You’ve made it. You’re a fourth-year medical student. You survived the MCAT and board exams. You have an application full of extracurriculars and research, and you’re ready to apply for an emergency medicine residency.
However, there is one obstacle that remains, one final endurance trial looming in your sights: the emergency medicine sub-internship.
For many medical students interested in EM, the EM sub-internship can be a stressful time. It is your baptism by fire, your time to shine and show program directors that you are a qualified candidate with the unique set of skills needed for EM residency. This sub-internship is not merely a suggestion; it is essential, as it is the pathway to receiving what is basically the currency of EM applicants and program directors — the standardized letter of evaluation, or SLOE.
The SLOE is nearly a universal requirement to apply for emergency medicine residency. This highly valued, highly scrutinized letter often holds more significance in the application process than many other aspects of an applicant’s CV. Given the magnitude that this letter holds, receiving a less than stellar evaluation can be detrimental to a student’s application. With this in mind, one might ask: Is there a way to overcome a less than ideal SLOE?
The short answer is yes. But let’s delve into the intricacies of this process.
First, what exactly is a SLOE, and what is its purpose? The SLOE is a standardized letter of evaluation that has been utilized for years in the emergency medicine application process. It was developed and implemented in 1997 and since has been a universal requirement for EM residency applications.
The idea behind the SLOE is to implement objectivity in the sometimes subjective world of medical student evaluation. It is a multi-factorial evaluation that includes assessment of basic physician functions, from the ability to take a history and physical and the ability to formulate a plan, to more EM-related skillsets such as procedural competency and recognizing emergent situations. Ultimately, the SLOE allows the evaluating program to reveal where they plan to place this applicant on their rank list: top 10 percent, top 1/3, middle 1/3, and lower 1/3. And while the entirety of the SLOE is taken into consideration, one aspect of the SLOE that EM program directors and applicant reviewers continue to emphasize is the rank system.
Not surprisingly, applicants vie to be placed in the top 10 percent or top 1/3. Not everyone can achieve this, especially since most programs do their best to use the full range of the rank list category, meaning that even students who perform well on their rotation may end up in the lower 1/3 category simply because they rotated with a very competitive class.
However, the perception among students and even application reviewers is that if the program ranks a student in the lower 1/3 tier, then the program has identified a potential issue or issues with the student. This can raise red flags for the reviewers of the application, possibly putting the applicant at risk of not receiving interview invitations from EM residency programs and/or not being placed highly enough on a program’s list so that they match.
So how, if at all, can a student overcome being placed in the lower 1/3 tier? This question was asked to EM program directors across the nation, and we now have some objective data to direct students on how to overcome this.
The survey was sent to every EM program director in the United States asking them their thoughts on what helps them overlook a lower 1/3 SLOE when reviewing applications. Of these surveys, 53 program directors from a mix of both academic and community programs across the nation responded, and three factors dominated the results on how to overcome a low ranking: (1) a good performance at the program where you are applying; (2) well-rounded life experience; and (3) a personal connection to the program. Let us discuss each of these in further detail.
Good Performance at Applying Institution
The old adage “seeing is believing” applies here. Not surprisingly, if you rotate at another program and perform well there, that will help you overcome a poor SLOE from another institution. The program will be able to evaluate you in person, having approximately one month to interact with you and gauge your performance and abilities. If that specific program had any questionable doubts about you given red flags from a prior poor SLOE, this is your opportunity to prove them wrong.
Well-rounded Life Experience
Maybe you were in the NFL or a AAA ball player in a previous career. Perhaps a concert violinist or a schoolteacher. Dig deep. What makes you unique? This can range from hobbies to volunteering gigs, basically anything that makes you, well, you. Programs want a well-rounded resident, not a mindless medical automaton. Your unique life experiences will add richness and diversity to the program where you are applying, which ultimately strengthens that program. Write a poem. Join a sports league. Learn to code. Play the piano. Just be sure to highlight these unique attributes when applying to residency.
Personal Connection
Even if you cannot personally rotate at a specific program, making yourself known to the faculty can pay dividends in this process. Look for a mentor at your program of interest, try to attend lectures or the weekly residency conference, and network via residency fairs. Anything you can do to reach out to these programs and make your name known will help improve your chances of overcoming a lower 1/3 SLOE.
Notably, a commonly held belief that research is the gateway to matching does not hold true in EM, as none of the program directors polled mentioned research as a pathway to overcoming a lower 1/3 SLOE. Given this, it is better to focus your attention on the aforementioned higher-yield prospects. You should also attempt to complete at least two EM sub-internships. Program directors revealed that one lower 1/3 SLOE can be mitigated by another SLOE that shows improvement.
No matter where you are in your medical career, it’s never too early to start taking action. Complete your Visiting Student Learning Opportunities (VSLO) applications early to ensure you can rotate at your top-choice programs, and be sure to rotate at programs you think would be a good fit for you. Work on making professional connections at these programs. Go out and live a little; continue to pursue your unique hobbies or passions.
Finally, if you are one of those with a lower 1/3 SLOE, do not give up. You have the proverbial ingredients to improve your application directly from EM program directors themselves — and all you have to do is act on it.