EM applicant who SOAPd IM, Looking for best way forward

[nitemann]

Hi all,

Hoping to get your thoughts on the best way to move into EM.

US MD
Applied EM this cycle (41 apps, 8 interviews, 1 waitlist) - narrow geography trying to stay close to wife's work, thus some programs were reaches
SOAPd into Categorical IM position at a program with a EM residency
Step 1 245, Step 2CK 246, Step 2CS Pass. Honored Surgery rotation 3rd year. 4 research experiences (1 EM related), no publications/presentations. 1 year work experience CNA before medical school.
Home institution SLOE was bottom 1/3, 2nd SLOE was top 1/3.

I met a ton of people during interviews who put out 100+ applications. My thought was that if I doubled my applications, with more apps toward programs better fit for my application stats, I would have received the handful of extra interviews necessary for a successful match.

Would it be best to
- Reapply the next cycle with 100+ applications -> (Problems: not guaranteed a 3rd SLOE in short time-frame, IM PD may generate mediocre letter)
- Wait a year to increase experience/research, definite 3rd SLOE, and potentially get a better letter from IM PD -> (Problems: Funding, could potentially double board)
- Complete IM residency -> (Problems: Funding, completed residency)

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[towelonthefloor]

The reason you didnt match is likely due to the SLOE.
Is it possible to rotate in the ED for a new SLOE at your program?
Does your new program know you have intentions of switching?
Ideally you need a new SLOE and a PD letter. The PD letter HAS to be positive as you arent the typical applicant and anything subpar will hurt your chances of matching.
And if you really have plans of switching, you need to be upfront about it with the program especially if this is a categorical spot. You dont want to burn any bridges.

You mentioned geographic restraints as well. The reality of a reapplicant is that its an uphill battle and that you should be open to moving anywhere in the country. Though your best chance is at your home program.
I was an reapplicant as well, and from my experience I would apply to as many programs as possible honestly. As a reapplicant, you dont know whats going to happen and there is no way to gauge if programs even look at reapplicants or not. Plus not matching a second time is exponentially worse than losing a few hundred bucks

 

[deuist]

First, why do you want to go into emergency medicine? Is internal medicine really all that bad? You could do a fellowship in critical care and see a lot of the same high acuity patients that we get in the emergency department. Intensivists also get to perform procedures such as intubations and central lines.

You mentioned that you are geographically isolated because of your wife's employer. Lots of us make sacrifices on specialty or location choice because of family obligations. There's nothing wrong in taking a well-paying job that you don't absolutely hate if that means that you can keep your family happy and secure.

Is there a combined IM/EM program at your institution? If so, could you eventually switch into such a role?

If you are dead set on going into emergency medicine, there are a couple of strategies:

Reapply this year. You will need to rotate through the emergency department and get another SLOE. You also need a letter of recommendation from your program director. I hope that you were honest when you scrambled in that your goal is emergency medicine and that you might not stick around after one year. If you spring a surprise on your program director after only a month on the job, you might not get the positive rec letter that you were seeking.

Apply after residency. You will most likely get a more positive letter of recommendation from your program director. Yes, Medicare funding will be an issue, but some of the private hospitals won't care and will just as likely pay for a top resident out of their own pocket. You will also have a backup plan by default should you fail to match the second time.

Some things you need to do to get a stronger application:

Publish a paper. You can hammer out a case report, clinical image, or novel letter to the editor in a matter of weeks. Some emergency medicine programs like to see that you are thinking about scholarly activities.

Find a mentor in the emergency department. During your first week on call, head down to the ED and start talking to attendings to gauge their interest in mentoring an off-service resident. Most of them will likely be unapproachable as they are busy with other tasks, but you might find one or two who are willing to work with you from time to time. You will also need to get a formal rotation in the department so that you can work on getting a SLOE.

Be upfront and honest with your new program director. If you are planning on leaving at the end of your internship, he/she will need to find a way to fill that PGY-2 slot.

 

[nitemann]

The reason you didnt match is likely due to the SLOE.
Is it possible to rotate in the ED for a new SLOE at your program?
Does your new program know you have intentions of switching?
Ideally you need a new SLOE and a PD letter. The PD letter HAS to be positive as you arent the typical applicant and anything subpar will hurt your chances of matching.
And if you really have plans of switching, you need to be upfront about it with the program especially if this is a categorical spot. You dont want to burn any bridges.

