Thematic Analysis of Emergency Medicine Applicants’ Personal Statements

Abstract

Background

The personal statement is an important part of the residency application. Although guidance exists, the composition of personal statements is not standardized; each statement reflects an applicant’s unique personality. In emergency medicine (EM), the personal statement could thus provide insight into why applicants are choosing EM and what they hope to accomplish in the field that could guide advisors and applicants.

Objective

To perform a thematic analysis of personal statements from applicants accepted into an academic EM residency program to gain insight into what successful applicants include in their personal statements, why applicants are pursuing careers in emergency medicine, and anticipated career goals.

Methods

Thematic analysis was performed on ten randomly selected personal statements from matched allopathic, U.S. applicants at a single, large, urban 3-year EM residency program between 2008 and 2015. Themes and sub-themes were identified and analyzed for frequency.

Results

Ten personal statements were analyzed. Thirty-one (31) unique themes were identified and grouped into five main themes: personal characteristics related to a career in EM (38.3%, 116/303), why I love EM (36%, 109/303), my story (13.5%, 41/303), my career in EM (8.9%, 27/303), and ideal characteristics of a residency program (3.3%, 10/303). The most common personal characteristics described were altruism and the ability to work well under pressure. Applicants love EM due to the diversity of patients and disease presentations and the ability to perform procedures.

Conclusions

Thematic analysis of EM applicants’ personal statements highlights the uniqueness of EM as a specialty and what draws applicants to EM.

Background

Emergency medicine (EM) is becoming a highly competitive specialty with 1.2 to 1.3 applicants for each available spot [1]. In 2017, there were 3575 medical students who entered the National Resident Matching Program (NRMP), hoping to pursue a career in EM, and each EM residency program received an average of 941.8 applications [1]. As the number of applications per program increases, it becomes more challenging for the selection committee, usually comprised of program directors and associate program directors, to screen and select applicants for interviews. While a universal medical application includes academic achievements, transcripts, United States Medical Licensing Examination (USMLE) scores, and standardized letters of evaluation (SLOEs), one of the most uniquely personal aspects of the Electronic Residency Application Service (ERAS) application is the personal statement.

A compelling personal statement plays a significant role in the overall application process by providing the opportunity for applicants to embed their personality, interests, and passion for EM into their application beyond the constraints of a curriculum vitae [2, 3]. Personal statements also provide program directors insights into applicants’ understanding and expectations of a career in EM. In the NRMP’s 2016 Program Directors survey, 66% of program directors cited personal statements as a crucial determinant in selecting applicants for interviews with an importance rating of 3.3 out of 5 [4]. Program directors also cited professionalism and personality with respective importance ratings of 4.9 and 4.5 out of 5, factors which are often reflected in the personal statement [4]. Some have even viewed the personal statement as an applicant’s perceived professional identity [5].

While formal and informal guidelines for writing personal statements are available from the American Medical Association (AMA), the Council of Emergency Medicine Residency Directors (CORD), medical school writing workshops, and student-centered websites, the impact of these efforts is unknown [6].

To our knowledge, the content of EM applicants’ personal statements has neither been explored nor previously published. Thus, the purpose of this study is to perform a thematic analysis of personal statements from applicants accepted into an EM residency program to better determine what successful applicants include in their personal statements and their perceptions of the specialty.

Methods

Personal statements of matched allopathic, U.S. applicants at a single, large, urban 3-year EM residency program between 2008 and 2015 were considered for inclusion in the study to ensure that no current residents at the time of the study would be included in the sample. Osteopathic and international medical graduates were excluded from this analysis as they make up a small portion of the EM applicant pool. During the study selection period, the EM residency admission committee was comprised of one program director and two associate program directors, all with various levels of education and leadership experience.

All eligible personal statements were screened for completeness and fully de-identified prior to analysis. Purposive sampling was used to create a sample representing the majority of applicants to EM residencies. Thematic analysis was used to explore the contents of EM applicants’ personal statements using an inductive coding approach to ground the study [7]. Manifest and latent coding were used to optimize the reliability of the thematic analysis. From the 100 available personal statements, two were randomly selected for generation of themes. All four authors, each with extensive experiences in residency selection (two authors were non-EM program directors, one author was the Director of Undergraduate Medical Education and EM Clerkship Director, and one author was Core Faculty and Assistant Director of an EM Clerkship), independently generated themes from these two personal statements. The authors then met to review and edit the themes through a collaborative, iterative process until the final themes were generated in consensus. Common themes identified by the authors were similar to those identified in prior studies in surgical specialties [8]. After thematic generation, ten (10) statements were randomly selected for analysis with plans to supplement these statements with additional personal statements as necessary to achieve theme saturation.

