Getting an attending job/fellowship in a larger city after a rural IM residency?

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calivianya

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Hi all! I know it’s really early for me to be thinking about this, but I’d like advice now so I don’t struggle with it for the next year and a half.

I got sent out to the boondocks for my third year DO school rotations (town of 15,000 people, largest town for 50+ miles). I feel like they worked us decently hard during my first IM rotation (teaching) and I saw some interesting pathology sent in from outside facilities - interesting and unusual enough that I’m getting two case reports out of my first rotation. I have a ton of previous clinical work experience so I’m not just pulling the working hard/interesting pathology out of thin air.

What I was most impressed with, though, was the way an intern who was literally messing up with every single patient was handled. The attending was visibly irritated during rounds, but never raised his voice and it was overall the most respectful complete reaming I’ve ever seen. I’ve worked in 8+ hospitals where I’ve seen blatant screaming, cursing, and throwing things for the types of mistakes the intern was making, so I couldn’t have been more surprised watching a pissed off attending stay so calm. It makes me want to stay here.

I’m just worried about how it would look when I do start hunting for future jobs/fellowships if I do end up matching here. They don’t have a fellowship in the specialty I’m thinking about, the town is tiny, and I know I don’t want to stay long term... but I’m not going to find this kind of compassion for mistakes everywhere and I’m really tired of getting yelled at. Feel like I’m too old to put up with that attitude crap anymore. This residency program also takes mostly DOs and IMGs with the very rare occasional US MD - the only ones I’ve seen are locals who grew up within 50 miles of the hospital.

If I kill the ABIM boards and do research the whole time I’m there, is matching a fellowship and/or getting an attending job in a large city realistic, or will people take one look at where I did residency and say nah, we’ll pass? I want pulm/crit at this point.

Current stats for reference: top 25% of class, 245-250 step 1, 730-740 level 1, 5+ research experiences (2 pubs), lots of volunteering. I think I’ve checked all the boxes.

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Hi all! I know it’s really early for me to be thinking about this, but I’d like advice now so I don’t struggle with it for the next year and a half.

I got sent out to the boondocks for my third year DO school rotations (town of 15,000 people, largest town for 50+ miles). I feel like they worked us decently hard during my first IM rotation (teaching) and I saw some interesting pathology sent in from outside facilities - interesting and unusual enough that I’m getting two case reports out of my first rotation. I have a ton of previous clinical work experience so I’m not just pulling the working hard/interesting pathology out of thin air.

What I was most impressed with, though, was the way an intern who was literally messing up with every single patient was handled. The attending was visibly irritated during rounds, but never raised his voice and it was overall the most respectful complete reaming I’ve ever seen. I’ve worked in 8+ hospitals where I’ve seen blatant screaming, cursing, and throwing things for the types of mistakes the intern was making, so I couldn’t have been more surprised watching a pissed off attending stay so calm. It makes me want to stay here.

I’m just worried about how it would look when I do start hunting for future jobs/fellowships if I do end up matching here. They don’t have a fellowship in the specialty I’m thinking about, the town is tiny, and I know I don’t want to stay long term... but I’m not going to find this kind of compassion for mistakes everywhere and I’m really tired of getting yelled at. Feel like I’m too old to put up with that attitude crap anymore. This residency program also takes mostly DOs and IMGs with the very rare occasional US MD - the only ones I’ve seen are locals who grew up within 50 miles of the hospital.

If I kill the ABIM boards and do research the whole time I’m there, is matching a fellowship and/or getting an attending job in a large city realistic, or will people take one look at where I did residency and say nah, we’ll pass? I want pulm/crit at this point.

Current stats for reference: top 25% of class, 245-250 step 1, 730-740 level 1, 5+ research experiences (2 pubs), lots of volunteering. I think I’ve checked all the boxes.
You are just at the beginning of clinicals... you will see other places with good staff... you do yourself a disservice if you are looking go to do a competitive fellowship like pulm/cc...
If you were to do hospitalist or pcp work, then you will m/l get a good education and be a competent physician.
 
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Don’t worry, there are just as nice and composed people at every place. Just like there are asshats in every place. This is IM... there’s tons of extremely weird personality disorders in medicine. They tend to love academics for the most part, so Ive seen.
 
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Thanks all. Maybe I’ve just worked unusually malignant places in the past, but it’s good to hear that good work environments are more common than I’ve seen.
 
If you are interested in a fellowship, I would recommend trying to get into a residency program that has that fellowship. Even if you don't want to stay at that program for fellowship, most of the fellowship directors of a given subspecialty know each other, especially if in a given geographic area. A LOR from a fellowship director that they know generally goes farther than the same LOR from someone they don't know.
 
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Hi all! I know it’s really early for me to be thinking about this, but I’d like advice now so I don’t struggle with it for the next year and a half.

I got sent out to the boondocks for my third year DO school rotations (town of 15,000 people, largest town for 50+ miles). I feel like they worked us decently hard during my first IM rotation (teaching) and I saw some interesting pathology sent in from outside facilities - interesting and unusual enough that I’m getting two case reports out of my first rotation. I have a ton of previous clinical work experience so I’m not just pulling the working hard/interesting pathology out of thin air.

What I was most impressed with, though, was the way an intern who was literally messing up with every single patient was handled. The attending was visibly irritated during rounds, but never raised his voice and it was overall the most respectful complete reaming I’ve ever seen. I’ve worked in 8+ hospitals where I’ve seen blatant screaming, cursing, and throwing things for the types of mistakes the intern was making, so I couldn’t have been more surprised watching a pissed off attending stay so calm. It makes me want to stay here.

I’m just worried about how it would look when I do start hunting for future jobs/fellowships if I do end up matching here. They don’t have a fellowship in the specialty I’m thinking about, the town is tiny, and I know I don’t want to stay long term... but I’m not going to find this kind of compassion for mistakes everywhere and I’m really tired of getting yelled at. Feel like I’m too old to put up with that attitude crap anymore. This residency program also takes mostly DOs and IMGs with the very rare occasional US MD - the only ones I’ve seen are locals who grew up within 50 miles of the hospital.

If I kill the ABIM boards and do research the whole time I’m there, is matching a fellowship and/or getting an attending job in a large city realistic, or will people take one look at where I did residency and say nah, we’ll pass? I want pulm/crit at this point.

Current stats for reference: top 25% of class, 245-250 step 1, 730-740 level 1, 5+ research experiences (2 pubs), lots of volunteering. I think I’ve checked all the boxes.

You're still early in the process, but for right now here's what I would say.

1) That training experience you describe sounds highly desirable as everyone wants to train at a program that's as supportive as what you witnessed. That said, keep in mind it was an n=1 example and not necessarily a trend. Additionally, rural programs have to work with the residents they have so what you saw may not be a product of character, but necessity.

2) If you seek fellowship training, your best bet is to go to an academic referral center. It's true that rural programs may offer more hands-on training and a close knit community, but fellowships like to recruit people from academic centers. That's how the game works. That said, if your heart is really set on a rural program, matching from a rural program is probably common occurrence, or atleast a more common one than SDN makes it out to be. It's still likely to be a small handicap you don't need to put yourself in though.

3) ABIM scores are treated as P/F and are an absolute non-factor in fellowship match or job placement. The biggest factors are your citizenship/visa status, residency program, research, letters, etc.

4) Pulm-crit is not super competitive to simply match so don't split hairs when looking at academic programs or even some community programs. That said, if you're looking to be the guy interviewed by CNN during the next pandemic, you're probably going want to go to a place with the best pedigree to keep your options open :p

Best of luck!
 
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