Unfortunately my medical school decided on the quarantine route, so I don't think I would be able to rotate before graduation.
My new PD does not yet know I have intentions of switching. If I decide the best plan is to reapply right away I would be in contact before starting.
In reapplication I would apply to the majority of programs, after going through SOAP/after SOAP my wife knows what it means to me

 

[towelonthefloor]

Unfortunately my medical school decided on the quarantine route, so I don't think I would be able to rotate before graduation.
My new PD does not yet know I have intentions of switching. If I decide the best plan is to reapply right away I would be in contact before starting.
In reapplication I would apply to the majority of programs, after going through SOAP/after SOAP my wife knows what it means to me

Sorry I should have specified, I meant to rotate in their ED as a resident once you start. Your new SLOE would be your performance as a resident.
The schedules should be made before starting, just make sure to request rotating in the ED early so you can get a new SLOE.
ED is a mandatory rotation for IM programs, but I think it varies when you are allowed to rotate in terms of timing

 

[nitemann]

First, why do you want to go into emergency medicine? Is internal medicine really all that bad? You could do a fellowship in critical care and see a lot of the same high acuity patients that we get in the emergency department. Intensivists also get to perform procedures such as intubations and central lines.

You mentioned that you are geographically isolated because of your wife's employer. Lots of us make sacrifices on specialty or location choice because of family obligations. There's nothing wrong in taking a well-paying job that you don't absolutely hate if that means that you can keep your family happy and secure.

Is there a combined IM/EM program at your institution? If so, could you eventually switch into such a role?

If you are dead set on going into emergency medicine, there are a couple of strategies:

Reapply this year. You will need to rotate through the emergency department and get another SLOE. You also need a letter of recommendation from your program director. I hope that you were honest when you scrambled in that your goal is emergency medicine and that you might not stick around after one year. If you spring a surprise on your program director after only a month on the job, you might not get the positive rec letter that you were seeking.

Apply after residency. You will most likely get a more positive letter of recommendation from your program director. Yes, Medicare funding will be an issue, but some of the private hospitals won't care and will just as likely pay for a top resident out of their own pocket. You will also have a backup plan by default should you fail to match the second time.

Some things you need to do to get a stronger application:

Publish a paper. You can hammer out a case report, clinical image, or novel letter to the editor in a matter of weeks. Some emergency medicine programs like to see that you are thinking about scholarly activities.

Find a mentor in the emergency department. During your first week on call, head down to the ED and start talking to attendings to gauge their interest in mentoring an off-service resident. Most of them will likely be unapproachable as they are busy with other tasks, but you might find one or two who are willing to work with you from time to time. You will also need to get a formal rotation in the department so that you can work on getting a SLOE.

Be upfront and honest with your new program director. If you are planning on leaving at the end of your internship, he/she will need to find a way to feel that PGY-2 slot.

In EM I love that you see aspects of outpatient, inpatient, and critical care. I fear I would get bored/burned out if constantly only exposed to one of those groups. I like that there's a pediatric aspect. And I like, as others have said, that even if a case is not challenging there is still a problem that needs to be solved. Lastly I like that there at least appears to be more control of your life than as a subspecialist.
My wife got to witness the impact of SOAP on me, so she is now on board with moving if necessary.
There is not a combined EM/IM program at my institution.

I think getting a good letter from my PD right off the bat would be challenging. The SOAP interview started off with "So now that your moving on from EM where do you see yourself going...". To which I replied that I had an interest in doing a CC fellow after EM so I thought that this path could also serve that purpose. This statement is true, but half of it was speaking from the perspective of needing to have a job to support my family. I fear that springing my EM thoughts on the PD too early could land me without a job.

Thank you for the tips on enhancing my application. I have written an abstract on some of my research that I hope to present at some point. Do you think new EM mentors would be the best place to get ideas for case reports/images?

Does anyone know that stats on IM boarded physicians matching into EM? I know there is independent applicant data on NRMP, but it does not break down into individual stats.

 

[deuist]

Do you think new EM mentors would be the best place to get ideas for case reports/images?

