Ch. 5 - Applying for Away Rotations
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Ch. 5 - Applying for Away Rotations

The away rotation plays a critical role in the EM residency match. For the medical student, it is an opportunity to explore different geography and learning environments that may vary by region or hospital. For the residency program, the away rotation offers an independent assessment of a student’s ability to learn and grow from the feedback they receive and demonstrate consistency across institutions and different clinical settings.

In the 2021 NRMP Program Director Survey, “Letters of Recommendation in the Specialty” — known in EM as the eSLOE (electronic Standardized Letter of Evaluation) — was one of the most commonly cited factors (90.5% of respondents) in selecting which applicants to interview and had the highest importance rating (4.8 out of 5).1 As eSLOEs can only be obtained through EM rotations at EM residency programs, it is no surprise that “audition elective/ rotation within your department” and “away rotation in your specialty at another institution” were among the other most important factors.1 (More information about the structure and content of the SLOE can be found in Chapter 6: Crush Your EM Clerkships, Secure Your SLOEs.

How Many Away Rotations Do I Need?

To be a competitive EM applicant, aim to complete two EM rotations and obtain two eSLOEs. Typically, this will be one home rotation and one away rotation. For students without a home EM rotation, this will be two away rotations at different institutions. Students should have at least one, but ideally two, eSLOE(s) submitted in time for the ERAS application opening in September to be granted interview offers. If you are unable to complete two rotations at EM residency programs by this time, the two eSLOEs should ideally be submitted by the end of October, as some programs prefer two eSLOEs before granting interviews.

PDs place a high value on away rotation evaluations. Two survey studies from 2018 and 2021 showed that performance on an away rotation is one of the most influential factors PDs consider when making interview selection decisions.1,2 At the same time, two studies from 2019 and 2020 demonstrated superior student performance on home rotations evaluations.3,4 This suggests that students should complete a home rotation first, followed by an away rotation.

Regarding the number of rotations needed to interview, two studies found 80– 90% of programs require at least one eSLOE to grant an interview; in addition, studies and data from EMRA Match have shown that 20–45% of programs require two eSLOEs to grant an interview.2,5,6 This variance may be due to differences in respondents and wording. Nonetheless, it shows the importance of having two eSLOEs for a competitive application. It is exceedingly rare for a program to require more than two eSLOEs. In fact, one study showed that students performed worse on their third rotation.4 Of note, this data is not meant to apply to subspecialty SLOEs such as ultrasound, toxicology, pediatric emergency medicine, etc. There is rarely a need for a third eSLOE and rotation — unless your advisor feels it’s needed to strengthen your application. If this is the case, it should be clearly explained in your residency application.

Osteopathic Candidates: For an osteopathic applicant with similar competitiveness to the average allopathic applicant, 79% of residency leadership respondents recommended two eSLOEs, and only 11% recommended submitting three or more.7 Remember, if your medical school does not have a residency program, you should secure two away rotations.

IMG Candidates: For an IMG applicant with similar competitiveness to the average allopathic applicant, 63% of residency program leadership respondents to a recent survey recommend two eSLOEs, whereas only 19% recommend three or more.7

Latecomers: Very few programs will extend an interview invitation with no eSLOEs (only 14 on EMRA Match at the time of publication), and 61% of programs who responded report extending offers with one eSLOE.6 Prioritize getting an eSLOE as early as possible after you choose EM. If you have a later letter, make sure to notify the residency programs when it is uploaded.

At-Risk Candidates: Having strong clinical skills but difficulty translating this knowledge in testing situations is a familiar struggle. Programs are more likely to consider students with weaker test scores if they have established a consistent pattern of strong clinical performance. Seeking out clerkships that do not have testing requirements as a criterion for grading may also be beneficial for you.

You are not required to submit an eSLOE from every EM rotation you complete. If you suspect that an eSLOE may not be very supportive, additional or alternative letters are often the best way to mitigate this. If you complete an EM rotation and do not submit an eSLOE from the rotation, remember that programs will be able to see that discrepancy — so be prepared to discuss it in your interviews.

Where Do I Want to Rotate?

Consider a few strategies when deciding where to rotate — targeted, exploratory, or practical.

