Coming off of Fellowship, Follow-up fell through

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Ronin2258

Ronin2258

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I successfully completed PGY-2 Surgery (preliminary) before going into a research fellowship with a follow-up in Anesthesiology. The follow-up fell through two months ago (intradepartmental politics,) after the Match, so there was nothing I could do to fill the slot. I have been through residentswap, findaresident, openspots, and even google searches to find a spot for next month, but to no avail. Spots have dried up it seems.

I have seen the difficulties that are being reported from the current senior medical school class on this forum about the Match becoming more and more cutthroat. I have grave concerns about being able to compete given these facts:

1. I had to take time off from school and change schools due to a medical condition that I have to make accommodations for (PM me for specifics, I don't like to advertise.)
2. I have board scores (all first time passed,) that I started in 2000, and finished in 2007. Step I and Step II were average for the time, they are now are low average.
3. I am much older than the average student/resident (late 30's.) (spent time in the military, and the medical condition is a VA service-connected disability.)
4. I am license capable.

I have also been looking for something in Acute Care clinics as a GP to tide me over/pay for the next match cycle, but most of the jobs I have seen listed require being board-eligible/board certified in something, usually a primary care specialty.

Given a choice, I would rather be in the operating room; I have tried to fall out of love with the place after falling in love with it as a scrub/anesthesia tech in the military, but everything I have ever seen in my medical school rotations and observing fellow residents in other specialties only reinforces my love of the place. The only specialty at the time that would keep me there and allow me to take care of this medical condition I have would be Anesthesiology.

I have the standard spread of loans, and no family at all (most of the ones worth talking to or gave a d*mn have been dead for years.) The schooling has been all of my own efforts to pay for. The research will only go on for the next month, and I am out of luck and funds.

Basically, I am looking for options and ideas on how to stay gainfully employed and clinical, while at the same time looking for a residency that will be condition-friendly and give me something to look forward to coming into work in the morning.
 
Depending on what specialty and position you are looking for, sounds like PGY2 or PGY3. Here is what I would recommend. Make a list of every single program and start sending them emails introducing yourself and your background. Ask for PGYxx spots if available and attach your USMLE scores and if you can get a PD letter send that as well. You were a military man so you can relate, surest way to get killed in a fight is to do nothing. Not really nothing I know you are probably doing all you can think of, but this is another suggestion. Scanning Resident swap they seem ot have 8 PGY1 spots for general surgery but Find a resident has not not sure how they gather data.

BTW I hijacked my spouse's account to post this. We are in a similar situation so you have to be proactive and do everything possible. I also PMed you.
 
Working on the locum bit as we speak. 2-years of surgery is making things a bit difficult. My hope is that I can get a locum spot or two around areas where there are residencies around that interest me to shadow in my off hours.
 
Ronin2258 said:
Working on the locum bit as we speak. 2-years of surgery is making things a bit difficult. My hope is that I can get a locum spot or two around areas where there are residencies around that interest me to shadow in my off hours.
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Should be very possible. Many residents at academic programs moonlight when taking time off to go into the research lab, and that's after only 2-3 years of residency.
 
Buzz Me said:
Should be very possible. Many residents at academic programs moonlight when taking time off to go into the research lab, and that's after only 2-3 years of residency.
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Moonlight doing what? Working in an ED? Not going to happen. Urgent care? Same deal - they need people to move the meat, and keepers (not temporary).

Unfortunately, 2 years of IM is more valuable than only 2 years of surgery. 3 years of surgery? Maybe. I know of one woman that did 4 years of GS and was working in an ED, but went back to EM residency.

The GSx moonlighters I knew when I was a resident (although mine was a very limited example - only internal moonlighting allowed) were lab residents that moonlit on trauma - doing night-call in-house for trauma (and every shift doing that bought another day in GSx clinic - I'm not kidding).
 
Got the license (sending off renewal this week.) It was a gift as it were from my PD (prelims usually didn't get a license out of this program.) The program was too small to accommodate me as a categorical.

Still waiting to hear from a few of the locums, though on the phone they seem hopeful (though that could be their PR training.)

Meet with the department chair today to go over paperwork and proofread both my latest publication and my CV/cover letter for the next cycle.
 
Ronin2258 said:
Got the license (sending off renewal this week.) It was a gift as it were from my PD (prelims usually didn't get a license out of this program.) The program was too small to accommodate me as a categorical.

