Ch. 7 - Building Your ERAS Application
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Ch. 7 - Building Your ERAS Application

By now, you have started to consider the different types of EM residency programs available (Chapter 4), you have completed or scheduled your EM clerkships and USMLE/COMLEX exams (Chapters 3 and 5), and it’s time to understand how you actually go about applying to residency programs. There are several components of the application, and each will impact your competitiveness (Chapter 8). Be sure to connect with your advisor as you build your application to discuss your unique concerns and help guide your decision making. As a reminder, students at schools without an EM residency or EM advising can email distanceadvising@cordjobboard.com for help finding an advisor.

The Electronic Residency Application Service

ERAS is a platform offered by the AAMC and used by most specialties for senior medical students applying for residency positions.1 The ERAS application helps you get a foot in the door in order to gain an interview invitation. It also provides a great deal of information about you, which residency leaders will use to help prompt interview discussion and determine your position on their rank list.

How Do I Create an ERAS Account?

Registering for ERAS requires a “token” that will be provided to your medical school’s dean’s office.

IMG Candidates: Visit ECFMG.org to purchase an ERAS token via the Online Applicant Status and Information Systems (OASIS) portal. Graduates of Canadian medical schools should visit CaRMS.ca for information how to register for ERAS. It is important to consult the ERAS “Residency Timeline for International Medical Graduates” on their website each year for exact dates.

Military Match: The military uses a separate application system through MODS (Medical Operational Data System); however, you must also apply through ERAS to be considered for civilian programs in case of deferment.

Know The Timeline

Keep key dates in mind when approaching the application process, and mark them on your calendar. The first is the date when ERAS opens and you can begin editing your application and uploading documents, typically in early June. Students may begin to submit their completed applications in early September. Exact dates may vary between cycles — double check the ERAS website for your year and mark these dates in your calendar!

Residency programs are granted access to applications and supporting documents on a set date, typically in late September. All applications submitted before ERAS opens to programs will be stamped with the same date and time. The early submission window was created simply to avoid technical difficulties related to the huge volume of applications being submitted simultaneously. Submitting your application before this date will help reduce the possibility of overwhelming the website and running into technical issues but will not give you any advantage in terms of when programs receive your application.

7.1 Timeline.png

Stick to the Timeline!

It is imperative that you submit your application before residency programs are granted access. Consider assembling your application in June of your fourth year to avoid delays. In a prior survey of PDs, only 15% of respondents stated that it was “highly likely” that an application would be reviewed if it were completed after the ERAS opening date.2

Regardless of when you apply, once you certify and submit your application, you will not be able to make changes other than on the “Personal Information” section and uploading additional letters of recommendation.

Military Match: The deadline for initial application to military programs through MODS is the second week of September, and supporting documents are typically due mid-October. Rank lists are usually submitted around this time as well. Keep these military-specific deadlines in mind as you must complete both MODS and ERAS simultaneously.

Latecomers: Do not wait for rotations or letters. Submit your application on time, and update it with additional documents as they become available.

The Components of ERAS

  • Personal and biographic information
  • Curriculum vitae (education, experience, licensure, publications)
  • Personal statement
  • Letter(s) of recommendation
  • USMLE transcript and/or COMLEX-USA transcript
  • MSPE (aka “Dean’s Letter”)
  • Medical school transcript
  • Photo (optional)
  • Residency program application list
  • Geographic preferences
  • Program signals

Personal and Biographic Information

This section is where you enter your basic demographic and biographic information, as well as military service obligations and couples matching.

There is also a section for you to include your NRMP match ID, which you will get when you register for the NRMP Match. This is a separate process from creating and submitting your ERAS application. You must go to the NRMP website (www.nrmp.org) to register and pay the one-time fee. Note that NRMP Match ID registration historically does not open until mid-September, and late registration for an additional fee begins after late January. You do NOT need this ID number to submit and certify your ERAS application, and you can add it later — so don’t wait for it. Still, do NOT forget this step because it is required to rank programs.

Couples Match: Discuss with your advisors and partner if you will disclose your couples Match status on ERAS. You are not mandated to disclose, and there are pros and cons to disclosure. In a recent CORD ASC-EM survey, EM PDs responded that they contact the PD from the corresponding residency program at their institution when considering a member of a couple. Disclosing couples matching status allows PDs from each specialty to lobby for their applicant’s partner. Alternatively, if a partner is applying to a specialty that is not offered at the same institution, some PDs may think the interview might be low-yield. When it comes to EM-EM couples, many programs may make extra efforts to interview both members of a couple if the status is disclosed, but a handful of programs may want to avoid EM-EM couples. In general, the attitude within the EM community is that the benefits probably outweigh the risks for most EM-EM couples.

