EMIGcast is an educational podcast that was created by medical students passionate about emergency medicine because they wanted to share the voices and ideas. Their goal is to provide free, practical and thought provoking content the next generation of emergency medicine physicians can access whenever and wherever they want.
In her first episode with EMIGcast, OHSU first year medical student, Tristen Zimmerman, talks rural emergency medicine with Dr. Anthony Ferroggiaro. Dr. Ferroggiaro is an OHSU Emergency Medicine faculty member and the medical director for the emergency department at Columbia Memorial Hospital. His unique career path has offered him extensive experience in both rural and academic settings, and on today’s episode he discusses each of these environments in the context of emergency medicine.
Extracorporeal Membrane Oxygenation (ECMO) is a life saving treatment that in recent years has shown to be effective for treating acute respiratory distress syndrome, cardiogenic shock, and other conditions involving cardiopulmonary compromise. In this episode, Lavinia Turian (MS2) talks with Oregon Health & Science University’s Adult ECLS Medical Director, Dr. David Zonies, about the mobile ECMO program that allows this advanced treatment to reach patients who live far from major medical centers that provide ECMO.
Sam here. I like numbers and stats. A lot. As many of you might be aware, March marks a special time for medical students everywhere as this is the pinnacle of years of blood sweat and step examinations called “The Match”
In todays episode we are going to take another look at the Match with a deep dive into statistical trends provided by the NRMP and AAMC. This will be continuing a series of podcasts we have done on both the path to EM and rotation advice.
Prior Episodes on matching into EM
Here are some post episodes related to appying to EM you might find helpful:
In looking at the following trends we scoured the available datasets on the NRMP, ERAS, and AAMC web pages to distill the most recent numbers specific to EM. As of May, the early match numbers for 2019 are out and we have combined those with the full data set from charting outcomes in the match from 2018 to get a fuller picture. The NRMP has done an excellent job in the recent year of making their data more interactive and you can find some impressive tools on their website at NRMP.org
The match statistics are fun but for the sake of radio I am going to round off the actual numbers to keep things a little more manageable.
Looking more globally, EM continues to be a popular specialty coming in as the 4th most popular track for US seniors after IM at number 1 followed by peds and FM. Also for prior graduates of US allopathic schools that either switch specialties or apply from a prelim year, EM remains a popular choice, placing 5th after anesthesia, FM, IM, and surg. There were 66 such people in the 2018 data set. Our friends at DO schools also pursue EM, with EM placing 3rd most popular after IM and FM. With the DO program integration, DOs are applying much more to EM than in the past, recently displacing peds as the third most common specialty.
EM also offers the 4th highest number of positions available in the match at round 3000 positions. IM is the dominate beast with nearly 8000 offerings, followed by FM with around 3500 and peds at 3000.
Another notable trend from 2018 was a higher percentage of US seniors ranking only a single specialty in the match. EM joined Ortho, OBGYN, Peds, and Gen surg in this trend. For EM around 80% of applicants only ranked EM positions. For these people that only ranked a single program 5% did not match which is identical to the average for US seniors for all specialties.
For the curious, we also looked at the US senior non-match rate for other specialties as a comparison. Again, these are for applicants that only ranked a single specialty which is around 77% of all US applicants. In other words, people that did not dual apply. Psych led the way with nearly 14% failing to match, followed by the usual suspects of Ortho, Derm, Plastics, OBGYN, and neuro surgery with around 10-13% failing to match. Peds was the lowest at 0.8%.
Is EM becoming more competitive?
EM first started participating in the match in 1983 and has been adding positions at a steady clip since then except for the single year of 1999. In 2019 EM offered ~2500 positions to a total of 3000 total applicants through 238 programs. That is 210 more positions and 18 more programs than last year which continues the ~7% growth per year. The number positions per applicant was 0.82 which is mostly unchanged from the past 13 years. The percentage of US seniors filling EM slots continues a trend and is the lowest ever at 65% in 2019, a 5 percent drop from last year. On it’s surface this last point seems frightening but in diving deeper we see that the number of US seniors applying and matching into EM has remained steady at ~95% and the change in percent filled by non US seniors is having a dilutional effect as more positions are offered and more non US seniors fill the gap.
So, is EM becoming more competitive? Well, it depends how you look at it. First let’s look at whether the number of applicants for the space available has really changed. Since 2006 (The first year Match data is publicly available) there were ~1,300 positions available and 0.85 slots per applicant (which includes ALL applicants in addition to US seniors). That number really has not changed, dipping to a low of 0.80 in 2011 and most recently 0.82 in 2019. So the ratio of applicants to positions has not budged in almost a decade and a half.
From the program directors’ point of view it may feel like EM is becoming more competitive. The number of applicants has not changed but the number of applications each applicant is submitting to ERAS is exploding. The available data is much more limited for ERAS but we can see that between 2014 and 2018 UMG applicants steady rose from ~35 applications per applicant on average to 50 in 2018, a 36% increase or about 4 more applications per applicant for each successive year. We can also see that the number of applications received per program is rising in sync. The average program received 800 applications in 2014 and jumped to 930 in 2018 or about a 16% increase.
