Failed to Match Into EM - What Now?

[monkeymedic]

Hi All,

This is a throwaway account but I have been a member on these forums since I was in High School. I greatly appreciate any and all advice anyone has to offer. I'm feeling pretty down right now but if brutal honestly is what you have to offer, I'd prefer that than false hope.

Brief Story (please ask for more info, this account won't allow me to be identifiable so I'm happy to give lots more info, I just don't want this to be a long post no one reads):
- A lot of interest in EM apparent from my CV (volunteer FD/EMT for 8 years, Peds-EM research in undergrad)
- Rough start to medical school, took LOA (voluntary, did not actually fail out) and restarted the next year
- Mediocre M1 and M2, passed everything.
- Dismal Step Scores: Failed Step 1, Passed with ~210 on second try, Step 2 ~215, Passed CS
- OK M3 year with Honors on EM elective and High-Pass on Anesthesia (great clinical comments, but test taking crippled me from getting higher than pass most of the time)
- Good M4 year with High Pass on Away 1 in EM, Pass at home institution (where the shelf was worth 55% of our grade, seeing a theme yet?), Honors on Away 2 in EM. Those were all the posted grades before ERAS opened.
- Away 1 interviewed me while I was there, Home institution interviewed me later in the season, Away 2 called me back for an interview 3 months later in December, got one more EM interview from a lower tier place. Also, dual applied into FM and got 4 interviews.
- Found out Friday that I matched into my 1st choice FM program. I was devastated.

Now, I knew that with my stats I needed a backup, but I thought that Away 2 would give me a shot for sure. All the residents and attendings liked me, my clinical comments were stellar, and the rotation coordinator said I had one of the highest clinical scores of any of the students they have ever had there (quite possibly due to the fact that it was my 3rd EM rotation in a row). I knew I wasn't a shoe-in, but I thought I had a good shot.

I spent most of Friday in a very depressed state and had no energy to do anything, but after talking with my Dean and a counselor, I felt better and have been keeping myself busy to try and move forward and not dwell on the past. I know I'm lucky to have a position for next year as there are thousands in a similar spot with no concrete plans for the next year.

My question is this: I'm not ready to give up my dreams of being an EM physician, but I don't know what paths there are going forward for me. No matter what, I have to complete my PGY-1 year in FM so all of the following options are based on that, but I'm hoping that you guys can weigh in on which option(s) are better and make suggestions for any other options that might be out there for me:

Option 1: Re-apply for the match in 6 months
Essentially, start PGY-1 year in FM in July 2016, and try to get a PGY-1 position in EM in July 2017. The issue with this is other than killing it and getting a really good letter from my PD in FM, I don't have much more to offer. Of course the blemishes on my record of my Step Scores can't be changed anyways so there's not much I can do to improve my application unless you guys see something I don't.

Option 2: Re-apply for the match in a year and 6 months.
Finish PGY-1 in FM, start PGY-2, and try to match to a spot in EM in July 2018. Same issues as Option 1 except I now have more experience under my belt.

Option 3: Finish my FM residency, and apply to EM as a second residency.
Not sure how much weight the PDs put into someone wanting to do a second residency and once again, my step scores won't change but I'll be further out from them?

Option 4: Work in outlying ERs as an FM grad for a few years, then re-apply to EM residencies.
Not sure how PDs feel about someone already having had some ER experience as an ER Attending but FM trained. I could even do some EMS medical direction in the meantime to boost my resume (something I wanted to do with an EM residency anyways).

Option 5: Give up on the EM residency. Work at an outlying ER as a FM trained physician and pick up EMS medical direction for some smaller FDs.
This is the ultimate fallback plan for me. I would never be able to work in the city, and in a decade or so when there's enough EM trained physicians to go around, probably not even in a suburb of a big city at a community hospital, but at least I'd get to do what I want to do with my life. And the reality is that in my career, we'll probably never have enough EM trained physicians to staff all the rural ERs.

Option 6: ???

I'm hoping that you all on here can give me some guidance as to what to do next. Part of the reason I am so upset is that I just don't know where to go from here. Certainly the dream can't have ended on Friday, but it sure does feel like it's a thousand miles further away than it was before.

Thanks for any advice you guys can offer.

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[Makati2008]

Hi All,

This is a throwaway account but I have been a member on these forums since I was in High School. I greatly appreciate any and all advice anyone has to offer. I'm feeling pretty down right now but if brutal honestly is what you have to offer, I'd prefer that than false hope.

Brief Story (please ask for more info, this account won't allow me to be identifiable so I'm happy to give lots more info, I just don't want this to be a long post no one reads):
- A lot of interest in EM apparent from my CV (volunteer FD/EMT for 8 years, Peds-EM research in undergrad)
- Rough start to medical school, took LOA (voluntary, did not actually fail out) and restarted the next year
- Mediocre M1 and M2, passed everything.
- Dismal Step Scores: Failed Step 1, Passed with ~210 on second try, Step 2 ~215, Passed CS
- OK M3 year with Honors on EM elective and High-Pass on Anesthesia (great clinical comments, but test taking crippled me from getting higher than pass most of the time)
- Good M4 year with High Pass on Away 1 in EM, Pass at home institution (where the shelf was worth 55% of our grade, seeing a theme yet?), Honors on Away 2 in EM. Those were all the posted grades before ERAS opened.
- Away 1 interviewed me while I was there, Home institution interviewed me later in the season, Away 2 called me back for an interview 3 months later in December, got one more EM interview from a lower tier place. Also, dual applied into FM and got 4 interviews.
- Found out Friday that I matched into my 1st choice FM program. I was devastated.

Now, I knew that with my stats I needed a backup, but I thought that Away 2 would give me a shot for sure. All the residents and attendings liked me, my clinical comments were stellar, and the rotation coordinator said I had one of the highest clinical scores of any of the students they have ever had there (quite possibly due to the fact that it was my 3rd EM rotation in a row). I knew I wasn't a shoe-in, but I thought I had a good shot.

