Interview Inducing Elective Behavior

In Mentorship by Brent Thoma2 Comments


In response to my post on reference letters (The Reference Letter Triple Crown), one of my favorite bloggers Facebooked me the following request (note, she also plays the “Would you rather” game!):

I would rather lick a public toilet seat than have to ask someone for a reference letter. I apparently went into the wrong profession to have that personality trait. Any tips on getting over the awkwardness??

As I’d rather she didn’t catch a toilet-transmissible infection, I figure I should get on that. In this post, I will offer my advice on how to perform “the ask” for reference letters in the least awkward way possible and get into associated elective behaviour that can win you props and help you score interviews. As usual, my opinions come from my experiences and relate most specifically to EM. As they are only my opinions, people are bound to disagree. Be sure to talk to lots of physicians and get as many opinions as you can on stuff like this.

6 elective behaviours that induce interviews:

Elective Behaviour 1: Attend Everything

It may seem obvious, but I’m always surprised when EM-inclined medical students decline invitations to the optional parts of our academic half-days. Be there and be interested! Half-days are your opportunity to check out a program’s academic foundation, get a better idea of how the residents and staff interact, and introduce yourself to the residents and program director. The same goes for any journal clubs or hang-outs that are arranged. It’s often possible to get invited even to events that medical students don’t usually attend if you’re friendly, present and interested. We want to show off our awesome program to the rock-star visiting medical student almost as much as you want to show off for us. Other big no-no’s at any event include showing up late, leaving early, and lighting up your face with the glow of your cellphone!

Elective Behaviour 2: Sniff out a Friendly

By “friendly”, I mean a resident that is med student-friendly. While most residents meet this description to some extent, there is a lot of variation between residents and programs in med-student friendliness and you want to find the biggest friendly you can.

How can you sniff them out?

The easiest way is to let them come to you. Follow #1, look friendly, and at most programs someone will come introduce themselves to you. They’ll almost certainly be a friendly.

Elective Behaviour 3: Get Friendly with the Friendly

No, not like that. Sicko.

Use the opportunity of the introduction to ask them some questions and gauge their level of friendliness. Most will be happy to talk to you about the ins and outs of their program in an informal way. There’s a fine line between interested and over-enthusiastic, but if you’re polite, ask good questions, are thankful for the help and are socially aware enough to ensure that you don’t take it over the top it should go well.

There’s a lot of reasons you should do this. First, it may score you invitations to events that you wouldn’t otherwise know about. Second, friendlies are great people to talk about the strengths/weaknesses of their program with. Having that type of conversation can help to make your personal letter to that school more insightful. Third, they can be helpfully supportive of your interview invitation and/or rank list. And fourth, they may be able to let you know who at their school you should do your best to meet/work with/get a reference letter from.

Elective Behaviour 4: Introduce yourself to the Program Director

This can be scary, but I’d recommend normalizing it for yourself. You’ve gone out of your way to travel to another city to check out their program on an elective, often at considerable personal expense. From what I’ve seen, the program directors (especially those at the smaller programs) are happy to say hi. If you’re going to a larger program where program director access is a bit more difficult, it might be worthwhile to send an e-mail to let them know that you’re coming, and that you’d be interested in meeting with them if they have the time. If they don’t respond don’t be offended, but do still say hi if you happen to see them. The lack of a response is much more likely to be because they are too busy than a desire to not meet you.

Elective Behaviour 5: Work hard

I wrote previously about 10 Ways to Rock EM Clerkship and all of that still applies. Regardless of how you’ve prepared, your reference letters are going to depend largely on how you do on shift.

In a single run-on sentence: show up early, let your preceptors know that you have an interest in EM, have a learning goal and tell them about it, get an orientation of the department on your first shift, work hard, be engaged, take ownership of your patients, pick the patients that are the most challenging for you (ie 30yo with lac vs 4yo with lac, take the 4yo!), follow up on your patients without prompting, stay late to see your patients to disposition, ask for advice both on a career in EM and on how you’re doing, read about whatever you’ve talked about after each shift so you can show that you did on the next shift and be super nice to the support staff and patients.

I think there’s yet another blog-post worth of content that could be expanded upon within that sentence, but it will have to do for now.