Still waiting to hear from a few of the locums, though on the phone they seem hopeful (though that could be their PR training.)

Meet with the department chair today to go over paperwork and proofread both my latest publication and my CV/cover letter for the next cycle.
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good luck man, i hate hearing about stuff like this happening to people. the politics are such BS
 
License renewal paperwork is now on the way. Easier than I expected from New York, or any regulatory bureaucracy.

One of my investigators' schools granted me clinical assistant professorship in his department. I don't know how much that means for anything, but it seems like a nice thing. At least it gives me something to put on my papers for affiliation. Any thoughts on a resident level getting this?

Called my old surgery program today for a final PD letter, updated to include the end of the year stuff for an application package. I have very little to no fear on the new letter; I hate to sound egotistical, I never had a bad evaluation. That letter is on the way.

Still nothing from the locums. I am going to be writing them to see if anything is available.

Politics suck. My best and only reliable defense is to keep on top of my job and on target. Attention to detail is everything.
 
Ronin2258 said:
License renewal paperwork is now on the way. Easier than I expected from New York, or any regulatory bureaucracy.

One of my investigators' schools granted me clinical assistant professorship in his department. I don't know how much that means for anything, but it seems like a nice thing. At least it gives me something to put on my papers for affiliation. Any thoughts on a resident level getting this?

Called my old surgery program today for a final PD letter, updated to include the end of the year stuff for an application package. I have very little to no fear on the new letter; I hate to sound egotistical, I never had a bad evaluation. That letter is on the way.

Still nothing from the locums. I am going to be writing them to see if anything is available.

Politics suck. My best and only reliable defense is to keep on top of my job and on target. Attention to detail is everything.
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BEST OF LUCK!!!! there are so many stories like this and then there are people who just get by so easily. i hope it works out for you. seems like you have a lot going for you.
 
IMHO I doubt you are going to get much love from the Locums. LT's are expensive to hire, and most places that employ LT search firms to find people will insist on full training.

On the other hand, finding your own moonlighting shifts is very likely. These types of shifts -- working in a small community ER, in a Nursing home on the weekend, etc -- will not be listed with Locums companies. They want people to fill in shifts here and there, not hire someone with benefits.

Start with small ED's, Call nursing homes, and if there are residency programs in the area you can try to contact them to see what residents do to moonlight (but they may not be interested in talking to you, if they want to keep those shifts for themselves)
 
Apollyon said:
Moonlight doing what? Working in an ED? Not going to happen. Urgent care? Same deal - they need people to move the meat, and keepers (not temporary).

Unfortunately, 2 years of IM is more valuable than only 2 years of surgery. 3 years of surgery? Maybe. I know of one woman that did 4 years of GS and was working in an ED, but went back to EM residency.
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aProgDirector said:
IMHO I doubt you are going to get much love from the Locums. LT's are expensive to hire, and most places that employ LT search firms to find people will insist on full training.
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This hasn't been my experience. I've been doing locums for 2 years, working mostly in small town ERs, while also covering inpatient medicine and nursing homes, and I've had no problems. Also, a lot of people I know have done moonlighting without finishing a residency. I had a friend who worked in ERs for 2 years after his PGY-2 surgery year, then eventually came back to surgery to finish.

Depending on the program, 2 years of surgery can make you a very effective locums doc. There are still places out there that train the general surgeon to be the last man-of-all-seasons in the hospital. The small towns that I've experienced are appreciative of that, and prefer us over our IM and FP counterparts.
 
SLUser11 said:
This hasn't been my experience. I've been doing locums for 2 years, working mostly in small town ERs, while also covering inpatient medicine and nursing homes, and I've had no problems. Also, a lot of people I know have done moonlighting without finishing a residency. I had a friend who worked in ERs for 2 years after his PGY-2 surgery year, then eventually came back to surgery to finish.

Depending on the program, 2 years of surgery can make you a very effective locums doc. There are still places out there that train the general surgeon to be the last man-of-all-seasons in the hospital. The small towns that I've experienced are appreciative of that, and prefer us over our IM and FP counterparts.
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My hospital was out in the middle of nowhere, but it was remarkably busy. Second and third years ran the consult service, including ER/trauma first responders. My second year had me in cases with only an attending that made me ask, "You realize I am the PRELIM second year, don't you?" Things like fem-fem, heart harvest, carotid endardectomies, a radical neck dissection, and I came 2 minutes close to actually controlling a ruptured AAA (senior made it in in time.)

