RAMS Foundations of Academic Emergency Medicine Roadmap by Society for Academic Emergency Medicine

Foundations of Academic EM Medical Student

Resident

Fellow

AUTHORS: Andrew Golden, MD; Maurice Hajjar, MD; John Hurley, Kendra Elm, MD; Martin Casey, MD; David Cisewski, MD; and Jean Sun Scofi, MD Welcome to the Foundations of Academic Emergency Medicine Roadmap, your definitive step-by-step guide on how to succeed in Academic EM.

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MEDICAL School INTRODUCTION Emergency medicine (EM) is a specialty that focuses on the diagnosis and management of patients with illnesses or injuries that require immediate medical attention. As the scope of EM is broad, it can be practiced in hospitals, urgent care clinics, emergency medical response vehicles, or disaster sites. A fulfilling and exciting career in emergency medicine (EM) starts with proper planning and hard work as a medical student. Students interested in EM have a number of opportunities for early exposure to assess their interest in pursuing a career in the field. Additionally, EM has a number of unique requirements that students in their third and fourth year of medical school should prepare for early. The purpose of this wiki is to assist students interested in EM to navigate medical school starting from the preclinical years, all the way through a successful match. The purpose of this guide is to discuss the fundamental components of medical school that will assist in your preparation for an emergency medicine residency and beyond.

Preclinical Years • Step 1

– Step 1 is one of the first milestones in your medical education. While there are many factors that determine your overall competitiveness for matching into an EM residency, a good Step 1 score is an essential component in this competitive field

• Extracurricular Opportunities

– Emergency Medicine Interest Group (EMIG)

■ Getting involved with your school’s EMIG is an easy way to get some exposure to everything that EM has to offer. EMIGs will often arrange lectures on relevant emergency medicine topics and organize hands-on procedure workshops (such as splinting, intubation, and suturing workshops) as well as talks on interesting topics from your home program’s expert on a given topic. These opportunities will allow students to network with residents and faculty and gain an insider’s look into what being an emergency physician is like. Becoming an EMIG member during your first and second year of medical school allows you to gain exposure to the field of EM before starting your clerkships. Otherwise, aside from shadowing in the ED, it can be difficult to gain any exposure to EM until your clinical years and many medical schools may not have students rotate in an EM clerkship until their 4th year of medical school.

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■ Apply for a leadership position on the school’s EMIG executive board. This process will vary depending on your school’s policies so speak to the current EMIG Chairs for more information.

■ If you envision research as a significant part of your career in emergency medicine, be sure to check out the Research Fellowship Guide for information about obtaining research opportunities early in medical school.

■ Click here for a link to EMRA for more information and resources about EMIG.

–C lick here for EMRA’s Advice page for first- and second-year students.

Clinical Years • Third Year

– Clinical Clerkships

■ A strong performance throughout your third year clerkships is a crucial component of future success. EM is all encompassing—the broad scope of practice of an emergency physician includes elements from each of your core clerkships. During your third year, you will be transitioning from the classroom to the clinical setting and the skills and habits you learn from each of your clerkships will be carried with you throughout your career as a physician. You should treat each clerkship as an immersion experience. Some medical schools will incorporate EM into the curriculum in the form of a clerkship, although this will vary.

– Electives

■ Electives are a great opportunity to explore other specialties or areas in which you’d like to dive deeper. If your school does not make EM a mandatory clerkship, a third year elective is a good way to get some exposure to the ED environment and learn what thinking like an emergency physician entails. Depending on what is available at your school, there may be both an EM elective and an EM sub-internship. It is generally recommended that you do not complete your EM sub-internship until you have completed all or most of your third year clerkships. Of course, it isn’t necessary to take an EM elective; you should use the opportunity to explore any area of medicine in which you’re interested. As always, it is important to discuss your third year schedule with an advisor in order to maximize your chance of success. Other electives that bestow skills that directly translate to EM include anesthesia, ultrasound, critical care, EMS, toxicology, pediatric EM, and urgent care.

•C lick here for CDEM’s M3 Curriculum Guide.

– Career Advising

■ Beginning in your third year, you should start to think about connecting with an advisor in your field of interest. Most likely, your school will have a more formal advising system that will connect you with advisors who will serve to mentor you as you

embark on the career decision making process. In addition to mentors through your school, there are a number of resources through SAEM that will connect students with mentors online. A clerkship director, associate program director, or program director can serve as a great advisor. ■ Click here for EMRA’s guide on developing a mentor relationship. ■ EMRA Advising Resources for Medical Students

–C lick here for EMRA’s Tips for Success as a MS3.

• Fourth Year

– Elective time

■ Depending on your school’s specific schedule, in January of your third year you should begin to think about how you will structure your fourth year. Generally, you will want to schedule your EM sub-internship and one away rotations between the months of May and September. Ideally, you should complete your home EM rotation or sub-internship prior to embarking on your away rotations. You should aim to have completed your EM rotation and at least one away rotation before submitting ERAS in September so that you have grades and Standardized Letters of Evaluation (SLOEs, see section below) as part of your application, although many programs will not begin downloading applications until the Dean’s Letter comes out in early October.

