Advice Needed (from both AOA +ACGME trained psychiatrists)

[Dr Shlimazel]

Hello everyone,

Longtime poster here but decided to change my moniker for identification prevention measures.

Stats:
--U.S. citizen
--preclin grades: mostly C's
--preclin red flags: remediated anatomy in MS1 via a single comprehensive test. Our school had a practice board exam at the end of second year that we were required to take: it was listed as a "course" on our transcript, even though it was not a course but instead an 8-hour in-house practice board exam that they administered to students immediately at the end of the year before most students had even started their intensive board studying. I scored below a 70% (mind you, this was before our dedicated board study time), so it shows this "course" as having failed on my transcript. I retook the practice test some weeks later, so my transcript shows this "course" as remediated.
--Board Scores: COMLEX 1 (exactly national average), COMLEX 2 CE (two points less than COMLEX 1, national average), COMLEX 2 PE passed on second attempt
--class rank: bottom quartile preclinical, second quartile upon graduation
--Reputation of medical school: standard osteopathic school
--Research: one publication before med school in a reputable chemistry journal, one year of a pilot translational epidemiologic research project in my MS3 established at our hospital by Tulane (no publications), one month of pathology research elective in MS4 (resulted in abstract acceptance to USCAP)
--clinical grades: mostly A's
--Honors in clerkships: for one pathology rotation in MS3 and one derm elective in MS4
--# and where you did away rotations: two, including one at a top academic center
--# of programs you applied to: 55
--Where invited for interviews (both offers and the ones you actually attended): 18
--graduation date summer 2016


This is my overview. I had entered medical school wanting to go into pathology. I made sure I had an MS3 elective in path, worked my butt off, got an awesome LoR, and sat down and generated an awesome personal statement.

Because all the AOA pathology programs shut down, I applied broadly to ACGME programs in the NE. I had interviews at several big names in NYC, NJ, and even Ivy League programs. I received feedback such as "Any place would be lucky to have you!" blah blah blah. Everything was going great.

Little did I know what would happen. Earlier in my MS3 year, I ran into some financial hardship and had to use my fin aid funds to take care of it, thus causing me to postpone registration for the COMLEX 2 PE (equivalent to USMLE CS). The earliest date I could register for that test was winter of my 4th year. I took the PE in the middle of interview season and it had been months since I had done a family medicine rotation.

I found out in January of my 4th year that I did not pass the PE, hence my application would not be complete in time for my programs to rank me. I was clearly extremely depressed, $8K in the hole, and no spouse/parental support to turn to after graduation (i.e. I needed to find a job that wasn't a transitional year/TRI,mainly because I was planning on being a PATHOLOGIST! I'm no good in the ICU!).

Ended up at a prestigious university doing a 2-year postdoc in neuro research (one publication currently under review) and also setting up a clinical trial for the PI.

Having worked in the lab (again) alone these past 8 months, I've had an epiphany that I don't want to do path anymore. I'm tired of looking at inanimate objects, the job market for path has become even worse and worse the past several years, and the way pathology is taught in a large academic center vs. community hospital is totally different--I would not be happy in the latter at all (there you're not a "physician," you're a glorified lab tech who NEVER wears a white coat, never participates in patient education/morbidity + mortality conferences/ city OBGYN free clinics/ performs blood transfusions for the IM team on the wards/ performs fine needle aspirations for ENT), it wouldn't be the version of pathology I'm drawn to.

The only other thing I liked in med school was psychiatry, and I actually liked it alot. I would be happy doing that. Psychiatry is pretty much psychiatry wherever you go (i.e. it's not dependent on the state-of-the-art equipment like pathology is). The majority of psychiatry residencies are in community settings (unlike pathology, which is almost exclusively at large academic centers), so I may be more competitive for that considering my couple red flags.

The problem I face now is that the psych attendings with whom I rotated in med school are no longer at that hospital and I cannot contact them for LoRs! I have NO LoRs from a psychiatrist I tried doing a psych observership, but due to my job, I was unable to get more than a couple days away and had to chalk that up as a simple educational experience vs. a letter-obtaining experience.

My plan was:
apply to AOA psychiatry programs as a first choice (because of my red flags), apply to low-tier/rural ACGME psychiatry programs simultaneously as a second choice, apply to low-tier ACGME pathology programs as a third choice.

My question/problem is:
How can I apply to ACGME psychiatry programs without a psychiatrist's LoR (I have old/current letters from pathologist's, IM, FM, and PM&R ONLY to play with)? For any of you who have trained at AOA programs, would lack of psychiatrist LoR pose a problem too?? If I had a clinical psychologist LoR instead of one from a psychiatrist, would this suffice or not really?



Thank you for your suggestions.

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[OldPsychDoc]

Here's what will hurt you for psych: a 2PE fail, the lack of objective evidence of psychiatric interest (coupled with all of your professional experience screaming "pathology!", and no LOR commenting on your aptitude for psychiatry.

You can't make up for the first any more than you already have, and there are still plenty of programs that will look past that if the CEs and clinical grades are ok.
You could do something voluntary to build on the second--maybe meet a community psychiatrist or two who would write something nice that you could submit as a psych letter. At very least it would serve as a psych-oriented line on your CV, and provide fodder for your psych-centered personal statement. Don't be passive about this--your psych attendings are MIA? Find new ones. Meet a psychiatrist in at least one program that you'd consider residency (even those "couple days away" can leave a decent impression of you as an interested person) and ask them to write something for you.
Finally--do you know how good those other letters are? Because if they praise your ability to relate to patients in IM, PMR, and FM and comment favorably on your clinical skills then that's the most important part. You can explain the lack of psych letter briefly in your PS, point them to psych comments in your Dean's letter, and hope someone is listening. You've got to find the specific and unique strengths of your application and emphasize them, so that the red flags ("remediated preclinical fails...eh...no big deal--he passed his boards and got As in clinical rotations--and hey, great personal statement.")

 

[Dr Shlimazel]

Thank you, Dr. OldPsychDoc.

The "silver lining" about the PE failure is that what I failed was actually the osteopathic manipulation part--it wasn't the patient interview, exam, or (God forbid) the humanism! So I'll make sure to mention that if it comes up during the interviews.

My other letters of rec are all very good (I didn't waive my right to see them), and they do hit on all those points you mentioned. When I had my pathology residency interviews a year ago, multiple programs made comments to me such as "Dr. X went on and on about your clinical acumen and beside manner, and he/she even sounded sad you were going into path!". So I guess that's good.

I tried reaching out to the community psych docs in my city, but none of them were interested in entertaining my presence in evening observerships/externships. As I said, I was able to get a couple days in (1.5 each) with two high-powered academic Pdocs affiliated w/ my current University I'm employed with, but I was told that most individuals observering with them, historically, have been IMG's whose relatives float them enough money so they don't need to work and can enjoy the luxury of spending 30-60 days straight on their observership. They both were very busy, both during rounding (a challenge to get any specific questions in/show off my knowledge) and after (as soon as we were done rounding, they had to leave to go to clinic). I don't have any ego and am not ashamed to beg and look desperate, but I just felt really stupid at the end of those days to even ask for any kind of written eval (and I had intended on asking for one before I started the micro observership). But I WAS very interested, and I actually DID end up learning a few things.

When you suggest meeting a community Pdoc "who would write something nice that you could submit as a psych letter", do you mean just cold call someone? Say, "Hey do you have half an hour to visit with me, and hear my curious and desperate story, and give your official yay/nay if you think I would make a good psychiatrist?"