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Terminated from residency. What should I do?

Started by BigSandwichGuy
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BigSandwichGuy

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I was terminated from residency 2 days ago and am struggling to figure out my next steps. The issues were mainly knowledge based; program leadership did give me credit for effort but I was already on probation and did not meet milestones.

Is there any path back into medicine? And are there any other jobs I can do with a DO degree? My PD is willing to be a reference for non clinical jobs, but I didn’t ask about alternative healthcare fields (eg PA school).
 
BigSandwichGuy said:
The issues were mainly knowledge based;
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You sure? It's hard to fire residents these days for strictly this, seeing as how all of our 'knowledge' is now in our phones. Anyone can learn and regurgitate something quickly.

But ok, if true, and/or if it was just a bad fit . . . .you'd have to go through the application cycle again.
 
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First of all, I'm sorry you're going through this. It must be terrifying and disappointing. Make sure you have help/supports to get through this.

You may have several options moving forward. You only mention medical knowledge issues, don't have any post history, so all we have to work with is what's in this thread.

The first issue is whether this is due to not passing L3. Some programs require this for promotion (although usually at the PGY-2 to 3 transition). All paths in medicine require passage of L3.

You could look for a new PGY-1 spot in the same field, or in a different field. You haven't mentioned what field you trained in. It's possible that with more time and/or a new environment you might improve.

The other (and probably better) option is to look for a PGY-2 position in Occupational Medicine or Preventive Medicine. These fields require 12 months of PGY-1 training, but don't need you to get promoted. Documentation that you did 12 months but would not be promoted would be fine. These fields are relatively non-competitive. The knowledge base is much smaller in these fields.
 
BigSandwichGuy said:
I was terminated from residency 2 days ago and am struggling to figure out my next steps. The issues were mainly knowledge based; program leadership did give me credit for effort but I was already on probation and did not meet milestones.

Is there any path back into medicine? And are there any other jobs I can do with a DO degree? My PD is willing to be a reference for non clinical jobs, but I didn’t ask about alternative healthcare fields (eg PA school).
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What field were you in? Do you have any attendings that would be willing to support you?
 
This was internal medicine at a lower tiered program in the Southwest and yes, I’m sure the termination was knowledge based. They said so explicitly along with noting that work ethic and professionalism were good.

In terms of PD support, it’s clear they would support me in non clinical endeavors if a new job were to ask to speak with the program, and it seems very likely they would not support IM again. We did not discuss other specialties.

Would it be a good idea to essentially beg for a FM LoR? I’m open to preventative medicine as well but it seems reasonable competitive as well.

If it matters, I’m first pass on all COMLEX with the second COMLEX score being low (<500), and failed Step 1 once without retaking it, which the program is aware of.

And I’m personally open to any specialty that isn’t primarily pediatrics.
 
Preventive and Occupational medicine are not competitive, at least not to my knowledge.

Do you think you had a medical knowledge issue? Do you think that more time at the PGY-1 level would address your issue? If so, perhaps you could reapply for either an IM or FM PGY-1. But you don't want to set yourself up for further failure if more time won't really address the issue.

I highly recommend looking into PM and OM.
 
BigSandwichGuy said:
This was internal medicine at a lower tiered program in the Southwest and yes, I’m sure the termination was knowledge based. They said so explicitly along with noting that work ethic and professionalism were good.

In terms of PD support, it’s clear they would support me in non clinical endeavors if a new job were to ask to speak with the program, and it seems very likely they would not support IM again. We did not discuss other specialties.

Would it be a good idea to essentially beg for a FM LoR? I’m open to preventative medicine as well but it seems reasonable competitive as well.

If it matters, I’m first pass on all COMLEX with the second COMLEX score being low (<500), and failed Step 1 once without retaking it, which the program is aware of.

And I’m personally open to any specialty that isn’t primarily pediatrics.
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If your knowledge base/clinical decision making in internal medicine was deficient, then I'm not sure that FM is a good idea.

