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3 years of prelim surgery---what can i do?

Discussion in 'Surgery and Surgical Subspecialties' started by Doctorino, May 7, 2008.

  1. Doctorino

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    Hi, i am nearing the end of my second year of prelim surgery. My program schedule is that the prelims do the same schedule as the categoricals, so I am technically finishing PGY2 like the categoricals. My residency has offered to let me do 1 more prelim year if I don't get a categorical spot, meaning if I do it I'll have finished PGY3 same as the categorical PGY3. If for whatever reason I am still unable to get a categorical spot, is there anyway for me to work as a physician or surgeon in any capacity with PGY3 general surgery training?
     
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  3. You'll be able to moonlight or do some locum tenens, if that's what you're asking. You'll have to get your full state medical license, DEA number and then apply for jobs that don't require you to be Board-eligible.

    Other threads in both this forum and General Residency may help (the ones talking about jobs available for those who chose not to finish residency).
     
  4. Miami_med

    Miami_med Moving Far Away
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    You may theoretically qualify to enter an SCC fellowship, and some of those technically go unfilled. You wouldn't be able to go to the OR, but you could probably get a job.
     
  5. Doctorino

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    any idea what type of moonlighting or locum jobs are there for those who have done PGY3 surgery? actual surgeon jobs where you can do standard operations for that level of training (hernias, appys, gallbladders, etc) or more like non-operative jobs like covering smaller ERs/working in urgent care office type of stuff?
     
  6. Doctorino

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    you mean do a SCC fellowship without finishing general surgery residency and then being able to work as a SCC attending (without being able to go to the OR), or you just meant having a job as SCC fellow for a year or two?
     
  7. jubb

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    I think you still have to finish an accredited surgery residency to be able to work as Surgical Critical Care doc despite completing the fellowship. You can't do it in 4 years like that. If you do a critical care fellowship though you may be able to find a spot at another program to finish your last 2 to 3 years of general surgery.
     
  8. Winged Scapula

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    You will not be able to get privileges as a surgeon without being Board Eligible, which means finishing a surgical residency.

    Any job you can get doing surgery is essentially moonlighting as a surgical resident; no one will give you unsupervised privileges for doing cases, even "level appropriate" ones without being BE - its a lawsuit waiting to happen. All it takes is one person to know you didn't finish residency to squeal (in the very unlikely situation that you would even get hired) and just open your checkbook (because you will not likely have malpractice insurance to cover you doing cases unsupervised either).

    Doing an SCC fellowship is not a bad idea; you won't be able to get a job as a surgeon with it, but It may increase your competitiveness while trying to get a categorical position while allowing you to keep your skills (somewhat) and knowledge base. There are Burns fellowships and others as well - look at apds.org for lists of what type of things are available with 3 years of training.

    Unfortunately, the options are limited...getting a job without being BE is pretty much impossible and it may be that getting one without being BC is next.

    PP with a group that supervises you, doing locum resident work, etc. is about the limit.
     
  9. Doctorino

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    Hey thanks. you guys say operating as primary surgeon for even basic cases would be out of the picture because of medico-legal matters, so what what kind of moonlighting jobs are available for someone with PGY3 level of general surgery training?
     
  10. Pilot Doc

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    I think you're being a bit pessimistic.

    You could certainly get a job first assisting somewhere. Would probably pay about what a PA makes.

    You could go into general practice somewhere that is short on docs and probably get privileges for very minor procedures, perhaps c-sections if they really need them.

    You could definitely get critical care work with 3 yrs surgery + a CC fellowship. (I managed to get privileges and malpractice coverage at 5 different hospitals in a major metro area to be a CC attending after 2 years of GS)

    WS makes good points that you will always have malpractice and credentialling issues hanging over your head. Being BC in anything would make your life vastly easier ... but you're employable now and can work as an attending with a little effort.

    And don't forget ER work.
     
  11. Pilot Doc

    Pilot Doc SDN Angel
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    I bet if you hunt hard enough you could find someplace that would let you do basic operations.

    Other moonlighting opportunities
    Anything you can find a PA or NP doing
    ER
    doc in the box/urgent care
    prison doc
    "house doctor"/hospitalist
     
  12. Winged Scapula

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    But he asked about working as a surgeon not as a first assistant, hence my answer.

