Strongly Considering a Second Residency in EM

[VentJockey]

I'm an IM PGY2 (soon to be 3). Some of you may recognize me from my participation on this forum, because I find it more interesting than the IM forum. In any case, for a variety of reasons I am strongly considering applying in the upcoming match for a second residency in Emergency Medicine. I love internal medicine, and fully plan on becoming board certified, but I think to do the things I really love most, I need to branch out and train in EM as well.

I recognize that second residencies are actually harder to get than a first residency due to funding issues. But, I think I should make my best effort at obtaining one and see what happens. (The reason I say I'm strongly considering, and not definitely planning to do this, are that I have to make sure financially my family will be OK with me earning a resident's salary for another three years. I think the answer is yes, but I obviously have to confirm everything.)

My question, that I hope some people on this forum can help me with, is what I should do in the upcoming months to maximize my chances. (I could also wait one year and apply then, which would leave me practicing IM as an attending for a year before starting....I think that this might make me an even less attractive candidate since there would be the concern that I'd have trouble adjusting back from attending to trainee role).

What I have in my favor:

Spotless record in my current residency (which I will plan to complete successfully)
Can get a glowing letter from my PD
Good relationship with the ED at my shop, who know me well from rotations with them as an intern and also as a consultant. I have no doubt I can get glowing letters from them.


What I have weighing against me:

Caribbean grad
Poor step one/good step 2/3
Already got a residency

So, I can throw down the 5K or whatever it costs to apply to all the EM programs in the country. I can ask the ER attendings who know me to introduce me to the PDs where they trained. I think if I get interviews I can do a very good job of articulating good reasons why I want to undertake the training and why I'm a good fit for the specialty. I've been told that I'm well spoken and likable in person, and that I interview very well. I have an established track record of competence and good conduct without any red flags (unless you count my status as a Caribbean grad as a red flag, but I think that is mitigated by my ability to function well in a US residency program).

I hate to make this a "what are my chances" thread, but feel free to comment on that if you have an opinion. But anyone with any advice on things I can do to improve my chances would be really kind and helpful if they responded. If anyone knows anyone who has done this, who'd be willing to talk to me about it, I'd be extremely grateful if you could introduce us.

Thanks for any input you guys can give me!

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[Doctor J]

What I have weighing against me:

Caribbean grad
Poor step one/good step 2/3
Already got a residency

The third point is probably the roughest. This means your program won't get money from Medicare for your last year of residency training. Meaning you won't make the hospital the >~$110,000 stipend for your last year of training - you'll COST them your salary plus the lost revenue of your "medicare reimbursement".

Still, you should do what you like. It seems like a little bit of a long shot to me, but ask yourself, if you don't try, will you regret it later in life? You may try and fail and still feel as though the exercise was worth it in terms of staving off regrets down the road.

 

[two guys]

I think you'll have a decent shot. Yes, your funding is an issue but programs will find a way to deal with this. They may only let you train for 2.5 years which does also come with some trouble for them covering the other shifts but you have some pretty real positives:

- board certified EM docs vouching for you is huge. A 3 year track record of playing well with others as a consultant will not be overlooked.
- you bring the perspective of an IM grad. There's not a huge gulf b/t EM and IM but they are diferent and it would be a big plus to have you around.

You might start by discussing this with your program director (make it very clear to him/her you're going to finish IM first). I think they'll be interested in helping as long as your going to finish IM first. Then talk with the EM program director at your shop. Those 2 individuals can probably estimate your chances better than most of us.

You might also try talking with "aprogramdirector". He posts on the general residency forum a fair bit and could probably chime in on the logistics of funding.

 

[gutonc]

The third point is probably the roughest. This means your program won't get money from Medicare for your last year of residency training. Meaning you won't make the hospital the >~$110,000 stipend for your last year of training - you'll COST them your salary plus the lost revenue of your "medicare reimbursement".

This is actually untrue. The funding varies from institution to institution but the funding available from CMS for residents/fellows beyond their initial training program length is 50% of DME and 100% of IME. The total amount changes but will be somewhere in the neighborhood of 60-75% of what they'd get for a fresh resident without prior training.

 

[Groove]

Why the change of heart? I think it always helps to get a general idea of why you have become disillusioned with IM to make sure its not something identifiable that could be overcome through say... a fellowship track. EM is great, but you have an enormous variety of subspecialty fellowships available to you and it's hard to imagine not being able to find at least something that would keep you interested and happy.

 

[VentJockey]

I appreciate the comments above. I'll definitely have those conversations with my PD and the ER (though sadly there is no EM PD at my hospital since there is no EM at residency).

