Doing a second residency??

[cabinbuilder]

Just curious. I will be finishing FP next year due to default circumstance. I still really want to do general surgery. Does anyone out there know about applying for a second residency? Do you just call up programs?😕 Any ideas about how you get paid since medicare has already paid for you to be taught? How does student loan deferment work. I suppose I could moonlight some, but I don't really want to see my kids any less than possible. 😱If anyone has some sort of ideas about this I would most appreciate the input. Snide remarks not necessary.😛 I just don't see myself ever practicing primary care. Thanks.😀

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[Leforte]

I have seen several people do two residencies.

We had one IM resident recently finish up then go into a OB residency.

There was also a FP resident, in her second residency. Her first was in Gen Surg and a fellowship in CT surgery! I asked her why she went back - she wanted to see a little of everything again. Crazy.

If you're interested call your GME office and ask them what limitation they would tell departments that are looking to match a resident who has completed a previous residency. I am sure there is some federal guideline regarding this.

Leforte

 

[cabinbuilder]

Thank you for your reply. Most helpful.

 

[Taurus]

Based on my understanding, the issue with second or more residencies is funding. When you initially match into a specialty, CMS allocates funding to the residency program for you so many years it takes to finish that specialty. For example, 3 years for FP and 5 years for surg. Once you complete your first residency, you don't get more funding from CMS. A residency program will have to eat your costs if you do a second residency with them. This will make most residency programs very leary about accepting you. You better be pretty darn good if you want to do a second residency.

 

[Winged Scapula]

Just curious. I will be finishing FP next year due to default circumstance. I still really want to do general surgery. Does anyone out there know about applying for a second residency? Do you just call up programs?😕

The process is the same - enroll in ERAS and use NRMP to apply for General Surgery programs as a Independent Applicant. You can also take a look at http://www.apds.org for job listings (although you would only be eligible for PGY-1/intern positions).

Any ideas about how you get paid since medicare has already paid for you to be taught?

CMS usually limits funding after completion of your "alloted" time based on your first residency to 50%. AProgDirector has an excellent thread somewhere here that discusses this. Any extra monies for training you must come from the program themselves, so a person doing a second residency may find some programs balking at paying for that resident. You'll need to discuss this with programs when you interview...programs will see that you've already completed one residency and its likely that if they have problems paying you, will not invite you for an interview.

How does student loan deferment work.

You would have to discuss that with your lender; you may have to go into forebearance to avoid payment on the loans.

I suppose I could moonlight some, but I don't really want to see my kids any less than possible. 😱

Probably not during a surgical residency unless you are spending time in a research lab. Many programs prohibit moonlighting and given the almost assured fact that you will be working at least 80 hrs per week, you probably won't want to moonlight if you hqave children.

 

[cabinbuilder]

Thanks for everyone's help with my questions

 

[f_w]

CMS usually limits funding after completion of your "alloted" time based on your first residency to 50%.

The 'Direct Medical Education' payment is cut to 50%. Depending on the patient structure of the hospital, this DME component is typically about 40k (20k after the 'initial residency period' runs out).

The 'Indirect Medical Education' payment is not affected by the length or number of your residencies. Depending on the patient and payor structure of the hospital, this is anywhere between 60k and 120k.

So, bottom line, your funding drops by approx 20k (or 20%) from what it could be if you where fresh out of medschool. This can be a reason for hospitals that have to rely on GME funding NOT to take you. At larger wealthier institutions where GME payments are just a small part of the mix, it makes less of a difference. Total number of funded residency slots is capped at 1997 levels for each hospital. Some places have grown their residencies nevertheless and just funded the extra slots out of patient care and endowment $$s (at one place in my training, 100 'funded' slots paid for 170 residents salaries).

There is a brochure on the AAMC website that explains some of the issues:
https://services.aamc.org/Publicati...version57.pdf&prd_id=153&prv_id=180&pdf_id=57
And here a slightly politically slanted explanation on how the feds arrive at the numbers they pay to the hospitals:
http://www.amsa.org/pdf/Medicare_GME.pdf

Knowledge is power. Some PDs have the impression that there is NO funding for a second residency. I had the info available at the time and managed to convince someone that I was worth it 😉

 

[Winged Scapula]

Thank you for the detailed explanation.

I too once thought that there was no funding for a second residency, recently learned it was 50% and now have icnreased my knowledge due to your post once again.

I am going to save this post and place it in a sticky since it is a FAQ!

 

[SurlyDoc]

The 'Direct Medical Education' payment is cut to 50%. Depending on the patient structure of the hospital, this DME component is typically about 40k (20k after the 'initial residency period' runs out).

