Advising Medical Students During COVID‐19: The Case for a Single Emergency Medicine Rotation for All

The COVID‐19 pandemic has disrupted the usual approach to exploring and applying into emergency medicine (EM) for medical students. On March 17, 2020, the American Association of Medical Colleges issued guidance strongly suggesting that medical students be removed from direct patient care. ¹ Many medical schools removed medical students from clerkships and postponed hosting visiting medical students indefinitely. An informal query of EM clerkship directors on the Clerkship Directors in Emergency Medicine listserv confirmed this trend in EM, with a clear majority of respondents pulling their students from clinical rotations and halting visiting student rotations.

For many EM‐bound medical students, the crucial spring time period to explore and focus in EM became a vacuum and the standard advice for how to successfully apply in EM was insufficient. With no change in the Electronic Residency Application Service (ERAS) timeline at this moment, the timeline compressed for students to prepare for their application. This disruption forced many educators to reexamine their advising paradigm for medical students applying into EM.

Pre–COVID‐19 Standards

Program director surveys routinely demonstrate that evaluations from EM rotations, specifically group standardized letters of evaluation (SLOEs) from home and away rotations, are the highest weighted factors in consideration of an EM residency application. ² , ³ , ⁴ , ⁵ , ⁶ Because of this, expectations have evolved such that EM residency applicants are commonly advised and expected to complete two EM rotations to be competitive. ⁷ This typically means completing one rotation at their home institution and one away rotation. A positive evaluation on an away rotation offers supporting evidence of translatable skills and can be seen as providing a less biased assessment of a student's potential to be a successful EM resident than a SLOE from a home rotation. However, the process of applying for and completing an away rotation can be competitive, expensive, and unpredictable for students. ⁸

Rationale for a Single Rotation

Given the increasingly competitive nature of obtaining away rotations, finding two EM rotations for all interested EM candidates had already become challenging. COVID‐19 amplified this challenge. Our EM student programs team supports the Council of Emergency Medicine Residency Directors Advising Students Committee in EM consensus statement that programs should be understanding about a single EM rotation and SLOE in this unprecedented year. ⁹ We strongly advocate for our national EM community to go one step beyond this statement and to align in a unified equitable recommendation for a single EM rotation for all EM‐bound students.

We recommend a single EM rotation for all applicants for the following reasons:

1. Equity. Away rotations in EM are a limited resource, and combined with travel restrictions there is significant potential inequity among students as they seek rotation experiences in a compressed time frame. We believe that students from “orphan” programs with no home EM residency program deserve first access to an away rotation, giving them the opportunity to obtain the critical single SLOE for their application. By focusing home students on rotating at their home program, this can open the door for students who need an away rotation the most.

2. Wellness. The significant emotional and financial stress of applying for away rotations that is typical of previous years is exponentially compounded this year. We anticipate that it will be exceptionally difficult this year for students to obtain away rotations. We also recognize that students applying for away rotations may go through the entire process only to have their away rotation canceled. A no‐away‐rotation policy with a written explanation in SLOEs may mitigate this stress.

3. Need for flexibility. There is still uncertainty at many institutions about when direct patient care experiences for medical students will resume. We must ensure that all medical students interested in EM secure one spot to rotate this summer in time for clerkship teams to draft SLOEs prior to ERAS opening. For this to happen, complete schedule flexibility of EM‐bound students is of paramount importance.

4. Safety. We do not anticipate the risks of COVID‐19 to disappear entirely this summer. We acknowledge the personal protective equipment (PPE) limitations that many institutions are facing right now, and we know that supply of and policies around PPE vary from institution to institution. While we expect any institution accepting away rotators to make efforts to ensure student safety, we recognize that it is difficult to ensure a consistent standard of PPE protection across all institutions.

Implementation

For those institutions with a home EM program, enacting a single rotation policy means canceling away rotations for your own students. We offer our experience as an example in guiding this process. Working together with the medical school dean's office, we canceled all EM away rotations for our students for the rest of the calendar year.

To implement this time‐sensitive decision, EM student programs teams must coordinate closely with the dean's office. At our institution, we had multiple meetings outlining the considerations above and coming to consensus on the best plan for our students and educational community. We provided registration with a list of our EM‐interested students who were then given priority for summer clerkship spots in our required EM rotation. All students applying in other disciplines were moved from summer spots to rotation dates later in the year. Even with these schedule adjustments, we additionally had to overload our clerkship by two or three students per month and fine‐tune the schedule and curriculum to be able to fit our EM‐interested students into this compressed time frame and ensure adequate clinical exposure for their rotation experience.

This process requires enhanced communication with EM‐interested medical students. It is critical to prioritize clear, consistent communication to students from EM student programs and the dean's office. Here we held several online group advising sessions. Students had many insightful questions about the no‐away rotation policy, and we had open discussions about the rationale for the policy and the ways in which we can provide additional support for them during this application cycle. We recognized specific challenges that this policy posed, including the distress of students who had to cancel or decline away rotation offers at programs they are particularly interested in exploring. We emphasize the uniqueness of this year and its impact on everyone and also reiterated the importance of consistency and equity in our approach. We also assured students that we will provide a very clear explanation of this policy on their SLOE. Additionally, given that students were not currently on clinical rotations, we offered an online personal statement workshop and ideas on how to start preparing their application materials now so that they can focus on clinical work when they return to clinical rotations this summer.

Discussion

There are many compelling reasons for the EM educational community as a whole to adopt a single rotation policy this year. Advisors and programs have a collective responsibility to our EM educational community. What we do affects others. If we are not able to host visiting students, there are fewer spots for all students. If we send our students out to do visiting rotations, they contribute to the consumption of the scarce resource of away rotations. With a single EM rotation policy, we all can focus on making sure each EM‐aspiring student obtains a quality EM rotation experience, scheduling home students on a home rotation and prioritizing any visiting rotation opportunities for students without a home EM residency program. In this reexamined advising paradigm we focus on factors we can control to equitably support students and our community.

There are potential downsides to a single EM rotation policy. Programs and students alike will not have as many opportunities to get to know each other without away rotations. Students with less competitive applications who can improve their chances in the Match by performing well on a second rotation will not have that opportunity. Prioritizing all summer spots for EM‐bound students means we may miss those students who “discover” EM later as their desired specialty when they rotate through early in their fourth year. However, we feel that the benefits outlined above strongly outweigh these downsides.

The rationale for a single EM rotation policy extends beyond the time of COVID‐19. The very real issues of equity are not unique to this time, but this time prompts us to reflect on what we can do as an educational community to mitigate these issues. We recognize that advocating for a single EM rotation is but one step in the important work of increasing equity in our approach to preparing and evaluating EM‐bound students. We look forward to seeing positive changes come out of this challenge. We predict that we may find a single institution's EM evaluation adequate for programs to make informed assessments. There are additional factors pushing programs to look for ways to evaluate candidates more holistically, including the upcoming pass/fail grading scheme for the USMLE Step 1 examination, and so the time is ripe for revisiting our applicant evaluation paradigm. We recognize that advisors and students from all institutions are facing similar challenges and hope that this discussion may be informative as each institution considers their best approach. We truly believe that programs, advisors, and students in EM will work creatively to overcome the challenges of this time to strive toward a successful, equitable match year for all stakeholders.

AEM Education and Training 2020;4:313–315