Does anyone know that stats on IM boarded physicians matching into EM? I know there is independent applicant data on NRMP, but it does not break down into individual stats.

You can publish in any field, not just EM.

Those stats likely don't exist as it's such a small number.

 

[erdoc111]

You may like IM more than you think. EM is really a high burnout field. Of course, I was told this in residency, but there is nothing like being 45 to help you understand how significant burnout is! (And I am a lot older than 45 now!!) There are so many great specialties in IM...
EM has been ok for me. I did a fantastic residency and enjoyed working in the ER when I was younger. If I had to do it again, knowing what I know now, I would pick something different. Read the EM forum and see the recurring topics and issues. These issues are not an exaggeration.

Sorry your match didn't work out. I am glad that you got a categorical spot and I hope this all works out for you better than you anticipate!!

 

[Splenda88]

Self disclosure: I am an IM resident...

I think you should give IM a chance... There are couple residents who SOAPed into my program after failing to match into EM. They did not reapply to EM after rotating in the ED. One of them told me SOAPing into IM was 'a blessing in disguise'.

 

[TulaneUnderdog]

Disclosure: I didn’t SOAP. I applied for both EM and IM programs with my EM programs ranking being in top but ended up not making it to my top specialty and being matched to IM.

IM truly might be a blessing in disguise. I don’t know why you want to go into a field that now; thanks to a blend of COVID-19, midlevel encroachment, and shady HCA tactics; revealed that it cannot sustain its own physician workforce unless it has enough NPs/PAs to piggyback on to cushion the salary.

That said, if ER still is where your heart lies, several of my upper levels have gone off to EDs after showing they did enough elective rotations in ED other than our single core (but none of them were good, high paying). The residents also moonlighted on clinic months to the sticks in low acuity EDs with ER docs willing to vouch for them. I guess IM is versatile enough and big Corps realize if NPs/PAs can do ED, then anyone else can. You’ll still never make it to any top ED that way and will likely be in a community setting but that’s the fair price honestly we should pay anyway for being trained outside the specialty. But I recommend you reconsider, do Pulm/Crit if you like ED for its procedural and high acuity as well as shift based work for less shifts/mo.

 

[bravotwozero]

Self disclosure: I am an IM resident...

I think you should give IM a chance... There are couple residents who SOAPed into my program after failing to match into EM. They did not reapply to EM after rotating in the ED. One of them told me SOAPing into IM was 'a blessing in disguise'.

Not to mention the endless possibilities with fellowships that actually do improve your bottom line and lifestyle.

 

[Rekt]

Congratulations, you've been saved. The only worse choice of picking a specialty over EM would be rad/onc.


Do IM and do a fellowship so you can actually get a job after. Especially with geographic restrictions.

 

[Splenda88]

Congratulations, you've been saved. The only worse choice of picking a specialty over EM would be rad/onc.


Do IM and do a fellowship so you can actually get a job after. Especially with geographic restrictions.

and pathology...

 

[emergentmd]

and pathology...

And anesthesiology
And OB/GYN
And Hospitalists
And Pedi
And FM
And Psych
And Gen Surg

 

[Splenda88]

And anesthesiology
And OB/GYN
And Hospitalists
And Pedi
And FM
And Psych
And Gen Surg

I don't know that EM is better than psych though.

 

[Franzd'Epinay]

Hi all,

Hoping to get your thoughts on the best way to move into EM.

US MD
Applied EM this cycle (41 apps, 8 interviews, 1 waitlist) - narrow geography trying to stay close to wife's work, thus some programs were reaches
SOAPd into Categorical IM position at a program with a EM residency
Step 1 245, Step 2CK 246, Step 2CS Pass. Honored Surgery rotation 3rd year. 4 research experiences (1 EM related), no publications/presentations. 1 year work experience CNA before medical school.
Home institution SLOE was bottom 1/3, 2nd SLOE was top 1/3.

I met a ton of people during interviews who put out 100+ applications. My thought was that if I doubled my applications, with more apps toward programs better fit for my application stats, I would have received the handful of extra interviews necessary for a successful match.