I spent most of Friday in a very depressed state and had no energy to do anything, but after talking with my Dean and a counselor, I felt better and have been keeping myself busy to try and move forward and not dwell on the past. I know I'm lucky to have a position for next year as there are thousands in a similar spot with no concrete plans for the next year.

My question is this: I'm not ready to give up my dreams of being an EM physician, but I don't know what paths there are going forward for me. No matter what, I have to complete my PGY-1 year in FM so all of the following options are based on that, but I'm hoping that you guys can weigh in on which option(s) are better and make suggestions for any other options that might be out there for me:

Option 1: Re-apply for the match in 6 months
Essentially, start PGY-1 year in FM in July 2016, and try to get a PGY-1 position in EM in July 2017. The issue with this is other than killing it and getting a really good letter from my PD in FM, I don't have much more to offer. Of course the blemishes on my record of my Step Scores can't be changed anyways so there's not much I can do to improve my application unless you guys see something I don't.

Option 2: Re-apply for the match in a year and 6 months.
Finish PGY-1 in FM, start PGY-2, and try to match to a spot in EM in July 2018. Same issues as Option 1 except I now have more experience under my belt.

Option 3: Finish my FM residency, and apply to EM as a second residency.
Not sure how much weight the PDs put into someone wanting to do a second residency and once again, my step scores won't change but I'll be further out from them?

Option 4: Work in outlying ERs as an FM grad for a few years, then re-apply to EM residencies.
Not sure how PDs feel about someone already having had some ER experience as an ER Attending but FM trained. I could even do some EMS medical direction in the meantime to boost my resume (something I wanted to do with an EM residency anyways).

Option 5: Give up on the EM residency. Work at an outlying ER as a FM trained physician and pick up EMS medical direction for some smaller FDs.
This is the ultimate fallback plan for me. I would never be able to work in the city, and in a decade or so when there's enough EM trained physicians to go around, probably not even in a suburb of a big city at a community hospital, but at least I'd get to do what I want to do with my life. And the reality is that in my career, we'll probably never have enough EM trained physicians to staff all the rural ERs.

Option 6: ???

I'm hoping that you all on here can give me some guidance as to what to do next. Part of the reason I am so upset is that I just don't know where to go from here. Certainly the dream can't have ended on Friday, but it sure does feel like it's a thousand miles further away than it was before.

Thanks for any advice you guys can offer.

Poor board scores(with one failure and a low passing score in the repeat) as well as a LOA probably killed your application. I would do option 5 and be happy you matched. Option 1/2 I would be careful doing....


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[SuziQ]

So sorry this happened to you! Why did you have to take a LOA? I think 1 or 2 will be really tough. Does the place you matched have an EM residency? I think option 4 would be super awkward. I honestly think option 3 is a possibility. Of course 5 is too. Good luck in whatever you choose!

 

[gamerEMdoc]

LOAs always scare me when I review applications. There better be a REALLY good reason for a candidates LOA (like a medical illness) or it's almost a kiss of death in my mind. I realize things happen, and I'm not completely heartless, but when people take time off because of things like relationship issues, or because they are did poorly on boards and want extra time to study, or whatever, it scares the heck out of me. Programs don't like to take risks, and the loss of a resident mid year can be devastating to staffing. As a program, you just can't risk a resident just one day deciding they need to quit, transfer to another field, another residency, etc.

As for your options, just remember, every year of FP residency you complete is one year of funding an EM program would lose if you matched there. That can have real consequences from a budget standpoint for some places. Just something to think about.

 

[tkim]

Had a guy who finished his FP residency then applied for our EM residency. Took him six years, but he's EM trained. It could happen.

 

[gamerEMdoc]

Had a guy who finished his FP residency then applied for our EM residency. Took him six years, but he's EM trained. It could happen.

Oh it absolutely happens. But its also 6 years of residency. Thats a little crazy, and alot of lost income, but then again, if you want to do it and its the only way you'll be happy, by all means, go for it.

 

[monkeymedic]

Poor board scores(with one failure and a low passing score in the repeat) as well as a LOA probably killed your application. I would do option 5 and be happy you matched. Option 1/2 I would be careful doing....

Why do you say to be careful with 1/2? It's one of the options my EM advisor talked to me about a few months ago but we didn't really expand upon it as he said not to worry about it as it wouldn't be an issue if I matched.

So sorry this happened to you! Why did you have to take a LOA? I think 1 or 2 will be really tough. Does the place you matched have an EM residency? I think option 4 would be super awkward. I honestly think option 3 is a possibility. Of course 5 is too. Good luck in whatever you choose!

I was not ready to start medical school. I came from an engineering background and I fulfilled some of the prereq's with non-traditional classes (for example, quantitative physiology counts as a bio class, but is not real physicology at all!)

LOAs always scare me when I review applications. There better be a REALLY good reason for a candidates LOA (like a medical illness) or it's almost a kiss of death in my mind. I realize things happen, and I'm not completely heartless, but when people take time off because of things like relationship issues, or because they are did poorly on boards and want extra time to study, or whatever, it scares the heck out of me. Programs don't like to take risks, and the loss of a resident mid year can be devastating to staffing. As a program, you just can't risk a resident just one day deciding they need to quit, transfer to another field, another residency, etc.

As for your options, just remember, every year of FP residency you complete is one year of funding an EM program would lose if you matched there. That can have real consequences from a budget standpoint for some places. Just something to think about.

See above for answer to LOA. I agree you don't want someone just up and leaving for a relationship issue or something like that. But would applying to change from FM to EM mid program be that bad of a sign when I have an obvious commitment to EM (as seen in my CV)?

My dean also told me that while it's a consideration to some programs, there are still a lot of programs that would trade that for someone with resident experience. Idk if that was just to make me feel better or if there is any truth to that.

Had a guy who finished his FP residency then applied for our EM residency. Took him six years, but he's EM trained. It could happen.

I need to find out where this is! My understanding is that there are not a lot of opportunities for changing field after you finish a residency (can happen, but VERY hard to do)

 

[Angry Birds]

My advice is to be grateful that you matched at all. So many people would kill just for that.

Finish your FP residency, try to get the EM fellowship, and you can still work at many ERs in the country.