Curriculum Vitae/Experiences

The CV is a collection of several individual sections within ERAS that is compiled into a different format for readers in case they prefer to view the items in one unified document. These sections occasionally are updated, but for the 2023-2024 cycle, these individual sections will include:

  • Education/training
  • Military service
  • Professional organization
  • Extracurricular clubs, activities, hobbies
  • Research
  • Teaching/mentoring
  • Volunteers/service/advocacy
  • Work

You will be limited to 10 total experiences and will have the opportunity to choose and expand upon your top three most meaningful. For each of these experiences, you will assign a setting (rural, urban, suburban, virtual), a focus area (basic science, clinical/translational science, community involvement/ outreach, customer service, health care administration, improving access to health care, medical education, music/athletics/arts, promoting wellness, public health, quality improvement, social justice/advocacy, technology), and a key characteristic (communication, critical thinking and problem-solving, cultural humility and awareness, empathy and compassion, ethical responsibility, ingenuity and innovation, reliability and dependability, resilience and adaptability, self-reflection and improvement, teamwork and leadership).

You will also have the ability to write an optional “other impactful experience” essay that is designed to allow applicants to provide additional information about their journey to residency that is not captured elsewhere.

While board scores, SLOEs, and medical transcripts provide objective data for residency program leadership, this section allows you to describe accomplishments outside of the classroom/clerkships and highlight personal qualities not captured elsewhere in the application. This section is often thought of as the “X-factor” of your application and helps reviewers gauge if you resonate with the program’s mission and values. It can be helpful to think of your CV as evidence to support the narrative you will reference in your personal statement and in interviews.

There is a real opportunity to stand out from other applicants. Simply listing your experiences does you a disservice — your application is much stronger if you include brief details of each activity to highlight your role and specific characteristics you developed through each experience. Describe what you learned from each experience, what new skill(s) you acquired, or how it made you a better person. Focus on writing more about the experiences that were the most significant to your personal and professional development. Take advantage of the personal interests/hobbies section; this is one of the few chances you will have to talk about who you are outside of medicine, and it’s frequently a great springboard for conversations during program interviews. A common pitfall in this section of the application is exaggerating the amount of time you committed to an activity or the scope of your role and responsibilities. Be truthful — always.

At-Risk Candidates: Applicants with a history of felony or misdemeanor convictions will be required to disclose this. An applicant with this history is best served accepting responsibility, taking ownership of any mistakes, and demonstrating conscious changes for the better.

Latecomers: Include activities and accomplishments in other fields on your CV if they are substantial. Leadership, work, and research in other specialty areas may still be relevant. Emergency medicine as a specialty requires a broad set of skills and interests.

Personal Statement

Personal statements can cause a high level of anxiety. How do you write a personal statement that effectively introduces you and captures your excitement about EM? What is the role of the personal statement? How does it differ from other parts of your application? How much will it matter?

A survey of EM residency directors showed the most influential components of residency applications are SLOEs, residency interviews, EM evaluations/grades, and clinical clerkship grades. The personal statement ranked below all of these components in importance.3 This is good news and bad news. A poorly written or inappropriate personal statement likely has more potential to harm than a good personal statement has the potential to help. It is unlikely a great personal statement will make up for an otherwise poor application, but sometimes a great personal statement can tip the scales in your favor.

So how do you write such a statement? Show (rather than tell) programs that you have the qualities to be a great resident by using examples from your previous experiences and achievements. Writing about how much you enjoy EM does not distinguish you from any other applicant; focus instead on what makes you unique. Describe the challenges you’ve faced to demonstrate your ability to persevere. Highlight how your previous experiences show your passions, values, and goals and how you plan to channel your intelligence, creativity, and compassion into your career. You don’t need to go into every past experience; choose key examples that highlight who you are and what you’re looking for in a residency. Programs want to know if you will be a good fit, so show your personality. Close by discussing what you are looking for in a residency program and what you want to gain from the next 3–4 years of your training.

Other essential facts that apply to all writing apply here, too.4 Edit your statement, put it away for a few days, and then edit again with fresh eyes. Ask those you trust to read it as well, especially your advisors. Take their recommendations with a grain of salt, but make sure you correct all spelling and grammar mistakes.

Although it is stressful, try to have some fun with the process. It is, by definition, the most personal part of the application. Allow yourself to reflect on what makes you really you, and let that shine through.

Each statement is limited to 28,000 characters. There is no limit to the number of personal statements that can be created, and you can create program-specific personal statements (but be very careful not to send the wrong statement to the wrong program). If there is something about a particular program that appeals to you, especially if this may not be communicated elsewhere in your application, this is the opportunity to let them know!