– Step 2 CS and CK

■ In January of your third year, you should also consider when you would like to take Step 2 CS and CK. There is a lot of variation in when medical students take their Step 2 exams and not all students will take Step 2 CK and/or CS prior to submitting their ERAS application. Many students will take Step 2 CK shortly after they finish their third year clerkships because it is likely when the material is the freshest in their minds. For example, if you finish your 3rd year on a rotation such as internal medicine or family medicine (both of which cover much of the material on USMLE), it may be convenient to begin your study time right after completing your rotation and shelf exam. While most programs will not require your Step 2 scores to grant you an interview, nearly every program will require your Step 2 scores prior to ranking. Furthermore, Step 2 CK is seen by many programs as more pertinent to EM than Step 1 since it is more clinically oriented and may be weighted more heavily when deciding on who to invite for an interview. As a result, a good Step 2 CK score can potentially offset relatively poorer performance on Step 1. Virtually all programs will require you to have taken Step 2 CK by the time rank order lists are due in February. Ultimately, it is important to discuss with your advisor when it is best for you individually to take Step 2 CK based on your goals. Less weight is put onto Step 2 CS since it is a pass/fail exam; however, failing is often considered a red flag on your application.

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– Researching programs

■ There are a number of resources available online to research residency programs to which you may be interested in applying. Aside from programs’ respective websites, several interactive databases of programs are available to students through EMRA (EMRA Match) and AMA (FREIDA). Your advisor will also be an invaluable resource in determining what your priorities are in a residency program and which programs might be right for you. Be wary of websites touting program rankings such as Doximity since it is unclear how these rankings were generated.

■ EM is unique in the context of residency since there are multiple program formats and settings that offer different types of experiences—programs can be three or four years and be located in an academic, community, or county setting. Approximately 25% of programs are four years long and they are generally programs with an academic lean, although there are many that are not. While residents will become proficient with foundations of EM in any setting, the style and culture of a program may differ between academic, community, and county programs. For example, students may choose a county program because of the strong social mission to the underserved or an academic program for the strong research mentorship. These three settings are also not mutually exclusive, as many hybrid programs straddle more than one realm. Of course, preference for program setting or length of training is a personal decision and no one type of program is necessarily better than all others—rather, the focus should be on what is best for the individual student’s career goals and personality.

–C lick here for EMRA’s advice page on preparing for a successful fourth year.

–C lick here for EMRA’s page on fourth year scheduling.

– Your home EM rotation (elective or sub-internship)

■ Your home EM elective or sub-internship is your opportunity to learn the foundations of how to think like an emergency physician. There are many good resources online that detail how to succeed on your home EM rotation:

■ The CDEM Curriculum — particularly useful at this stage is the M4 curriculum. ■ The EM Clerkship Primer ■ EMRA’s Skill Demonstration Videos ■ The 3-Minute EM Oral Presentation ■ WikEm

■ While the above links go into detail about the specific expectations of an EM rotation and how to meet them successfully, overall, the basic tenets of being a good medical student apply—show up early, be enthusiastic, have a good attitude, offer to help, work hard, and be thorough. If you’ve succeeded during your third year clerkships, you already know how to succeed on your EM rotation.

– Away Rotations and VSAS

■ Click here for SAEM’s Clerkship Directory ■ Plan early: In order to obtain the requisite number of departmental Standardized Letters of Evaluation (SLOEs, see section below), it may be necessary to complete an away rotation. Aside from being evaluated in a theoretically more objective environment, the away rotation (also called an “audition rotation”) is a great opportunity to demonstrate to a program where you are interested in matching how you will perform as an intern. This can be really helpful if you are interested in matching at a particularly competitive program or have a strong geographic preference to a specific region.

■ The process for applying to away rotations can be daunting and somewhat confusing—some programs use the Visiting Student Application Service (VSAS) while some use their own proprietary application process. Even still, programs that use VSAS may have very different application processes and requirements. The most important part of the away rotation application process is starting early. In January of your third year, you should begin researching programs at which you are interested in rotating and looking into their requirements. Some programs require letters of recommendation or personal statements that may take time to obtain or write. Additionally, all programs will require up-to-date immunizations and tuberculin testing with documentation (often in the form of their hospital’s specific forms) which may require that you set up multiple appointments over the course of weeks with your primary care provider or student health services to obtain. Finally, deadlines between programs will often vary and may be as early as February. The number of away rotation positions you apply to will vary depending on how desireable a rotation it is and which month you are applying for, but generally it is recommended to apply to approximately 3-4 away institutions for every 1 away rotation you wish to complete (note: you can often apply for multiple months at a single institution).

■ Once you are accepted for an away rotation, you will need to alert your school and find temporary housing, if your away rotation is in a city far from home. One excellent resource is Rotating Room which is a site specifically designed for medical students completing away rotations to sublet their apartments or rooms.

■ Performance matters: The away rotation is your opportunity to demonstrate your clinical acumen and abilities in a theoretically more “objective” environment. It is your chance to shine and show a program how well you can perform as a resident. While they may be daunting, luckily the same rules for success as your home rotation apply for your away rotation— showing interest and enthusiasm will go a long way. Rotation directors will take into account how many EM rotations you had prior to this one when evaluating you (it is part of the SLOE).

• Remember—treat any interaction you have with any individual at that institution—patient, guest, or healthcare staff— as part of the away rotation!

• Try to set up a mid-rotation feedback session with someone from the program leadership—the clerkship director, APD, or PD—and ask for feedback on your performance. Additionally, ask for any advice they may have on how you can be better prepared for the upcoming application cycle.

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– The ERAS Application

■ Gauging Competitiveness

• While EM has become more and more competitive in recent years, it is still considered a medium-competitive specialty compared to some of the ultra-competitive specialties like dermatology, orthopedics, or plastic surgery.

• Charting Outcomes in the Match is an especially helpful document, as it reports vital statistics for each specialty (such as mean Step 1 Score) and breaks down overall match success by a number of different application components.

