Programs Friendly to Switching to EM/Second Residency

[monkeymedic]

Hi All,

TL;DR: I matched into FM after failing to match into EM 3 years ago. I want to give it another shot. Plan A is to find an open PGY-2 spot, but failing that, I am registering for the match again. What EM programs are more friendly when it comes to taking someone that has already completed an FM residency?

Full Post:

Some of you may know my story, but for everyone else here's a quick recap so you don't have to dig through my history.


I am a current FM PGY-3. I've always wanted to do EM, but I had 2 major red flags:
1. Step scores with a Step 1 failure, and mediocre Step 1 and Step 2 and
2. Taking an LOA shortly after starting med school because I wasn't prepared academically.

Other than the academic failures listed above, I have always been told I had a strong application (if you completely ignore those flops). I had a strong showing in my M3 and M4 years (3 Honors, 1 High Pass, 1 Pass in EM rotations), but with my step scores, and in particular the step failure, it was just too much of a mountain to overcome.

I am now a PGY-3 in a full-spectrum, unopposed FM program with an ED that is affiliated with an EM residency program. The Medical Director of the ED is willing to write me a letter and a lot of the EM Attendings here (adjuncts but not core faculty for the EM program at our sister hospital) are also willing to help me when we start hearing about open PGY-2 spots. With Step 3 passed, I am hoping that my mediocre Step 3 score and poor Step 1 and 2 scores will be less of a factor. My PD is also writing me a letter with the intent of showing EM residencies I am cut out for this and hoping they will see they are taking less of a chance on me than I appear on paper. In particular, my PD will point out that I have scored above the mean every year so far on the In-Service Exam and that last year I was 1.5 Standard Deviations above the mean and hopefully show that my test taking woes are behind me.

The "Plan A" is to try and find an open PGY-2 spot I can slot myself in to and with the large number of EM attendings at my hospital (90k visits per year, Level 1 Trauma Center, and the group covers this hospital and 2 other trauma centers so a lot of attendings!) plus him all having known me well in the many months I have spent with them, that I will be able to network my way into having a good chance at one of those spots. However, we know that I am at a disadvantage due to not being an EM resident looking for a PGY-2 spot and some programs could potentially run into funding issues.

Which brings me to "Plan B" which I am hoping for advice on. Plan B is to re-match into a Categorical PGY-1 spot with the NRMP this Spring. If I can't get a PGY-2 spot by the time ROLs are due, the hope is that I will have had enough interviews and made a good enough impression on at least one program to give me a shot. But does any one know of programs that would be more friendly to someone who has already been through an FM residency and looking to change into EM? Obviously there isn't a list anywhere, but I am hoping that with the colelctive expertise of this forum, we can help me make a list of places I need to consider. I have no geographical restrictions and at this point am willing to go ANYWHERE if it results in me being an ABEM Boarded doc.

Thanks!
-MM

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[Istaretoomuch]

Hi All,

TL;DR: I matched into FM after failing to match into EM 3 years ago. I want to give it another shot. Plan A is to find an open PGY-2 spot, but failing that, I am registering for the match again. What EM programs are more friendly when it comes to taking someone that has already completed an FM residency?

Full Post:

Some of you may know my story, but for everyone else here's a quick recap so you don't have to dig through my history.


I am a current FM PGY-3. I've always wanted to do EM, but I had 2 major red flags:
1. Step scores with a Step 1 failure, and mediocre Step 1 and Step 2 and
2. Taking an LOA shortly after starting med school because I wasn't prepared academically.

Other than the academic failures listed above, I have always been told I had a strong application (if you completely ignore those flops). I had a strong showing in my M3 and M4 years (3 Honors, 1 High Pass, 1 Pass in EM rotations), but with my step scores, and in particular the step failure, it was just too much of a mountain to overcome.

I am now a PGY-3 in a full-spectrum, unopposed FM program with an ED that is affiliated with an EM residency program. The Medical Director of the ED is willing to write me a letter and a lot of the EM Attendings here (adjuncts but not core faculty for the EM program at our sister hospital) are also willing to help me when we start hearing about open PGY-2 spots. With Step 3 passed, I am hoping that my mediocre Step 3 score and poor Step 1 and 2 scores will be less of a factor. My PD is also writing me a letter with the intent of showing EM residencies I am cut out for this and hoping they will see they are taking less of a chance on me than I appear on paper. In particular, my PD will point out that I have scored above the mean every year so far on the In-Service Exam and that last year I was 1.5 Standard Deviations above the mean and hopefully show that my test taking woes are behind me.

