Failed Step 1, want EM/IM, now what???

[Ohboy123]

Here's my story:

U.S. 3rd year
Failed Step 1 due to death in family (grandmother, who lived with us for many years).
Took it again, only got 207
Go to your avg state school - passed all basic sciences but no honors.
Lots of work in student run clinic - leadership etc.
Before med school, EMT

Significant research at a top 15 EM institution:
2 EM papers published (1 of which presented at natl conference)
1 IM paper published
1 EM project currently working on

I cannot imagine doing ANYthing but EM/IM (combined program).
Geographic location doesn't matter in regards to program. I am really lost and scared now. How screwed am I? What should I do now till graduation to maximize (if any) chances of matching?

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[hackinmage]

destroy the step II make sure you take it so you can get your score by october latest, get straight honors in core clinicals (do as close to these ideals as you can). To do IM/EM you have to impress faculties of both sides, i highly suggest doing a IM sub-i and a EM sub-i at a place with a EM/IM program that you like.

Don't focus on research as much anymore, you have enough to prove to them that your a badass, spend your time making sure you destroy that step II.

on a side note, what is it about doing IM and EM that drives you? I'm curious why it has to be both rather than one or the other, is there a specific field you wish to go into?

I'm not going to lie to you, it's gonna be difficult, but make it happen (most programs don't care about basic science grades, its all about core rotation grades)

 

[dotcb]

setting yourself up for only being happy with one outcome (EM/IM) without the stats to land it, might be a recipe for unhappiness. consider doing one field or the other. I interviewed at about 5 of these programs and ultimately chose EM - I think you might just not be able to do it with those stats. Open yourself to other options instead of being set on one rare thing.

 

[Ohboy123]

destroy the step II make sure you take it so you can get your score by october latest, get straight honors in core clinicals (do as close to these ideals as you can). To do IM/EM you have to impress faculties of both sides, i highly suggest doing a IM sub-i and a EM sub-i at a place with a EM/IM program that you like.

Don't focus on research as much anymore, you have enough to prove to them that your a badass, spend your time making sure you destroy that step II.

on a side note, what is it about doing IM and EM that drives you? I'm curious why it has to be both rather than one or the other, is there a specific field you wish to go into?

I'm not going to lie to you, it's gonna be difficult, but make it happen (most programs don't care about basic science grades, its all about core rotation grades)

Thanks dude. Your advice is truly appreciated. I'm going to work as hard as I can!

For me, EM/IM works because it addresses the limitations of each field. I like working in fast paced environments, but I also want to have the opportunity to build rapport with my patients. I like doing some procedures but also building crazy long differentials too. EM puts me on the front lines of caring for the undeserved, while IM let's me manage complex patients with more than just 1 (main) problem.

You're right. If EM/IM doesn't pan out, then I would certainly do either of them alone - but I would have to flip a coin to really say which I prefer more.

 

[Ohboy123]

setting yourself up for only being happy with one outcome (EM/IM) without the stats to land it, might be a recipe for unhappiness. consider doing one field or the other. I interviewed at about 5 of these programs and ultimately chose EM - I think you might just not be able to do it with those stats. Open yourself to other options instead of being set on one rare thing.

Understood, but is EM/IM more competitive than just EM or IM?

There is no matching outcomes data so that's part of why I initially posted. I feel like it only appeals to a smaller group of people to begin with. If you have any idea of #'s, let me know!

What made you switch to just straight EM?

 

[Arcan57]

Thanks dude. Your advice is truly appreciated. I'm going to work as hard as I can!

For me, EM/IM works because it addresses the limitations of each field. I like working in fast paced environments, but I also want to have the opportunity to build rapport with my patients. I like doing some procedures but also building crazy long differentials too. EM puts me on the front lines of caring for the undeserved, while IM let's me manage complex patients with more than just 1 (main) problem.

You're right. If EM/IM doesn't pan out, then I would certainly do either of them alone - but I would have to flip a coin to really say which I prefer more.

Pick one specialty and focus your efforts on that. I'd suggest doing IM and then a pulm/CC fellowship then working in an inner-city teaching hospital as an attending. That would meet your requirements as stated in the second paragraph.