Preventative or occupational medicine might be a good idea.
 
I'd chalk it up to a few things.

Overall, there were a lot of problems that lasted for months more than they should have, particularly with regards to workflow. Firstly, notes took until beyond sign out for like 8 or 9 months, which isn't against our program's rules but of course does hamper learning quite a bit. But even then, I would study though it wasn't valuable studying given the fatigue from working 1-2 hrs over-time daily; this is the main thing I attribute lack of knowledge to. I was also asking already hospitalized patients way too much ROS, which cost time as well.

Then, about 1-2 months ago, some seniors taught me how to be efficient in notes, and I was then taking maybe 10 min per progress note and 20-25 per HPI. I got much better almost instantly and used the additional time for studying, and I do think I was learning more but it appears to have been too little too late. Had this happened 3-4 months ago, I'd probably still be a resident. I do truly believe that I could excel at a repeat year in IM or an intern year in FM given the chance at a fresh start.

But, with both FM/IM and preventative medicine, my big concerns revolve around the role of the PD. It's unlikely he endorses me for medicine again, especially IM or FM, so the question then is if there are any paths to a new residency that don't need PD involvement.

That being said, if I had both a repeat IM and a PM/OM acceptance today, I would take the IM acceptance, but am open to PM/OM.
 
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As a TYR PD, I have had experience with applicants in your position. what the ones that were eventually successful did was put time between themselves and their next residency. As in a couple of years. In the meantime, they conducted research. since this allowed them to remain in the sciences while giving them time to study medicine. They then only applied to a TYR or Preliminary IM year. this gave them an option to see how they are doing and they can then weight their next move. All of them went into Occupational Medicine/Preventive Medicine and they are very happy.

Judging from your post, as this is the only thing I can go on, you have a large issue with time management. You should be able to get through all of your notes by the end of the working day. There are limits to the census that you have on a daily basis for this reason.

Forget IM right now. Being dismissed from an IM program and your PD not supporting an application for a new IM residency will waste not only your time but your money as well and it will not bode well for your mental health.
 
BigSandwichGuy said:
A little over a year, but I didn’t get promoted.
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So technically can't you apply for a medical license (need 2 years if you're an IMG)? You were in residency for longer than 12 months? I knew a guy who was in a similar situation and didn't get promoted and actually had to repeat some blocks (which he never passed) but crossed the 12-month mark and was able to apply for a license. He got really lucky and got into a PGY1 spot for FM at a different program a year later bc he had a friend who was a chief resident that vouched for him big time.

I would say get your license and take whatever residency you can get. PM/OM are great. I m FM and PM/OM are the hot fields right now. Take anything, anywhere at any PGY level.
 
BigSandwichGuy said:
I was terminated from residency 2 days ago and am struggling to figure out my next steps. The issues were mainly knowledge based; program leadership did give me credit for effort but I was already on probation and did not meet milestones.

Is there any path back into medicine? And are there any other jobs I can do with a DO degree? My PD is willing to be a reference for non clinical jobs, but I didn’t ask about alternative healthcare fields (eg PA school).
Click to expand...
Teaching
 
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@NontradICUdoc

I agree that IM would likely be not feasible by now. With regards to the TYR path, how would I go about it practically. I was thinking best thing to do would be work a regular job (whatever min wage one I can find) for a year and attempt the 3 Steps again (Step 1 would be a retake).

What else would I need? I assume a tailored personal statement, but would I also need new LoR? And how would I go about getting it?
 
BigSandwichGuy said:
@NontradICUdoc

I agree that IM would likely be not feasible by now. With regards to the TYR path, how would I go about it practically. I was thinking best thing to do would be work a regular job (whatever min wage one I can find) for a year and attempt the 3 Steps again (Step 1 would be a retake).

What else would I need? I assume a tailored personal statement, but would I also need new LoR? And how would I go about getting it?
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Have you passed COMLEX level 3?
 