Programs need to rank around 6 people per positions offered to ensure they fill. According to the 2018 Program directors survey, the average program had 11 positions to fill and received over 900 applications for those 11 positions. These 940 were filtered down to 200 invites to interview and around 150 interviews hosted with about 5 percent of interviewees going unranked by any one program. Obviously, a lot of filtering has become the norm and approximately 30% of applications are rejected based on a standardized screening process used by program directors. EM is a bit of an outlier in that it has a more holistic view of applicants but Step 1 scores remain an easy filtering metric.
STEP 1 scores
Step 1 scores has a trend are difficult to summarize because the distribution is very wide with over half of people with just above passing scores successfully matching and a few applicants with above a 250 failing to match. That said, 2018 finally showed a slowing in the Step 1 arms race with nearly identical matching numbers for given scores in 2016. The greater trends in step 1 are a bit more dismal as both the average step 1 score has risen, the average step scores for both successful matches and non-matches into EM has increased in lock-step. The raw averages were step 1 scores of 233 for matched applicants and 220 for unmatched applicants, but let’s take a deeper dive.
Due to the increasing average, it is no surprise that the scores at the lower end of the curve have shown a decline in successful matches. At the top end we can see that anything above a 211 has around a 90% chance of matching or better. At the bottom of the step 1 curve the trends are dramatic. A score between passing and 200 had over an 80% chance of matching from 2006 up until 2011 but from 2014 to now that average has dropped to essentially 50% successful match rate. Similarly, for scores between 201 and 210 had around an 80+ percent match rate now more recently at 75%.
In an attempt to curb the application super storm, the AAMC has started to publish a very handy chart that attempts to quantify the point of diminishing returns, as a part of their “Apply smart” program. They divide the total number of applicants into 3 tertials for step 1 cutoffs that contain identical number of applicants and identify the point at which additional applications do not appear to increase the odds that an applicant will match. For EM their suggested cutoff for a step 1 score less than 218 was 29 programs, a step 1 above 219 but lower than 235 would see decline after 24 applications, and those with a 235 or better may only need to apply to 19 programs. If you remember to our earlier statistics, we found that the average applicant applied to 50 programs. It is worth noting that in my discussions with advisors, they are actually recommending applying to well over double the numbers put out by the AAMC.
Interview season data is a new part of the program directors survey. The season starts September 15th when ERAS applications are released to programs and concludes February 20th when rank lists by applicants and programs are due and the results published March 15th. The vast majority or around 60% of interviews are offered during October, 20% during November and a trickle of 8 and 4 percent in December and January. The actual interviews were mostly conducted from November and December with around 20% in January.
I want to talk briefly about the couples match as the fees and applicant strategies have recently changed. Couples matching is a complex process because of the haphazard way that the couples match has been integrated into the main residency match. In brief, couples have to submit a rank order list of equal length, can select “no match” as an option for one person but in order for a match to be successful both people must match at programs at the same rank order position on their combined lists. Due to the constraint of being required to match on the same line of the rank list, previous couples matchers would allegedly create rank order lists generated by spread sheets that would be thousands of line items long to cover every possible permutation of acceptable match sets. 2018 saw the first limit on the length for couples match permutations to 700 and in 2019 it was dropped further to no more than 300 items. Fees for both ERAS and the NRMP match are on a sliding scale. There is no data available for EM specific couples matches but in 2018 93% matched as a couple, 6% had only one individual match (The other may enter SOAP). Just over 1% of couples failed to match both individuals. The couples match rates have been steady for the past 15 years.
The NRMP match fees are separate from ERAS fees. An applicant that applies only to EM and follows the recommended 30 applications from the AAMC “apply smart” program we spoke of earlier would spend a total of $504 for the privilege of applying and ranking, not including travel expenses ($419 ERAS and $85 NRMP). For a hypothetical couples match let’s assume a doubling of the recommended applications to 60 resulting in 20 programs to be ranked and maxing out the permutation rank order list to 300, a couple would spend $3,618 in total for both people ($1199 ERAS and $610 NRMP for $1809 each), again not including travel expenses.
There is no ceiling effect for the fee schedules. For the sake of argument, an EM applicant that chose to apply to all 238 programs would be assessed $5,827 in application fees through ERAS and assuming they ranked all 238 programs would be charged an additional $6775 for the match with a grand total of $12,602 for the privilege of applying. An applicant that went the EM-or-bust approach would spend ~$6,000 on applications and a more realistic rank list.
I left the SOAP match, aka the scramble for the last because it is such a downer. All the travel and worry and money spent to do it all again – I think we all know people that have been in this position and it is truly heart breaking. 2017 actually saw a complete fill of EM with no positions available for SOAP and 1100 positions available for SOAP applicants. 2018 saw a small improvement of 10 positions available in EM of again around 1100 total slots. 2019 data is not yet available but from reliable sources we feel confident that there were around 15 EM slots available in the SOAP match.