You put your entire future/career at risk if you don't hold on with dear life to the residency you matched into, due to your previous scores and leave of absence.

You can also try for EM residency after completing FP. But hold on to your current residency with dear life and don't let your PD or program know your feelings.

 

[tastyb33f]

The EM fellowship is a good way to go - like people above have said, it won't open ALL the ED doors for you, but many. Here's a list of available EM fellowships from FM: https://nf.aafp.org/Directories/Fellowship/Results

 

[sawboned]

Yah to echo last last posts - complete your family practice residency with gusto and do a one-year family medicine emergency medicine fellowship. The Monroe Clinic in rural Wisconsin has one, for example.

They then do an ABPS certification. Sure, it's not ABEM, but it's a step above simple FP BC.

Again, there are numerous excellent smaller volume EDs that may need you. The emergency medicine they practice is just as real as bigger shops, and then some. Not to mention EMS opportunities galore.




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[gamerEMdoc]

Our program actually had a resident graduate who had previously completed an FP residency. It does happen. He completed FP residency, worked a few years in our ED's fast track as well as a local rural ED, then applied to our residency.

It's a tough situation regarding leaving FP to go to EM midway through residency. Obviously, your current FP PD is unlikely to want to give you a stellar LOR to leave his/her program after being there a for a few months. And if you don't match, they are going to be in constant fear of you leaving each year. It just seems like it could be uncomfortable. Is there an EM program at the same site where you are going as an FP resident?

 

[monkeymedic]

Once again, thank you to all who replied. I have been down in the dumps all weekend and decided to put htis out of my mind until I could get a grasp on things and you all have been very helpful.

My advice is to be grateful that you matched at all. So many people would kill just for that.

Finish your FP residency, try to get the EM fellowship, and you can still work at many ERs in the country.

You put your entire future/career at risk if you don't hold on with dear life to the residency you matched into, due to your previous scores and leave of absence.

You can also try for EM residency after completing FP. But hold on to your current residency with dear life and don't let your PD or program know your feelings.

The EM fellowship is a good way to go - like people above have said, it won't open ALL the ED doors for you, but many. Here's a list of available EM fellowships from FM: https://nf.aafp.org/Directories/Fellowship/Results

Yah to echo last last posts - complete your family practice residency with gusto and do a one-year family medicine emergency medicine fellowship. The Monroe Clinic in rural Wisconsin has one, for example.

They then do an ABPS certification. Sure, it's not ABEM, but it's a step above simple FP BC.

Again, there are numerous excellent smaller volume EDs that may need you. The emergency medicine they practice is just as real as bigger shops, and then some. Not to mention EMS opportunities galore.

So these are all good points and I have looked into them all actually. I've heard that leaving my FM residency could be tricky, but it could be worth a shot if I have a decent chance at matching my second go around. I wouldn't do it twice in a row. If I try for it PGY-1 and fail I wouldn't do it again PGY-2. It would also make any remaining years I had there very awkward I think with the faculty knowing that I wanted to get out and couldn't. On the other hand, while I'm sure I can try to be as happy as possible there (and fake it when I am not) I'm not sure I can do it for all 3 years. I did a half day a week at an FP clinic 1st and 2nd year, had a month rotation 3rd year, and 2 months outpatient 4th year in addition to various clinic time on my other rotations and it is by far the least favorite setting I have worked in. I agree with Angry Birds in that I need to try and see the positive in it--that many people would much rather be in my position than theirs, and I ranked the program because I'd rather have a job in something I don't like than no job at all--but it's still disappointing. Maybe it'll clear with time. As a non-medical friend told me in trying to cheer me up--lots of people graduate and don't land their first choice or second or third choice job. So what? You work for a few years and then try to change later--at least you have a job while looking for another job. I'm trying to replay that advice over and over in my head.

My advisor also told me that for a variety of reasons, people leave EM PGY-1 spots and they may look to fill with PGY-2's. These would be non-match positions. Are these any more realistic to get than trying to Match a second time?

In regards to the EM fellowship, I've been told that it really doesn't add a lot to one's portfolio. The places that need ER docs that badly to take FM trained docs don't care about a fellowship whereas the places that can pick and choose and grab EM docs won't care about a certification in EM for a family med doc. Is this true?

Our program actually had a resident graduate who had previously completed an FP residency. It does happen. He completed FP residency, worked a few years in our ED's fast track as well as a local rural ED, then applied to our residency.

It's a tough situation regarding leaving FP to go to EM midway through residency. Obviously, your current FP PD is unlikely to want to give you a stellar LOR to leave his/her program after being there a for a few months. And if you don't match, they are going to be in constant fear of you leaving each year. It just seems like it could be uncomfortable. Is there an EM program at the same site where you are going as an FP resident?

My dean (once again, could just be trying to make me feel better) said that more often than not, a PD will help someone leave their program into another field, even if they do so begrudgingly. She said that it would be even more awkward for my PD to not help in any way he could and then have a resident that held a grudge for the next 2 years. If he knows the chances are small for changing specialties (which they always are) then he'd rather help me and make me happy and most likely get to keep a resident that wouldn't be upset with him than being even more likely to keep a resident that held a grudge.

There is not an EM program at the site I am at. We are an unopposed family med residency though we do have a VERY robust trauma surgery fellowship and we have the leading trauma center in the region (Level 1, double the volume of the next closest trauma center and up until the last trauma center opened had more volume than the rest in the area combined). We are also not far from the rural sticks so there are lots of FDs that need EMS medical direction that go with one of our trauma docs or a family med doc just for lack of options. (Since I work with some of those departments in the field as a medic, I've actually had fire chiefs approach me about taking over their EMS medical direction once I am eligible.)

 

[Angry Birds]

It's a big gamble. You start the first year of your FP residency and then within a few short months you apply for EM programs. But you would absolutely need your PD's approval to apply. Once you let your PD know he is going to look for a replacement for you. If you don't match and he finds a replacement, guess who is out of a job?

You've already had problems requiring a LOA before and failed board exams. So, it's much more risky to gamble in your situation. My strongest recommendation once again is that you count your blessings and finish your FP residency as happily as you can.