In the targeted approach, you can aim for a specific program or region of the country to explore “personal fit” and demonstrate interest. This is the ideal approach for many, as geography and “fit” are among the most important factors in applicants choosing an EM program.8 Many programs also prefer a “known” candidate, and this should offset the fear that you might perform poorly on an audition rotation at a specific institution. Regional competitiveness can vary based on the perceived desirability and concentration of residency programs. In a more competitive region, obtaining an eSLOE from a program there may be advantageous (even if you do not “honor”), as programs from the same region will see your dedication to that geographic location.

An exploratory strategy may be an option if you’re less geographically inclined. Rotating in a different region adds perspective and opens opportunities during the application season. You should also consider varying clinical environments. Academic, county, and community are a few of the characterizations a hospital/ program might have, and they impact how learning is accomplished and patient care is practiced. Exploring different practice environments will help you be more prepared come interview season.

Like interviews, away rotations can be expensive and inconvenient. As a practical strategy, we strongly advise you to consider the cost of living, housing, transportation, and your academic schedule when planning for away rotations. To successfully match into EM, your performance and professionalism are more important than where you rotated. It is reasonable to choose an away rotation in the same region to contain cost. Also, discuss your interest in completing an away rotation with your financial aid department and advisor, as there might be options to extend loans to cover costs.

Osteopathic Candidates: Certain states and programs have been more “friendly” to osteopathic applicants in the past (see Chapter 8: Understanding Your Competitiveness). EMRA Clerkship Match reports that 86% of clerkship programs accept osteopathic students.4

IMG Candidates: Only 23% of clerkships listed in EMRA Clerkship Match report accepting international students.6 International medical schools often have a list of affiliated sites, as well as a list of unaffiliated sites at which past students have rotated. Students from international medical schools may benefit from seeking the advice of graduates who have matched into EM to inquire where they completed their EM rotations.

Military Match: Students should do at least one, and may end up doing all, of their rotations at a military EM site. Group eSLOEs from military rotations remain useful for gaining interviews at non-military programs.

Couples Match: Consider away rotations in cities where both you and your partner are interested in matching. Check with your mentor — depending on your specific application profile, you may need to do two away rotations to maximize your chances for success in the couples Match. This is particularly true if your partner is applying to a competitive specialty.

How Do I Find Rotations?

Several resources exist to help you find available away rotations. Most residencies will have a clerkship, and you can find information on the residency website. The AAMC’s Visiting Student Learning Opportunities (VSLO) site is a portal for away and global rotations in all specialties.

Specific to EM, the EMRA Clerkship Match tool allows applicants to browse, search, and filter nearly 300 residency programs and approximately 200 clerkships.6 Clerkship filters include:

  • Participation in VSLO
  • USMLE Step 1/COMLEX Level 1 required
  • Spot availability indicator
  • Rotation types
  • Flexible rotation dates
  • Interview policy
  • eSLOE authorship
  • Consider DO students
  • Consider IMG students
  • Housing availability
  • Vehicle recommended

EMRA offers an updated list of away rotations specific to international students, diversity-oriented opportunities, and more.

SAEM also has a Clerkship Directory with a filter tool based on several learning environment factors (region, hospital setting, trauma designation, and number of residents per year). If you’re interested in a specific institution, check the program’s website directly.

An increasing number of EM departments and institutions offer stipends to students from underrepresented groups to rotate via diversity externship scholarships. These can be found on the department websites or through EMRA, AAMC, CORD, and SAEM databases.6,9,10,11

Osteopathic Candidates: Fewer than one-third of osteopathic medical schools having affiliated residency programs, so osteopathic students must apply smart, early, and realistically to obtain two early academic rotations to provide them with competitive eSLOEs.12 Recent data suggest that on average for most allopathic and osteopathic students, approximately one in 4-5 clerkship applications results in an acceptance.13

IMG Candidates: Similarly, international medical graduates will not have a home EM rotation and will need to obtain 2–3 SLOEs to be considered for an interview.

When Do I Apply? When Do I Rotate?

Most institutions begin accepting applications in March or April, with a small minority of programs opening before March.6 The timing varies by institution (see Figure 5.2). This does not account for application preparation time, so students should plan accordingly. Factors that complicate planning your away rotations include home institution core rotations and other schedule requirements that often extend into mid- to late-summer, as well as inflexibility of the away rotation schedule. Only three out of every 10 clerkships listed in EMRA Clerkship Match advertise flexible rotation dates.6

5.1 VSLO Timeline.png

Students usually complete their home and away rotations in the summer, but many students will not be able to complete their second rotation until late summer, fall, or sometimes winter. On EMRA Match, nearly 33% of programs report requiring two submitted eSLOEs to grant an interview — putting you at a disadvantage if your EM rotations are not completed by the time programs start to review ERAS applications.6 This does not bar any student from matching into EM, however, and we strongly recommend students seek advice and plan ahead. In general, students should have a minimum of one eSLOE submitted by the time of ERAS applications open to programs for review in mid-September to qualify for receiving interview offers.