For COMLEX L3, a letter from your PD documenting good professional standing is required. Hence I think the OP is going to need to wait until they get restarted in a program to take it. This is a big difference between COMLEX L3 and USMLE S3.

I am not convinced that a TY year is a good or reasonable idea. They tend to be more competitive than IM or GS prelims as they are often seen as less work although I expect that's program dependent. It's also not clear to me that it gets you any closer to completing a residency -- after a TY what comes next? Will an IM or FM program be willing to take you as a PGY-2? Maybe -- but maybe not.

I am also not a fan of trying to retake the steps. I don't think they will make you a more competitive candidate.

I still think your best option is to reapply for residency spots now, as is. You'll need some sort of gap year since spots may not open until next July, but it's unlikely that the type of job you could get will make a difference. Research is unlikely to help, and it would be impossible to get anything done in time for this year's cycle.

Applying for an OM or PM PGY-2 may be a good option. Although your PD said they will support you for non-clinical jobs, they may be very happy to say you completed enough of a PGY-1 to move into PM or OM. You'd apply this year for R positions to start in July, and be free to take a spot if something happened to open earlier. This is probably the easiest / safest / most reliable way forward.

The other option is to reapply for a PGY-1 position. You could reapply for IM or FM PGY-1, hopefully be more successful by starting again with what you know now. You mentioned your PD wasn't supportive of that, so that may be an uphill battle. And, PD's may or may not be willing to take a chance on you. For sure, you'll end up at a "worse" place. If you were doing IM in the hopes of doing a fellowship, only the least competitive fields would remotely remain open.

And you could do both -- apply for PM/OM and PGY-1 positions at the same time, and see what happens. I strongly advise you not to apply for GS prelim spots -- although they are the least competitive, I really worry about your performance in that kind of environment.

Non clinical careers are an option also, but there's no clear pathway forward for that. Often mentioned are "teaching" but realistically getting a teaching spot after something like this seems unlikely. "Consulting" is also a stretch, since consulting firms look for "pedigree" - they want to brag about where their worker bees are from. There are reports here of people getting hired by insurance companies (or the state) to do insurance reviews -- and that might be an option but you'd have to hunt for it. None of this pays well.

Residency application season is coming up quickly. If you want to participate, you need to get started ASAP.
 
When I was applying (now 10 years ago wow!) it seemed like pathology was wide open and desperate to take residents that showed even a little interest in the field (ie had a pathology LOR). Psych was also wide open for PGY2 positions and upward.
 
NotAProgDirector said:
Psych has become much more competitive over the last 10 years. Path is still an option also.
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Yea but PGY2s and PGY3 (some of which will still take you if you completed a PGY1) are still available scattered throughout the states. This is assuming the OP can get credit for their PGY1 year since they completed over 12 months.
 
BigSandwichGuy said:
@NontradICUdoc

I agree that IM would likely be not feasible by now. With regards to the TYR path, how would I go about it practically. I was thinking best thing to do would be work a regular job (whatever min wage one I can find) for a year and attempt the 3 Steps again (Step 1 would be a retake).

What else would I need? I assume a tailored personal statement, but would I also need new LoR? And how would I go about getting it?
Click to expand...
1. Why would you want to take steps 1 and 2 over again. There is no point.
2. You would need new LORs. When I look at LORs, if they are not recent I don’t continue with the application. To me those are red flags. Why did you not take the time to get new letters, what are you trying to hide.
3. Would suggest finding a job in the non clinical world and then see if you can find observerships.
 