    Perhaps, and you are right that he could probably get privileges for minor procedures, but hernias, gallbladders? Would be tough - he isn't trained as an FP, isn't trained as a surgeon, but I suppose there might be some places really short on help that might consider it.

    Thanks for your input. Very valuable.
     
  13. Raidergate

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    How much actual operating have you done as a prelim? Would you be able to meet any of the minimums for the various procedures you'd be applying for priviledges to perform?

    I thought the first rule of being a doctor, especially a surgeon, is to first do no harm. After really only two years spent in the OR, with probably fewer cases overall, being that you're a prelim, I'd be really hesistant to even try to perform unsupervised procedures any more complex than stuff like lines, chest tubes, i&d'ing pus, open appys and the like.

    I'd try like hell to try to find a way to finish my training, rather than go the route you've mentioned. You owe it to yourself, your pocketbook, and your future patients.

    Just my humble, less than 2 weeks from being minted an md, opinion, though. :D

    Good luck in the future.
     
  14. Pilot Doc

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    There's precedent for both hernias (shouldice) and GB's (some FP programs) being done by non-surgeons. But I agree, it would be a very out of the way locale that would allow that.

    Someone else had PM'd me for details on my CCM work. I (and many others at my institution) moonlit in the lab as CCM attendings at various hospitals around our area after 2 years of GS, which included a lot of ICU time. These were all places that had 24 hr ICU physician coverage, generally all CCM boarded, and needed people to fill out nights & weekends. They were mixed med/surg ICU's and I was responsible for managing 10-20 beds, writing all notes, performing all procedures and typically providing coverage for urgent/emergent issues on the floor.
     
  15. In general, you'd be looking at the same moonlighting jobs available to ANYONE with at least two years of training (plus an unrestricted license and DEA number): LTACs, nursing homes, small hospitals, urgent care centers, ERs, and the like.
     
  16. Doctorino

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    apparently to be eligible for a SCC fellowship after 3 years of general surgery residency you need to be a categorical resident who will be going back to finishing your general surgery residency after the SCC fellowship. in other words they don't take people with 3 prelim years.
     
  17. Miami_med

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    Are you 100% sure about that. I'd actually be pretty surprised. They are often desperate to fill these fellowships. Also, I really don't think that there is any national requirement that you have to go back and finish your residency. I'd verify wherever you got your advice. Of course, I'm not quite at that level of training myself, so I could be wrong.
     
  18. XoQo

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    Docterino is right -- but there is a difference between getting a surgical critical care position and actually being eligible to sit for the surgical critical care certifying exam. I don't think you are eligible to receive the surgical critical care certificate from ABS until you complete certification in surgery.

    The following is taken from this URL. The bolds have been added by me for emphasis and are not in the original:

    http://home.absurgery.org/default.jsp?certsccce

    General Requirements

    Applicants must:
    • Be currently certified in surgery by the American Board of Surgery.The ABS will also accept current diplomates of other ABMS surgical boards, providing their primary certifying board supports their application for SCC certification.
    • Have a currently registered full and unrestricted license to practice medicine in the United States or Canada.
    • Have satisfactorily completed a program in surgical critical care or anesthesiology critical care accredited by the Accreditation Council for Graduate Medical Education (ACGME).
    • Be actively and primarily engaged in the practice of surgical critical care as indicated by holding full surgical privileges in this discipline in approved hospitals.
    • Submit for the ABS' review a detailed report regarding 50 patients cared for during the fellowship, including all deaths (up to 25 cases). Cases must be from the applicant's fellowship and verified by the program director.
    • Adhere to the ABS policy on Ethics
    and Professionalism.

    Examination While in Residency

    Applicants who complete an ACGME-accredited surgical critical care or anesthesiology critical care fellowship after completion of three years of surgery residency may apply for SCC certification and take the examination while still in residency. A full and unrestricted medical license is not required at time of application. The SCC certificate is not awarded, however, until certification in surgery is achieved. When entering the SCC program, applicants must have a guaranteed categorical residency position in an accredited surgery program available to them upon completion.
     