Imagine if you struggle in residency like you did in medical school--or you fail step 3 or your in service exam--guess who is on the chopping block? It's the resident who told his PD already that he doesn't like FP anyways.

As for the EM fellowship, it's something you can consider. I personally think it would give you a leg up.

 

[Angry Birds]

I've seen too many people who left or get kicked out of their residency programs and are now doing nothing in life. These people are desperately trying to re-match and would take any residency spot in any specialty, even those they turned their noses up at before. They are unemployed and living with their parents, failures in life.

Don't be that person. Know how absolutely valuable your residency is. It's a golden ticket. You just don't realize it yet.M

Also you don't recognize that you are at much higher risk to be a problematic residency candidate than others, since you had problems in medical school. Therefore you want to be a happy, hard working resident in the eyes of your PD, so that if you run into problems later on, your PD thinks "well, he sure is a great guy and hardworking."

By the way, family clinic is great. You see kids and family grow up and build strong bonds with patients. I'm sure many of us EM guys would trade one EM shift a week for that. But we can't since we are not trained for that.

 

[gman33]

I am going to give you an honest opinion.
I might sound like a d..k, but that is not my intention.

You have zero shot at matching into EM next cycle.
3 huge red flags.
failed step 1, LOA, pass on home EM rotation (which will be viewed about the same as a fail)

Count your blessings that you matched into anything and do everything in your power not to mess up that opportunity.
Finish that residency and if still interested in EM, start pursuing other options in your third year.
That may mean another residency, fellowship, whatever.
If you don't like FM, maybe try to do a fellowship in sports medicine.
That's a nice field with good pay and a way better lifestyle than EM would provide.

I am not a fan of encouraging FM grads to go practice EM in a rural spot.
Those are incredibly hard jobs with little to no backup.
You will not be adequately prepared to do that job.

I could probably do an appy if I had to, but that doesn't mean it's a good idea.

 

[monkeymedic]

It's a big gamble. You start the first year of your FP residency and then within a few short months you apply for EM programs. But you would absolutely need your PD's approval to apply. Once you let your PD know he is going to look for a replacement for you. If you don't match and he finds a replacement, guess who is out of a job?

Is this common where a resident states he's going to try to match, the PD find someone to fill the spot and the resident could potentially be left out in the cold? I know it's not a great number of interns who try to switch, but it still seems like a decent number--are all of them essentially taking this chance?

Imagine if you struggle in residency like you did in medical school--or you fail step 3 or your in service exam--guess who is on the chopping block? It's the resident who told his PD already that he doesn't like FP anyways.

This is an excellent point--but would the PD rather have an unfilled spot than having to remediate someone? (hopefully it won't come to this)

I've seen too many people who left or get kicked out of their residency programs and are now doing nothing in life. These people are desperately trying to re-match and would take any residency spot in any specialty, even those they turned their noses up at before. They are unemployed and living with their parents, failures in life.

Don't be that person. Know how absolutely valuable your residency is. It's a golden ticket. You just don't realize it yet.M

By the way, family clinic is great. You see kids and family grow up and build strong bonds with patients. I'm sure many of us EM guys would trade one EM shift a week for that. But we can't since we are not trained for that.

I think you're absolutely right that I have no idea how really valuable this position is. I know I'm lucky to have anything at all given how many people were left out in the cold but I don't think I see the true gravity of the situation since I have been so down this weekend with just very little motivation to do anything and very teary at times. Even though I've gotten plenty of sleep this weekend I am here sitting in clinic between patients still very tired and just daydreaming about crawling back into bed.

I'm sure the clinic would be a great place for some people, but having done extensive clinic time in medical school, I know it is not for me. Could it change in the next 3 years? Possibly, but at this point in my medical career, I think I can start to trust my own intuitions as to what I do and don't like and I have a feeling it's not very probable that I will like clinic.

 

[monkeymedic]

I am going to give you an honest opinion.
I might sound like a d..k, but that is not my intention.

You have zero shot at matching into EM next cycle.
3 huge red flags.
failed step 1, LOA, pass on home EM rotation (which will be viewed about the same as a fail)

Thank you for your reply. You are not at all being a d..k. This is what I need, an honest evaluation of my options and my chances at each option. I actually just learned today of programs that need to fill EM PGY-2 spots that allow applicants to apply for those spots outside of the match after having either 1 year in EM elsewhere or 2 years in any other ACGME in another specialty. Would I have any better shot at these in a couple of years? Given Angry Birds' post above, it does sound like there is some risk involved in informing my PD that I am trying to transfer but if these programs would give a decision before the Match, perhaps the risk is less?

Count your blessings that you matched into anything and do everything in your power not to mess up that opportunity.
Finish that residency and if still interested in EM, start pursuing other options in your third year.
That may mean another residency, fellowship, whatever.
If you don't like FM, maybe try to do a fellowship in sports medicine.
That's a nice field with good pay and a way better lifestyle than EM would provide.

I am not a fan of encouraging FM grads to go practice EM in a rural spot.
Those are incredibly hard jobs with little to no backup.
You will not be adequately prepared to do that job.

I could probably do an appy if I had to, but that doesn't mean it's a good idea.

I agree that it would not be ideal to practice EM as just a FM boarded physician. However, being an EM physician is something that I really want to do with my life. If that means doing another residency, I would take the chance in a heartbeat. I'm less keen on the FM fellowship as it does not seem to open that many doors and I would still be "inferior" compared to ABEM boarded docs. While the same problem exists practicing EM as an FM boarded physician (being "inferior" or less qualified), I would at least be doing something I loved and I could figure out steps to doing a second residency (or just being happy with the FM practicing in an ED). At least that's my thought on it at the moment.

 

[gamerEMdoc]

I definitely wouldn't encourage the EM fellowship route. It's always going to be looked at as inferior to ABEM board. You'll never get to work in academics if you would want, and any major ED isn't going to hire you unless they can't get anyone else. Which would be the same as if you didn't do the fellowship. So, it seems pointless to me. If you are going to do an extra year, you might as well just do two more and do a 3 year EM residency.