• Based on the most recent NRMP Program Director Survey, the most important factors for obtaining an interview invite from a program are the USMLE Step 1 score (or COMLEX Level 1 score), letters of recommendation in chosen specialty (SLOEs), MSPE/Dean’s Letter, USMLE Step 2 CK score (COMLEX Level 2 CE score), and grades in required clerkships. The most important factors for being ranked by a program are interactions with faculty during interview and visit; interpersonal skills; interactions with housestaff during interview and visit; feedback from current residents; and the USMLE Step 1 score (or COMLEX Level 2 CE score).

• As always, it is important to discuss with your advisor where you fit into the EM applicant pool based on your cumulative medical school performance.

– Letters of Recommendation and the Standardized Letter of Evaluation

■ In EM, the most important letter you will need for you application is the Standardized Letter of Evaluation (SLOE). The SLOE is not a letter of recommendation in the traditional sense (i.e., it is not a “character letter” or “narrative letter”); rather, it is a standardized evaluation form that directly compares your performance to that of your peers and can only be completed by an emergency physician. It is considered one of the most important, if not the most important, components of your application. For most programs, you will generally need at least two SLOEs, although the requirements of a given program may vary somewhat. One SLOE should come from your home institution and additional SLOEs should come from each institution at which you completed an away rotation. It is generally considered a red flag to have completed an away rotation at an institution and not have obtained a SLOE from that institution.

■ While a SLOE can be written by a single emergency physician with whom you worked closely, SLOEs are often times written as “departmental” or “group” SLOEs, which represent your cumulative evaluation by everyone you worked with in the department. These are often signed by the program director and/or the department chair in addition to the SLOE writer and are often considered to have more weight than an individual SLOE. The policy on how SLOEs are written varies between programs so it is important to ask your rotation director at the beginning of your rotation what their process is for obtaining a SLOE.

– Writing your personal statement

■ You can view the generic SLOE form online here. ■ Your personal statement is an opportunity to show programs a more personal side of you that may not shine through in your application. It should concisely convey to programs why you are interested in EM and what path you took to get there. In short, it is your chance to tell your story and discuss the unique attributes you will bring to a residency program. While you should certainly express yourself and utilize your personal writing style, many advisors caution students about trying to be too creative or avant garde. In general, the personal statement is one of the less important components of your application and while it will rarely make or break your application, overall many would argue that it is better to err on the side of taking a more conservative approach. Rarely will interviewers remember how “great” a personal statement was, but they may remember one that had very little time invested, has numerous grammatical errors, etc. Additionally, the personal statement is your opportunity to discuss any red flags you may have on your application, such as a course failure, a leave of absence, etc. It is a great opportunity to “tell your side of the story” and discuss how you’ve grown from your experience with hardship and how it has made you a more resilient candidate.

– Filling out ERAS

■ The Electronic Residency Application Service (ERAS) is the online common application for residency. Here, you will fill out all of your identifying information, biographical information, and all of your experiences throughout medical school which will ultimately transmitted to programs electronically. More information on the ERAS application is available here.

■ In addition to the information you fill out on ERAS, you will need to transmit your USMLE scores and additionally have your school submit a transcript and Dean’s Letter (or Medical School Performance Evaluation, MSPE) to ERAS on your behalf.

■ While you can begin filling ERAS out during the summer, you cannot officially submit it until mid-September. While most students will attempt to submit on this first day, it is not an absolute requirement; however, it is generally recommended that you have a complete application submitted when the MSPEs are transmitted to programs on October 1st. In general, earlier is better. Be sure to check websites of each program to determine their absolute deadlines for a completed application.

• The Interview Season

– Interview Invitations

■ Many programs do not begin sending interview invitations until several weeks after the Dean’s Letter (the MSPE) is released in early October, although some will begin soon after ERAS submission. Interview slots often fill up very quickly so it is important to respond promptly to ensure you obtain your preferred date. Interview invites are sometimes granted directly through ERAS or via email but the vast majority are managed through a third-party software such as Interview Broker or Thalamus.

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■ Because of the logistical and financial constraints of interview season, students will often try to group interviews in the same city or region in the same week. While it is not always possible, the program coordinator may be able to assist you in scheduling interviews consecutively.

– Coordinating Interviews

■ Financing interview season

• The costs associated with interview season can quickly amount to a small fortune between flights, rental cars, and lodging, among other expenses. While many students resort to loans, there are several ways to cut costs, such as driving instead of flying (if reasonable) and staying with friends or family; see more detail below.

– Travel and Accomodations

■ As noted above, it is optimal (but not always possible) to book interviews in close geographic proximity in the same week. This can keep the costs of flights down. If you don’t already have frequent flyer accounts with your preferred airlines, you can usually apply online within minutes. Many students will also take advantage of travel credit cards that award points on various types of purchases along with other travel-related benefits; however, speak with a financial aid advisor to determine if this is a wise decision based on your individual personal finances.

■ While some residency programs will have arranged discounts with hotels nearby, the cost of hotels can be one of the largest incurred during residency interviews. Staying with friends or family is an excellent alternative but if none live in a particular city you’re interviewing in, residents of that program will often make spare bedrooms or couches available. Reach out to the program coordinator well in advance of your interview to determine if this is a possibility. Additionally, your school may have programs in which alumni from your institution will offer to host students, so ask your advisor about these options. Finally, AirBNBs are often priced more competitively than hotels, although experiences may vary so be sure to carefully read reviews before booking.