NotAProgDirector said:
I am not convinced that a TY year is a good or reasonable idea. They tend to be more competitive than IM or GS prelims as they are often seen as less work although I expect that's program dependent. It's also not clear to me that it gets you any closer to completing a residency -- after a TY what comes next? Will an IM or FM program be willing to take you as a PGY-2? Maybe -- but maybe not.
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It is really dependent on the program. My program is not an easy program. It is IM based and you are treated just like a categorical IM intern. With the exception that you get more elective time and go to a different clinic. That being said, a TYR program, if you get the right one, can boost a previous poor performance. After TYR, you can go into any categorical program that would take you. Some programs even prefer their TYRs over outside people if their applications is a bit weaker since they know the person and would rather deal with the known than the unknown. PM/OM, FM, IM are all options after a TYR year. It is a way to show that your clinical skills now are much better than before. In addition, it is a way to get more up to date LORs from new attending physicians.
 
To summarize everyone's points and confirm my understanding.

It seems like there are two options. One is apply as is with just the COMLEX on ERAS using the same letters. Hope the combination of low scores and lack of Step (plus a failure that must be disclosed if asked) don't drag my application further.

And the second would be essentially to add a gap year and do observerships and work on applying after.

It seems like there is consensus that applying to a categorical IM residency won't be successful barring the PD changing his mind. Either way, it'll need to be a different type of residency be it FM, PM/OM etc.

@NotAProgDirector

I do have a question for you in particular. You talked about how PM/OM may be more open than IM if the PD doesn't support an IM redo. Would you be able to elaborate on this? Is it that a new specialty is likelier to excuse an unsupportive PD? And you did also discuss how applying this September would be possible, would this be with the same letters?

And I was thinking that taking USMLE would be helpful for two reasons. One is to maybe do better on Step 2 and 3 than COMLEX, which I do think is doable. But also, any application for a full license will necessitate Steps 1, 2, and 3 as one cannot take COMLEX 3 outside of good standing in a program, but I still am unaware of most jobs that would hire a license only non residency completing person, and would prefer completing residency anyway
 
BigSandwichGuy said:
To summarize everyone's points and confirm my understanding.

It seems like there are two options. One is apply as is with just the COMLEX on ERAS using the same letters. Hope the combination of low scores and lack of Step (plus a failure that must be disclosed if asked) don't drag my application further.

And the second would be essentially to add a gap year and do observerships and work on applying after.

It seems like there is consensus that applying to a categorical IM residency won't be successful barring the PD changing his mind. Either way, it'll need to be a different type of residency be it FM, PM/OM etc.

@NotAProgDirector

I do have a question for you in particular. You talked about how PM/OM may be more open than IM if the PD doesn't support an IM redo. Would you be able to elaborate on this? Is it that a new specialty is likelier to excuse an unsupportive PD? And you did also discuss how applying this September would be possible, would this be with the same letters?

And I was thinking that taking USMLE would be helpful for two reasons. One is to maybe do better on Step 2 and 3 than COMLEX, which I do think is doable. But also, any application for a full license will necessitate Steps 1, 2, and 3 as one cannot take COMLEX 3 outside of good standing in a program, but I still am unaware of most jobs that would hire a license only non residency completing person, and would prefer completing residency anyway
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PM/OM is considered fairly open to taking in people that didn't fit well in other specialties. You could certainly get the ability to get comlex 3 done during that training program with good standing. I think taking USMLE steps is not productive for you at this time and can only potentially hurt you.

Do you have anyone at your program that would be willing to write you a letter of rec supporting you? You want to make sure they feel comfortable writing one to support you, because that will help you get a new place in the future. You should reach out to those people now and try to get something together, particularly if you are looking to try and match in the upcoming cycle.
 
A residency like OM/PM requires a prelim IM year. But, you don't need to show the skills that are required to get to the PGY-2 level. The skills needed in OM/PM are different, so those programs may be willing to consider applicants that did well enough to complete 12 months of IM PGY=1 but did not meet criteria to get to PGY-2.

Much of this depends upon what you mean when you state that your PD "won't support you for clinical training". If there was something in your performance that was bad enough that they think you can't be a clinician at all, that's an enormous problem. But from your posts I think they didn't promote you because you didn't do well enough to be a PGY-2 and start supervising others. As a PGY-2 in OM/PM, you would not be supervising anyone and would be "starting again" with a new set of skills.
 