Just wondering, if you dislike clinic and FP, why was FP your backup, and not IM? At least with IM, you could have had the track of going into critical care as an alternative. And why was your first choice of FP program at an unoposed FP program with no EM residency in house (that you could have tried to switch into at a later time?).

 

[sawboned]

Regarding the question of the edge that you raised with family practice emergency medicine fellowship, I would say yes definitely an edge - again, at least at smaller volume shops.

A fellowship demonstrates to me, further competence in the resuscitative part of emergency medicine as well as a dedication to the vocation. In the numerous small volume EDs I am familiar with, we are not going to hire a family practice physician straight out of residency without years of ED experience (which begets a catch 22).

I would however hire you with a fellowship.


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[gman33]

An em program with an open pgy-2 spot would try to fill it with a transfer.

You may have a shot at one of these, but it's a longshot.

I stand by my original post, just finish out fm and figure it out from there.

 

[Angry Birds]

An em program with an open pgy-2 spot would try to fill it with a transfer.

You may have a shot at one of these, but it's a longshot.

If he does one year of FP, I don't see how he could even theoretically take an EM-2 position.

Isn't it that you get a maximum of six months credit even if you did a complete FP or IM residency?

Also, he clearly wouldn't be able to fill the shoes of an EM-2. So, I can't see an EM residency taking him at all for an EM-2 slot that opens up. Most likely, they'd try to get another EM resident, but this obviously means there would be an open slot somewhere. I've seen this happen before though. What ended up happening was that the program lost a resident in that class, and just increased its next year residents by one. And this would probably be in the next match.

The only shot the OP would have at an EM residency is:

1) Complete the FP residency and apply for an EM residency after that, getting a maximum of six months credit for off-service rotations. The credit probably wouldn't help him graduate earlier, as he would simply get a couple extra electives and EM blocks.

Of course, this option has the disadvantage of a 5-6 year residency. Also, funding is an issue, making him less attractive of a candidate, although some programs might appreciate his experience, which might offset the funding issue.

2) Complete one year of FP and try to front-load his schedule with electives, and do as many away rotations as he can at an EM program with a residency. This way he can snag some SLOE's.

But, as soon as he tells his Family Medicine PD--and he must do this right away--I think the chances of him losing his FP-2 position are extremely high, since the PD would really want to fill that slot, either by snagging another FP-2 or securing an extra FP-1. I believe a hungry FMG with great step scores could sign outside the match, correct?

So, it's a very high stakes gamble, and with those red flags, I think it would be a very, very bad idea. No bueno.

 

[goodoldalky]

OP, have you looked at things from a different perspective? One of my partners is married to someone who never completed a residency and opened a medspa and makes way more money than he does these days.

There are lots of different things you can do with FP like sports med that may suit you.

Or perhaps you will be one of those who does a residency and then pursues some Non clinical or quasi clinical jobs, pharm or biomed consulting, management (you have any business background or training?). There's still a lot of options when you get to the other end of residency... I'd probably plug away, do the best you can in FM, and keep your eyes peeled. Good luck!

 

[monkeymedic]

Sorry for taking a bit of time to reply guys, a busy couple of days with clinic and paperwork and credentialing and the sort. Once again, thanks to everyone that has taken the time to give me some of their opinions!

I definitely wouldn't encourage the EM fellowship route. It's always going to be looked at as inferior to ABEM board. You'll never get to work in academics if you would want, and any major ED isn't going to hire you unless they can't get anyone else. Which would be the same as if you didn't do the fellowship. So, it seems pointless to me. If you are going to do an extra year, you might as well just do two more and do a 3 year EM residency.

Just wondering, if you dislike clinic and FP, why was FP your backup, and not IM? At least with IM, you could have had the track of going into critical care as an alternative. And why was your first choice of FP program at an unoposed FP program with no EM residency in house (that you could have tried to switch into at a later time?).

So I will address the fellowship question in a second below. FP was my backup because I was told by my advisors that I needed a backup late in October and my best shot of matching into a backup was for family med. By the time I submitted ERAS it was mid November and I think they thought FM was more likely than IM. As far as why the choice in my FM program, there weren't a lot of choices. I got 4 interviews in January and all were at unopposed programs or programs that might have one or two other specialties in house. None of them had EM residencies.

Regarding the question of the edge that you raised with family practice emergency medicine fellowship, I would say yes definitely an edge - again, at least at smaller volume shops.

A fellowship demonstrates to me, further competence in the resuscitative part of emergency medicine as well as a dedication to the vocation. In the numerous small volume EDs I am familiar with, we are not going to hire a family practice physician straight out of residency without years of ED experience (which begets a catch 22).

I would however hire you with a fellowship.

Between your post and gamerEMdoc's post it seems like this is going to be very situational. If I complete my FM residency, it seems like it will depend on where I want to go whether the fellowship will give me any sort of edge. I actually spoke to an attending at a community ED here the other day (busy ED with 75k visits per year but no academic program) who stated that his group really on recruits EM trained physicians but they would seriously consider a FM trained guy with 10 or 20 years of experience. (They are always double or triple covered anyways). He said that in his mind, there's no reason to do the fellowship, with respect to his group, because for an FM guy, the experience is what counts, not the training.

An em program with an open pgy-2 spot would try to fill it with a transfer.

You may have a shot at one of these, but it's a longshot.

When you say longshot, what are we talking about? Are there a lot of applications for these open spots? Obviously any EM to EM lateral transfer/relocation would probably beat me out, but then whatever program they were leaving from would have an opening.

If he does one year of FP, I don't see how he could even theoretically take an EM-2 position.

Isn't it that you get a maximum of six months credit even if you did a complete FP or IM residency?

Also, he clearly wouldn't be able to fill the shoes of an EM-2. So, I can't see an EM residency taking him at all for an EM-2 slot that opens up. Most likely, they'd try to get another EM resident, but this obviously means there would be an open slot somewhere. I've seen this happen before though. What ended up happening was that the program lost a resident in that class, and just increased its next year residents by one. And this would probably be in the next match.

