Proceed with Caution Before Assigning “Red Flags” in Residency Applications

Author Affiliation
Shellie Asher, MD, MS Albany Medical College, Department of Emergency Medicine, Albany, New York
Kimberly A. Kilby, MD, MPH Albany Medical College, Department of Family and Community Medicine, Albany, New York


To the Editor:

We read with interest the paper by Bohrer-Clancy et al.1 regarding variables in applications to emergency medicine residency that correlate with “adverse outcomes” in training programs. We have some concerns regarding the methods of this paper, and therefore the validity and generalizability of its results.

Inclusion of “extension of residency” as an isolated “adverse outcome” is problematic. These residents were not placed on formal remediation, nor did they fail to complete the residency. Is the extension of residency training for non-academic reasons an “adverse outcome” that should be avoided, or should residency programs and institutions provide a supportive environment such that residents who need additional time due to personal, medical, or family reasons can receive the support they need in order to finish successfully and go on to productive careers? This is the central tenet behind the ACGME’s (Accreditation Council for Graduate Medical Education) Next Accreditation System, which places clinical competency and educational outcomes before program length. In addition, it is unclear with which domains or competencies residents with adverse outcomes had difficulties. Ability to predict issues with medical knowledge, communication, or professionalism may be an important distinction to make depending on the resources of the program to address these issues.

Another concern is the inclusion of a leave of absence (LOA) for any reason as an indicator of potential difficulty. While some reasons for LOA may portend future challenges in medical training, all LOAs are not created equal. It is the responsibility of student advisors to make recommendations regarding LOAs during medical school, and to attach a stigma to any LOA may pressure students to make decisions that are not in their best interest for fear that it will impact their chances of successfully matching.

Although some of these limitations are addressed in the paper, program directors may not have the time or inclination to dive into the details of the study and may take the results at face value, thereby unfairly disadvantaging students who may have taken a LOA for a variety of legitimate reasons during medical school. As educators with a responsibility for providing support, guidance and accountability in medical education, we must not claim that we want students and physicians to achieve educational milestones and also cultivate their own wellness, and then penalize them and future applicants for taking steps to do so.

With respect,

Shellie Asher, MD, MS

Kimberly A. Kilby, MD, MPH


Section Editor: Mark I. Langdorf, MD, MHPE

Full text available through open access at

Address for Correspondence: Shellie Asher, MD, MS, Albany Medical College, Department of Emergency Medicine, 43 New Scotland Ave., MC 139, Albany, NY 12198 Email: 7 / 2018; 19:737 – 738

Submission history: Revision received February 15, 2018; Accepted February 20, 2018

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.


1. Bohrer-Clancy J, Lukowski L, Turner L, et al. Emergency medicine residency applicant characteristics associated with measured adverse outcomes during residency. West J Emerg Med. 2018;19(1):106-10.