Many clerkships also process applications on a rolling basis, and other students may change their schedule, creating availability as the audition rotation season progresses. Because of this rolling process, it is best to apply as early as possible, allowing for maximum availability in rotation time slots. Institutions may review in bulk and fill their spots early. Delaying your application or limiting your rotation time slots may limit your options.

Military Match: Military rotations are usually set up in January by contacting the program directly via email. Contacts are updated on the MODS (Medical Operational Data System) website.

Latecomers: Consider following up with programs that may not have initially offered a rotation position, as open spots may become available with late cancellations from other students. You can also utilize the spot availability indicator filter on EMRA Clerkship Match.

How Do I Apply for Away Rotations?

Most applications can be completed through the AAMC’s VSLO system. Approximately 70% of clerkships on EMRA Clerkship Match participate in VSLO.6 Visit the VSLO website to create an account and receive specific instructions regarding the application process.

Application requirements may vary slightly across programs. In general, materials you should gather before applications open include:

  • An updated CV
  • Personal statement/letter of intent
  • Professional photograph
  • Proof of USMLE Step 1/COMLEX Level 1 completion
  • Medical school transcript
  • A letter of recommendation from an EM advisor*
  • Proof of positive vaccine titer response
  • Immunization record
  • Proof of BLS and/or ACLS certification
  • A certified background check and drug screen**
  • N95 Respirator fitting

This list is by no means exhaustive, as some programs require institutionspecific paperwork and/or training. To best prepare, an applicant can often look at previous years’ requirements if still on VSLO or on the program’s website to have a better sense of what a specific program may require.

*Some rotations will ask for a letter of recommendation from an EM advisor. Do not stress out if you have not worked in the ED yet — this does not need to be someone you’ve worked with, just someone who knows you’re serious about pursuing a residency in EM.

**Some institutions, but not all, will ask for a new, certified background check and/or a drug screen. As they are not universally required, you should review individual requirements specified by your desired institutions.

IMG Candidates: International students will also want to consider their visa status when applying for clerkships. International students can use EMRA Match to find clerkships that are open to IMGs and residency programs that will sponsor visas.

Some of the proposed materials are more difficult to plan for submission than others. For instance, not every applicant will have taken Step 1/Level 1 by the time applications open. However, on EMRA Clerkship Match, 89.9% of programs require a Step 1/Level 1 score for consideration of a rotation spot — with 44.4% of programs specifically requiring Step 1 and 45.5% accepting a Level 1 passing score in place of Step 1.6 With the recent transition of both Step 1 and Level 1 to pass/fail, we anticipate an increase over the next few years regarding the number of programs that accept Level 1 instead of Step 1 for osteopathic students. However, if specifically required by your desired rotations, it is worth considering taking Step 1 to have a score report by the time VSLO opens.

Clerkship Application & Vaccination Timeline

Proof of positive vaccine titer response is another component that requires advanced planning. Timing is important here, as any negative titer results will require a booster and a designated waiting period for antibody response. Be prepared! Do not let this requirement delay you from submitting applications. While most clerkships make use of the AAMC Standardized Immunization Form, which only requires Hepatitis B titers, some institutions that do not use this form may require MMR or varicella titers as well. To be safe, having all five drawn is advantageous, but that needs to be considered against your financial situation. Other testing and vaccinations to consider include being up-to-date on the influenza vaccine and having documentation of a recent two-step tuberculin skin test (aka PPD) or QuantiFERON Gold test. Also, consider institutions’ requirements regarding COVID-19 proof of vaccination.

IMG Candidates: A small population of candidates may have received the Bacille Calmette-Guerin (BCG) vaccine outside of the United States and subsequently tested positive on their PPD. For healthy, asymptomatic applicants, proof of Isoniazid (INH) completion and a recent normal chest X-ray report should suffice. However, in rare instances, these candidates may be asked to undergo additional testing.

A proposed timeline for gathering documents and having titers drawn is listed. This will allow you to apply to a few programs that begin accepting applications in February. Most programs may not accept rotation applications until March or April, however, so it is important to visit VSLO and plan on an individual basis.