At-Risk Candidates: Applicants with a facet of their application that is likely to be considered a red flag, such as a USMLE/COMLEX or course failure, a felony or misdemeanor conviction, a gap in their CV, etc., should use the personal statement to address these issues.5 The new other impactful experiences essay may also be an appropriate place to address these.

These components are likely the initial places a reviewer will look for an explanation. If they do not find one, there is little incentive for them to go any further in considering you for an interview. Take ownership of your past and do not make excuses. Articulate how you have emerged from your challenges better equipped for a career in EM. Most importantly, have your advisor read your statement and give you feedback.

Latecomers: The personal statement may be a good place to explain how you came to EM as a specialty, but keep it concise. Be sure your statement also shares experiences that convey the bigger picture of who you are and what you have to offer.

Dual Applying: You can create and assign different personal statements to different programs, which is important for students applying to both EM and EM-combined programs or programs in a different specialty.

Letters of Recommendation

In Chapter 5: Applying for Away Rotations, it was discussed that the eSLOE obtained at the end of each EM clerkship is the single most crucial component of your application.2,3,6 As a reminder, eSLOEs are obtained from rotating at EM clerkships at institutions that have an EM residency program. While historically, applicants may have completed more than two total EM rotations, post-COVID, only a total of two EM rotations are typically recommended or required.7

ERAS allows you to submit a maximum of four Letters of Recommendation (LoRs) to each program, but it is not necessary to upload four. It is variable how many total letters a program will want before they consider a student’s application to be “complete enough” to offer an interview, though some programs require three total letters, making this a good target number. It is important to know that after four LoRs are assigned to a program, you can’t remove/add LoRs. Therefore, if you plan to perform a late categorical or subspecialty EM rotation (September or later) but are counting on this rotation for a SLOE, it is important to leave a LoR spot open for this SLOE at the time of your initial application submission. Additional letters can be added as they become available, but do not delay submitting your applications while waiting for SLOEs to be uploaded.

Within ERAS, you must enter the names and titles of your letter writers, the specialty the letters will be used to apply to (emergency medicine), and whether or not you waive the right to view each LoR. In general, applicants waive the right to review their LoRs, allowing letter writers to provide a candid assessment. Once a LoR entry has been confirmed, you will be provided with a unique Letter ID and Letter Request Form that can be delivered to LoR authors by email directly from ERAS (with an optional custom message), or downloaded as a PDF, with instructions for letter writers on how to upload the LoR.

While it can be to your advantage to have both eSLOEs uploaded by the time ERAS applications open for programs to review, it’s not a deal-breaker. Many programs will still consider you with only one eSLOE at the time of file review and interview offer, though the majority want to see a second eSLOE by the time of ranking. Refer to EMRA Match and program websites for eSLOE number requirements and preferences. A third eSLOE is rarely suggested but may be beneficial if you have red flags or had a challenging rotation.8

In addition to the two eSLOEs recommended from your clerkship experiences, you can add LoRs from other faculty members with whom you have worked closely, either in SLOE format or narrative format. You may request a SLOE from an EM faculty member that works at a hospital affiliated with an EM residency program (eSLOE for academic EM faculty), one at a hospital not affiliated with an EM residency program (SLOE for non-academic faculty), or an EM faculty member you worked with during a subspecialty rotation such as ultrasound, EMS, pediatric EM, or toxicology (SLOE from an EM subspecialty rotation). O-SLOEs (Off-Service Standardized Letter of Evaluation) can be used for non-EM letter writers, such as faculty members from other specialties, such as surgery or internal medicine, who know you well and can provide an additional perspective on non-EM parts of your application.9-11

You should preferentially request that non-EM letter writers utilize the O-SLOE form, as this carries slightly more weight than a standard narrative LoR. Other options for LoRs are narrative letters from research mentors, medical school advisors or deans, and individuals with whom you’ve worked closely on important projects or initiatives — just realize that these will likely carry less weight than a clinical LoR.

Just like personal statements, you can have more LoRs uploaded to ERAS than you can disseminate to each program and can choose to send different letters to different programs. However, it is important to note that each program should receive both of your academic EM faculty group eSLOEs. Academic EM faculty group eSLOEs carry more credibility and weight than the other types of SLOEs.10

Latecomers: While studies show that letters from a physician in a specialty other than EM, even in O-SLOE format, carry less value than an EM eSLOE, these letters are still valuable, especially as you may have a mentor or advisor from a different specialty who has worked closely with you.6 You can consider including a non-EM LoR if you had a strong relationship with the writer and feel they can speak to attributes or qualities less described in your other letters. Be sure to leave room in ERAS to upload two eSLOEs, even if they will be uploaded after you submit your application.