Looking back on that year, I think I got to do a bit more than my year would allow normally.

Right now, the roadblock per the locums is not being clinical for the last couple of years. The local VA's GME director is trying to line me up some outpatient clinic time to get back in the swing of things. One of the secondary goals is to get close enough residencies (hopefully Anesthesiology,) that I could network/shadow a bit. But the primary thing with locums is to keep reasonable income coming in while applying.

Another question I have to clinicians that went back for a second residency; what hoops did you have to go through to apply for that second residency? ERAS? (ugh) Other application methods? I ask this as I have a feeling I will have to go through the same or similar path to get back into a residency.
 
SLUser11 said:
This hasn't been my experience. I've been doing locums for 2 years, working mostly in small town ERs, while also covering inpatient medicine and nursing homes, and I've had no problems. Also, a lot of people I know have done moonlighting without finishing a residency. I had a friend who worked in ERs for 2 years after his PGY-2 surgery year, then eventually came back to surgery to finish.

Depending on the program, 2 years of surgery can make you a very effective locums doc. There are still places out there that train the general surgeon to be the last man-of-all-seasons in the hospital. The small towns that I've experienced are appreciative of that, and prefer us over our IM and FP counterparts.
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I am happy to be wrong. Thanks for the feedback.
 
Update: Well, the VA GME director was more than happy to get me into a clinic to get back into the swing of things enough to do locums, and thought my plan was a good idea. The groups I was talking to were more than willing to take me on if I did have documentation I have been clinical for a few months. He directed me to the chair of primary care at the hospital.

The chair of primary had other ideas. Thinking I could be red flagged if I messed something up on a locums assignment, (granted, valid concern,) it would damage my chances at residency. He basically refused the request, and thought I would be better off doing administrative work or going back into research until I can apply for residency again. Of course, all those options are not available at any of the local hospitals.

I have been in the service long enough to know when someone is blowing me off, which I felt he did.

I will be talking to the GME director again as soon as the Independence Day holiday is over with to discuss other options. Both he and the anesthesiology chairman (not the PD,) are on vacation until then.

F*** me sideways. (FMS) >.<
 
Ronin2258 said:
I will be talking to the GME director again as soon as the Independence Day holiday is over with to discuss other options. Both he and the anesthesiology chairman (not the PD,) are on vacation until then.

F*** me sideways. (FMS) >.<
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How does a GME director (and, less importantly, a department chair) get the end of June and beginning of July off, when new residents are coming in, in droves? Hell, I couldn't get the first week off of my 2nd year when I was just the resident (the other side of the coin).
 
Apollyon said:
How does a GME director (and, less importantly, a department chair) get the end of June and beginning of July off, when new residents are coming in, in droves? Hell, I couldn't get the first week off of my 2nd year when I was just the resident (the other side of the coin).
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The GME director is for the VA hospital only. All the local residents start with their home hospitals first.

The chair for my department isn't scheduled to give his incoming speech until after the holiday. He is also close to retirement.
 
It's a thought.

I have a little wiggle room financially...not much, but enough time to hack things out with the appropriate people when the come back and see where to go from here.
 
Ronin2258 said:
It's a thought.

I have a little wiggle room financially...not much, but enough time to hack things out with the appropriate people when the come back and see where to go from here.
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where are you located? if you are near me i could perhaps help you out until your get your stuff together. shoot me a PM.
 
PharmaTope said:
where are you located? if you are near me i could perhaps help you out until your get your stuff together. shoot me a PM.
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Done.

I shouldn't have long to wait. Both the chairman and the GME director should be back in the office on the Monday the 5th. The chairman is helping as much as he can, and the GME director, if I can't get into clinics to reacclimate, should be able to direct me other options.
 
Couldn't you get a job as a surgical assistant type and/or hospitalist-type for a surgeon or group of surgeons? I know it might be hard to find, but I've seen people do jobs like that. Yale used to hire people to do research fellowships where they also worked in the stepdown surgical unit at night...I heard they get worked pretty hard...it's the CT surg dept. It would be a job, though. Maybe you could get hired on somewhere as a surgical assistant for a year.

One other thought - I really think you need to apply to other specialties besides anesthesia. Not that you should give up, but you need fm or IM as a backup. I know it's not what you wanted, but sometimes you have to make lemonade from the lemons, and you need some sort of backup plan. Fm residencies would for sure take you, and depending on the residency there might be a lot of options for doing procedures.
 
