Availability of Emergency Medicine Away Rotations

Abstract

Objectives

Residency directors in emergency medicine (EM) have been placing increased value on the Standardized Letter of Evaluation to evaluate the escalating numbers of residency applications received each year. This has placed added significance on EM away rotations (ARs). We sought to determine the overall availability of ARs in EM.

Methods

We surveyed clerkships sites at the end of 2018–2019 application season. The survey requested data about maximum rotation spots available, actual number of students that rotated, and data about application processing and rotation offer decision making.

Results

We received 190 responses, of which 129 (49% of 262 clerkship sites surveyed) provided data regarding available positions and student rotators. A total of 3,472 ARs were completed at the responding sites. The average capacity ratio (CR; maximum available AR spots divided by AR completed by students) for responding sites was 1.57. AR availability varied by time and geography. Most AR positions were filled during peak season (CR = 1.22); however, many went unfilled outside of this time frame (CR = 2.41). Geographic data showed some locations had significant unfilled AR availability.

Conclusions

Our survey data show that there are at least 1.5 AR positions per applicant. Students can be reasonably expected to complete one AR and, in select cases, a second. CR during peak season indicates nearly saturated AR positions. Flexibility of rotation timing and tools to link open AR positions with students needing to complete a rotation will help optimize filling available AR positions. Continued effort in application advising from home clerkships and processes to ensure equitable distribution of AR positions among students will help ensure interested students obtain a position.

In recent years, completing an emergency medicine (EM) rotation at another program, also known as an “away rotation” (AR), has become increasingly important for applicants to EM residency programs. ¹ , ² , ³ , ⁴ The clerkship grade and Standardized Letter of Evaluation (SLOE) from ARs offer program directors an objective second opinion of a student’s performance and are highly valued by PDs when reviewing applications. ¹ , ² , ³ , ⁴ Students are advised, both formally and by peers, to complete at least one AR. ⁵ , ⁶ , ⁷ Although a third rotation is not recommended in most cases, some students are completing multiple ARs. ⁶ , ⁸ , ⁹ Students and their advisers have reported difficulty obtaining ARs. In a recent study, students reported applying to an average of 15 ARs. ¹⁰ Given the importance of the AR in the EM application process, we sought to determine if sufficient ARs exist to meet student needs. We hypothesized sufficient AR availability but that other factors including application processing, competition among students, and timing create an impression of limited supply.

METHODS

We created an 18‐item survey (Data Supplement S1, available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1002/aet2.10487/full) using Qualtrics software, Version February 2019. The survey started with a brief project summary and was organized in three sections. Questions about application processing (i.e., who selects students to complete an AR?) were multiple choice. The second section asked the number of applications received, maximum number of visiting students, and actual number of rotating students. The third part inquired about subspecialty SLOEs. The survey was pilot tested by the Council of Residency Directors (CORD) Application Process Improvement Task Force and VSAS subcommittees and revised as needed.

The survey was administered from February to April 2019. The authors identified 262 unique clerkship rotation sites by reviewing the SAEM and EMRA clerkship directories and all SLOEs for standard EM rotations submitted to their programs in the 2018–2019 application season. Reviewing SLOEs identified 22 sites that were not included in either clerkship directory. SLOEs written from non‐EM residency sites were counted but subspecialty SLOEs were not. ¹¹ The survey was sent directly to all 262 clerkship directors and additionally distributed via CORD and CDEM listservs. Self‐reported data using a survey were chosen over collecting data from a central source (i.e., VSAS) as not all clerkship sites use VSAS. Loma Linda University Health Institutional Review Board determined that the project was not subject to review. Data analysis was performed using Excel 2010 Version 14.0 (Microsoft Corporation).

RESULTS

Survey invitations were sent to all 262 unique EM clerkship rotation sites identified for the 2018–2019 application cycle. We received 190 responses. Twenty‐six responses were excluded due to duplication of previous entries or providing identification information only. These 164 responses provided the data for analysis of application processing. Nine of the 164 clerkship sites were not affiliated with a residency program. Of the 164 responses, 35 did not provide rotation availability data or did not accept visiting students. The remaining 129 (49%) sites are the basis of our analysis of AR capacity. Four sites were nonresidency affiliated, the remaining 125 sites were affiliated with a residency program. Each of the seven geographic regions in the United States are represented in the analysis, including 36 states and the District of Columbia. ¹²

A total of 3,472 ARs were completed at 129 sites during the 2018–2019 application cycle, resulting in 3,222 SLOEs authored. The average number of rotators per site was 27.3 (range = 0–101). An average of 25.1 (range = 0–84) SLOEs were authored by rotation sites.

