and monetary investment will be poor. If you are a marginally competitive candidate, seek guidance from both an EM advisor and a general academic advisor to develop an appropriate application strategy.

Less Competitive

Your application likely will have some of the following components and none of the components of a competitive or very competitive candidate:

• USMLE Step 2: 220-239¹³
• Fewer than two eSLOES supporting a residency in EM
• Passing grades on EM rotations or a combination of pass and high pass grades*
• Limited exposure to EM through extra-curricular projects or interest groups

How this affects your application strategy:

• You may be well-suited for emergency medicine but should develop a residency search strategy with an experienced, dedicated, EM-specific advisor to optimize chances and align resources.
• You should plan to apply to about 35–45 programs with which you are well aligned in the above categories based on NRMP, Residency Explorer, or EMRA Match data.¹³

Competitive

The vast majority of applicants fall into this category! Your application will have at least two of the following components, but also may have some criteria of a very competitive or less competitive candidate:

• USMLE Step 2: 240-259¹³
• Two eSLOES that support a residency in EM
• A combination of pass, high pass or honors grades on EM rotations*
• Demonstrated commitment to EM in EM-related volunteer, research, or work projects

How this affects your application strategy:

• You are well-suited for a residency in EM and have a good chance at matching. General advising resources will apply to you, though an EMspecific advisor is best at guiding you to success.
• You should plan to apply to about 25–35 programs with which you are well aligned in the above categories based on NRMP, Residency Explorer, and EMRA Match data.¹³

Very Competitive

Your application will have two or more of the following components:

• USMLE Step 2: > 260
• Two eSLOEs that strongly support a residency in EM
• High pass &/or honors grades on EM rotations*
• Demonstrated commitment to EM in EM-related volunteer, research, or work projects.

How this affects your application strategy:

• You have a great chance at matching in EM and general advising resources and advice will apply to you, though an EM-specific advisor is best at strategizing for success. An applicant in this category should pursue their interests in the specialty and follow usual advice for the Match.
• You should plan to apply to about 20–25 programs with which you are well aligned in the above categories based on NRMP, Residency Explorer, and EMRA Match data.¹³

*Some schools only give pass/fail grades or administer a very low percentage of high pass and honors grades. Letter readers will be able to see this and determine your performance based on other components of the eSLOE, including comparison to your peers, but a pass/fail-only course makes it more difficult to determine your own competitiveness. In this situation, it is especially important to ask your letter writer the anticipated level of support their eSLOE will convey.

Tips for Increasing Competitiveness

There are many elements under your control, but by the time you apply to EM, some of them might already be settled. In that case, try these tips:

• Prepare for and do well on USMLE Step 2 early enough that it can be included in your ERAS application at the time of submission in mid- September.
• Perform at your best during your EM rotations, and obtain feedback from early EM rotations and mentors to augment your performance on future rotations.
• Rotate at two EM residency programs, ideally at your home institution and at an away institution. In some cases, a third rotation may be helpful, particularly if your home institution doesn’t have an EM residency or if you’re a less competitive applicant.

• Find an advisor in EM to help you assess your competitiveness and identify strengths and weaknesses. Ideally, this person should have experience in advising EM students, be part of core faculty of an EM residency program, and might be a clerkship director, PD, or APD. If you need assistance in finding an EM-specific advisor, email distanceadvising@cordjobboard.com to get connected.
• Consider participating in research, getting involved in a national EM organization, and networking with EM physicians. The advice and networking that comes with these experiences can help you as much — or more than — the projects themselves.

• The vast majority of applicants fall into the competitive category — and despite your anxiety, the likelihood is that you do, too!
• Competitiveness for EM residency programs is determined by a number of variables, many of which you can control or contribute to.
• In general, being professional, scoring well on your board exams, and performing well on your EM clerkship tend to play the largest role in determining competitiveness.
• While great board scores can get you in the door, they are not as important when ranking — this is where intangibles like your interpersonal skills come into play.
• Your application, just like you, is multifaceted. There is no magic formula that guarantees success in the Match. Work with your advisor to assess your own competitiveness by considering elements that are given the most weight by program directors and residency programs, as well as elements that have trended toward success in past matches.

References

1. Love JN, Smith J, Weizberg M, et al. Council of Emergency Medicine Residency Directors’ Standardized Letter of Recommendation: The Program Director’s Perspective. Acad Emerg Med. 2014;21(6):680-687.
2. Negaard M, Assimacopoulos E, Harland K, Van Heukelom J. Emergency Medicine Residency Selection Criteria: An Update and Comparison. AEM Educ Train. 2018;2(2):146-153.
3. National Resident Matching Program, Data Release and Research Committee: Results of the 2022 NRMP Program Director Survey. National Resident Matching Program, Washington, DC. 2022. Accessed September 29, 2022. https://www.nrmp.org/wp-content/uploads/2022/09/PD-Survey-Report-2022_FINALrev.pdf
4. Harmouche E, Goyal N, Pinawin A, Nagarwala J, Bhat R. USMLE Scores Predict Success in ABEM Initial Certification: A Multicenter Study. West J Emerg Med. 2017;18(3):544-549.
5. National Resident Matching Program. Results and Data: 2022 Main Residency Match®. https://www.nrmp.org/wp-content/uploads/2022/05/2022-Main-Match-Results-and-Data_Final.pdf
6. National Resident Matching Program, Data Release and Research Committee: Results of the 2021 NRMP Program Director Survey. National Resident Matching Program, Washington, DC. Accessed on Sept 20, 2022 at https://www.nrmp.org/wp-content/uploads/2021/11/2021-PD-Survey-Report-for-WWW.pdf
7. National Resident Matching Program. Charting Outcomes in the Match: Senior Students of U.S. Osteopathic MedicalSchools, 2022. https://www.nrmp.org/wp-content/uploads/2022/07/Charting-Outcomes-DO-Seniors-2022_Final.pdf
8. Negaard M, Assimacopoulos E, Harland K, Van Heukelom J. Emergency Medicine Residency Selection Criteria: An Update and Comparison. AEM Educ Train. 2018;2(2):146-153.
9. National Resident Matching Program. Charting Outcomes in the Match: U.S. Allopathic Seniors. July 2022. https://www.nrmp.org/wp-content/uploads/2022/07/Charting-Outcomes-MD-Seniors-2022_Final.pdf
10. Pelletier-Bui AE, Schrepel C, Smith L, et al. Advising special population emergency medicine residency applicants: a survey of emergency medicine advisors and residency program leadership. BMC Med Educ. 2020;20(1):495. Published 2020 Dec 7. doi:10.1186/s12909-020-02415-8
11. Boysen-Osborn M, Andrusaitis J, Clark C, et al. A Retrospective Cohort Study of the Effect of Home Institution on Emergency Medicine Standardized Letters of Evaluation. AEM Educ Train. 2019;3(4):340-346. Published 2019 Jul 30. doi:10.1002/aet2.10374
12. Emergency Medicine Residents’ Association. EMRA Match. https://webapps.acep.org/utils/spa/match#/search/map. Accessed Aug. 8, 2022.
13. National Resident Matching Program, Charting Outcomes in the Match: Senior Students of U.S. Medical Schools, 2022. National Resident Matching Program, Washington, DC 2022. Accessed Oct. 27, 2022. https://www.nrmp.org/wp-content/uploads/2022/07/Charting-Outcomes-MD-Seniors-2022_Final.pdf
14. AAMC. ERAS Statistics: ERAS 2023 Preliminary Residency Data. https://www.aamc.org/data-reports/interactive-data/eras-statistics-data. Accessed Jan. 8, 2022.