The "Plan A" is to try and find an open PGY-2 spot I can slot myself in to and with the large number of EM attendings at my hospital (90k visits per year, Level 1 Trauma Center, and the group covers this hospital and 2 other trauma centers so a lot of attendings!) plus him all having known me well in the many months I have spent with them, that I will be able to network my way into having a good chance at one of those spots. However, we know that I am at a disadvantage due to not being an EM resident looking for a PGY-2 spot and some programs could potentially run into funding issues.

Which brings me to "Plan B" which I am hoping for advice on. Plan B is to re-match into a Categorical PGY-1 spot with the NRMP this Spring. If I can't get a PGY-2 spot by the time ROLs are due, the hope is that I will have had enough interviews and made a good enough impression on at least one program to give me a shot. But does any one know of programs that would be more friendly to someone who has already been through an FM residency and looking to change into EM? Obviously there isn't a list anywhere, but I am hoping that with the colelctive expertise of this forum, we can help me make a list of places I need to consider. I have no geographical restrictions and at this point am willing to go ANYWHERE if it results in me being an ABEM Boarded doc.

Thanks!
-MM

So I have 0 recs on specific programs but...

Now that DO and MD programs are integrated there are currently 171 ACGME 3 year programs. If you are fine going somewhere that isn't a brand name I don't see why you wouldn't be able to find a spot given you've showed you're competent enough to finish an FM residency.

I was surprised looking at the list:

EMRA Match

 

[Apollyon]

Just a note - you seem almost "hung up" on getting a PGY-2 spot. The most you can get is 6 months credit, if you match in a 3 or 4 year program, and this is not automatic. Most, if not all, PGY-2 spots require the first year to have been EM.

 

[Rendar5]

FAU is a new program that has taken Fresh IM residency graduates in its first two classes for a second residency, but they were people already known to be good to faculty. That said many programs out there will take ppl for a second residency. I had a former FM practitioner at my own residency which was well established.

 

[BoardingDoc]

Just a note - you seem almost "hung up" on getting a PGY-2 spot. The most you can get is 6 months credit, if you match in a 3 or 4 year program, and this is not automatic. Most, if not all, PGY-2 spots require the first year to have been EM.

Agreed. I don't know why one would expect to start as a pgy2 after completing an FM residency. I know several people who are currently in or have already finished an EM residency after completing an IM residency or an FM residency. All of them started EM as an intern.

 

[deleted480308]

Agreed. I don't know why one would expect to start as a pgy2 after completing an FM residency. I know several people who are currently in or have already finished an EM residency after completing an IM residency or an FM residency. All of them started EM as an intern.

I have to agree here, maybe credit for a few of the tertiary months but I wouldn’t expect them to be supervising interns in the Ed as a senior level EM resident on month 1.

 

[enalli]

Agreed. I don't know why one would expect to start as a pgy2 after completing an FM residency. I know several people who are currently in or have already finished an EM residency after completing an IM residency or an FM residency. All of them started EM as an intern.

I have to agree here, maybe credit for a few of the tertiary months but I wouldn’t expect them to be supervising interns in the Ed as a senior level EM resident on month 1.

I don't know the ACGME rules behind whether his prior training can count, but expecting to come into PGY-2 after having finished an unopposed FM residency doesn't sound that ridiculous to me. It's not like the OP spent the last 3 years prescribing statins in the outpatient clinic; he probably spent a significant amount of time as a senior resident in the ICU, L&D ward, OR, and, yes, the ED. Someone who completed an unopposed FM residency is probably more than capable to hold their own against someone who just finished an EM intern year (who, odds are, spent at least half the year in off-service rotations). Maybe they won't have ED workflow down, but their clinical acumen is probably just as good, if not better.

 

[Rendar5]

I don't know the ACGME rules behind whether his prior training can count, but expecting to come into PGY-2 after having finished an unopposed FM residency doesn't sound that ridiculous to me. It's not like the OP spent the last 3 years prescribing statins in the outpatient clinic; he probably spent a significant amount of time as a senior resident in the ICU, L&D ward, OR, and, yes, the ED. Someone who completed an unopposed FM residency is probably more than capable to hold their own against someone who just finished an EM intern year (who, odds are, spent at least half the year in off-service rotations). Maybe they won't have ED workflow down, but their clinical acumen is probably just as good, if not better.