The 'Indirect Medical Education' payment is not affected by the length or number of your residencies. Depending on the patient and payor structure of the hospital, this is anywhere between 60k and 120k.

So, bottom line, your funding drops by approx 20k (or 20%) from what it could be if you where fresh out of medschool. This can be a reason for hospitals that have to rely on GME funding NOT to take you. At larger wealthier institutions where GME payments are just a small part of the mix, it makes less of a difference. Total number of funded residency slots is capped at 1997 levels for each hospital. Some places have grown their residencies nevertheless and just funded the extra slots out of patient care and endowment $$s (at one place in my training, 100 'funded' slots paid for 170 residents salaries).

There is a brochure on the AAMC website that explains some of the issues:
https://services.aamc.org/Publicati...version57.pdf&prd_id=153&prv_id=180&pdf_id=57
And here a slightly politically slanted explanation on how the feds arrive at the numbers they pay to the hospitals:
http://www.amsa.org/pdf/Medicare_GME.pdf

Knowledge is power. Some PDs have the impression that there is NO funding for a second residency. I had the info available at the time and managed to convince someone that I was worth it 😉

Thanks for the awesome post! Do you have any idea if this is how AOA funding is as well? Or just ACGME?

 

[Stephen902]

does preliminary general surgery pgy1-2 positions count towards any totals?

 

[NotAProgDirector]

All years of training count.

 

[justinkthomas]

I a person can donate $40K a year for PGY1 and PGY2, would that increase the ability for an IMG to get a spot in radiology or pathology? I am looking for ethical ways to help my wife get a spot in Southern California. Donation to a foundation, to a program that is underfunded, etc....

 

[squareknot]

I a person can donate $40K a year for PGY1 and PGY2, would that increase the ability for an IMG to get a spot in radiology or pathology? I am looking for ethical ways to help my wife get a spot in Southern California. Donation to a foundation, to a program that is underfunded, etc....

According to what others have been speculating on these boards, it's more like 100K. It's highly likely that 40K a year is not nearly enough to fully fund a resident. Also, it wouldn't go well with the folks over at GME.

 

[Reductio]

According to what others have been speculating on these boards, it's more like 100K. It's highly likely that 40K a year is not nearly enough to fully fund a resident. Also, it wouldn't go well with the folks over at GME.

Yeah, It's 80K to train at a nearby program, and probably more at mine. I think the federal money is about 100K per resident. At one point, the other program had to come up with that money for a resident... so the number was tossed around.

It can be seen as a "conflict of interest" or something. You can't not be paid by the residency because then your motivation can be questioned, and it somehow ties into accountability and standard of care. Related to why you must bill insurance, and must bill the patient for the remainder, and collect the copay, and all that. I dont really understand it, but apparently having consistent cash flow in medicine keeps the lawyers from catching wind of anything.

 

[bluray]

Having completed a U.S. Residency, will not make you a more attractive candidate it will make you a far less attractive candidate. Having just applied to 150+ primary care programs only to get 5 interviews, not matching and with no luck in the scramble. I can attest that having completed a US residency is not looked upon favorably. This is due to the funding issue. Even thought a program may only loose 20K out of the 120K they get from the government they would much rather have their full funding and are willing to take any other applicant with funding over someone with out funding. Many program directors said they would like to have me in their residency, they just can't risk loosing the funding. One program director explained, where candidate with out funding, fit into the match, he said I should not try to scramble but wait until after the scramble was over and then apply to any remaining open positions, unfortunately after the scramble there are only a handful of of open positions are being chased by many of the 12,000 applicants who did not match.

“The 2011 Main Residency Match was the largest in NRMP history, with more than 26,000 positions and almost 38,000 applicants.” from http://www.nrmp.org/

 

[Apollyon]

All years of training count.

Yikes - 4 month bump.

I thought that positions not leading to board eligibility (such as prelim) do NOT count against the clock, as there is no set length (like 5 years for general surgery or 3 years for IM) for preliminary programs (most are 1 year, but I've seen surgery prelims up to PGY-4). The set length comes from a chart in the green book. I don't know if it is available online.

 

[gutonc]

Yikes - 4 month bump.

I thought that positions not leading to board eligibility (such as prelim) do NOT count against the clock, as there is no set length (like 5 years for general surgery or 3 years for IM) for preliminary programs (most are 1 year, but I've seen surgery prelims up to PGY-4). The set length comes from a chart in the green book. I don't know if it is available online.

All years count against the "clock" as aPD stated. But the clock doesn't get started until you start a terminal residency. So if you do 2 surgery prelim years and then manage to match in an FM program, your clock is set at 3 years, but you only have 1 more fully funded year since you've already used 2 of your 3 years as a prelim.