– Interview Preparation

■ Knowing your application inside and out is the most important component of preparing for your interviews. Be prepared to answer questions about anything you put on your application—including that esoteric hobby you put on your application or that poster you presented as a first year! You never know what might create a connection with your interviewer. In addition, if there are any “red flags” on your application (e.g. a USMLE failure, leave of absence, etc.), then you should be prepared to discuss why this occurred and how you have grown from the experience.

■ Prior to your interviews, it is important to have read up on the programs at which you will be attending interviews. Program websites are a great first resource for information, particularly on curriculum, training sites, and ongoing research projects. Reviewing the website is also a good way to come up with questions specific to that program.

■ Many schools offer mock interviews and it is strongly recommended that you take advantage of them. Even if you feel confident discussing your application, it is often a great opportunity to get a sense of any mannerisms or ticks you may have (do you say “um” or “uh” after every word?) as well as to practice answering difficult questions.

– Interviewing

■ Interviews are your chance to see if a program is a good fit for you and for a program to determine if you are a good fit for them. It’s important to get a feel for how well you get along with the residents, faculty, and program leadership and whether you see yourself in that environment for the next several years. While many factors go into what makes one residency or another better for a given person, your gut feeling and your overall perceived “fit” with the culture of a residency program are among the most important ones. The pre-interview dinners are often just as valuable as the interviews themselves, since they give you a chance to interact in a less formal setting with your potential future colleagues. Try to have questions prepared as well for the leadership, interviewers, and residents. Having no questions may be perceived as lack of interest.

■ While not an absolute requirement, many students will send thank you notes via email to the program directors or interviewers with whom they spoke. However, some programs prefer no post-interview communication so it is important to check with the program coordinator on what their program’s specific policy might be.

■ Click here for ALIEM’s guide to Dos and Don’ts of Residency Interviewing. • The Rank Order List and the Match

– Overview of the Match

■ Click here to see how the match works (video from the NRMP).

■ The Match is designed to give priority to student preferences over program preferences. It is crucially important to rank programs in your preferred order, NOT the order in which you think you’d most likely match at a given program. In other words, you don’t gain anything by ranking a program first that isn’t your top choice simply because you think you’re more likely to match there than at a “reach” program. Because you don’t know where a program will rank you, you’ll only miss out if you try and “game the system.” Rank the programs at which you interviewed in the order you’d like to match!

Further Reading:

–A AMC’s Careers in Medicine: Emergency Medicine (sign in required)

–E MRA’s Medical Student Survival Guide

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RESIDENCY INTRODUCTION The transition between being a medical student and becoming a resident is a steep learning curve. Not only will you have new responsibilities, but you will need to learn how to think on your feet and work efficiently within your hospital environment to provide the best care for your patients. The purpose of this guide is to offer provide a foundation of knowledge that will prepare you for the challenges and opportunities of an emergency medicine residency.

Transitioning from Medical Student to Intern Below you can find some advice from current residents that can guide you during your internship year as a young emergency medicine resident: • Work hard during every rotation and learn as much as you can. • Meet people from all other specialties and become friends with them. • Don’t take things personally. You will be rotating on different services and there will be times when people will say some unpleasant things about the ED in front of you. This tends to happen given that the nature of our job is to admit patients so that they can get the appropriate care in the hospital. Remember that every resident is overworked/sleep-deprived and may have something else going in their lives that you are unaware of. • When a nurse approaches you with a concern regarding a patient, stand up and go see the patient! You’ll be surprised and humbled about the many times you will catch something because a nurse helped you out. • Be thorough. If you don’t do a thorough physical exam on your patient, don’t expect they will get one from the senior resident/ fellow/attending. Take ownership of your patients. • Advocate for your patients to get the care that they deserve. • Read/learn one thing about a patient everyday. It’s difficult to find time to study, but spend at least 15 minutes reading about something every day. • Spend time at the bedside with your patients and families. Address goals of care early on with your patients, the sooner you attain these crucial communication skills, the easier it will be in the future.

Residency The primary goal of every emergency medicine resident is to develop the skills that will eventually allow them to become an effective, proficient physician. This takes years of dedication and training to develop throughout the course of residency. Determining individual career goals and pursuing academic and extracurricular interests are other important priorities. While community practice may be an ideal work environment for many residents, some will decide to work in academic medicine. The “Attending Section” below will provide further information regarding the differences between academic and community practice. In order to pursue a career in academic medicine, residents may benefit from additional experiences, such as scholarly pursuits or a focus in a specific niche, during residency to make them more attractive as a candidate for an emergency medicine physician in an academic program. Below you can find some general advice from program directors about additional experiences or requirements for academic positions: • Work hard at your clinical skills. • Find a niche. Experience as much as you can early on in residency to find out what you like. When you have identified an area of interest, find a project (or more than one project) within that niche. If you have multiple interests and are uncertain of where you want your niche to be, then get projects in multiple areas to try them out. • Demonstrate effectiveness. When you take on a project, then make sure you complete it. Be responsive with your mentors so that they view you as responsible and effective. Have an “end product” that you can show potential future employers. No matter what your niche, you want to be able to prove that you are someone who gets things done. • Build a CV that demonstrates your interest in your particular niche. If you want to be an educator, then you should have demonstrated interest and involvement in education, with the more leadership and innovation demonstrated the better. In operations, develop some patient care protocols, complete a QI project, do something tangible to show your interest/skill in that area. • Be present, involved, and engaged. This is how you find opportunity and how you will be identified for opportunity. • Demonstrate that you have learned bedside teaching skills. Collect evaluations, complete an elective, take a course. • Demonstrate that you have lecturing skills. • If you don’t have time to do any of the above during residency, then you need a fellowship. You may need a fellowship anyway, depending on your ambition for leadership positions. Involvement does not necessarily require a fellowship, but sometimes leadership does. It depends on what your overall career goals are and what kind of department you are considering. • Consider getting involved on a national level. While not specifically for individuals planning to work in academic emergency medicine, the USMLE Step 3 exam and the ABEM annual in-training exams are required during residency training. For more information, visit these links about Step 3 and the in-training exam.