To identify themes, the authors divided themselves into teams of two; each team was responsible for independently identifying themes in half (5) of the personal statements. To minimize researcher bias, each team included a non-EM trained physician and an EM-trained physician. The authors utilized Dedoose [9], a qualitative data management software program, to code the statements and analyze the data for frequency of themes and sub-themes. Once each team concluded its independent review, both teams would review the personal statements coded by the other team before reaching consensus on the identification of the themes for all ten personal statements. This study was deemed exempt by the Thomas Jefferson University Institutional Review Board.

Results

Ten (10) personal statements were analyzed. Thirty-one (31) unique themes were identified and grouped into the following five main themes (Table 1):

1. Personal characteristics related to a career in EM (38.3% of themes): This theme includes personal characteristics that make the applicant suitable for a career in EM such as being altruistic or working well under pressure.

2. Why I love EM (36% of themes): This theme includes the reasons why an applicant specifically chose emergency medicine for a career, such as the diversity of patients and the ability to perform procedures.

3. My story (13.5% of themes): This theme includes a personal story of growth and overcoming challenges and personal experiences with the medical system that inspired the applicant to pursue medicine as a career.

4. My career in EM (8.9% of themes): This theme includes what applicants aspire to in their future careers as emergency medicine physicians and includes goals such as pursuing specific research interests or fellowships.

5. Ideal characteristics of a residency program (3.3% of themes): This theme focuses on the characteristics of the applicant’s ideal residency program such as a challenging environment that offers autonomy or caring for an underserved population.

Table 1.

Frequency of themes and sub-themes determined by a random selection of personal statements for emergency medicine (EM) residency from a tertiary academic center from 2008 to 2015

Codes grouped by theme	Frequency (n)	Percent of total codes
My story	41	13.5
Clinical vignette	9	3.0
Volunteer experience in medical setting	11	3.6
Personal experience with medical system	5	1.7
Story of personal growth	16	5.3
My career in EM	27	8.9
Leadership	8	2.6
Academic and research	11	3.6
Clinical medicine	8	2.6
Personal characteristics	116	38.3
Identifying problems	11	3.6
Part of a team	8	2.6
Thrive in chaos	5	1.7
Work ethic	6	2.0
Work unusual schedule	3	1.0
Work well under pressure	15	5.0
Altruistic	24	7.9
Decision making	7	2.3
Demonstrate EM knowledge	5	1.7
Determination	11	3.6
Manage complex situations	5	1.7
Personal accomplishments	16	5.3
Residency program characteristics	10	3.3
Better doctor	6	2.0
Independence	1	0.3
Challenging	3	1.0
Why I love EM	109	36.0
Alleviate suffering	6	2.0
Differential diagnosis	14	4.6
Diversity of patients	31	10.2
First point of contact	6	2.0
Impact long term health	10	3.3
Motivating patients	3	1.0
Procedures	15	5.0
Acuity of patients	14	4.6
Preventive care	10	3.3

A total of 303 theme statements were applied across the 10 personal statements, with an average of 30.3 themes per personal statement (SD = 8.01, range = 21–46). Table 1 displays the frequency of themes. Table 2 displays selected quotes from the common themes and sub-themes.

Table 2.

Selected quotes or emergency medicine personal statements as characterized by the five main themes