JerryMeister said:
"The chair of primary had other ideas. Thinking I could be red flagged if I messed something up on a locums assignment, (granted, valid concern,) it would damage my chances at residency. He basically refused the request, and thought I would be better off doing administrative work or going back into research until I can apply for residency again. Of course, all those options are not available at any of the local hospitals."

If you do this you might as well dig your own grave for any possibility of getting into another residency in the future...the longer you are away from touching/treating patients the less desirable you are to a residency program.👎
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Hence my talking to the GME director when he returns on Monday. I have left an e-mail to schedule time, and I plan to go into GME Monday to arrange it. I am dying to get back into the hospital again. I need to get back into the swing of things ASAP.
 
Just an update:

Letter from the new PD (who was my mentor while I was there,) came in. I knew that I would not get a bad letter from the program, considering while I was there, I was exchangeable with the categorical PGY-2s. CC'ed to me by the PD request, one of the quotes include;

"...demonstrated an excellent level of growth and development and a commitment to his patients was exemplary. He worked hard and developed surgical knowledge even though his primary interest remained in a career in anesthesia."

They knew at the start of second year about the medical condition. They respected the decision I made about making a career on the south side of the curtain difficult, if not irresponsible of me in regard to patient safety. I still gave them my best effort.

As for getting into the VA for clinic time; Still working on it. The GME director had clinic today, so I couldn't talk to him for long. I would like to see if there is something that I can do clinically.

The locums recruiters state I should be back in a clinical environment for at least 6 months prior to being let loose on assignment (and to be honest, I prefer it that way.)
 
Well, I am now at wits end.

The most I could do with the Primary Care is shadow, which wouldn't be enough clinical experience to grab a locum spot. >.<

I am contracted for a research tech spot, but that ends at the end of August.

I have been through a few places, but are either overqualified or underqualified for positions (surgical assistant, surgical tech, etc.)

I have picked every brain I could find, and they are hitting the same brick wall I am, with no appearance of a crack.

Non-clinical is harsh, as the only one I seem to qualify for is a lab rat, which will not keep me afloat financially due to loans and bills.

So the tasks is as follows:
  1. How to keep gainfully employed to stay ahead of bills and loans, and go through ERAS/NMRP *shudder* again.
  2. How to get back into clinical work, preferably something that takes advantage of my current skill set/training.
  3. How to get back into residency that is both condition friendly (or at least condition neutral,) as an attending (I can deal with a moderate circle of hell for residency,) preferably takes advantage of training I currently have.

I have had no disciplinary action at all. In fact, the residency program I left was able to grant me an updated PD letter that by people who have read it say is strong. I only left because it was a preliminary slot I was filling (PGY-2 Surgery, finished in good standing.) I haven't screwed up, and my license is clean. First time pass on the boards. It has been an upper level dispute between chair and PD that that botched up things to keep me from residency here (I was told 3 weeks before the Match, at a point I couldn't even apply, let alone interview/match/scramble.)

Any advice from members? :help: :bang:
 
As for an anesthesia spot, your best chance at this point is applying again via ERAS for a spot to start, sadly, in 2 years (since you don't need to do an internship again). Although the delay sucks, applying via the match will give you the most options / chances. Your application is not without it's "issues", so you'll want to apply broadly. You hope that some program interviews you, sees that you could actually start as a PGY-2, has a PGY-2 open, and offers it to you. If not, then you work on matching. As mentioned elsewhere in this thread, it's probably a good idea to apply to a less competitive specialty also to be safe -- FM or perhaps IM.

As for income now, my advice remains the same as above. Looking for a "job" is probably a mistake -- Locums aren't going to hire you because of the lack of recent clinical experience, and you haven't found any other offers out there. You should contact local ED's and nursing homes, and see if they have any moonlighting slots open. These won't be a "job" per se -- they are individual shifts and you get paid per shift. But, instead of being hired all you need is to be credentialled, and since they can dump you any time they want they usually will be less strict about how much clinical experience you might have. If you shop around enough, you might be able to find enough shifts to actually make a decent living. And, all of this would generate clinical experience which would open other doors.

It's not clear from your other posts whether you've explored this or not. You do NOT want to call the HR department. You want to speak to someone in the ED who is in charge of moonlighting schedules, and find out from them how to get credentialed and whether they would be willing to use you.