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A successful career in academic Emergency Medicine is built on three essential pillars: Scholarship, Education, and Career Development. These pillars can also be developed during residency as fellows: Scholarship: Scholarship takes a variety of forms in residency - as simple as a case report to as complex as a multicenter RCT. For those residents who are dedicated to research as part of their career, looking through the academic research track will be able to support their future goals. . While the end product of research may be variable, the purpose of performing scholarly work in residency includes obtaining a broader skill set in research methods, learning specialized knowledge in a certain niche within emergency medicine, and developing ideas on how to continue to advance the field. The specific research requirements for each program and fellowship are broad, but participating in thoughtful, productive scholarly work will likely prove beneficial in a career in academic emergency medicine. For more information about performing research as a resident, take a look at page 24 in this SAEM Newsletter and this review of the available opportunities for resident scholarship. SAEM has also published a great guide to research grant opportunities that will be invaluable for obtaining research funding. Additional funding opportunities from the SAEM Foundation can be found here. Education: Almost all academic emergency medicine physicians will have a role in the education of junior learners, including residents and medical students. Those who are interested in being more involved in the education of learners would likely benefit from fellowship training in medical education or simulation fellowships. Participating in teaching electives or opportunities will help refine educational practices that will be invaluable as an attending in academic medicine. Most residency programs have opportunities to participate in medical student education in bedside teaching curricula, simulation experiences, and medical student workshops. If you would like to get more involved with teaching and education projects in your institution, your residency leadership team and medical student clerkship directors will be great resources to help point you in the right direction. While teaching techniques are beyond the scope of this conversation, these SAEM Newsletters from 2010 (page 13) and 2009 (page 8) have helpful tips on making you a better education Career Development: Similar to teaching and education, mentorship is core to academic medicine. Developing the skills of an effective and influential mentor to junior residents and medical students will be helpful in defining your role as a mentor within academic medicine. However, finding personal mentors is also extremely important. For guides on finding mentors, read a review from the SAEM GME committee and page 16 from this SAEM Newsletter. Many institutions allow residents to serve as mentors for medical students in Emergency Medicine Interest Groups (EMIG). Additionally, as you progress through residency, there will will be plenty of opportunities to serve as mentors to younger residents in your program. You can also sign up for EMRA’s mentoring program by submitting your information here. There are a number of resources already published regarding how to be an effective mentor; common tips about serving as a mentor include:

– Set goals and objectives for your mentor-mentee relationship – Mentor based on your skills and abilities – Dedicate the time and energy necessary to develop an impactful relationship – Be open to sharing stories and experiences

– Listen – Encourage self reflection – Celebrate your mentees accomplishments – Lead by example

Regardless of whether emergency medicine residents apply to fellowship or straight to an academic position, there are certain requirements for each application. It is advised that you update your curriculum vitae (CV) regularly throughout residency to include your skills and accomplishments. This will ease the transition into your career as an attending or a pursuit of fellowship. For guides on creating these documents, visit these links: curriculum vitae and cover letters. To fulfill a specific role within emergency medicine, some residents may go on to complete fellowship training in a number of fields. As emergency medicine is still a relatively young specialty, the structure and format for all of the fellowship programs is variable, but the SAEM Fellowship Directory is a great resource so see all of the potential options available. Considering applying to fellowships early is crucial, as some fellowships require application and interviewing in the second to last year of residency training. Further information regarding fellowships can be be found in the “Fellowship” page. Additional options after graduation from emergency medicine residency include applying immediately to work as an academic emergency medicine physician. Job requirements are, of course, individualized to each individual position; however, there are a number of important questions to ask when considering applying for a role in academic medicine. Dr. Arthur Kellermann considers some of these questions in his article entitled, “Are You Considering an Academic Career?” Typically, residents in their last year of training will begin to start apply for faculty positions at academic centers early in the academic year. This is dependent on a number of factors, including job availability and geographic location; the best specific advice should be obtained from local faculty mentors or residency leadership. Of course, working with your residency leadership team as you near the end of residency and consider job opportunities will be key. They will be instrumental in helping you to finalize your CV, provide mock interviews, and help you negotiate the best opportunities available. There are a number of decisions that must be considered when deciding on the best job for each graduate; however, this publication provides a step by step guide for considering each of these decisions, including interviewing, contracting, and signing on the dotted line.

Fellowship INTRODUCTION There are a wide variety of Fellowship training options available to Emergency Medicine residency graduates. These include Critical Care, Ultrasound, Toxicology, Research, Administration, Medical Education, and Simulation, just to name a few. These fellowships vary in duration, requirements, and availability in different regions of the country. While plentiful, the sheer variety of fellowships in Emergency Medicine can make the fellowship application process challenging to navigate. That’s where RAMS can help. This section of SAEM Roadmaps serves as a basic introduction to EM fellowships. We will discuss requirements and timelines in general terms that are applicable to any fellowship training program. For information about specific fellowships and academic tracks, please return to the SAEM Roadmaps homepage and select a Specialty Track. The purpose of this guide is to discuss the essential components of fellowship that will assist your decision to specialize within a career in emergency medicine.