Themes	Selected quotes
Personal characteristics related to a career in EM	Altruism:     “Contributing to the community has been a standard that I have upheld throughout my adulthood.”     “I am driven to provide for the needs of my patients and provide them with the best possible service.” Personal accomplishments:     “I founded the international health interest group, Global Health Forum, which introduces medical students to current issues in international health and helps them gain medical experience abroad during their education.” Work well under pressure:     “My even-tempered, quick, logical thinking during stressful situations will complement nicely my other attributes.” “I am well suited for emergency medicine because of my ability to work under pressure, and to stay calm and think logically in stressful situations.”
Why I love EM	Broad patient and disease presentations:     “I can deal with the drunk who is uncooperative, the rambling schizophrenic or the demented elderly person.”     “What fascinated me the most was the variety of the field, as no two shifts in the emergency room are ever the same. The profession has elements of nearly every field of medicine - from procedures, to primary care, to obstetrics/gynecology, to psychology, and everything in between.” Patient acuity:     “Although Emergency Medicine can be considered the ‘jack of all trades’ specialty in certain regards, it is commonly misunderstood that they are, in fact, masters of acute intervention and prioritization.”     “…stabilizing the unstable patient…” Forming differential diagnoses:     “What I enjoy about emergency medicine is the constant need to think about atypical presentations for common diagnoses.”     “I enjoy the responsibility of formulating a differential based on the history and interrogating those suspects with a complete, but directed physical exam and laboratory studies.”
My story	Personal growth:     “…these changes have been immeasurable treasures that allowed me to grow into the person I have become.”     “During this time, I learned the valuable lesson of how to deal with adversity while fulfilling my professional commitments.” Volunteer/personal experiences:     “I learned that my mother had been living with the secret of advancing breast cancer which she had kept from her family, her friends, and even her doctor.”     “In my undergraduate years I volunteered for 4 years at a community emergency department, as well as with Habitat for Humanity.” Clinical vignette:     “I remember one patient with an asthma exacerbation due to crack cocaine use. The medical team gave him some nebulizer treatments. It soon became obvious he was not responding to the treatment and the attending physician performed a rapid sequence intubation. The experience inspired me.”
My career in EM	Future goals in emergency medicine:     “Beyond residency, I hope to complete a fellowship in International Emergency Medicine.”     “I plan on continuing to make research a part of my career and hope to bring more evidence-based practice to the field of Emergency Medicine.”
Ideal characteristics of a residency program	“I seek a residency program that is as excited at producing excellent physicians as caring for anyone, with anything, at any time.”

All personal statements included a discussion of such personal characteristics. Some applicants provided specific examples of characteristics, while other applicants simply stated that they possessed the characteristic. The most commonly cited personal characteristic was being altruistic, followed by personal accomplishments and specific examples of how they work well under pressure.

The next most commonly identified theme was why I love EM, and all ten personal statements included comments reflecting this theme. Applicants discussed a myriad of reasons why they love the field of emergency medicine. The most commonly cited reason was the diversity of patients and disease presentations, being able to perform procedures, the acuity of patients, and building a differential diagnosis. Patient acuity was described in specific terms by listing acute conditions such as acute stroke and acute coronary syndrome as well as in general terms about managing acute needs..

This theme was identified in nine out of ten personal statements. There was diversity in how applicants discussed their story, from accounts of personal growth to experiences within the medical system, and specific clinical vignettes that inspired them to choose EM. Finally, all personal statements included comments about the applicant’s expected future career, which included post-residency goals as well as ideal residency program characteristics..

Occurrence of themes was also identified among the personal statements. The most commonly co-occurring themes were personal accomplishment and leadership, preventive care, and impacting long-term health. The next most common co-occurring themes were identifying problems and working under pressure, altruism and determination, and differential diagnosis and diversity of patients.

Discussion

This study marks the first published report on personal statement contents from successful applicants to emergency medicine residency programs. The most commonly expressed themes in applicants’ personal statements were the description of personal characteristics that made the applicant well suited for the specialty. Applicants often provided specific characteristic examples that made them particularly prepared for a career in EM (Table 1). Previous work focusing on applicants’ personal statements to other residencies (internal medicine, general surgery, ophthalmology, and pediatrics) also identified similar themes to those characterized in our study [5, 8, 10, 11]. Our analysis identified that EM applicants frequently discussed their ability to work well under pressure and altruism, which appears to be a theme unique to EM personal statements when compared with the work done in other specialties. Describing personal characteristics is in keeping with the American Association of Medical Colleges (AAMC)’s advice to portray marketable abilities [12]. Additionally, the characteristics mentioned by applicants—altruism and ability to work well under pressure—represent distinct personality characteristics of EM residents when compared to the general physician population [13].