So looking at the postings here: http://www.saem.org/membership/services/residency-vacancy-service
It seems like they would consider any rising EM-2 for the open EM-2 spot, but they would also consider any rising PGY-3 or above in ANY ACGME specialty for an open EM-2 spot. Of course this is based on a sample size of 3.

One actually mentions "have successfully completed two or more years in an ACGME-accredited program in another specialty, be in good standing and have the support of their current program director, if training is not complete." Does this mean that I could potentially start as a EM-2 after I finish my FM residency, even if I have been out for a couple of years?

The only shot the OP would have at an EM residency is:

1) Complete the FP residency and apply for an EM residency after that, getting a maximum of six months credit for off-service rotations. The credit probably wouldn't help him graduate earlier, as he would simply get a couple extra electives and EM blocks.

Of course, this option has the disadvantage of a 5-6 year residency. Also, funding is an issue, making him less attractive of a candidate, although some programs might appreciate his experience, which might offset the funding issue.

2) Complete one year of FP and try to front-load his schedule with electives, and do as many away rotations as he can at an EM program with a residency. This way he can snag some SLOE's.

But, as soon as he tells his Family Medicine PD--and he must do this right away--I think the chances of him losing his FP-2 position are extremely high, since the PD would really want to fill that slot, either by snagging another FP-2 or securing an extra FP-1. I believe a hungry FMG with great step scores could sign outside the match, correct?

So, it's a very high stakes gamble, and with those red flags, I think it would be a very, very bad idea. No bueno.

Option 1 here seems like the safer option as I would have a backup plan already done if I can't match into EM or fill an open EM-2 spot (see above) I have work as an FM attending and I could try again at a later date with no real financial pressures or worry that I might lose my spot somewhere.

In regards to option 2, do PDs start looking for someone as soon as they announce their intention to leave? One advisor (who's advice I take with a large grain of salt having gotten bad advice from her before) said that most PDs will be very supportive of a candidate leaving and write a good letter because they don't want an unhappy resident. But at the same time, switching programs isn't easy to do and they know there's a good possibility the resident will stay and that's another reason they try to do their best to help--they don't want to sabotage the resident's chance of leaving, have them not leave, and then resent the PD for the next 2 years. In that scenario, it seemed like the PD wouldn't start looking for someone until I was gone. Also, I am no contract lawyer, but in the resident contract, doesn't it seem to imply that there are certain conditions that must be met to be promoted and renew the contract and that as long as those conditions are met, you will be promoted? Or does telling someone you are looking for another job typically void some part of that contract?

OP, have you looked at things from a different perspective? One of my partners is married to someone who never completed a residency and opened a medspa and makes way more money than he does these days.

There are lots of different things you can do with FP like sports med that may suit you.

Or perhaps you will be one of those who does a residency and then pursues some Non clinical or quasi clinical jobs, pharm or biomed consulting, management (you have any business background or training?). There's still a lot of options when you get to the other end of residency... I'd probably plug away, do the best you can in FM, and keep your eyes peeled. Good luck!

I care much more about my own happiness than I do money. As long as I make enough to live a comfortable life, I don't really care how much I'm earning. Maybe things will change, and I'll keep an open mind, or maybe this is just me being disappointed talking, but at this point I feel like I would rather not do medicine than do FM for the next 30 years. Using an FM residency as a means to an end (trying to get into an EM residency, trying to get an ER job) is something I can put up with for 3 years, but if I ran out of options based on where life took me, I've considered making enough money to pay back loans and live out a comfortable life and then switching out of this career path and finding work doing something else, perhaps as an EMS medical director, or even go back to being a medic. (As an aside, being a medic has been one of the most enjoyable things in my life and going to work didn't feel like work ever. EM has been the same way when I've been on those rotations.)

 

[gman33]

When I say longshot for matching into a PGY-2 spot, it's hard to give a percent chance.
If you were an outstanding candidate with no red flags and you matched into ortho, I'd give you a chance of 10%.

In your case, I'd say the chances would be closer to 0%, but anything is possible.

 

[Angry Birds]

MonkeyMedic -

I'm in a bit of a rush right now, but I'll say this:

1) There is a difference between possibility and plausibility. Although it may be possible for you to apply for an EM-2 position.... from a plausible standpoint, I don't think the program would think you could handle an EM-2's responsibilities. I did a TY-year (with a total of three ED blocks--since I did both my electives in EM), and after the completion of that, I was nowhere ready to be an EM-2, which is why I started as an EM-1. You simply couldn't handle the patient load, responsibilities, procedures, moving the meat, etc.

Therefore, I think that what you showed may be how certain universities will accept applications with a minimum score, but that minimum score is nowhere near the actual average / real cut-off.

2) When my buddy switched IM programs, completing IM-1 at one program and then transferred to an IM-2, the moment he told his PD that he was needing to switch programs, the PD immediately started looking for a replacement, and found one before my buddy matched into another IM-2. And my buddy was *extremely* well-liked by his PD and the program in general... It's just that the PD and the program didn't want to be down a resident the next year.

From the PD and program's point of view, they might as well look for a replacement for you immediately. If they find one, they get someone who actually wants to be in the program. If they don't find one, then they can still take you in case you don't match into EM. Either way, how does it hurt them to find a replacement prophylactically?

3) Your chances of matching into EM-2 are, let's say, about 3%. The chances of your PD finding a replacement for you about 70+%. Does this sound like a good gamble to you?

 

[BoardingDoc]

I cannot for the life of me see an EM program accepting an FM PGY2 resident into an EM PGY2 spot. The responsibilities of an EM2 is something that takes a good year to develop as an EM PGY1. I mean no offense to the OP, but you quite frankly do not have the required skills to assume a PGY2 EM role.

 

[monkeymedic]

When I say longshot for matching into a PGY-2 spot, it's hard to give a percent chance.
If you were an outstanding candidate with no red flags and you matched into ortho, I'd give you a chance of 10%.

In your case, I'd say the chances would be closer to 0%, but anything is possible.