Re-applicants to EM: If applying to EM after beginning a residency in another specialty, it is critical to include a supportive LoR from your current program director, describing your performance as a resident.

USMLE or COMLEX Transcripts

Within ERAS, applicants must authorize the release of their Step/Level scores from the NBME/NBOME by entering their USMLE/COMLEX ID and paying a onetime transcript fee. You can track the status of your transcript request by logging back into ERAS. If your Step 2 score is not available at the time of your initial application, you must log back into this section of ERAS and select “Resend My Scores.”

Guidance about when to take USMLE Step 2 can be found in Chapter 3: Third Year and Planning for Fourth. Information about how your USMLE/COMLEX scores should influence your application strategy can be found in Chapter 8: Apply Smarter, Not Harder: Understand Your Competitiveness.

Osteopathic Candidates: You can upload COMLEX transcripts, USMLE transcripts, or both. If uploading COMLEX transcripts, you must authorize their release and pay a transcript fee, similar to the process for uploading USMLE scores. As mentioned in Chapter 2: The Preclinical Years, acceptance of COMLEX Level 1 may change with USMLE Step 1 and COMLEX Level 1 now being pass/fail examinations, but that is still unknown. Available data indicates that if you are an osteopathic medical student, taking at least USMLE Step 2 in addition to COMLEX Level 2 will open more opportunities for residency interviews. Refer to EMRA Match for programs that will accept COMLEX scores alone when helping make your application decisions (hint — it will not be a majority of programs!).12-14

IMG Candidates: USMLE transcripts for IMGs are released by ECFMG rather than NBME.

Medical Student Performance Evaluation (Dean’s Letter)

The MSPE is not a letter of recommendation but rather a narrative summary of your performance throughout your clinical clerkships. It emphasizes strong attributes demonstrated throughout your medical education, highlights your accomplishments, and addresses any red flags or difficulties. It also provides a narrative of your clinical clerkship performances.

The MSPE traditionally includes your rank compared to your classmates, and this can help you gauge your competitiveness as an applicant; however, not all medical schools have a class ranking system. In this case, your school will indicate this in the MSPE. Check with your dean ahead of time to understand your institution’s process so you understand your competitiveness.

At-Risk Candidates: Be familiar with your MSPE so you can address any red flags, such as course failures or professionalism issues, in your personal statement and during your interviews. Take ownership of the issues, reflect upon what you have learned, and be ready to explain the changes you have made to ensure that the past will not repeat itself during residency. It is often beneficial to work with your letter writers to help address these potential red flags.

Latecomers: If you changed specialty choices, be sure to update your dean as soon as possible. They may choose to emphasize different aspects of your strengths or accomplishments as they relate to EM.

Medical School Transcript

Your transcript is a list of your preclinical and clerkship grades. Your MSPE will provide more detailed information about your clerkship performances. While basic sciences grades have been ranked lower in terms of importance to residency programs, performance in required clinical clerkships is cited as being highly valued.3

Photo

This is optional, but the vast majority of applicants do upload a photo to ERAS. While your photo does not need to be from a professional photographer, you need to appear professional. No selfies!

Upcoming Changes

The Supplemental ERAS application was a new addition to EM in the 2022- 2023 cycle, adding program signaling to the overall ERAS application.1

Successful changes from the Supplemental ERAS application will be integrated into ERAS in upcoming cycles. Changes to the CV/experiences section of your ERAS application can be found in the “CV / Experiences” section of this chapter.

The following paragraphs describe other key elements of the Supplemental Application that will be incorporated into the general ERAS application during the 2023-2024 cycle. For the most up-to-date information regarding the ERAS application, please refer to the ERAS website.

PROGRAM SIGNALS are a method by which applicants can indicate a strong interest in a program. In the 2022-2023 cycle for EM, applicants had the opportunity to submit five program signals. It is anticipated that applicants in the 2023-2024 cycle will have the opportunity to submit seven signals. For the 2023-2024 cycle, the formal recommendation from ERAS is to signal the programs that you are most interested in, INCLUDING your home institution and institution(s) where you completed an away rotation. Note: This is a change from the 2022-2023 cycle where EM specifically requested students to not signal their home or away rotation institutions.

While it remains to be seen how EM programs will use these signals, prior specialties have utilized them as part of a holistic process to decide whom to invite to interview or as a tie-breaker.15 Program signals may help you stand out at programs where you do not have a clear geographic connection. You should discuss the planned use of your signals with your advising team to maximize their utility.