It's not about clinical acumen. They will not have spent 12 months of their 36 month FM residency doing required EM rotations. Great, they get to skip 1-2 EM months, 1 L&D month, 1 MICU month and maybe a SICU or PICU rotation? Where's the entire year of EM residency they accomplished?

Now can they graduate early? Sure plenty of programs will allow that. The ones I'm familiar with will have them graduate 4-6 months early depending on what they accomplished, but they still start as EM interns.

 

[gro2001]

Hi All,

TL;DR: I matched into FM after failing to match into EM 3 years ago. I want to give it another shot. Plan A is to find an open PGY-2 spot, but failing that, I am registering for the match again. What EM programs are more friendly when it comes to taking someone that has already completed an FM residency?

Full Post:

Some of you may know my story, but for everyone else here's a quick recap so you don't have to dig through my history.


I am a current FM PGY-3. I've always wanted to do EM, but I had 2 major red flags:
1. Step scores with a Step 1 failure, and mediocre Step 1 and Step 2 and
2. Taking an LOA shortly after starting med school because I wasn't prepared academically.

Other than the academic failures listed above, I have always been told I had a strong application (if you completely ignore those flops). I had a strong showing in my M3 and M4 years (3 Honors, 1 High Pass, 1 Pass in EM rotations), but with my step scores, and in particular the step failure, it was just too much of a mountain to overcome.

I am now a PGY-3 in a full-spectrum, unopposed FM program with an ED that is affiliated with an EM residency program. The Medical Director of the ED is willing to write me a letter and a lot of the EM Attendings here (adjuncts but not core faculty for the EM program at our sister hospital) are also willing to help me when we start hearing about open PGY-2 spots. With Step 3 passed, I am hoping that my mediocre Step 3 score and poor Step 1 and 2 scores will be less of a factor. My PD is also writing me a letter with the intent of showing EM residencies I am cut out for this and hoping they will see they are taking less of a chance on me than I appear on paper. In particular, my PD will point out that I have scored above the mean every year so far on the In-Service Exam and that last year I was 1.5 Standard Deviations above the mean and hopefully show that my test taking woes are behind me.

The "Plan A" is to try and find an open PGY-2 spot I can slot myself in to and with the large number of EM attendings at my hospital (90k visits per year, Level 1 Trauma Center, and the group covers this hospital and 2 other trauma centers so a lot of attendings!) plus him all having known me well in the many months I have spent with them, that I will be able to network my way into having a good chance at one of those spots. However, we know that I am at a disadvantage due to not being an EM resident looking for a PGY-2 spot and some programs could potentially run into funding issues.

Which brings me to "Plan B" which I am hoping for advice on. Plan B is to re-match into a Categorical PGY-1 spot with the NRMP this Spring. If I can't get a PGY-2 spot by the time ROLs are due, the hope is that I will have had enough interviews and made a good enough impression on at least one program to give me a shot. But does any one know of programs that would be more friendly to someone who has already been through an FM residency and looking to change into EM? Obviously there isn't a list anywhere, but I am hoping that with the colelctive expertise of this forum, we can help me make a list of places I need to consider. I have no geographical restrictions and at this point am willing to go ANYWHERE if it results in me being an ABEM Boarded doc.

Thanks!
-MM

First of all, congratulations on almost being done with residency. That's a big accomplishment. No matter where you go from here, you will have a solid backup as well as a set of additional skills and a different perspective on things.

However, in terms of your plan A: I don't think it's possible. I am not a PD/APD and will be happy to be corrected by one, but my understanding is that ACGME rules changed around 2012 and now you can only get a maximum of 6 months of credit for any post graduate training. So you will not be able to enter as an EM PGY2. You might be able to get a lot more elective time though, or perhaps not have to re-do some rotations (however, that will be up to your PD, as apart from credit, there may also be staffing issues to consider).