November

  • Get titers drawn. If any are negative, immediately get a booster. Titers typically may not be re-drawn for 6–8 weeks.

December

  • Update your CV and choose an appropriate professional photograph.
  • Gather other previously mentioned documents as time permits.
  • Visit program websites to research programs.
  • Ask an EM advisor for a letter of recommendation, if required by desired rotations.

January

  • Complete background check, if necessary.
  • Establish and execute a firm plan for up-to-date TB testing.
  • Have titers redrawn (if necessary and not already completed).
  • Write your personal statement/letter of intent for the programs that require it.

February–April

  • Submit VSLO application(s) as soon as each program accepts submissions.

Not all clerkship programs use VSLO, which attempts to standardize the process, but they will in general have similar requirements. Find specific rotation requirements and instructions at individual programs' websites outside of VSLO.

Latecomers: Targeting applications towards programs that do not utilize VSLO in an effort to secure a rotation may increase your chances of success, as these programs may receive fewer overall applications compared to programs available on the VSLO platform.

How Do I Get Accepted for an Away Rotation?

Expert opinion recommends that an average student applies to 5–7 institutions to receive 1–2 invites. Be cautious in over-applying for EM away rotations. A recent study in 2022 showed that EM-bound students, as a whole, received one away rotation offer for every 4-5 applications submitted.12 DO candidates submitted twice as many applications as MD candidates while experiencing a similar rate of offers received. Peer influence, peer online advising networks, and self-assessment were the most often reported causes of increased applications.12 Consult with your advisor to determine the right number of applications for your personal situation and goals.

In general, clerkship directors value genuine student interest in matching at their program or region. In the current application environment, however, a common sentiment is that student interest is hard to gauge. If a program requests a statement of interest, this can be a great opportunity to communicate your particular interest in the region and the program. Local ties, for example, are valuable to mention.

Personal, direct communication to the clerkship director or coordinator, beyond the letter of interest requested by the application, may be helpful in some cases but detrimental if overused. Reach out through direct communication judiciously, reserving it only for a few institutions (maximum of three) in which you are most interested.

Your home institution can also help you secure an away rotation if you communicate specific interests. It is acceptable to want to leave your home institution for residency training. Many programs, especially those with a large cohort of EM-bound medical students, will appreciate that disclosure. In that case, your home institution may have faculty connections to a particular region who can help you secure a rotation. Again, overuse of this strategy will also dilute its effect.

Latecomers: Contact your home EM advisor directly and as soon as possible once you decide to pursue EM, as they can be an invaluable resource of experience and connections in your effort to complete application requirements.

Attendance at conferences and other networking opportunities may be helpful. National conferences, such as ACEP’s Scientific Assembly in the fall, are a great opportunity to network face-to-face. EMRA hosts an ongoing array of both virtual and in-person opportunities for students. The Medical Student Forum is held twice a year in the spring and early fall, so attendees will have enough lead time ahead of VSLO applications to establish a network, follow up, and apply. You can learn more about programs and make connections at EMRA’s fall residency fair, but it is important to recognize attendance does not guarantee an away rotation. This is especially true for students attempting to secure a rotation or interview at more competitive institutions.

Troubleshooting & Tips

How do I deal with conflicting home requirements and away rotation schedules?

  • Address it early with the dean of your home institution or contact the away rotation clerkship director. Some institutions will make exceptions or help you troubleshoot. Asking for an exception implies genuine interest. Reserve this only for rotations you would almost certainly accept if offered.

I do not have EM faculty at my institution. Where can I find individualized advice?

I couldn’t secure an away rotation at a program I was very interested in. How can I still show interest and learn more about the program?

  • Often, institutions will offer away rotations in a subspecialty area of emergency medicine. A subspecialty SLOE from these rotations is less influential than a categorical EM rotation eSLOE, but a strong performance may resonate with that specific program — and you will gain valuable knowledge, a new skill set, and familiarity with the institution. Common subspecialty rotations include EMS, global health, pediatric EM, research, toxicology, ultrasound, and wilderness medicine. These subspecialty rotations can be identified using the filter included in EMRA Clerkship Match.

What if I don’t get or can’t do an away rotation?