Elective Behaviour 6: The Ask

EM is probably one of the most awkward specialties to get reference letters in. Students often only get to work a couple of shifts with any given attending and still have to “do the deed.” What can they do to make it (slightly) less awkward?

First, find a good preceptor to ask. Generally there will be a few physicians each rotation that you will work with for more than a shift or two. They are your best bets, but talk to your Friendly, remember the Reference Letter Triple Crown and try to find someone that you hit it off with that meets some of those criteria. If none of them do, there may be opportunities to switch your shifts around. If you can do that without stepping on any toes (ask your Friendly!), I’d highly recommend it.

The times that I hit it off with a preceptor I was generally surprised with how easy “the ask” was. Occasionally, they’d offer to write a letter before I even took the leap. Other times they’d realize what I was going for and lighten the mood. Regardless, I tried to make it less awkward for myself by remembering two things:

First, they’ve all been where you are right now. How will you respond to a student asking you for a reference letter when you’re a big-shot emergency physician? Pretty well, I hope. Why? Because you remember what it was like to be in that position. It’s the same for most of them.

Second, if you’re working with an EM physician at an academic center who knows that you’re gunning for emerg, they will probably expect to be asked for a reference letter. You’re not the first student that has approached them, and you won’t be the last.

Many others will tell you to be sure to ask for a “strong” reference letter, with emphasis on the “strong.” This may have some value, it may not. Personally, I think judging your general interactions and considering how your post-shift evaluations went is a better barometer of how supportive they will be of your application, but there’s really no way to know. This is one of the reasons that CaRMS drives everyone bonkers.

Thoughts From A Prospective Applicant:

I would agree with all of the thoughts listed above; here are some extra pointers for the behaviours mentioned above:

1: Good schools will try to schedule you in shifts that do not overlap with academic half days. In my experience, it has not been TOO difficult with getting your shifts changed in order to attend half-day. Some schools also have an understanding that you may attend your shift after half-day is over, but I would recommend just looking at your schedule as soon as you receive it in order to change things around if you need to. Most schools have their specific day of the week for half-day listed online so you can plan ahead.

2: If sniffing out a friendly is difficult for you, some schools keep track of where their recent graduates go for residency. I would highly recommend asking your administration if they know of anyone who is an EM resident at wherever you will be doing your elective. Obviously, this might be easier at smaller schools where everyone knows everyone passing through. Upper-year medical students are also a valuable source of knowledge for these recent graduates – I’ve found that the knowledge gets passed down through each year, so usually SOMEONE knows someone.

3 and 4: Pretty straightforward.

5: Do some research before your shift! You can look up specific physicians that you will be working with online – some of them will have research interests in sports medicine, toxicology, etc. I’ve had some success doing this and bringing up their research on shift, or making sure that I have my toxidromes up to date before making a fool of myself. Prep yourself with apps on your phone, practice your differentials, do all of this stuff before beginning your rotation.

6: I’ve had good success with using the AFMC student portal to request working with specific supervisors when making my elective application. Bonus points if you can add that you have already discussed this with the potential preceptor on to your request. As mentioned above, some schools are good with allowing you to move shifts around so that you can get 2-3 shifts with the same preceptor. If you find someone you “click” with, and they’re agreeable to having more shifts with you, do take the initiative to email the school’s elective coordinator to see if you can change your shifts around. DO NOT attend these extra shifts unless you have cleared it through the school.

Final tip: keep a log of all the interesting cases you see with a preceptor, or cases in which you think you did a really good job on. You can use this log to give your letter writer specific details when reference letters are due. It’s a lot more effective than trying to remember off the top of your head a patient that you saw more than 4 months ago!


CaRMS is stressful. Asking for reference letters can be awkward. However, there are some things that you can do to minimize that. Fortunately, the majority of the medical students that have worked hard to secure an EM residency will get one. Best of luck!

Thanks for reading!

Note: This post was originally published on BoringEM on March 2, 2013. It has been updated by Kelly Lien & Brent Thoma and republished on December 11, 2017.

Dr. Brent Thoma is a medical educator, blogging geek, and trauma/emergency physician who works at the University of Saskatchewan College of Medicine. He founded BoringEM and is the CEO of CanadiEM.