In terms of your plan B: just apply to all the programs in the country. This may sound crazy and expensive (something like $5-6 k for ERAS alone). However, the expense is just not that important in the grand scheme of things. Just consider one year of attending income for FM and EM attending. The difference is going to be more than $5k. Another way to look at it is: if you match in EM, it will be a small price to pay for fulfilling your dream; if you don't match, you will take an FM attending job and will make the $5k back really quick.

As for if it's crazy/necessary: there is no way to know. Many PDs might not have encountered someone with your story, so there is no way to figure out who or how many would be receptive. Also, please don't take this the wrong way, but your application doesn't scream about you being the most desirable candidate. Yes, you have a couple of things going for you, but you also have several red flags. And while personal recommendations and people willing to root for you, make phonecalls, etc, go a long way, a lot more people say they will help you than will actually do it come the match. People are really reluctant to do it unless they are super invested in your success. In addition to all the usual biases, personal issues, and general randomness of the match... It just seems like you should go really really really broad. Worst case, you decline a bunch of interview.

 

[monkeymedic]

Just a note - you seem almost "hung up" on getting a PGY-2 spot. The most you can get is 6 months credit, if you match in a 3 or 4 year program, and this is not automatic. Most, if not all, PGY-2 spots require the first year to have been EM.

True, I don't want to sound as if I think this is a sure thing, it's far from it, but I have heard stories and know people personally that have done this.

Agreed. I don't know why one would expect to start as a pgy2 after completing an FM residency. I know several people who are currently in or have already finished an EM residency after completing an IM residency or an FM residency. All of them started EM as an intern.

I have to agree here, maybe credit for a few of the tertiary months but I wouldn’t expect them to be supervising interns in the Ed as a senior level EM resident on month 1.

I don't know the ACGME rules behind whether his prior training can count, but expecting to come into PGY-2 after having finished an unopposed FM residency doesn't sound that ridiculous to me. It's not like the OP spent the last 3 years prescribing statins in the outpatient clinic; he probably spent a significant amount of time as a senior resident in the ICU, L&D ward, OR, and, yes, the ED. Someone who completed an unopposed FM residency is probably more than capable to hold their own against someone who just finished an EM intern year (who, odds are, spent at least half the year in off-service rotations). Maybe they won't have ED workflow down, but their clinical acumen is probably just as good, if not better.

I agree, I shouldn't feel like I am entitled to a PGY-2 Spot, but I am hopeful because there are 2 people I personally know (in real life!) who switched from Gen Surg to EM after 2 and 3 years respectively and both were given PGY-2 standing or close to it. I don't know exactly how many months of credit they received, but I know in one case it was definitely more than 6.

I agree that there are a wide range of FM programs and my challenge will be to show that I haven't been sitting on my butt in the clinic 9am-4pm writing grandma for her statin and HTN meds. I have kept a case log of my EM cases as well as a procedure log. I hope by showing that I have ran more than 100 Codes as senior resident (more if you include my intern year), placed nearly 90 central lines, and have an ICU admission rate of ~14%, I can show that I am picking up the challenging cases and picking up extra shifts that no one else wants to get the experience.

It's not about clinical acumen. They will not have spent 12 months of their 36 month FM residency doing required EM rotations. Great, they get to skip 1-2 EM months, 1 L&D month, 1 MICU month and maybe a SICU or PICU rotation? Where's the entire year of EM residency they accomplished?

Now can they graduate early? Sure plenty of programs will allow that. The ones I'm familiar with will have them graduate 4-6 months early depending on what they accomplished, but they still start as EM interns.

If I can graduate 6 months early, that's a win. Actually, graduating 0 months early from an EM residency is a win in my book. Anything extra is icing on the cake. From "ABEM's Policy on Equivalent Credit for Training in Other Specialties" Feb 2017. (Apparently I can't post a link, but you should be able to find the policy via Google)

"A maximum of 12 months of equivalent credit may be granted for 24 months or more of prior ACGME-accredited, non-EM residency training; of the 12 months, up to two months can be for EM rotations. (See #3 below for the criteria the EM rotations must fulfill."

So I would get credit for 2 MICU, 1 Trauma Surgery, 1 Peds ED, 1 L&D and 2 ER months at minimum. Plus I can fill in a couple of electives with floor months. The question that the EM Dept Chair hasn't been able to get clarity on is if all 6 months I spent in the ED can count towards my EM residency. "See #3 below" is what we get hung up on--I technically was a resident at a rotation site for an EM program--we accept rotators in our ED and one of the big name training programs rotates through our ED since we are a large Level 1 Trauma Center to help them with Trauma experience. Our ER Attendings are Adjunct faculty. So we aren't sure if these 6 months can still count or not. In any case, it's not a big deal if even nothing counts. Like I said earlier, a shorter residency is more desirable, but is really just the icing on the cake.