GEOGRAPHIC PREFERENCES allow you to express a preference, or lack of preference, for particular geographic divisions and practice settings. Both allow you to select a preference and provide a written explanation to explain this choice.

Geographic division preference allows for a selection between nine regions, as determined by the U.S. Census (eg, Pacific, East, North Central, South Atlantic, etc.). It is recommended that you carefully inspect the map on the U.S. Census site before making a selection to ensure the states you are interested in fall within them.16 If you opt to select preferences, only programs that fall within the geographic divisions you have selected will be notified of this choice and receive the corresponding essay — if you select no preference, all programs will be notified of this selection and the corresponding essay. If you do not respond to the question, no preference information will be shared with any program.

Setting preference allows for a selection between a rural practice setting, urban practice setting, or no preference. If you indicate a preference or lack of preference, this choice and the corresponding essay are shared with all programs.

The Bottom Line

  • Be honest on your application; do not inflate your accomplishments or involvement in anything. Program directors look for congruence. They want to make sure the person they interact with on the interview day is consistent with the person they see on paper
  • Anything on your application is fair game to be discussed further in an interview. If it is on your application, be prepared to talk about it!
  • Spelling and grammar errors can be a kiss of death. Spend time making your application clear, crisp, and error-free. From the ERAS site, you can print your application to review for errors. Have friends, family, and mentors read over your application before you submit it.
  • Stick to the timeline. It is okay to not have two eSLOEs uploaded by the date ERAS is open to programs, but you must have your application (including other LoRs) submitted by this date. Do not submit late!

References

  1. Association of American Medical Colleges. 2023 ERAS MyERAS Residency User Guide. https://students-residents.aamc.org/media/9716/download
  2. 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.
  3. 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.
  4. Olson DP, Oatts JT, Fields BG, Huot SJ. The residency application abyss: insights and advice. Yale J Biol Med. 2011;84(3):195-202.
  5. Graves AJ, Brown BM, Oller KL. To the Editor: Using the Personal Statement to Address Application Deficiencies. J Grad Med Educ. 2022;14(5):621.
  6. National Resident Matching Program, Data Release and Research Committee. Results of the 2022 NRMP Program Director Survey. https://www.nrmp.org/wp-content/uploads/2022/09/PD-Survey-Report-2022_FINALrev.pdf
  7. Clerkship Directors in Emergency Medicine, Council of Residency Directors in Emergency Medicine, Emergency Medicine Residents Association, SAEM Residents and Medical Students. Consensus Statement for Emergency Medicine 2022-2023 Residency Application Cycle Regarding Emergency Medicine Away Rotations. https://www.cordem.org/globalassets/files/consensus-statements/2022-2023-em-consensus-statement-statement-final_.pdf
  8. 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.
  9. Hillman E, Lutfy-Clayton L, Desai S, Kellogg A, Zhang XC, Hu K, Hess J. Student-Advising Recommendations from the Council of Residency Directors Student Advising Task Force. West J Emerg Med. 2017;18(1):93-96.
  10. Lutfy-Clayton L, Morrissey T, Pelletier-Bui A, et al. The Emergency Medicine Applying Guide. Council of Emergency Medicine Residency Directors Advising Students Committee in Emergency Medicine. 2018. https://www.cordem.org/globalassets/files/committees/student-advising/2018-applying-guide-cord-cdem-emra-rsa.docx.pdf
  11. Lutfy-Clayton L, Morrissey T, Thibodeau L, Pelletier-Bui A, Hillman E. The Emergency Medicine Applicants FAQ. Council of Emergency Medicine Residency Directors Advising Students Committee in Emergency Medicine. 2018. https://www.cordem.org/globalassets/files/student-resources/em-applicant-faqs.pdf
  12. Emergency Medicine Residents’ Association. EMRA Match. https://webapps.acep.org/utils/spa/match#/search/map
  13. Weizberg M, Kass D, Husain A, Cohen J, Hahn B. Should Osteopathic Students Applying to Allopathic Emergency Medicine Programs Take the USMLE Exam? West J Emerg Med. 2014; 15(1):101-106.
  14. Smith L, Jarou Z, Lufty-Clayton L, Hillman E, Karr E, Christensen R, Kellog A, Mancini M, Pelletier-Bui A, Stobart-Gallagher M. The Osteopathic Emergency Medicine Applying Guide. https://www.cordem.org/globalassets/files/committees/student-advising/2020-updates/asc-em-osteopathic-student.pdf
  15. Association of American Medical Colleges. Supplemental ERAS Application Guide. https://students-residents.aamc.org/media/12326/download?attachment
  16. U.S. Census Bureau. Census Regions and Divisions of the United States. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf
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