To answer the question about "why the change of heart?" I'd say that there really hasn't been a change of heart at all. I still love Internal Medicine, and I fully intend to use my skills as an internist throughout my career. But, for me, there are limitations to my training as an internist that will keep me from achieving the goals I have set for myself. Those limitations are lack of trauma training, lack of ability to manage children in any meaningful way, and lack of ability to do anything surrounding pregnancy. I am very passionate about international humanitarian work, and the most interesting opportunities I've found all involve times when I'm the only doctor available in a very undesirable situation. To take one of these positions with my current training is a set up for unnecessary bad outcomes. As an example, I could imagine one of these assignments involving treating HIV and XDR TB in a hospital somewhere in rural western Africa. That's something I can do with my internal medicine training and a couple of textbooks to look up things I'm not familiar with. But, what about the nights on call? When you're the only doctor in the building? What do I do when someone gets in a motorcycle accidents and is brought unconscious in the back of a pickup truck? Or what about the woman who comes in active labor with some sort of an obstetrical emergency? I need to at least know how to stabilize and buy myself time to call in someone who can do something. Right now, I'm very effective at treating adults with medical illness in the context of a hospital full of resources and specialists. I want to expand my skills to be able to better serve the people who need me. Additionally, I've found the may favorite part of medicine are the crises. Codes, massive transfusions, airway problems and RRTs. I'm the only person I know who goes to sleep at night when I'm on call hoping to be woken up with something interesting. I fell that I function very well in those, and really get a lot of satisfaction from managing a crisis. I think that since I enjoy managing crisis situations, I'd do well to get some top notch training in it and be able to practice in a setting where I'm going to be frequently exposed to that. So to sum it up: I want to get comfortable treating kids and pregnant women, managing trauma, or be able to practice in a setting where I'm regularly called upon to manage crises. But I don't intend to walk away from my skills as an internist, either.

 

[DeadCactus]

This is actually untrue. The funding varies from institution to institution but the funding available from CMS for residents/fellows beyond their initial training program length is 50% of DME and 100% of IME. The total amount changes but will be somewhere in the neighborhood of 60-75% of what they'd get for a fresh resident without prior training.

I really hate how persistent the "OMG you won't have any funding!" rumor is...

 

[gutonc]

I really hate how persistent the "OMG you won't have any funding!" rumor is...

I try man...I try.

 

[Birdstrike]

Why the change of heart? I think it always helps to get a general idea of why you have become disillusioned with IM to make sure its not something identifiable that could be overcome through say... a fellowship track. EM is great, but you have an enormous variety of subspecialty fellowships available to you and it's hard to imagine not being able to find at least something that would keep you interested and happy.

I agree. I'm not saying EM wouldn't work out for him, but for the love of God (as Arcan57 would say) why not strongly consider a fellowship? Why do a lateral move and start over when you can do a fellowship building on what you've already done and become a specialist in something? Cards, GI, ICU, EM...whatever. Pick based on the hours, money and lifestyle you want. I got news for you. The rest of it is all the same s**t. It really is.

 

[docdragon]

You have ideas about your future jobs -- what organizations are on your radar? Have you talked to them About this question? Do you have any elective months? Could you do any of this with a fellowship?

It might be worth talking to people who have been there & done that. EM is tremendously useful for the crises, but a lot of the old-school international/mission docs came from medicine... And learned to do surgery... Or surgery and learned to do medicine. Things have changed in much of the world.

 

[Droperidol]

You have a good shot to get in I think, however, you should really evaluate this option versus your multiple subspecialties. What if you go into EM and then find out you want CC? I'm sure you've thought about it but make sure you talk to as many people who would look out for your best interests before becoming an intern again. You should also really know the pros and cons of EM before such a move. I love my life but I soul searched long and hard before choosing it in med school and a handful of my colleagues have not and you can see the cynicism and burn out developing in them.


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[gman33]

If I read your post correctly, you want to do a whole other residency to be better trained for international volunteer work?

 

[Doctor J]

My mistake. Thanks for the clarification, gutonc. My point still stands, albeit less strongly. Why would a program willingly take on a resident that would end up being less cost effective than a fresh grad?

Although, sometimes this decision does get made simply because the applicant is strong, comes recommended, and seems "low risk".