I'd say that my PD's opinion has both aspects. I do not believe he thinks I am dishonest nor lazy, and he has said the opposite more than once. At the same time, he is very earnest that my career in future is outside of medicine. So, to answer both @NotAProgDirector and @ThoracicGuy questions, there is next to no chance at a letter, particularly since, outside of my own faults, our hospitalist group is quite small and very close to the PD. My PD does not think I should be a doctor, but at the same time, he does think positively of me and would not disparage my character should a program talk to him.

That's why I was thinking more on the lines of forget about this cycle, seek FM (and maybe IM plus PM/OM) observerships, and apply with those letters. If I had more docs willing to support me this cycle, I'd have attempted this cycle.

It seems like there is a consensus against STEPs but not having one clearly destroyed me when I applied (under 10% interview rate), so it's one of those things that if there's time I want to attempt if there's time and/or I end up improving quite quickly in prep for those. That and some of my interviews who asked about Step didn't seem to believe applying with Comlex only was allowed, and that definitely hurt.

But my focus isn't on Step either which way as much as it is on the question of "how can I return to residency knowing the PD won't support it."
 
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BigSandwichGuy said:
At the same time, he is very earnest that my career in future is outside of medicine
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That is, honestly, completely ridiculous. You might do just fine in another field. I would go and talk to your PD again, tell them you've tried to get advice and you might be considering a change to OM or PM. They may decide that's a completely reasonable step. Unless your problems are so profound that you truly couldn't function as a physician in any field/venue. But at that point, I can't imagine them supporting you for a non clinical career either.
 
BigSandwichGuy said:
I'd say that my PD's opinion has both aspects. I do not believe he thinks I am dishonest nor lazy, and he has said the opposite more than once. At the same time, he is very earnest that my career in future is outside of medicine. So, to answer both @NotAProgDirector and @ThoracicGuy questions, there is next to no chance at a letter, particularly since, outside of my own faults, our hospitalist group is quite small and very close to the PD. My PD does not think I should be a doctor, but at the same time, he does think positively of me and would not disparage my character should a program talk to him.

That's why I was thinking more on the lines of forget about this cycle, seek FM (and maybe IM plus PM/OM) observerships, and apply with those letters. If I had more docs willing to support me this cycle, I'd have attempted this cycle.

It seems like there is a consensus against STEPs but not having one clearly destroyed me when I applied (under 10% interview rate), so it's one of those things that if there's time I want to attempt if there's time and/or I end up improving quite quickly in prep for those. That and some of my interviews who asked about Step didn't seem to believe applying with Comlex only was allowed, and that definitely hurt.

But my focus isn't on Step either which way as much as it is on the question of "how can I return to residency knowing the PD won't support it."
Click to expand...

Seeing as you had <10% interview rate, I really do think you should strongly consider PM/OM. Did you do any rotations outside of your core attending group? If so, did you work well with any of them? They could be sources for letters as well if you had a good experience on their rotation.

The longer you wait, the worse it will be for you to return. Your goal is to get board certified in something so you have a chance at a medical career. While observerships can I guess help a little, FM or IM programs will want input from your PD and prior residency. They may even call your PD up and discuss you directly. PM/OM may do it as well, but you still have a better chance at landing a spot there. There's always the chance that you could go back for a second residency after PM/OM and you've shown you can handle things there.

As NaPD stated, you should probably look to have another conversation with your PD.
 
BigSandwichGuy said:
I'd say that my PD's opinion has both aspects. I do not believe he thinks I am dishonest nor lazy, and he has said the opposite more than once. At the same time, he is very earnest that my career in future is outside of medicine. So, to answer both @NotAProgDirector and @ThoracicGuy questions, there is next to no chance at a letter, particularly since, outside of my own faults, our hospitalist group is quite small and very close to the PD. My PD does not think I should be a doctor, but at the same time, he does think positively of me and would not disparage my character should a program talk to him.