Of note, the bonus (for you) in this situation is that you have a full license. In many states (including NY), IMG's cannot get a full license until they complete 3 years of training. The fact that you have a license should help.
 
im sorry man, this sounds terrible.
 
aProgDirector, thanks for the input. I have a few people I could talk to to see if there is something in a local ER or nursing home (lab ratting for the EM dept at the school here.)

If you don't mind, I would like to PM you for a discussion.
 
You don't have to comment/reveal anything you aren't comfortable with, but have you considered surgical assist?

After your prior career and two years as a surgery resident, you should have enough experience to get hired. You can also go solo and market yourself to practices. You'd have to get credentialed which can take awhile, but if your medical condition doesn't prevent you from doing some surgical stuff, it might be worth looking into in the meantime.
 
Winged Scapula said:
You don't have to comment/reveal anything you aren't comfortable with, but have you considered surgical assist?

After your prior career and two years as a surgery resident, you should have enough experience to get hired. You can also go solo and market yourself to practices. You'd have to get credentialed which can take awhile, but if your medical condition doesn't prevent you from doing some surgical stuff, it might be worth looking into in the meantime.
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It is something I have considered, and as I have said before, I have been in love with the operating room for years. Considering that the position is usually a PA spot, I would have to find a work-around the HR department. I can see them going, "You are overqualified, you have an MD."
 
Ronin2258 said:
It is something I have considered, and as I have said before, I have been in love with the operating room for years. Considering that the position is usually a PA spot, I would have to find a work-around the HR department. I can see them going, "You are overqualified, you have an MD."
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We have several surgical assist groups here...they are staffed by CSAs, PAs and MDs/DOs. The latter are a few retired OB-Gyns, some FM types. Several of them are younger and left their practices for one reason or another. One only did 2 or 3 years of surgery residency; rumor has it that he invented something that made him rich and he quit. Then again, his surgical skills are awful...so perhaps that was good thing. Sadly both the FM and Ob tell me they make more assisting than they did in practice - they do a lot of ortho and spine which is well reimbursed.

You don't have to be hired by a hospital - I know employees of groups and individual surgical assists. One of the latter is a surgeon who decided not to go back after she had children. She fot herself credentialed and then called all of her friends and offered her service - works well for her because she can take or leave jobs as she sees fit. So there are options.

The reason why a lot of groups hire a PA is that they can assist in the OR and round on patients. You wouldn't be as useful as the former (because you couldn't round or take call) but some surgeons don't need that.
 
aProgDirector said:
As for an anesthesia spot, your best chance at this point is applying again via ERAS for a spot to start, sadly, in 2 years (since you don't need to do an internship again). Although the delay sucks, applying via the match will give you the most options / chances. Your application is not without it's "issues", so you'll want to apply broadly. You hope that some program interviews you, sees that you could actually start as a PGY-2, has a PGY-2 open, and offers it to you.
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I was a coordinator in anesthesia for five years. PD is right. If you apply outside the match, your application will probably just get tossed. It will get a preliminary scan, and then the reviewer will assume that you've got issues you're not being completely up front about. If they're kind-hearted, you might get a "thanks but no thanks" letter.

Even going through the match will be difficult. Use your personal statement to explain as much as you're willing to reveal about your medical condition and how it has affected your change in career plans. Emphasize your military experience, and the discipline and strong work ethic you learned or cemented during your years of service. Have your application complete and ready to submit the day ERAS opens. Most programs will send two or three "rounds" of invitations, and usually at least one before Nov 1 (when Dean's letters are released). If you haven't heard from programs you applied to after several weeks, try contacting the coordinator by phone (e-mail as a second choice). Usually when someone called me and seemed legitimate/sincere, I would screen their application, again if they'd already been "cut" on the first review. Then if the person seemed worthy of a second look, I'd ask the PD to review.

FYI, if I still worked at my old program and you did as advised, you'd almost certainly get a personal review of your application by my PD. I retired from the USAF about seven years ago so miltary folks automatically get extra credit. Hopefully you'll find an equally sympathetic coordinator who will take the time to listen to your story.

Good Luck!
 
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Thanks for the advice everyone. For surgical assistant, I will have to ask around to a few groups around the area.