 

[VentJockey]

I very much appreciate all the responses this thread has generated. You all have been very helpful. I'd like to discuss with you the topic that was brought up about medicine subspecialties. It was my intention upon entering residency to do a CC fellowship. I love the ICU setting....some of the time. What I like about it is the crisis management and acute critical care. I like responding to an RRT and bringing the patient to the floor and getting them squared away. I like responding to codes and running the code, and bringing the patient to the unit for a cooling protocol. I like the massive transfusions. Basically, any time there is an acute problem to be solved right away, I'm highly interested. However, there is a dreadful part of the ICU that I don't like: the highly detailed longitudinal care of the critically ill patient. They have a new acid base disturbance, and then they get an ileus, and now we have to talk about the pros and cons of TPN, and now ICU delirium and don't forget to replete that potassium and on and on it goes. Literally thousands of little details on a daily basis that drive me crazy.

So, I ask myself: if I spend two or three years of extra training, would I find myself happier being an intensivist or a double boarded EM/IM guy? I'm sure I could find situations where I get to manage more acute care as an intensivist. Since I like to work at night, I could cover ICU at night and largely spend my time admitting and putting out fires. I could probably get a job as a critical care flight doc, which I think would be fascinating, though I hear these jobs tend to go to the EM guys. But if I do an EM residency, I think I could work at a high volume/high acuity center that would let me spend large portions of every day in a resusc bay, doing the work that I already know I prefer. I think it would be easier to get jobs doing critical care flights. Am I thinking correctly? Do my expectations align with reality? Given all that I've just said, what are you opinions on whether I'd be happier as an intensivist vs ER Doc?

 

[FranticFrancis]

VentJockey, you've being answering my questions lately in threads that I post in this forum, but only now have I truly seen how our minds work similarly and how our professional needs are somewhat the same. I'm not here to retribute the favor of answering my questions, I'm here to tell you that I support your ideas and to say that I plan to mirror your actions and follow the same path (even though I know I might not do it, once I've decided my pathway several times, and have changed again an equal amount of times). Finally, I hope you succeed in your 'quest' achieving double boarding qualification. Good luck, mate!

Ps.: I'm a Non-US IMG, and I know nothing of anything, but I would guess you have a strong claim and at least some programs would be happy in having you as their resident.

 

[Arcan57]

Hanging out in the resusc bay all day is actually pretty abnormal for an EP. Most places won't have a high enough volume of crit care to guarantee a hyper acute only experience. The norm in non-academic shops is intermittent critical patients mixed in with a deluge of moderate to low acuity. In academic shops, everyone thinks they're going to be the doc in the bay but usually end up pulling fast track shifts in the main ED while spending the majority of their time in community affiliates.

 

[SoCuteMD]

My mistake. Thanks for the clarification, gutonc. My point still stands, albeit less strongly. Why would a program willingly take on a resident that would end up being less cost effective than a fresh grad?

Although, sometimes this decision does get made simply because the applicant is strong, comes recommended, and seems "low risk".

There are places that don't have all their residents funded through Medicare. For any places that rotate through a VA, the VA may fund 1 or more "spots" a year.

I very much appreciate all the responses this thread has generated. You all have been very helpful. I'd like to discuss with you the topic that was brought up about medicine subspecialties. It was my intention upon entering residency to do a CC fellowship. I love the ICU setting....some of the time. What I like about it is the crisis management and acute critical care. I like responding to an RRT and bringing the patient to the floor and getting them squared away. I like responding to codes and running the code, and bringing the patient to the unit for a cooling protocol. I like the massive transfusions. Basically, any time there is an acute problem to be solved right away, I'm highly interested. However, there is a dreadful part of the ICU that I don't like: the highly detailed longitudinal care of the critically ill patient. They have a new acid base disturbance, and then they get an ileus, and now we have to talk about the pros and cons of TPN, and now ICU delirium and don't forget to replete that potassium and on and on it goes. Literally thousands of little details on a daily basis that drive me crazy.

So, I ask myself: if I spend two or three years of extra training, would I find myself happier being an intensivist or a double boarded EM/IM guy? I'm sure I could find situations where I get to manage more acute care as an intensivist. Since I like to work at night, I could cover ICU at night and largely spend my time admitting and putting out fires. I could probably get a job as a critical care flight doc, which I think would be fascinating, though I hear these jobs tend to go to the EM guys. But if I do an EM residency, I think I could work at a high volume/high acuity center that would let me spend large portions of every day in a resusc bay, doing the work that I already know I prefer. I think it would be easier to get jobs doing critical care flights. Am I thinking correctly? Do my expectations align with reality? Given all that I've just said, what are you opinions on whether I'd be happier as an intensivist vs ER Doc?

I know a fair number of people who split their time between ICU and ED. I don't know many who have managed to strike a good balance, and I only know one who, 3+ years into practice, is still splitting time between the two fields.