  • While away rotations have many practical benefits, they also pose difficult hardships and may not be feasible for some students. Parenthood and pregnancy are two such situations that may constrain the ability of one or both partner(s) to travel far from home. Family illness and caregiver needs may affect others. In general, EM programs are sensitive to work-life balance and personal wellness. Nevertheless, these situations require a thoughtful approach to your communication with programs.
  • If you’re in this situation, it’s most important to have a trusted, experienced advisor help you develop a plan. Complete an additional EM subspecialty elective at your home institution. The ideal elective would give you an opportunity to demonstrate your clinical skills to EM faculty who could then write an additional faculty-only SLOE. Finally, you should thoughtfully and deliberately explain the reason for being unable to complete a traditional away rotation — this communication should be part of the plan you develop with your advisor and be included in your ERAS personal statement.

I accepted an away rotation, but then I received an invitation from my top-choice program. Is it OK for me to cancel my original rotation?

  • Yes, but please be considerate when canceling an away rotation. If the rotation is several months out, such that the program can accommodate another student, then a cancellation is typically understandable and should be accompanied by polite and honest communication.
  • Last-minute cancellations of away rotations are strongly discouraged and will be frowned upon — with the exception, of course, of personal emergencies.

The Bottom Line

  • Your EM rotations should be affiliated with an EM residency program so you can obtain a group eSLOE.
  • With rare exceptions, EM candidates should complete two EM rotations to acquire a total of two eSLOEs. If available, one of your two rotations should be a home rotation.
  • You should have a minimum of one eSLOE by the time residency programs can view applications in ERAS (mid-September) to be considered for interview invitations. Having two eSLOEs submitted by this time will maximize your competitiveness.
  • It is highly unusual for an applicant to require three eSLOEs to match, and it does not necessarily make you more competitive. In fact, doing extra away rotations may be harmful to your colleagues who are having difficulty obtaining their first away rotation.
  • An away rotation should be affiliated with an EM residency program so that your SLOE can be completed by an EM faculty member.
  • VSLO is the standard way to secure away rotations, but there are other ways that will require more personal inquiry. In general, current expert opinion suggests you should apply to 5-7 clerkships to get 1-2 invites. Consult with an advisor to confirm an application strategy that supports your personal situation.

References

  1. National Resident Matching Program, Data Release and Research Committee. Results of the 2021 NRMP Program Director Survey. https://www.nrmp.org/wp-content/uploads/2021/11/2021-PD-Survey-Report-for-WWW.pdf
  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. Wilson D, Laoteppitaks C, Chandra S. A comparison of standardized letters of evaluation for emergency medicine residency applicants. West J Emerg Med. 2020;22(1):20-25.
  4. 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.
  5. King K, Kass K. What do they want from us? A survey of EM program directors on EM application criteria. West J Emerg Med. 2017;18(1):126-128.
  6. Emergency Medicine Residents’ Association. EMRA Match. https://webapps.emra.org/utils/spa/match#/search/map. Accessed January 2, 2023.
  7. National Resident Matching Program. Results of the 2017 NRMP Applicant Survey by Preferred Specialty and Applicant Type. http://www.nrmp.org/wp-content/uploads/2017/09/Applicant-Survey-Report-2017.pdf.
  8. Gordon D, Wallenstein J. Away Rotations: Addressing and Navigating the Chaos. Council of Emergency Medicine Residency Directors, 2018 Academic Assembly, San Antonio, TX.
  9. Council of Emergency Medicine Residency Directors Student Advising Task Force. (2018). [CORD SATF Advising Addenda Study]. Unpublished raw data.
  10. Explore URiM opportunities for visiting students. Students & Residents. https://students-residents.aamc.org/students/explore-urim-opportunities-visiting-students. Accessed January 17, 2023. Diversity oriented away/scholarship programs. Apply for Away Rotations. https://www.emra.org/students/advising-resources/apply-for-away-rotations/diversity-oriented-scholarship-programs/. Accessed January 17, 2023.
  11. SAEM. Underrepresented minority scholarships. SAEM.org. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/underrepresented-minority-scholarships. Accessed January 17, 2023.
  12. Stobart M, O'Connell A. Medical Education Accreditation System: Evaluating Factors for Match Success in Emergency Medicine. West J Emerg Med. 2018;19(5). https://escholarship.org/uc/item/9cc5n91z Accessed January 15, 2023.
  13. Zhang XC, Gordon D, Lutfy-Clayton L, et. al. Away rotation applications in emergency medicine: Medical student behaviors, outcomes, and stressors. J Emerg Med. 2022;62(3):401-412.
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