 

[Apollyon]

Thank you! I did not know that second wrinkle. I thought that prelim time was "free".

 

[Reductio]

Yeah, It's 80K to train at a nearby program, and probably more at mine. I think the federal money is about 100K per resident. At one point, the other program had to come up with that money for a resident... so the number was tossed around.

UPDATE - aPD answered this question in detail on another thread. If I may paraphrase:

When a resident DOESN'T have full funding due to exceeding their allotted GME years, their program will get 50% of Direct Medical Education (DME), and 100% of IME covered. DME is relatively fixed at 60K for all programs. So, programs stand to lose around 30K per year.

 

[gutonc]

Thank you! I did not know that second wrinkle. I thought that prelim time was "free".

I used to think so too...then aPD schooled my dumb a**. Just spreading the knowledge.

 

[Shoushu]

All years count against the "clock" as aPD stated. But the clock doesn't get started until you start a terminal residency. So if you do 2 surgery prelim years and then manage to match in an FM program, your clock is set at 3 years, but you only have 1 more fully funded year since you've already used 2 of your 3 years as a prelim.

So who funds the other 2 years? Doesn't the program stand to lose lots of money if they hire this guy with 2 surgery prelim years? Would many FMs want someone with 2 surg. prelim years?

If the guy matches Gen. Surg (don't know how hard with 2+ years in prelim), the clock then... not only starts but grandfathers the time, right?.... 2 prelim + 3 Gen. surg, still do 5 years, instead of 7.

 

[core0]

So who funds the other 2 years? Doesn't the program stand to lose lots of money if they hire this guy with 2 surgery prelim years? Would many FMs want someone with 2 surg. prelim years?

If the guy matches Gen. Surg (don't know how hard with 2+ years in prelim), the clock then... not only starts but grandfathers the time, right?.... 2 prelim + 3 Gen. surg, still do 5 years, instead of 7.

There are two payments to the program. Direct Graduate Medical Education (DME) and Indirect Medical Education (IME) payments. DME is for the costs of educating the resident and IME is for the indirect cost of educating the resident (attending inefficiencies, PD pay, support staff etc).

For DME you get 1.0 FTE during the years of your residency and 0.5 FTE after the residency. The clock is set once you begin the categorical portion of your residency. So if you did a year of surgery then went into family practice you would have your "clock" set at three years once you started FP. Since you had already used one year the program would receive 1.0 DME for two years and 0.5 DME for one year. IME is fixed and would be paid in full for the whole four years.

In your example above, someone who did a two surgery prelims might not enter as a PGY-3. If they did two sequential internships (or the program did not give them credit for the full two years) then they would have four years of surgery left and the last year would be funded at 0.5 DME.

I will leave it to APD to say exactly how much DME and IME are worth. The issue with DME is its based on the Medicare payments to the hospital. So if the hospital had a large Medicare population the payment is more and the relative hit of the 0.5 DME is more. My understanding for many programs the payments are similar so during the 0.5 DME years the program is getting around 75% of the money. If the program has relatively less Medicare payments the program might get more like 90% of the money. A program with a lot of Medicare might get around 60% of the money. That and the hospitals overall health will play a factor on whether they are willing to take a resident that isn't fully funded.

Also remember that all fellowships are funded at 0.5 DME. From an institutional standpoint there has to be some incentive to do this.

 

[DrJosephKim]

I know a few residents who switched into different specialties after their first year. Good luck and please be sure to let us all know how it goes for you so that others can learn from your experience. This is a common question and we don't see too many people return to share how they did it.

 

[NotAProgDirector]

I will leave it to APD to say exactly how much DME and IME are worth. The issue with DME is its based on the Medicare payments to the hospital. So if the hospital had a large Medicare population the payment is more and the relative hit of the 0.5 DME is more. My understanding for many programs the payments are similar so during the 0.5 DME years the program is getting around 75% of the money. If the program has relatively less Medicare payments the program might get more like 90% of the money. A program with a lot of Medicare might get around 60% of the money. That and the hospitals overall health will play a factor on whether they are willing to take a resident that isn't fully funded.

Also remember that all fellowships are funded at 0.5 DME. From an institutional standpoint there has to be some incentive to do this.

This is all correct, except that it's the IME that is correlated with the percentage of medicare patients receiving care. The IME is almost always the bigger of the two payments, and varies widely among programs for complex reasons. Programs get 50% of the DME and 100% of the IME for residents beyond their initial periods. Since the IME is bigger, this results in >75% funding.