It is noteworthy that discussion of why I love EM is included in all the personal statements examined in this study. The most commonly cited reason was the diversity of patients and disease presentations. This element has been identified in personal statements from internal medicine applicants, and we posit the frequency of this theme within EM applicants may be attributable to publications that recommend including this element [5, 10, 14]. Interestingly, this theme was not found in personal statements of those pursuing anesthesia or radiology residencies [3, 15]. This discrepancy may relate to different resources and advising strategies for students applying to these fields or specialty-specific differences in expectations. The next most commonly mentioned reason for pursuing a career in EM was the opportunity to perform procedures; this reason was also identified as a common theme in applicants to surgical residences but not by applicants to internal medicine and pediatrics [8, 10, 11].

EM applicants also expressed an attraction to the acuity of care and taking care of patients in the acute phase of illness. This provides a unique perspective compared to themes identified in the literature concerning other specialties [3, 5, 8, 10, 15–17]. This finding along with the identification of specialty-specific personal characteristics again highlights the specialty-specific information that can be gleaned from personal statements. This may inform program directors of the alignment between applicant and program goals for training.

Almost all applicants discussed my story, which was their personal narrative for why they chose EM. This theme was presented in a wide variety of ways, but universally, the applicants explained their journey from an influential tipping point (e.g., personal experience or volunteer experience) to the present state of applying for an EM residency. This theme was also identified in dermatology, general surgery, internal medicine, ophthalmology, and pediatrics residency applicants [5, 8, 10, 11, 18]. This is also in keeping with the AAMC’s Careers in Medicine advice that the personal statement “be personal” [12]. The presence of this theme across multiple specialties may indicate good penetrance of the AAMC’s Careers in Medicine advice or natural concordance and agreement among program directors about what is important in a personal statement.

Due to a high prevalence of common features within personal statements across specialties, there is an overall perception that these documents are becoming more impersonal over time [3]. We have identified common themes found in personal statements written by applicants who ultimately matriculated to academic EM residency programs. Thus, an argument can be made in favor of standardizing the personal statement. This could potentially be advantageous to both programs and applicants if executed appropriately. If there was consensus among program directors for a given specialty on which theme(s) they find most useful in selecting applicants for interview, applicants could be encouraged to focus their statements on those theme(s). Program directors would have additional information perceived as valuable and applicants could more clearly focus on their narratives.

However, the goal of the residency application process is to identify which applicants best fit at a training program, and although the residency application incorporates information from a variety of sources, the personal statement remains the only portion of the application that provides a direct dialogue from the applicant to the program. As such, it allows for creativity and provides a tremendous opportunity for the applicant to identify and accentuate the elements of their application and background they believe would be most helpful to a selection committee. Our study identified unique characteristics discussed in personal statements that reflect the unique characteristics of emergency physicians demonstrating that it is possible to have distinction among personal statements. This could be lost with standardization of personal statements.

Limitations

This study was conducted at a single institution, with randomly selected statements, over an 8-year time frame, and only included applicants who matched into EM. Common themes may be different for applicants who go unmatched. Similarly, the statements were from applicants who matched at an academic residency program. Themes from applicants applying to a primary community program may be different. Osteopathic and international applicants were excluded, and these personal statements may express different themes than those captured in this study. Additionally, we acknowledge our sample size was small, and we did not consider other factors that might influence personal statements, nor did we attempt to analyze whether these personal statements improved or hindered the applicant’s likelihood of matching.

Conclusion

This study marked the first attempt at thematic analysis of personal statements of accepted applicants at an allopathic 3-year EM residency program. All statements included discussion of personal characteristics that make the applicant suitable for EM, why the applicant loved EM, and the applicants’ future goals. The most commonly cited personal characteristics were altruism and an ability to work under pressure. The most commonly discussed reasons for loving EM included the diversity of patients and being able to perform procedures. While this study was limited to a small sample of personal statements at a single institution, the themes identified in personal statements can be helpful in informing program directors how applicants view the practice of emergency medicine and can help guide prospective applicants on how to structure their personal statements. Future studies will be conducted to expand this pilot study by analyzing personal statements from multiple EM residencies and including osteopathic, international, and unmatched applicants. Further exploration could also include the impact of gender and underrepresented minority status on personal statements.

Compliance with Ethical Standards

This study received an ethical approval (IRB-Exempt no. 18E.436).

Conflict of Interest

The authors declare that they have no competing interests.