Why Should I Pursue Fellowship Training in Emergency Medicine? • To obtain specialized knowledge in a focused area of EM in order to facilitate clinical practice, scholarship, and education at an academic institution • To strengthen your resume for the EM job market • To obtain an additional degree or certification sponsored by a fellowship program • To acquire additional skills for scholarship such as grant-writing or study design • To advance individual career goals that align with a fellowship curriculum (for instance, obtaining NIH funding through an EM Research fellowship) In general, completing a fellowship will give you a competitive edge, particularly if you are pursuing an academic career in EM; however, this advantage needs to be weighed against opportunity costs, including losing some of the independence and on-the-job experience that you would gain as an attending physician, as well as receiving a lower salary (typically comparable to a PGY5-7 pay scale).

ACGME vs Non-ACGME Accredited Fellowship Programs The ACGME, or Accreditation Council for Graduate Medical Education, is an independent body that defines the standards and requirements for medical education, including EM fellowships. Fellowship programs can seek ACGME accreditation if they meet these standards. To maintain accreditation, fellowship programs must be regularly evaluated via milestones, trainee feedback

sessions, and logs. The main advantage of training at an ACGME-accredited fellowship is that the curriculum will be standardized, and the program will undergo regular review to ensure a certain quality of training. For more information on accreditation, visit the ACGME website. EM fellowships in Toxicology, Critical Care, and Ultrasound are now ACGMEaccredited, among others. There is a much larger subset of EM fellowships that are non-ACGME accredited. This means that the fellowship program is overseen by the individual institution rather than the ACGME. Evaluation processes and curriculum requirements therefore vary significantly. The advantage is that you have a greater chance of finding a program that can cater specifically to your needs, since programs have the freedom to design individualized curriculums and get creative in their educational offerings. The disadvantage is that, in the absence of standardization or independent oversight, there is a risk that the fellowship program will not be held accountable for failing to meet your educational needs. If you decide to pursue a non-ACGME accredited fellowship, research your options carefully. The advice or experiences of recent graduates will be particularly helpful. Take care to review the program’s website, and contact the individual program with specific questions.

SAEM Approved Fellowships In addition to ACGME accreditation, some fellowship are also “SAEM approved.” With appropriate assistance, resources, and oversight, additional fellowship opportunities may be established. The discussion of establishing new fellowship programs is outside the scope of this document; however, this may be an option for additional specialized training.

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Fellowships with Advanced Degrees Some fellowship programs include an advanced degree or certification that can either be required or optional for graduation. Common examples include Medical Education fellowships that offer a Masters of Education degree, Administration fellowships that offer a Masters of Business Administration (MBA) degree, or Health Policy fellowships that offers a Masters of Public Health (MPH) degree. One of the most common certifications is the Registered Diagnostic Medical Sonographer certification associated with Ultrasound fellowships.

LIST OF EMERGENCY MEDICINE FELLOWSHIPS For a comprehensive database of all the available fellowships in Emergency Medicine, please visit the SAEM Fellowship Directory. You will be able to search for fellowships by specialty, region, and institution. Here is a sampling of some of the fellowship options available to Emergency Medicine physicians: - Hospice and Palliative Medicine

- Faculty Development

- Hyperbaric and Undersea Medicine

- Geriatric Emergency Medicine

- Pediatric Emergency Medicine

- Global International Emergency Medicine

- Ultrasound

- Health Policy

- Sports Medicine

- Injury Control

- Toxicology

- Legal Medicine

- Administration

- Medical Informatics

- Cardiovascular Emergencies

- Neurologic/Neurovascular

- Clinical Forensic Medicine

- Sex and Gender in Emergency Medicine

- Clinical Pharmacology

- Simulation

- Clinical Research

- Telemedicine

- Critical Care & Emergency Medicine

- Transport Medicine

- Disaster Medicine

- Trauma and Critical Care

- Education

- Ultrasound

- EMS

- Wilderness Medicine

- Environmental Health

- Womenâ&#x20AC;&#x2122;s Health and Gender

ACADEMIC CAREERS IN EMERGENCY MEDICINE WITH OPTIONS FOR FELLOWSHIP TRAINING For more information on different academic career pathways in Emergency Medicine, please visit SAEM Roadmaps. This resource includes fellowship, job interview, and other career advice for several common academic tracks in Emergency Medicine. More tracks are being added every day, so make sure to check back! - EM Medical Education Track

- EM Administration Track

- EMS Track

- EM Research Track

- Pediatric EM Track

- EM Simulation Track

- EM Critical Care Track

- EM Ultrasound Track

FELLOWSHIP FAQ Do I need to pursue fellowship to have a career in academic Emergency Medicine? Absolutely not. There are many highly successful EM physicians at academic institutions who never received fellowship training, and instead relied on job experience, higher education (such as an advanced degree), scholarship and/or teaching for their success. In fact, depending on your particular situation and background, it may be more advantageous for you to pursue on-the-job experience or an advanced degree immediately after residency. That being said, fellowship training is viewed more and more favorably by academic institutions, especially as job candidates become increasingly competitive. Because of the wide variety of different pathways into academics in Emergency Medicine, the first question you should ask yourself as a medical student or resident isn’t whether you should obtain fellowship training, but what type of career you want to pursue. Decide first if you want to practice in an academic or community setting, and if you want specialized training in Critical Care, Ultrasound, Pediatric EM, etc. Once you have a clear idea of your interests in Emergency Medicine, it will become much easier to decide if fellowship is the best pathway to fulfill your goals. Keep in mind that fellowship is not synonymous with sub-specialization in Emergency Medicine. For some fields, such as Ultrasound or Toxicology, there is a well established pathway to an academic appointment which involves ACGME-accredited fellowship training. However, there are also many other fields such as Medical Education, Research, or Administration for which fellowship is not required, though it’s certainly viewed favorably. Here’s some questions you can ask to help determine if fellowship can help you achieve your career goals: - Will the fellowship provide concrete opportunities for education and career advancement, including a structured curriculum and readily accessible faculty mentors?