  19. kirurg

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    I worked with a Family Med fellow whose husband is a chief surgical resident at an Ivy League program. He was an IMG, finished surgical training in his home country, did a prelim year in the US, didn't match, did a SCC fellowship (at a well-respected institution), and then got a spot in his current program through the connections he made during fellowship. This was about 5 years ago, so not sure if the rules have changed. It worked out great for him though, so may be worth looking into further...
     
  20. Pilot Doc

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    I bet you could find someplace to take you. Bigwigs on a committee write the rules - people in need of warm bodies do the hiring. It might not "count" but that doesn't matter as you wouldn't be board eligible anyway.

    That said, as mentioned above, finishing a residency, any residency, is the best thing for your long term job prospects.
     
  21. mallika123

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    i was somehow under the impression that it was easier to convert to a categorical after 2nd yr of prelim...atleast that was what i heard at a lot of the prelim interviews from Prog Directors & faculty..so if one could get thru 2nd yr of prelim i thought it was much easier as more people drop out then?
    cuz apparently some stats say that the conversion rate to categorical is around 60% if you've done 2nd year.- as opposed to the normal 9-10% chance after 1st year..is that true?
    i was kind of banking on it-i ranked my prelims in that order! the one's that assured me 2 yrs before the one's where prelim was only a year..
     
  22. njbmd

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    You need to move into a categorical slot in another program if your program cannot accommodate you. Your chances of doing this depend on your program director's willingness to make some calls and fully support your move to another program.

    If you want to practice surgery, you have to be BE (finish a surgical residency with minimum five clinical years). Yes, you might be able to get into a critical care fellowship but most of those fellowships will require that you have a PGY-4 year at a program before they accept you. The other thing that might happen is you will run out of eligibility for postgraduate medical training funding if you keep doing preliminary years (seven is max).

    Go to the APDS website (do a Google search) and start applying for categorical positions at the PGY-3 and PGY-4 level right now with the assistance of your current program director. Be sure that you weed out the malignant programs as some of them will routinely have openings. You should also make sure that your ABSITE grades and evals are top notch since you are going to have to sell yourself at a later time than most people.

    Your program director (and chairman) should become your best advocates at this point making sure that prospective programs know that they just couldn't accommodate you (not that you are a poor resident). They should also want you to be able to practice surgery since you have been in their program for the past two years.

    Finally, if you are not able to get something categorical in surgery in the next year, it's time to move into another specialty that you can obtain BE/BC in. Again, you are facing end of eligibility for postgraduate funding because of the number of preliminary years that you have completed.

    There is no automatic or easy "conversion" to categorical from preliminary surgical slots. This a risk that anyone in a prelim slot will be taking when they accept a prelim slot. After one year of prelim, you have to make sure that you either have a categorical slot in your program or you re-enter the match (or outside the match) apply for a categorical slot elsewhere. Your competitiveness for a categorical slot is going to rely heavily on your evaluations and in-service exam scores so make sure that these are top level.

    While a fair majority of people who are decidedly interested in surgery who are in prelim slots can often get into categorical positions, these categorical slots become very rare after PGY-2 level. (I actually know of few programs that allow a prelim three years.) Most people who have been able to thrive for two years in surgery,will tend to finish the residency. After three years, it's almost unheard of to leave a residency position unless you just aren't interested.

    To the OP: get busy right now and find something categorical at the PGY-3 level that starts in July. Sometimes you can get lucky but don't spend a third year in a prelim slot unless your PD knows for sure that they are going to pick you up for categorical next year or you just can't find anything categorical out there.
     
  23. DOCTORSAIB

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    Why can't the OP's freakin PD give him one of the categorical spots?

    I mean the poor dude busted his butt for 2 years already.

    And if I made him repeat yet a 3rd prelim year I'd at least GAURANTEE him a categorical spot (PGY-whatever). Sheesh..:mad:
     
  24. Doctorino

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    thanks for the advice everyone. someone mentioned if i don't get categorical surgery then i should switch to a specialty where i can become BC/BE. the thing is the specialties that comonly take prelim surgery residents are fm, im, psych. but i've been checking out some of the jobs people have been saying you can do with 2 years of surgery residency and they pay decent, at or even above what say a fm doctor makes. so is there really a good reason for me to go back to PGY1 in another specialty after doing PGY3 years of surgery residency when i can make as much (or more) as those BC/BE in that specialty?
     