That's why I was thinking more on the lines of forget about this cycle, seek FM (and maybe IM plus PM/OM) observerships, and apply with those letters. If I had more docs willing to support me this cycle, I'd have attempted this cycle.

It seems like there is a consensus against STEPs but not having one clearly destroyed me when I applied (under 10% interview rate), so it's one of those things that if there's time I want to attempt if there's time and/or I end up improving quite quickly in prep for those. That and some of my interviews who asked about Step didn't seem to believe applying with Comlex only was allowed, and that definitely hurt.

But my focus isn't on Step either which way as much as it is on the question of "how can I return to residency knowing the PD won't support it."
Click to expand...

I agree with the others that your PD’s statements seem odd. Has he ever specifically stated what he believes your “deficits” are? Does he think you can’t work under pressure? Does he think you have some sort of learning disability or cognitive deficit that precludes you from being an effective physician (all of which are unlikely if you have done reasonably well until now?) You say he is otherwise complementary of your work ethic and personality in general. I wonder if he is just “talking tough”, but if he would supply at least a neutral letter (or maybe even better than that) when push comes to shove.

I agree that you may be perfectly fine doing PM or OM. You may even be fine at a different FM program.

Hearing about your matching issues with applying with COMLEX only, I’m concerned that you may have applied to the wrong programs during the first match. (Or maybe there are other red flags on your app?) It’s actually fairly common for DO applicants not to take the USMLE, and there are still plenty of programs in specialties like FM who will interview DO applicants who have taken COMLEX only. So this time around, it may behoove you to try to find the right places to apply. I definitely would not try to take the USMLE steps at this point. I think that would be a big waste of time that would be better directed towards finding programs that are sympathetic to your application.

I personally recommend that you start talking to FM, OM, PM, etc programs that were historically osteopathic. These programs will have no problem with a DO applicant who has only taken the COMLEX exams, and IME they are much more forgiving when it comes to taking applicants who were not successful in a previous program. (It’s actually fairly common on the Osteopathic side to see residents who failed out of one program and continued in another. When I was a 3rd year on OB, I clearly remember an OB resident who was on her *fourth* program - she got kicked out of one, another shut down, and then she got kicked out of another, and she STILL found another program to finish her training.) You can’t try to limit yourself to a specific locale or anything - look far and wide. But there is most likely an osteopathic FM program in rural Montana or something who is willing to take a chance on you.
 
I started searching PM and OM residency positions and to me 1) there arent that many positions out there (21 OM and 40 PM) 2) they seem actually competitive to do and many of the residents in the positions have already completed a residency of some sort and usually come from good schools. Surprising.
 
So far I have vetted personal statements for all of IM, FM, and PM/OM ready to go. As @NRAI2001 said, the number of PM and OM are simply scant and many of them are at top tier schools. Im applying to pretty much anything in PM and OM that isn’t a top tier school.

Realistically, probably only thing I can change is adding LoR after the fact. Else, I’ve accepted that this cycle is itself unlikely. I’m eyeing next cycle but hoping that maybe a miracle happens this cycle.

That being said, for IM and FM, I know no LoR from a previous program is a solid disadvantage for multiple reasons . I did ask 2 other attendings on top of PD and did get no’s, which was expected as the entire attending fleet is very close to him.

So I was banking on an observership LOR plus a non-condemning statement from the PD if and when a program were to call him. My idea is maybe an IM program or at least FM program could take a chance on that.

I also do wonder if, among PDs willing to take a terminated resident to begin with, how they would view a “attempted with everything they have but didn’t make it” review, which is almost certainly what he’ll give if called. I could see them going the direction of maybe agreeing with the PD that all stops in medicine have been pulled but also maybe saying that I’ve likely learned some lessons, asking me what those lessons are during an interview, and then giving it a decent shot.
 
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