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- Does your ideal job or academic niche require fellowship training? Would you be less competitive or unqualified without it? - What is the opportunity cost of pursuing fellowship? Is there a readily available position in your area of interest, or at your institution of interest? - Are you comfortable with the compensation in fellowship, compared to the higher compensation you would receive as a full time EM attending physician? In general, fellowship training is viewed favorably by academic institutions, and will give you a competitive advantage. However, itâ&#x20AC;&#x2122;s important consider the opportunity costs and real added value of fellowship compared to on-the-job experience, an advanced degree, or other training opportunities. Consider what type of career you want first, then decide whether you want to pursue fellowship; not the other way around. To explore the different types of career pathways in academic Emergency Medicine, please see SAEM Roadmaps, our official academic career guide.

How do I find the right fellowship program for me? Finding the right fellowship program is similar to finding the right residency program. It is important to identify programs with mentors that can support your education and help you obtain your ideal job after you graduate. Depending on your interests, you may need to perform a lot of research for individual programs. In addition to reaching out these programs directly, you can also refer to the comprehensive SAEM Fellowship Directory. Since new fellowships are being developed and approved in EM every day, some newer fellowship programs may not be listed. If you are interested in a specific hospital or location, you should reach out to them directly to express interest.

What is the application process and timeline for fellowship in Emergency Medicine? In general, EM residents make the decision to pursue fellowship in the spring before their last year of residency, i.e. spring of PGY2 year at a 3-year program or PGY3 at a 4-year program. The application process varies widely depending on the type of fellowship, ranging from a structured match program to a simple interview and handshake with the Fellowship Director and Department Chair. Most ACGME-accredited EM fellowships participate in a national fellowship match process, while most non-ACGME-accredited fellowships each have their own institutional application process. Fellowships that include an advanced degree or certification will additionally require an application to a graduate school. You should always reach out to individual fellowship programs to obtain information regarding their unique application process and requirements.

What are the roles and expectations for a fellow? The role of the fellow will vary depending on the type of fellowship and institution, but there are some general requirements that are universal. These include resident and/or medical student teaching responsibilities, research and/or QI project requirements, and a

minimal number of clinical hours required for graduation. Fellows typically take on a clinical role that is functionally similar to an attending physician, though you will also have a faculty mentor or supervisor. You should reach out to individual fellowship programs to clarify the specific roles and expectations. Some important questions to ask include: - How much faculty oversight will there be for clinical shifts? - How much faculty mentorship will I receive for research and projects? - What are my teaching responsibilities for residents and students? - Will I be directly supervising residents, students, or PAs? - Will my clinical role be functionally similar to that of an attending physician? - What facilities will I work at? - Will I be able to moonlight?

INSIDER ADVICE What advice do you have for residents pursuing fellowship in Emergency Medicine? “Research your options. Consider more strongly locations where you would want to work afterward.” - Barry Wagner, MD, Ultrasound Fellow “Fellowship is great if you want to be in academics. otherwise, consider the decision wisely because its an extra 1-3 years and all your coresidents who graduate with you are making six figures, so the gratification is delayed, but, if its what you want to do, its 100% worth it. I would also consider a fellowship that will really set you apart -- in my opinion, things like Research and Peds seem to be more sought out after, while US is becoming quite common and may not be as big of an edge as it used to be.” - Lauren Klein, MD, Research Fellow “Gain as much knowledge about the field as you can. The moment you become interested in a specialty, you should seek out a variety of mentors and opportunities for more exposure to the field. Get a feel for what careers in the specialty are like in academic centers, private institutions, and different areas of the country. If you need to build your CV, try to find research opportunities or leadership opportunities through your home institution and national organizations. Lastly, start gathering information on specific fellowship training programs several months before the application deadline.” - Ken Dodd, MD, Critical Care Fellow “I think you should really consider how the fellowship might help to advance your career. A lot of fellowships are also fairly flexible, so if

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you have an interest in a specific area, then make it known. For example, my fellowship is technically medical education/simulation, but I have a special interest in administration/operations and less interest in simulation. HCMC doesn’t have a administration fellowship, but I was able to adapt the medical education fellowship to meet my special interests. Lastly, I would say that you should think about doing your fellowship somewhere where you think you want to work afterwards. It can really serve as a way to get your foot in the door at a specific program (assuming you do well) and you can also use it to see if the program is a good fit for you.” - Rochelle Zarzar, MD, Education and Simulation Fellow “I think like any other decision you make in life, it helps to make that decision as soon as possible. I decided to go into EM as an MS4 and into med toxicology halfway through my PGY3 year. I think that is a little late to be making these decisions, and I was lucky that I was able to adapt and find great mentors on the fly.” - Eddie Garcia MD, Toxicology Fellow