Would it be best to
- Reapply the next cycle with 100+ applications -> (Problems: not guaranteed a 3rd SLOE in short time-frame, IM PD may generate mediocre letter)
- Wait a year to increase experience/research, definite 3rd SLOE, and potentially get a better letter from IM PD -> (Problems: Funding, could potentially double board)
- Complete IM residency -> (Problems: Funding, completed residency)

I don't know how risk-averse you are, but if I had gone through the SOAP to match into a categorical program, I would just finish IM, then consider re-applying afterwards.

My fear would be not matching again, losing my categorical spot, then being blackballed from returning to IM.

Regarding funding for your specific situation: once you start your PGY-4 year, medicare will pay the hospital 50% of what they normally would. How much of a deal-breaker this is depends on how reliant the program is on Medicare funds.

 

[Apollyon]

Regarding funding for your specific situation: once you start your PGY-4 year, medicare will pay the hospital 50% of what they normally would. How much of a deal-breaker this is depends on how reliant the program is on Medicare funds.

Wrong. It's about 80%, between DME and IME. Not 50%. These are the things that med students read, and think are gospel (50% payment).

 

[Franzd'Epinay]

Wrong. It's about 80%, between DME and IME. Not 50%. These are the things that med students read, and think are gospel (50% payment).

Well, the 50% for the DGME portion is spelled out in the law, which makes it a pretty quotable figure: Social Security Act §1886:

(C) Weighting factors for certain residents.—Subject to subparagraph (D), such rules shall provide, in calculating the number of full-time-equivalent residents in an approved residency program—
(i) before July 1, 1986, for each resident the weighting factor is 1.00,
(ii) on or after July 1, 1986, for a resident who is in the resident’s initial residency period (as defined in paragraph (5)(F)), the weighting factor is 1.00,
(iii) on or after July 1, 1986, and before July 1, 1987, for a resident who is not in the resident’s initial residency period (as defined in paragraph (5)(F)), the weighting factor is .75, and
(iv) on or after July 1, 1987, for a resident who is not in the resident’s initial residency period (as defined in paragraph (5)(F)), the weighting factor is .50.

Regarding the IME portion: The way this is calculated is murkier to me, but it was my understanding that the IME was just a bonus percentage added to medicare claims, and that wouldn't change much by the addition of one resident.

You seem pretty confident, so it's likely my last assumption is wrong (i.e. the bonus will increase significantly with one extra resident). Feel free to enlighten us on the actual math. I'm open to learning more about it.

 

[Apollyon]

Well, the 50% for the DGME portion is spelled out in the law, which makes it a pretty quotable figure: Social Security Act §1886:



Regarding the IME portion: The way this is calculated is murkier to me, but it was my understanding that the IME was just a bonus percentage added to medicare claims, and that wouldn't change much by the addition of one resident.

You seem pretty confident, so it's likely my last assumption is wrong (i.e. the bonus will increase significantly with one extra resident). Feel free to enlighten us on the actual math. I'm open to learning more about it.

It's been hashed and rehashed nearly innumerable times. I'll call for an expert here @NotAProgDirector . He has the best word on this.

 

[NotAProgDirector]

IME is hard to predict, because it depends on many factors including the percentage of medicare patients seen, the resident to bed ratio, and baseline costs in 1997. But, in general, it's larger than the DME payment. So usually residents beyond their IRP can be billed for at least 75% and usually 80+% of the full amount allowed. The exact figure will vary by hospital, hence hard to nail down.

Just so we're clear, the OP was from last year and hasn't logged in since starting internship. Nothing we say her is going to help them now.

 

[theWUbear]

The world is your oyster
You can end up in an academic center educating as well as seeing patients
You can end up a bad ass intensivist
You could stay take a job where you do hospitalist weeks and critical care weeks
You can end up in a subspecialty of IM you don't know you're going to love yet
You can end up doing CC/pulm and doing outpatient pulm
You can end up the medical director for you group and dabbling in administration
You can go Full Admin and end up a regional medical director, or a CMO

 

[monkeymedic]

Wrong. It's about 80%, between DME and IME. Not 50%. These are the things that med students read, and think are gospel (50% payment).

I did this calculation for a few EM programs when I was looking around. DME is 50%. IME varies by institution, but was usually between 70-80%. There was one place it was close to 85%