First of all, congratulations on almost being done with residency. That's a big accomplishment. No matter where you go from here, you will have a solid backup as well as a set of additional skills and a different perspective on things.

Thank you! It has definitely been a challenge!

However, in terms of your plan A: I don't think it's possible. I am not a PD/APD and will be happy to be corrected by one, but my understanding is that ACGME rules changed around 2012 and now you can only get a maximum of 6 months of credit for any post graduate training. So you will not be able to enter as an EM PGY2. You might be able to get a lot more elective time though, or perhaps not have to re-do some rotations (however, that will be up to your PD, as apart from credit, there may also be staffing issues to consider).

See the link above, you can get up to 12 months, but there are a lot of stipulations. I can hopefully get more elective time to pursue some research and prehospital care (which I am very interested in). I didn't think about the staffing issues, but that is another very good point you make--if someone is dropping out of an EM program after EM-1, they want to replace him with someone that is going to work those shifts! Not someone that is just going to have elective time and try and leave early! But at this point, I'll take whatever I can get!

In terms of your plan B: just apply to all the programs in the country. This may sound crazy and expensive (something like $5-6 k for ERAS alone). However, the expense is just not that important in the grand scheme of things. Just consider one year of attending income for FM and EM attending. The difference is going to be more than $5k. Another way to look at it is: if you match in EM, it will be a small price to pay for fulfilling your dream; if you don't match, you will take an FM attending job and will make the $5k back really quick.

As for if it's crazy/necessary: there is no way to know. Many PDs might not have encountered someone with your story, so there is no way to figure out who or how many would be receptive. Also, please don't take this the wrong way, but your application doesn't scream about you being the most desirable candidate. Yes, you have a couple of things going for you, but you also have several red flags. And while personal recommendations and people willing to root for you, make phonecalls, etc, go a long way, a lot more people say they will help you than will actually do it come the match. People are really reluctant to do it unless they are super invested in your success. In addition to all the usual biases, personal issues, and general randomness of the match... It just seems like you should go really really really broad. Worst case, you decline a bunch of interview.

That sounds ridiculously expensive, and quite crazy, but you are not the first person to suggest it. I think it runs about $30 per program and SAEM tells me there are 241 programs so that's about $7230 just on application fees. Quite a chunk of change, but probably still worth it. I have a permanent license so I could probably even make that up moonlighting every weekend for a few months.

No need to apologize, I know I am not the most desirable candidate. The only things I have going for me are the fact that the red flags were 5-7 years ago, and I have been on the right path since then, but I know plenty of places will filter out my application without even seeing it. I know to put all of my confidence in others helping me out, but I know of at least one person (our EM Dept Chair) that has gone out of his way to help other residents who wanted to switch into EM before, and he already made some phone calls for me (without even me asking) to get me an away rotation at a Nationally known program. He knew I was looking at away rotations and recommended I try for one that I was pretty sure would say no. When I called over to sort something out with my application the next day (one of my documents got corrupted when I attached it), I found out he had already called over on my behalf and the rotation was already approved. Don't get me wrong, I know there are plenty of people who say they will help, and perhaps some of the others who have offered their help were just saying it, but I know at least I have one guy in my corner who is the real deal and has already gone to bat for me.

I was thinking of applying to about 100-125 programs, but now that you're the 3rd person that recommended applying to all of them, I might just do it. Maybe it's crazy and excessive, but I don't want to look back 9 months from now thinking "what if...?"

Thanks to everyone who has commented so far! I'm following this thread and reading in my downtime, but the hospital computers don't have access so I only post when I'm at home (hard to post from a tiny iPhone). I still haven't heard any names yet, so if anyone knows any program that has taken FM residents in the past, please let me know! (PM me if you don't want to post it publicly).

Thanks!
-MM

 

[enalli]

Why don't you try reaching out to some PDs asking if they would consider you based on your funding situation? Best case scenario, they say yes and you are now on their radar. Worst case scenario, they say no and you know not to apply.