MonkeyMedic -

I'm in a bit of a rush right now, but I'll say this:

1) There is a difference between possibility and plausibility. Although it may be possible for you to apply for an EM-2 position.... from a plausible standpoint, I don't think the program would think you could handle an EM-2's responsibilities. I did a TY-year (with a total of three ED blocks--since I did both my electives in EM), and after the completion of that, I was nowhere ready to be an EM-2, which is why I started as an EM-1. You simply couldn't handle the patient load, responsibilities, procedures, moving the meat, etc.

Therefore, I think that what you showed may be how certain universities will accept applications with a minimum score, but that minimum score is nowhere near the actual average / real cut-off.

2) When my buddy switched IM programs, completing IM-1 at one program and then transferred to an IM-2, the moment he told his PD that he was needing to switch programs, the PD immediately started looking for a replacement, and found one before my buddy matched into another IM-2. And my buddy was *extremely* well-liked by his PD and the program in general... It's just that the PD and the program didn't want to be down a resident the next year.

From the PD and program's point of view, they might as well look for a replacement for you immediately. If they find one, they get someone who actually wants to be in the program. If they don't find one, then they can still take you in case you don't match into EM. Either way, how does it hurt them to find a replacement prophylactically?

3) Your chances of matching into EM-2 are, let's say, about 3%. The chances of your PD finding a replacement for you about 70+%. Does this sound like a good gamble to you?

I think that what you guys say makes a lot of sense after hearing the explanations. That being said, would anything change if I completed FM? If I tried to slot into an EM-2 spot, I'd have the same problems right? And if so, would the advice be to rematch into a categorical position then?

I also agree that the safest option would be to complete the FM residency and then figure out my life from there. If this thread has taught me anything at all, it's that while not matching into EM is definitely not ideal, it also isn't the end of the road for me in terms of wanting to do emergency medicine as a career.

I cannot for the life of me see an EM program accepting an FM PGY2 resident into an EM PGY2 spot. The responsibilities of an EM2 is something that takes a good year to develop as an EM PGY1. I mean no offense to the OP, but you quite frankly do not have the required skills to assume a PGY2 EM role.

No offense taken. I think you make a good point. But if that's the case, would I be any better suited for the position after I finished a FM residency? Wouldn't I still have the same issue that the responsibilities of a EM-2 would still require a year's worth of training as an EM-1? The reason I ask is that at some point there has to be enough experience right? Otherwise they wouldn't even say that on the residency vacancy posting that they'll consider non-EM wanting to switch into EM?

 

[Groove]

Your chances of matching into EM are slim to none and as mentioned already, it would be very risky for you to alert your PD of your intention to "abandon ship", so to speak. Finish your FM residency and see how you feel at that point. You have a multitude of fellowships available to you that allow you to custom tailor your career in a myriad of ways that are certain to bring you the same degree of career satisfaction that you "realistically" would have attained in EM.

 

[BoardingDoc]

No offense taken. I think you make a good point. But if that's the case, would I be any better suited for the position after I finished a FM residency? Wouldn't I still have the same issue that the responsibilities of a EM-2 would still require a year's worth of training as an EM-1? The reason I ask is that at some point there has to be enough experience right? Otherwise they wouldn't even say that on the residency vacancy posting that they'll consider non-EM wanting to switch into EM?

That's a good question. You would have a great deal of knowledge about acute, non-emergent issues (of which we see plenty of in the ED), but you would still have a significant knowledge gap in procedural skills and the management of acute medical emergencies. I suspect you could pick these skills up in an EM fellowship, or could try to jump into an EM PGY2 role. I still think the fellowship is by far the easier and more feasible route in that case than trying to jump into an EM residency. I don't think it's impossible to do, I just think it would be harder logistically and that you'd still have some procedural and emergency management issues up front.

 

[Angry Birds]

I think that what you guys say makes a lot of sense after hearing the explanations. That being said, would anything change if I completed FM? If I tried to slot into an EM-2 spot, I'd have the same problems right? And if so, would the advice be to rematch into a categorical position then?

I also agree that the safest option would be to complete the FM residency and then figure out my life from there. If this thread has taught me anything at all, it's that while not matching into EM is definitely not ideal, it also isn't the end of the road for me in terms of wanting to do emergency medicine as a career.



No offense taken. I think you make a good point. But if that's the case, would I be any better suited for the position after I finished a FM residency? Wouldn't I still have the same issue that the responsibilities of a EM-2 would still require a year's worth of training as an EM-1? The reason I ask is that at some point there has to be enough experience right? Otherwise they wouldn't even say that on the residency vacancy posting that they'll consider non-EM wanting to switch into EM?

I think the maximum time of credit you can get is six months, even if you've completed another whole residency. Someone can correct me if I remember this incorrectly.

However, your chances would be a bit higher--nay, significantly higher--after you complete a whole residency. The level of knowledge you'd bring as an attending FP is much much higher than as someone who just has an intern year. Also, more years would have elapsed since your red flags and you could by then have proved to be a stellar resident.

Also, just so you know, I currently work an hour outside a major city and most of the docs here are FP or IM trained. I'm leaving this job and it was a temporary stop for me, but there are tons of opportunities that will be there for you in EM if you complete FP residency. Just get over the fact that you didn't match EM and get on with your life. You'll be fine.

 

[?atypical CP]

How do you feel about cold weather and hockey?

Your FM residency will be recognized by the College of Family Physicians of Canada. Most EM docs in Canada were originally FM graduates who completed an extra year of EM training (this is called the "2+1" pathway). They work everywhere, not just in rural EDs.

http://www.aafp.org/cme/creditsys/about/credit-statements/cfpc-agreement.html

http://canadiem.org/frcpc-or-ccfp-em-what-is-best-for-you/

 

[BoardingDoc]

Just curious, is there a big difference in pay if you're FM working in ED vs if you're EM? If not, that's good, but if so, then that might be a good reason for OP to try for a second residency in EM after FM.

That issue is determined by location specifics. I have never seen an advertisement where FM docs are offered a lower rate than EM docs. I have, however, seen many job ads that specify that they will only take EM BC/BE docs. If those jobs pay more, then yes, there is an issue. On the whole, no there isn't.