What are some important questions to ask fellowship programs? “The right questions to ask depend on the specialty, applicant, and when in the cycle the applicant is contacting a program. It is important for applicants to make a list of what is most important to them when searching for a training program.” - Ken Dodd, MD, Critical Care Fellow “What sort of jobs are people getting after fellowship is the most important thing. Also, for one year fellowships it’s tricky because you are looking for jobs before you really start it, so you have to be proactive right away.” - Lauren Klein, MD, Research Fellow “I think it is important to feel out how much flexibility there is if you have special interests that maybe aren’t traditionally a core part of the fellowship. Make sure you know whether or not the program will support you exploring these other interests. I think asking about the job potential at the institution is also helpful in considering your life plans and whether or not you might have a future at the institution.” - Rochelle Zarzar, MD, Education and Simulation Fellow “There are so many (fellowship options). Remember that getting into EM fellowship is not as competitive as going into EM residency (as a general rule). Make sure you find something that you really like.” - Eddie Garcia MD, Toxicology Fell

attending INTRODUCTION Now that you’ve completed decades of schooling, countless hours in libraries and hospitals, worked hours you didn’t think were humanely possible, you’ve finally reached the long awaited day when you get to call yourself an attending. But you’re still faced with a major decision - in what sort of setting do you want to work? The purpose of this guide is to offer an overview of the 3 main settings that emergency medicine attendings have the opportunity to work in following residency or fellowship.

Picking the setting that’s best for you. When searching for positions as an attending physician in emergency medicine, one of the first questions to consider is what type of practice setting do you desire? For example, academic emergency medicine versus community emergency medicine. Often this is something many residents have considered prior to graduation, and have likely tailored their career path throughout their residency training. here are always opportunities to move between these different practice environments; therefore,nothing is set in stone. Additionally, working in an emergency department is not the only option upon graduating residency. Below are some general descriptions regarding attending positions in varying environments.

Attending in a community setting: • Attendings in a community setting primarily take care of and disposition patients. Community settings can vary widely in terms of volume, patient population, physician coverage and hospital environment (i.e., urban vs. suburban vs. rural). The scope of practice will also vary widely depending on the hospital designation (e.g., tertiary referral center or trauma center), and whether or not the hospital has readily available consultants. Community attendings may be employed by the hospital, a private contracting group, or may even function as independent contractors. There is also the opportunity to take on leadership roles within community emergency medicine; for example, serving on a board of directors, or becoming the director of the emergency department. Additionally, fellowship training could allow an attending to take on a leadership role within a particular niche in a community setting. Examples include serving as an EMS medical director or ultrasound director for the community practice group or hospital system. • Performance is generally evaluated through efficiency and productivity metrics such as relative value units (RVUs), quality metrics such as patient satisfaction scores and clinical metrics, and physician citizenship and professionalism that includes meeting attendance and timely chart completion. • Follow the link for a helpful document about finding a job in the community setting.

Attending in an academic setting: • An attending in an academic setting can assume a number of different roles. In general, the responsibilities of a core faculty member will include

– clinical service

– resident and medical student education (including bedside and didactic teaching)

– protected time to satisfy a department’s educational requirements. Non-clinical responsibilities, which are important for faculty progression on their promotion and tenure track, often include didactics, mentoring, implementing departmental initiatives, and scholarly activity. Regular scholarly activity is generally required of core faculty members; however, it is not limited to original research and can include efforts such as contribution to textbooks, national presentations, and case reports.

• Attendings in an academic setting often hold an extra-clinical position, such as a clerkship director, program director, or head of a subspecialty division. Core faculty can assume a number of other positions with varying degrees of each of these responsibilities. For example, departmental chairs will focus much more on the administrative and operational aspects of the department while program directors will focus on resident education and career development. Clinical practice in an academic setting often differs from that in other settings in that the attendings responsibility is to educate residents and ensure that they are treating patients safely. Thus, attendings in this setting often do not see patients primarily but rather hear presentations from residents. They may perform less procedures, for example - overseeing and teaching residents through a procedure rather than performing it themselves. Opportunities to practice independently remain available, specifically during protected time for residents before/during/after their residency conferences and retreats. In addition, if there are other residencies within the hospital, there may be a lower threshold for calling a consultant; therefore, the scope of practice of emergency physicians at that institution may be limited relative to that of a community emergency physician. Because many residency programs incorporate community exposure into residents’ training, many academic attendings will still have the opportunity to work in a community setting if staffed by the same group of physicians. While institutionally dependent, protected time may come in the form of clinical shift “buy down,” wherein attendings may reduce their clinical workload by committing more heavily to non-clinical activities. Buy down may occur in a number of ways, with one of the most common being the use of external grants to fund the pursuit of clinical research. This can also occur internally through departmental support of administrative positions.

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Below are some helpful links from SAEM about developing a career in academic emergency medicine: – SAEM Academic Career Guide – SAEM Online Education Portal for Faculty Development – SAEM Junior Faculty Development Forum 2017

Entrepreneurship and the private sector • A subset of emergency physicians pursue careers in the private sector, either in conjunction with their clinical careers or full time. This commonly manifests as consulting for any number of different industries, but physicians are increasingly joining startup companies with a biomedical focus. • Areas of focus can include:

– Patient satisfaction

– Medical informatics

– Patient safety

– Best practices

– Coding and reimbursement

– Health insurance

– Operational management

– Biomedical investment analysis

– Physician recruitment

• Training and experience requirements are more nebulous than those desired for an academic career and depend on one’s specific area of focus. For example, advanced degrees may be useful for physicians interested in conducting pharmaceutical industry research and development.

Additional Resources: ACEP Career Guidance Website ACEP and EMRA’s Official Online Career Center (Job Search)