Whats next? Shot down by Medicare funding issues and 2nd residency

Well I was told by the PD of a program that basically since I've completed previous residency (FP) that basically I've used a good part of the Medicare funding that comes to the hospital to fund any position that I would apply for in doing a 2nd residency.

Basically he told me it would be an unfunded position with me and due to politics he couldn't see it happening. I said basically I'd have to win the lottery and be unfunded most of the residency right? He laughed and said Yea. He said that he, himself could not get a residency if he wanted to either because that Medicare money has been used.

I'm not sure what options, if any, I have at this point. Recently the hospital I've been interested in doing GenSurg or ENT training at was in jeopardy and was just stabilized so that the residency programs would continue and now this. I hope its not the end of a dream.

I would like to hear advice or your thoughts of this experienced group as I respect your input. I apologize if this topic has been rehashed before.

L2C

I have known of a hand full of people to do second residencies. One did general surgery after internal medicine, but they all had some sort of connection that got them there. They were also at large institutions where the funding wasn't as big of an issue.

Work as an IM attending for three years or so and save some cash, pay for the GS residency yourself. You can always IM moonlight during the second residency.

FYI: Most surgical residencies do not allow moonlighting except during lab years.

At any rate, the PD you spoke to is only partly right. Funding for residencies from CMS (Medicare) comes in two forms: DME and IME.

After the "clock" runs out, you get funded @ 50% rather than 100% for DME...IME is still funded the same. Your hospital would get 1/2 rather than the total amount of your salary + benefits, in addition to the IME.

Many programs already supplement salaries over the CMS amount; all fellowships are paid for this way as the "clock" has run out.

So what it boils down to is that you have to find a program that is willing to take you, with the reduction AND has the funds to pay you. I am pretty doubtful that a program would be willing to accept a resident who won't take a salary or who actually pays for the "privilege" of being a resident. It is too ripe for abuse (eg, we've had this conversation frequently when someone desparate for a Derm or other competitive position offers to take out loans and pay for the position).

People do second residencies all the time. It is untrue that you cannot get a second residency simply based on CMS funding. I personally know several people doing second residencies: a surgeon who went back and did Rads with an IR fellowship, an internist who went back and did Urology, a surgeon who went back and did Anesthesia, a surgeon who did Psychiatry (after being injured) and so on. Clearly people are finding programs willing to give them a shot.

Winged Scapula said:

FYI: Most surgical residencies do not allow moonlighting except during lab years.

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Maybe a better chance at moonlighting after GS-PGY-3... hence, living off one's savings earned after a few years as an IM attending.

Winged Scapula said:

So what it boils down to is that you have to find a program that is willing to take you, with the reduction AND has the funds to pay you. I am pretty doubtful that a program would be willing to accept a resident who won't take a salary or who actually pays for the "privilege" of being a resident.

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My comments above concerning supplimenting the costs include working within the program guidelines (ie. taking the PGY salary); but, there are multiple ways to finance a second residency, especially as a licenced doctor.

hi L2C ....can I ask you a question?? why do you want to do this second residency in general surgery???

Actually, unfunded spots are relatively common. They are often given to IMGs from Gulf oil states; their countries have a vested interest in paying very large sums of money to have rigorously trained surgeons come back and serve the country. Many US hospitals have formal relationships with specific sovereign oil funds.

And the people they train are often terrific. It's a sort of win-win: the US hospital can keep its # of categorical residents with their US Medicare funding, and get an extra body working for free who brings in twice that much. The foreign country gets a US-trained doc who is fully versed in the latest treatment modalities and is well suited for a medical leadership position back home.

Now, Love2Cut, I highly doubt you're dripping with Kuwaiti oil money, and I have no idea how you'd set up a similar arrangement, but it can indeed be done.

BlondeDocteur said:

Actually, unfunded spots are relatively common. They are often given to IMGs from Gulf oil states; their countries have a vested interest in paying very large sums of money to have rigorously trained surgeons come back and serve the country. It's a sort of win-win: the US hospital can keep its # of categorical residents with their US Medicare funding, and get an extra body working for free who brings in twice that much...

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I am no expert on these arrangements. WS may have more knowledge. But, I think you are somewhat incorrect in some aspects.
One matter I encountered was "IMGs from Gulf oil states" often apply with a statement at the end of their application stating their native nation will fully fund. I was told by such IMGs that the programs accepted them because their home nation pays the MedCtr/University double and then cuts a check to the IMG at the standard PGY level. Some academic attendings had stated this as well. They stated there are some in the community that find the arrangement distasteful because it creates an unfair competition with US grads funded at half the rate of the "IMGs from Gulf oil states".


As for the win/win. A program can NOT graduate more then approved by ACGME/RRC. Each program has a set number of ACGME/RRC approved categoruical spots. It doesn't matter to the RRC/ACGME who funds those spots. In fact, it is quite common for programs to be approved for more spots then are Fed funded. So, if the program is approved to graduate 5 categoricals, it can have only five. Those five could be composed of 4 fed funded and 1 foreign funded. But, it can NOT be 5 fed funded and 1 foreign funded. The program will get in trouble with the RRC if it has more grads then approved (there are certain exceptions).

J.

Here you go:

http://www.acgme.org/acWebsite/navP.../IIIABCD_ResidentAppointments_Explanation.pdf

http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf

JackaDeli-- I think the arrangement you described was pretty much identical to what I was saying.

And 'graduation' for them is often a nebulous concept. They work alongside categoricals and finish with equal numbers of cases, but they were sort of ghosting the entire time. Often times the program prints up a certificate stating they completed all the training-- but they don't formally graduate. This is perfectly acceptable in their home countries and gets them the job they need, while not taking up a categorical spot. Thus, win-win.

The above post about IME and DME is correct. However, IME pays quite a bit. So the lost of DME according to one PD is about $10,000 per year. The hospital gets more in IME than your resident's salary. That PD told me that the funding excuse is simply an excuse much of the time.

Just a little background. I have wanted a career in surgery every since I observed a partial parotidectomy on a patient with a Warthin's tumor. I was in my 1st year of medical school at the time and every since then it just "clicked". I believe that it is in my blood.

I obtained an allopathic residency (I am a D.O.) in family medicine and became board certified upon my completion of that training. This was to pay back 4 years of an IHS (Indian Health Service) scholarship that I received during medical school to pay for my educational costs. I completed my 4 year obligation last July and was looking into starting surgical training.

Even when I was an intern/resident in FP I made it clear that I planned to one day be a surgeon. Since then I have seen a friend of mine, one of our attendings, a resident classmate, and two other residents that came after me start a surgery residency, a surgery residency, OB/GYN, surgery residency, and ophthalmology residency respectively. So I know that this is possible to do.

It has now become quite obvious to me that there are untold number of unfunded positions in probably every specialty and fellowship. It appears that a PD can probably make it happen if they are so inclined. I think probably the PD I talked to has given me the "stonewall" treatment. This may or may not be for good reason as the hospital was near actually closing if funding could not be found as recent as one month ago. So, why hire a resident if only partial funding will be received for him/her?

I appreciate that comments from you WS and the other posters. I definately understand this process more than I did before. I'll just keep punching and maybe something will come through sometime.

L2C