Or I guess you could also approach it from a "do an EM residency then a CC fellowship", but that path is likely more difficult.

 

[BADMD]

Understood, but is EM/IM more competitive than just EM or IM?

EM/IM is going to be different. The idea isn't to produce someone who is board eligible in both specialties. The goal is to produce a physician who is beyond both. The extra two years are spent doing more than learning IM. Those years are spent honing research skills and becoming an academic. That being said, at least a few of the programs I am aware of would rather let the EM/IM slot be unfilled, than to give it to someone who doesn't fit the plan.

So, if you want to be EM/IM, you have to show that you have the academic credentials to do it. First and foremost, you need good Step scores, so you need to do fairly well on Step II. Then you can to try and score as well as possible in your clinical rotation and you really need to do well in EM and IM. Showing a research interest is good, but that needs to be second to the above. Leadership stuff is good and will strengthen your application, but will not reinforce a weak application.

 

[Venko]

Here's my story:

U.S. 3rd year
Failed Step 1 due to death in family (grandmother, who lived with us for many years).
Took it again, only got 207
Go to your avg state school - passed all basic sciences but no honors.
Lots of work in student run clinic - leadership etc.
Before med school, EMT

Significant research at a top 15 EM institution:
2 EM papers published (1 of which presented at natl conference)
1 IM paper published
1 EM project currently working on

I cannot imagine doing ANYthing but EM/IM (combined program).
Geographic location doesn't matter in regards to program. I am really lost and scared now. How screwed am I? What should I do now till graduation to maximize (if any) chances of matching?

I'm sorry for your loss of your grandmother and hope that you've found some peace with that. I can imagine the situation you are in is quite difficult and I agree with the advice that has thus far been provided.

The only additional thought I have has to do with the statement about failing step 1 because of the loss in your family. Only you will know the truth and you know your academic body of work better than I ever will, but one potential pitfall in telling an interviewer this statement is that your grades and retake of the exam are not stellar. Some interviewers may think that you should take more ownership of the failure from an academic perspective as it is not that you had been honoring everything else and then failed this one test; they may also think to themselves that you had not had a strong comeback performance either.

Needless to say, this is a small detail, but having interviewed a few people for residency, it might be best to say that "one contributing factor was..." as opposed to "I failed because..."

I do wish you the best of luck in IM, EM, or the combo...or wherever else life takes you and again, I'm really sorry that you had to experience such loss.

Best Wishes,
TL

 

[AmoryBlaine]

Be really careful about thinking that there are deficiencies in each field that are corrected by training in both. There are very few presentations in the ED that benefit from the construction of a longer differential. At some point you need to accept the specialty for what it is and plan on doing that.

The ED is not the place where people with weird problems get figured out by House-style docs. An EM doc needs to keep cool under fire, be an expert in resus and procedures, and know how to prioritize. You do not owe it to your future patients to have an IM level of knowledge.

I say this because your scores are going to make matching in one of the few EM/IM programs very difficult, possibly not possible. As others have said you should feel free to apply to all of them but figure out which one you like better an also apply to both of them. If you want to do EM/IM to make you a "better" EM doc then apply to EM alone and just read a lot.

 

[History of EM]

The antidote to a low step 1 score is a stellar step 2 score.

But I also think you should just pick one or the other. EM >> IM

 

[OncoticPressure]

According to the 2010 NRMP Program Director's survey, 16% will not consider you with a failed first attempt at Step 1 and 74% will seldom consider you.

http://www.nrmp.org/data/programresultsbyspecialty2010v3.pdf

Take this into consideration, work on doing better on Step 2 and apply broadly.

 

[Ohboy123]

Thanks everyone, this means a lot. The last couple of months have been a downward spiral. It's frustrating to see everything I have worked for get washed away so quickly. As someone above mentioned, ultimately this was/is my responsibility and is up to only me to salvage.

Game plan:
Rearranged my schedule - leaving 4 wks to study for Step 2, writing it beginning of Sept. 4th year. Will be buying year long pass to UW and doing ?'s with my rotations.