  25. TaiShan

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    I think we should eliminate these PGY2/3 prelim surg positions totally. I know some IMGs would sign up for anything and programs do need warm bodies, but it doesn't make it right.

    To OP, the things you can do are pretty much urgent care/FM stuff. You would better just get into FM and have much more option after a formal residency training.
     
  26. Winged Scapula

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    We are entering an era of more regulation and requirements. One in which, it is possible to envision those who are not BE/BC, being not allowed to practice. There are already places that will not hire you without being BE, next step is to require BC. Seems to me that you are safer from am employment stand-point to be BE/BC in *something*.
     
  27. Doctorino

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    Hey everyone, when all was said and done I took them up on their offer to do a 3rd prelim year. As I mentioned in my first post my schedule each year has mirrored the categorical residents even though I'm a prelim, so this year my schedule is the same as the categorical PGY3's.

    Anyways this will be my last prelim year at this program as they've let me know up front. So unless something short of a miracle happens and they decide to sign me up as a categorical or I find a categorical spot somewhere esle, I got to find something to do with 3 years of GS residency.

    I've been pondering what you guys have been saying and came across something else too. Apparently there are some general thoracic surgery fellowships (lungs only, no hearts) that are open to non-BC/BE surgeons. But these fellowships aren't accredited.

    So if after this PGY3 I do one of these non-accredited general thoracic fellowships is there any chance I can work as a general thoracic surgeon?
     
  28. Pilot Doc

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    I'm guessing you will get a lot of responses along the lines of "Hell no! Are you crazy?" And I suspect they're right.

    That said, if you work as a general thoracic surgeon after rolling your own 4 year, non-BE training program, than you ought to be just as capable of being a plain old general surgeon after 3 years.

    Just for sport - here's my plan for how to do surgery without finishing a residency. (And for our gentle readers, some surgery residencies were 3 years not that long ago - there are probably surgeons trained that way still in practice.)

    1) finish 3 years. Make a concerted effort to gain competence in B&B GS procedures - scopes, appies, choles, breast
    2) find a rural location that is underserved. Apprentice yourself to a GS and spend some time first assisting. Ingratiate yourself to the local population and hospital. Preferably do this in a very favorable malpractice climate
    3) Try to gradually gain the ability to work independently

    Another good option would be to simply work as a first assistant only. I bet you could do that easily in a number of locations. There are plenty of docs with no surgical training at all who do that.
     
  29. SocialistMD

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    You could try for this. If you get it, you'll have only wasted a year.
     
  30. gonogo

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    I think the DIRECT pathway is very competitive. Not to say that the OP won't have a chance, but I can imagine those programs sponsoring the DIRECT pathway as tough to get, or tougher, than GS.
     
  31. BlondeDocteur

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    with the attrition rates in gen surg being what they are, what are the chances of there being an open PGY-2/PGY-3 spot somewhere in the country this year? If I were you, Doctorino, I'd be on the Find-a-Resident type sites like white on rice.
     
  32. Doctorino

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    Is there a limit in the total number of prelim years allowed in general surgery?

    As I mentioned I'm in my 3rd and final prelim year at my current program but if I don't get categorical somewhere next year can I keep doing prelim surgery at another program?
     
  33. Winged Scapula

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    The American Board of Surgery is now prohibiting people from training at more than 3 programs, so if you spent each year at a different program then no, you cannot move on to another one.

    In addition, they have also discouraged allowing residents to be Prelims more than 2 years. You must spend your final two years at the same program as a categorical.

    I think you will find it exceedingly unlikely to get a 4th Prelim year as programs are not willing to train someone they can't graduate as being Board Eligible.

    From ABS:

    Prior residency training in ACGME-accredited surgical residencies as a preliminary (non-categorical) resident at the PGY-1 or PGY-2 level will be credited on a year-for-year basis if satisfactory completion of each year is documented in writing by the responsible program director. Such credit will be awarded only if completed within a five-year period preceding the request for credit. Training at the PGY-3 level will only be accepted if accomplished as a categorical resident in an accredited program.
     

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