 

[Angry Birds]

Just curious, is there a big difference in pay if you're FM working in ED vs if you're EM? If not, that's good, but if so, then that might be a good reason for OP to try for a second residency in EM after FM.

At my current job, the rate is only minimally different. Also, I think it's negotiable.

 

[NERDY]

Try the SAEM webpage, spots open up after the match (and you might get some credit for the rotations you finished).

 

[Groove]

Just curious, is there a big difference in pay if you're FM working in ED vs if you're EM? If not, that's good, but if so, then that might be a good reason for OP to try for a second residency in EM after FM.

Depends on location and supply/demand of BCEM docs. In my city the difference is marginal but I'm in the South and we have a paucity of EPs around here.

 

[sawboned]

Regarding pay, we found this to be true as well. Hired a national firm to study just this issue for us. They concluded we should be paying our non-EM boarded the same as boarded.

 

[Angry Birds]

Regarding pay, we found this to be true as well. Hired a national firm to study just this issue for us. They concluded we should be paying our non-EM boarded the same as boarded.

to clarify my own views, I do think that EM boarded docs SHOULD get paid more.

 

[sawboned]

Indeed. No offense to anyone but I would like to value EM board certification with higher pay than non. It was frustrating though understandable when admin chose to follow our consultant's guidance.

 

[Doctor4Life1769]

This is ridiculous.
OP had no chance to match EM. Should be happy with FM - lots of variety.
Perhaps if interested in EM, maybe get experience or fellowship, then apply for EM residency.
I'm surprised anyone at his institution gave him potential advise to switch mid-residency.

 

[Angry Birds]

On the other hand I can sympathize with the OP on his heart ache but we just want to give him realistic and good advice

 

[bashwell]

OP, if (as some people are saying above) FM working in ED usually pays similar rates to EM, then FM seems like a good way to go.

Only real issue seems to be if more hospitals in the future will require BC/BE EM instead. No idea how likely this is though? Maybe it means you'll only be able to work rural?

 

[Angry Birds]

OP, if (as some people are saying above) FM working in ED usually pays similar rates to EM, then FM seems like a good way to go.

Only real issue seems to be if more hospitals in the future will require BC/BE EM instead. No idea how likely this is though? Maybe it means you'll only be able to work rural?

I think the severe shortage of EM trained docs means that this won't happen any time soon.

But yes, I agree with you that in many places rural will be the only place to go. I'm EM trained and working at a rural shop right now, which is why most of my colleagues are not EM trained. I'm leaving this gig in a few months. It wasn't bad but I now want to work closer to home.

 

[Doctor4Life1769]

OP, if (as some people are saying above) FM working in ED usually pays similar rates to EM, then FM seems like a good way to go.

Only real issue seems to be if more hospitals in the future will require BC/BE EM instead. No idea how likely this is though? Maybe it means you'll only be able to work rural?

With regards to your second paragraph, it's already pretty much that way.

 

[EskimoFriend13]

I'm always a little surprised when people say they hate primary care. I enjoyed family medicine because it was fast paced with a lot of variety, and pulled from all areas of medicine, especially when someone came in with something acute or new. I mean add some procedures, a handful of critical patients, and take out the follow up and we have EM right? Seems less of a leap than most other specialties. Though I could have been happy in any specialty minus surgery and even that's just because the intensity of personalities would wear me down.

 

[Angry Birds]

I'm always a little surprised when people say they hate primary care. I enjoyed family medicine because it was fast paced with a lot of variety, and pulled from all areas of medicine, especially when someone came in with something acute or new. I mean add some procedures, a handful of critical patients, and take out the follow up and we have EM right? Seems less of a leap than most other specialties. Though I could have been happy in any specialty minus surgery and even that's just because the intensity of personalities would wear me down.

The one thing I missed the most after my Transitional Year was our free clinic. It was fun.

What I hated was Internal Medicine rounds.

But, I agree: FP clinic is not all that different from EM / urgent care.

 

[cbrons]

LOAs always scare me when I review applications. There better be a REALLY good reason for a candidates LOA (like a medical illness) or it's almost a kiss of death in my mind. I realize things happen, and I'm not completely heartless, but when people take time off because of things like relationship issues, or because they are did poorly on boards and want extra time to study, or whatever, it scares the heck out of me. Programs don't like to take risks, and the loss of a resident mid year can be devastating to staffing. As a program, you just can't risk a resident just one day deciding they need to quit, transfer to another field, another residency, etc.

As for your options, just remember, every year of FP residency you complete is one year of funding an EM program would lose if you matched there. That can have real consequences from a budget standpoint for some places. Just something to think about.

What about LOAs from first year? (As opposed to 2nd or 3rd)?

 

[racerwad]

What about LOAs from first year? (As opposed to 2nd or 3rd)?

How would a severe illness or a failed class(es) be different depending upon what year of school you're in?

 

[e30ftw]

You had a rather low chance of matching EM in the first place.

The logical solution is to exceed in Family Medicine, take extra ortho/trauma/anesthesia rotations, do an EM fellowship post-residency, and get a job staffing an ED.

You likely won't be able to work at large hospital groups in metropolitan areas, but will have no problem finding jobs at community hospitals outside city center. There are plenty of spots 1 hr away from cities who hire FM grads; so you can live in the middle 30 min both ways..

 

[BlackDynamite]

I'm hearing EM residency grads saying FM grads can't work in large ED's. Aren't half of the ED's run by CMG's anyway? Are these corporations really looking for more expensive labor, or are you guys saying EM grads wouldn't want a FM grad to join their private group?


Sent from my iPhone using SDN mobile

 

[K31]

I'm hearing EM residency grads saying FM grads can't work in large ED's. Aren't half of the ED's run by CMG's anyway? Are these corporations really looking for more expensive labor, or are you guys saying EM grads wouldn't want a FM grad to join their private group?


Sent from my iPhone using SDN mobile

A lot of the job emails I get from CMGs specify EM BC/BE only. Only rural jobs include FM/IM/etc. in what they take.