For US seniors, about 12 percent will be eligible to participate in the SOAP match, which can be a full non-match or a partial where an applicant only matched to a prelim year or categorical but not both. 5% of US seniors did not match in 2018, a stable rate since the 1990’s.
It is worth noting that matches accomplished in the SOAP are considered successful matches by most institutions, so when you hear the “100% match” headline, keep this in mind.
That was a metric ton of data I threw at you, let’s recap.
EM continues to be popular being the 5th most common specialty both in offered positions and applications. The ratio of applicants and positions offered has not changed in the last 15 years. We saw that US seniors make up a lower proportion of matches but have not changed in their 95% success match and the change is due to stagnate applications by US seniors while more positions open.
EM feels like it is becoming more competitive due to more applicants applying more broadly and gently rising step scores but few other metrics give compelling evidence of a more competitive field.
The AAMC has attempted to quantify the point of diminishing returns for application in EM to around 30 for most people. Interview season is broad with many interviews still being conducted in January.
ERAS and NRMP fees have increased especially effecting the couples match.
We hope you enjoyed this episode and will see you again next month. Thanks again for listening to EMIGcast.
These tables were created with data collected from the NRMP match archives.
In the following table the trend in percent matched for grouped scores on step 1 is shown. For example, in the first group those that scored between a 191 and 200 are shown as percentage that matched into EM over time from 2006 to 2018. In 2006 85% of applicants in this score range matched but in 2018 only 63% with this same score were able to match. Scores above 250 near 98% match rates and are not shown.
In the following graph the mean step scores as reported by the historical match data are shown over time with blue indicating those that matched in EM and the orange showing those that did not match into EM and black as the step 1 average for all test takers. Trend lines are shown as dashed lines.
A clinical presentation of abdominal pain, n/v, increased thirst and incontinence in a young female her first week of college. Take a listen to figure out what’s going on, how to diagnose and treat this common and potentially life-threatening illness.
On this episode, Kate Rodman (MS-2) and Will Hockett (MS-3) discuss advances in the treatment of opiate use disorder in the Emergency Department.
Opioid misuse and addiction have been on the rise ever since opioid pain relievers became widespread in the 1990s. In 2017, the U.S. Department of Health and Human Services declared a public health emergency to address the opioid crisis, and in that year alone over 47,600 people died in the United States due to overdosing on opioids. In addition to changing prescribing practices, Emergency Departments across the country are trying to combat addiction. A randomized control trial out of Yale in 2015 showed a spotlight on the potential for ED initiated buprenorphine treatment for patients presenting with opioid dependence. The results of this study, along with widespread interest in combatting opioid addiction, spurred emergency departments across the country to initiate programs to prescribe buprenorphine to patients at presentation. The ability to engage patients right away with treatment in the ED is an exciting new opportunity to combat the opioid crisis.
Kick off your new year with this short clinical episode on Hyperkalemia. MS3 Gabby Gioia from OHSU sits down with Dr. Corey Slovis, Chairman of Emergency Medicine at Vanderbilt University to talk diagnosis, complications and treatment for high levels of potassium.
As Dr. Slovis says, hyperkalemia is “The only acute electrolyte abnormality with the potential to kill”. He gives discusses the five causes of HyperK, and the 5 EKG changes to look for – it’s more than just peak T waves!
On this episode, Lavinia Turian (MS2) discusses with Dr. Martin Smilkstein about what it is like practicing medicine on the Navajo Reservation at the Chinle Comprehensive Health Care Facility as part of the Indian Health Services. Dr. Smilkstein dives into detail about some of the challenges faced working in the emergency department, including a shortage of long term personnel and the high acuity of care seen. He also provides some insight on what it might be like for students and residents to rotate through a clinic on the reservation. The Indian Health Services sees a unique patient population that many providers and students have not had the opportunity to work with. We hope you enjoy this episode!
For more information about the Indian Health Services and how to get involved, visit: www.ihs.gov
“Interest & career longevity & staving off longevity are absolutely reasons people consider and do go on to do fellowships. Fellowships are certainly a great opportunity. They are a training that make you a specialist within that field but fellowships are not required to practice emergency medicine”.
Are you interested in pursuing a fellowship after Emergency Medicine Residency? Check out this podcast with Dr. David Jones, practicing EM Physician at OHSU and Co-Director of EM Education Fellowship. He offers insight into why to pursue a fellowship, salary implications and long-term effects on practicing medicine.
Ally Gallagher (MS3) sits down with Dr. Blake McKinney and Dr. John Dutton of CirrusMD, a telemedicine company that provides remote acute care to patients across the country. Drs. McKinney and Dutton discuss the expanding role of telemedicine, its challenges, and the potential impact on the future of healthcare delivery.
Dr. McKinney is a co-founder and Chief Medical Officer and Dr. Dutton is the Medical Director of CirrusMD. Both are practicing emergency medicine physicians in Northern California.