The only reason I don't mention my condition here is because we are on somewhat public forum. I am more than willing to share it with both potential bosses and through PMs. My personal statement has it described in detail, and the fact it has had NO impact on my work since diagnosed and treated. I had it read over by the chair of anesthesiology here, who has been as much help as he can, to assure it reads well. PD here unfortunately looks at the old scores and tosses it.

And AnesCoord: Air Force 8 years myself, 1995-2003. Enlisted as the scrub tech/anesthesia tech, and got my commission as a MSC officer through school, until the condition hit. I usually miss being in at least once a day or so. 🙂

My problem with ERAS is going to be funding. The contract I have just keeps me above water for now. The fact I can't hold off the student loans doesn't help matters either >.<

Those are the main reasons for trying to find something better to do for fun and profit (mostly profit,) that also gets me back clinical.

Please forgive the light humor. It has been my sanity saver/vent.
 
Ronin2258 said:
Thanks for the advice everyone. For surgical assistant, I will have to ask around to a few groups around the area.

The only reason I don't mention my condition here is because we are on somewhat public forum. I am more than willing to share it with both potential bosses and through PMs. My personal statement has it described in detail, and the fact it has had NO impact on my work since diagnosed and treated. I had it read over by the chair of anesthesiology here, who has been as much help as he can, to assure it reads well. PD here unfortunately looks at the old scores and tosses it.

And AnesCoord: Air Force 8 years myself, 1995-2003. Enlisted as the scrub tech/anesthesia tech, and got my commission as a MSC officer through school, until the condition hit. I usually miss being in at least once a day or so. 🙂

My problem with ERAS is going to be funding. The contract I have just keeps me above water for now. The fact I can't hold off the student loans doesn't help matters either >.<

Those are the main reasons for trying to find something better to do for fun and profit (mostly profit,) that also gets me back clinical.

Please forgive the light humor. It has been my sanity saver/vent.
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you got any friends you can ask for help? family? heck, ask your church, tell them your situation (if you go to church). tell them you will gladly pay back the money and such. people are very understanding.
 
PharmaTope said:
you got any friends you can ask for help? family? heck, ask your church, tell them your situation (if you go to church). tell them you will gladly pay back the money and such. people are very understanding.
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Unfortunately, that is a no across the board. I have been pretty much on my own. Most of my family that could help have been gone for years, and those that are left were in the "quit dreaming and get a job" mindset. Really blew them out of the water graduating med school. It has been only by my own wits that I have been able to keep working towards the goal. I feel I have pulled all the strings that I have access to.

Pretty much self made here.
 
Ronin2258 said:
Unfortunately, that is a no across the board. I have been pretty much on my own. Most of my family that could help have been gone for years, and those that are left were in the "quit dreaming and get a job" mindset. Really blew them out of the water graduating med school. It has been only by my own wits that I have been able to keep working towards the goal. I feel I have pulled all the strings that I have access to.

Pretty much self made here.
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i hear ya 🙁. Really nobody you could depend on at all to help out, med school buddies, any people from residency?

It just blows my mind how people don't help each other out in this day. Although I have experienced similiar things.

I know a guy who was sleeping in call rooms and got rid of an apartment basically was in hospital 365 days of the year.
 
PharmaTope said:
i hear ya 🙁. Really nobody you could depend on at all to help out, med school buddies, any people from residency?

It just blows my mind how people don't help each other out in this day. Although I have experienced similiar things.

I know a guy who was sleeping in call rooms and got rid of an apartment basically was in hospital 365 days of the year.
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Hope it doesn't come to that. But yeah, most of the people who are able to help are helping as much as they can. Most of them are out of the local academic centers, and do very little in private practice. My resources are a Chairman of Surgery at a university program, a Chairman of Anesthesiology, my old program director/mentor, and some connection to the VA. All of them are so far removed from private practice and smaller hospitals that it is difficult to make connections.

OK, I have found FA positions, listing for PAs/RNs at some local critical access hospitals. Most of the area is surrounded by residencies, and most surgeons here are grouped out of their respective hospitals/universities (quite a number of surgical residencies in the area.) Do I go right to the heart of the matter and make an appointment with the Director of Surgery to see if I can get in, or do I risk HR and their application process? How do the FMGs/IMGs do this?

The only reason I am looking in the area (SE Michigan/Northern OH,) is due to the funding issues of moving and debt payments, in the same reason as ERAS. >.< Otherwise, I would be open to anywhere.
 
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