For interviews, from beginning of Dec to end of Jan that's 8 weeks and I have 2 easy electives [a 2 weeker and a 3 weeker] and 3 weeks completely off. [is that enough? i'm going to apply to many many programs]

Regardless of me and my scores, it sounds like doing combo EM/IM isn't the holy grail (perhaps why there are so few programs) and has it's own controversies.

SO, I think I will apply EM 1st and IM 2nd (and do the CC later). Also, picked up in my schedule an IM specialty elective and advanced EM elective too.
As far as LORs, I have already 1 strong from EM (my PI), 1 strong from FM (from student run clinic director), 1 fairly strong from IM (advisor), 1 fairly strong from IM (my other PI).

?: Do I need to worry about also applying FM? I don't have an interest in it (like none) and would prefer EM or IM/CC, but is this something I should pursue?

 

[hackinmage]

well if you really like EM you can always do FM with a EM certification, depending on where you live community hospitals will hire you for the ED

 

[jbar]

well if you really like EM you can always do FM with a EM certification, depending on where you live community hospitals will hire you for the ED

There are other posts on this this but it seems that the basic consensus is that there will be fewer and fewer positions for non EM boarded physicians to work in community hospitals.

 

[FlameBoy]

I work the ER as a BC FM in a small rural hospital and do PRN at 1 other, my employer is begging to have me fill in at 2 other local hospitals and I have 2 other firms recruiting me for other positions. There is plenty of work for any PC docs in any hospital in a city of less than ~70,000 that I know of. They pay you less, but you have a lot of down time during the night.

 

[Groove]

My philosophy is that dual board programs rarely make sense outside the ivory white towers of academia. Realistically speaking, you can't be awesome at both, so you ultimately need to pick one and stick with it. I haven't met many naturally inclined EM physicians who are genuinely attracted to IM. I can't stand the thought of an internal medicine residency and would consider that the vilest torture one could think to inflict on me. If you're worried about having some continuity of care but want to still be able to work in the ER, then as someone already mentioned, FP with an ER fellowship would be your best shot followed by working in a lower volume/acuity community ED. That would be far easier to attain having already failed Step 1 which already is a somewhat reliable prognostic indicator that you probably won't score in the top 5% on both Step 1 and 2. There's always exceptions but let's be realistic here. I'm all for telling someone what they want to hear but I think you're just setting yourself up for disappointment. Do some soul searching and figure out what you really want to do. I hate saying it but every time I meet one of the dual track residents such as Med/Peds or EM/IM, etc.. They just always strike me as someone who ultimately couldn't make their mind up and wanted to put it off as long as possible. I have yet to meet a Med/Peds person who can give me a very practical or realistic explanation of how they intend to use both very well in their future practice. Most people can't be exceptional at more than one specialty.

 

[Apollyon]

I have yet to meet a Med/Peds person who can give me a very practical or realistic explanation of how they intend to use both very well in their future practice. Most people can't be exceptional at more than one specialty.

One guy I know from where I was a resident said he was really interested in congenital heart disease, and med/peds then a cards or peds/cards fellowship set him up for that. Others said that they liked the family medicine aspect of it, without (their words) having to "waste" time on Ob and on surgical services, and that Med/Peds was better than FM to get fellowships.

 

[gutonc]

I have yet to meet a Med/Peds person who can give me a very practical or realistic explanation of how they intend to use both very well in their future practice. Most people can't be exceptional at more than one specialty.

I have a Med/Peds colleague who is also training in both peds and adult onc with a focus on AYA (adolescent/young adult) oncology. I also know a couple of M/P folks who then did Medical Genetics fellowships. The congenital heart disease thing is an obvious choice for double boarding.

I will agree that it is rare to find double boarded folks outside of academics but not unheard of.

 

[Apollyon]

Yeah, I meant to clarify - the guy saw congenital HD in people who are now adults (who would have just been dead as kids years ago), which is why he liked it.

And I hadn't thought about the oncology aspect.

 

[Cmaj7th]

a family friend who went to medical school with my mom did a dual residency in EM/FM. he told me he wanted to have the broadest skillset possible since rural/underserved towns are his game. I think he likes the idea of being the oldschool country doc.

he picks up shifts in the ER, runs a FP practice, and does some hospitalist work sometimes. pretty badass if you ask me.