Some responses only partially completed the first survey section with multiple‐choice questions about application processing. Data are reported as the number of affirmative responses for that item (n) and the percentage of all responses for that question. As seen in Table 1, most respondents are affiliated with a residency program (95%, n = 155). Clerkship directors (66%, n = 109) most often select visiting students. A limiting factor for visiting student rotation availability is the number of home students completing an EM clerkship. The two groups of students complete the same rotation at 74% (n = 116) of sites and 81% of sites report ARs being limited by the number of home students completing an EM rotation. Most respondents did not.

Table 1.

AR Application Processing and Selection Considerations by Clerkship Sites

Question (n = total responses)	Yes (%)	No (%)
Residency affiliated (164)	155 (95)	9 (5)
Use VSAS for application processing (158)	106 (67)	52 (33)
Clerkship director selects students for AR (156)	109 (70)	47 (30)
Visiting students complete same rotations as home students (157)	116 (74)	41 (26)
AR spots limited by number of home students (113)	91 (81)	22 (19)
Subspecialty AR spots available (130)	54 (42)	76 (58)

AR = away rotation; VSAS = visiting student application service.

To assess a clerkship site’s capacity to accept visiting students during the application season, we calculated a sites’ capacity ratio (CR). The CR formula divided the maximum AR capacity by the number of ARs completed by students. Our results show a mean CR of 1.57 and median 1.41. Nearly all of the clerkship sites (125 of 129) that provided complete data for CR calculation were affiliated with a residency program. The mean CR for the 125 residency affiliated clerkship sites was 1.56.

Figure 1 shows CR clustered by state. CRs ranged from 1 to 3.33. The average of state CRs was 1.59. States with the highest CR were Montana, Louisiana, and Arkansas. Washington, Minnesota, and Connecticut had CRs of 1.

Figure 1.

EM clerkship CR (maximum available AR positions/actual number of students completing away rotation) for application season 2018‐2019 calculated by state. AR = away rotation; CR = capacity ratio.

The number of available positions varies greatly by time of year. Figure 2 shows a large spike in the number of rotators and the number of available ARs in July thru October. The CR during peak season of July thru October is 1.22, compared to 1.57 for the entire season. A total of 2,580 ARs were completed during peak season with a maximum available 3,147. The CR during off‐peak AR season is 2.41, nearly twice that of peak season. Almost 1,500 AR positions were unfilled during off‐peak season. March thru May were the 3 months with the lowest total AR availability and number of rotations completed (Table 2). The data show 1.0 or fewer ARs completed by students per site in March thru May, compared with a maximum of 6.1 rotators per site at the peak of the season in August.

Figure 2.

Plot of maximum EM AR capacity and ARs completed during application season 2018–2019. AR = away rotation.

Table 2.

Cumulative AR Data for Application Season 2018–2019 Reported by Month

Month	Maximum Capacity	Actual Rotators	Capacity Ratio	Max Rotators at a Single Site	Mean Actual Rotators Across All Sites
March	306	105	2.91	14	0.9
April	319	91	3.51	12	0.8
May	347	118	2.94	16	1.0
June	456	230	1.98	12	2.0
July	687	567	1.21	16	4.8
August	844	748	1.13	18	6.1
September	835	695	1.20	16	5.7
October	781	570	1.37	16	4.7
November	629	341	1.84	16	2.8
December	492	173	2.84	14	1.5

AR = away rotation; Maximum capacity = maximum number of visiting students allowable for a month; capacity ratio = maximum capacity/actual rotators.

DISCUSSION

Our survey was performed and the data analyzed prior to the COVID‐19 pandemic, which may cause long‐lasting changes in the need for ARs. Our data confirm that, if we return to previous capacity, there are sufficient positions available for students to complete at least one AR with room for more than half of applicants to complete a second. The visiting student CR for 2018–2019 was 1.57, indicating that there are more than enough positions for each student applying to EM to adhere to CORD Advising Students Committee in EM guidelines of completing one AR. ⁶ Guidelines also indicate a need for certain applicant populations to complete two ARs. ⁶ Our data indicate 5,696 AR positions were available this season. NRMP data show 1,823 US seniors and 1,225 independent applicants applied to EM this season; 3,048 applicants included EM somewhere on their rank order list in 2018–2019. ¹³ Our data indicate nearly twice as many AR positions available as applicants ranking EM in 2018–2019. Given the survey response rate there are possibly even more available AR positions.

While there are clearly enough AR positions for EM applicants to complete one AR, many students still perceive a lack of AR positions. We suspect rotation timing plays a large role. There is a large spike in maximum AR availability in the peak of the application season, July thru October. This likely reflects both the desire of programs to “audition” potential applicants as well as clerkships’ response to the increased demand for ARs from EM‐bound students as they prepare their ERAS application for submission in late September and early October. ¹⁴ With a peak season CR of 1.22 it seems AR availability and completion are nearly maximal during these months. Although nearly 600 AR spots were unfilled during peak season, 1,058 ARs were completed in off‐peak months. Based on the responses we received, the capacity for clerkships to accommodate all students completing an AR during peak season does not currently exist.

One way to expand AR availability is by utilizing rotations in nonpeak months, which are currently going unfilled. There are a large number of unfilled rotation spots early in the year (March thru May). These available rotations do not align with the traditional academic calendar as many students do not advance to the fourth year of medical school until July. Additionally, rotation dates do not always align between the student’s home school and those at the desired AR. Increased schedule flexibility on the part of both home and hosting medical schools as well as students and advisors would facilitate AR completion in nonpeak months. Likewise, residency programs interviewing applicants with one SLOE and reviewing SLOEs that are submitted later in the season would help. September has the second‐highest availability, but SLOEs are not available for initial application submission. Regarding overall AR availability, 78% of clerkship directors did not anticipate a significant change in the number of ARs for the upcoming year when responses were collected in early 2019. It is likely the COVID‐19 pandemic will significantly affect AR availability for at least application season 2020–2021.

Matching student demand with AR availability is another area for optimization. More than half of sites’ CR was <1.5, which meant the AR positions were full or nearly full. Conversely, nearly one‐third of sites’ CRs were >2—fewer than half of the available positions were filled. We cannot hypothesize as to why some sites were relatively full and others were not. A mechanism by which students desiring an AR and clerkship sites with available positions are brought together, such as EMRA Match or SAEM clerkship directory, could be very effective at ameliorating this supply and demand mismatch.

An additional concern that was not addressed in our survey was potentially inequitable distribution of ARs among students. Some students secure two or more ARs before other students secure a first. This problem is exacerbated when examining students without a home EM rotation who are expected to complete two ARs. A process to ensure fair distribution of ARs among students with a uniform notification of acceptance from clerkships and deadline for students to commit to the rotation would help students secure available ARs and clerkships fill positions.

LIMITATIONS

Our survey response rate was 49%. An additional limitation we encountered was the absence of a central list of EM clerkship sites. Searching various sources, we found disparate results with all being less than the 262 sites we contacted. Our survey relied on data reported by clerkship sites, opening up the possibility of recall bias. We collected data about total number of applications received by a clerkship site but were not able to glean data about number of applicants unable to secure an AR. There may be a small number of students who were unable to secure an AR, which is data not collected in our survey. These students might also be missed by NRMP data because some students may decide to eschew applying to EM residency after being unsuccessful securing an AR.

CONCLUSION

Our survey shows there are over 1.5 away rotation positions for each applicant to EM and, given our response rate, possibly more. It is reasonable to expect all students to be able to complete one away rotation, with capacity for a second away rotation in certain instances. Conservatively, and accounting for temporal factors, if all students complete the recommended one away rotation there is still ample capacity for students belonging to at‐risk subgroups to complete an additional away rotation. Peak season capacity ratio of 1.22 indicates nearly saturated away rotations during the high demand period July to October. Greater flexibility to complete away rotations during nonpeak months as well as optimizing existing tools to link students with available away rotation positions can help address this issue. Processes to fairly distribute away rotations to all interested students and continued effort to provide students with high‐quality advising are important as well.

Supporting information

Data Supplement S1. Qualtrics Survey Software.

AEM Education and Training 2021;5:1–5