Halfway through residency, not EM

[thinkingthoughts]

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Back in med school, I liked EM, but didn't think I could deal with the weekend/night shifts for a career. The attendings had significant burnout and vented to me on every shift, which made things less attractive. I figured it'd probably be better for me to avoid EM.

Fast forward to now. I'm in FM and happy in my program. As part of our curriculum, we do a month of EM every year. I never thought I'd say this, but I've been loving it, sometimes more so than FM. I'm given a lot more autonomy than I did as a medical student so I have a much better understanding of the expectations in EM. Love the wide breadth like FM but I appreciate the higher acuity, opportunities for more procedures, and all the craziness going on. I still like the continuity and lifestyle of FM, but part of me thinks I would've been a better fit for a combined FM/EM program. Probably wouldn't have been competitive enough, but that's another issue.

I'm not sure where to go from here. I don't mind practicing FM, but I also have the EM itch and would love the capability to work in the ED. From what I gather, EM fellowships don't allow me to practice in any ED. And the EDs that do hire primary care physicians don't necessarily require an EM fellowship. I don't mind working rural EDs, but I know my FM training won't fully prepare me for everything that walks in. I've thought about doing a second residency, but I've heard that there may be funding issues. The EM attendings at my community hospital are happy to write glowing LORs, but I'm assuming that those won't suffice as the SLOE is the standard. What's the best way to get my foot in the door?

 

[TheComebacKid]

If you like FM, I would find a way to make FM work for you, whether it's in an ED/urgent care setting or inpatient/outpatient FM setting. Unless you absolutely hate FM, I don't see why you should do a second residency.

Full disclosure, I don't really know the hiring process in EDs for FM trained physicians. I don't know how many of them require fellowships. What I can tell you is that there are definitely opportunities, primarily in rural EDs for FM physicians. You won't be working in a level 1 trauma center environment with a constant barrage of crashing trauma patients. However, rural EDs can definitely be challenging in their own way, and every so often you will get a sick patient and you will be pushed to stabilize them in a resource poor environment, which is not easy.

I think you have good insight and recognize that there are deficiencies in your FM training when it comes to working in the ED. As long as you stay humble, are willing to learn and grow, I think there's definitely opportunity. If you choose to go back to do EM residency, I would contact PDs and ask them what they are looking for in terms of SLOEs. Also, search around on this forum as I do believe that exact question has been asked before.

 

[deleted109597]

The funding issue only matters to older, more estabilished programs. All of the CMG ones pay their own way and don't get CMS monies. If you want to do it, apply broadly (or transfer).

 

[Brigade4Radiant]

Finish your residency then apply to one of the newer HCA hospital residencies there should be a lot more popping up in the southeast.

 

[Moose A Moose]

Let this be a lesson to you all to follow your gut and not listen to some jaded hospital workers.

 

[illegallysmooth]

Back in med school, I liked EM, but didn't think I could deal with the weekend/night shifts for a career. The attendings had significant burnout and vented to me on every shift, which made things less attractive. I figured it'd probably be better for me to avoid EM.

Fast forward to now. I'm in FM and happy in my program. As part of our curriculum, we do a month of EM every year. I never thought I'd say this, but I've been loving it, sometimes more so than FM. I'm given a lot more autonomy than I did as a medical student so I have a much better understanding of the expectations in EM. Love the wide breadth like FM but I appreciate the higher acuity, opportunities for more procedures, and all the craziness going on. I still like the continuity and lifestyle of FM, but part of me thinks I would've been a better fit for a combined FM/EM program. Probably wouldn't have been competitive enough, but that's another issue.

I'm not sure where to go from here. I don't mind practicing FM, but I also have the EM itch and would love the capability to work in the ED. From what I gather, EM fellowships don't allow me to practice in any ED. And the EDs that do hire primary care physicians don't necessarily require an EM fellowship. I don't mind working rural EDs, but I know my FM training won't fully prepare me for everything that walks in. I've thought about doing a second residency, but I've heard that there may be funding issues. The EM attendings at my community hospital are happy to write glowing LORs, but I'm assuming that those won't suffice as the SLOE is the standard. What's the best way to get my foot in the door?

If you really want to work EM, you need an EM residency. I did two months in med school with an FM doc who worked an urgent care alongside his family practice. He was not even remotely prepared for even the most minor of urgent matters.
How far along into your residency are you?

 

[DeadCactus]

I would work with your residency to maximize the amount of time you can spend in the ED during your program, finish the residency, find the kind of FM job you think you would like best, network, go to a few conferences/skill clinics, pick up a few rural EM shifts. Try it out for a bit. Make sure you really want to be an EM physician and if you do, then apply for EM residencies and get the proper gold standard training. A lot of people think and talk about switching residencies. Some do it, but anecdotally, it seems to be a phenomenon of trainers. People get out of residency, start making good money and working normal hours, and realize there is a lot of variability in what practicing their specialty means. Another residency then suddenly becomes very unappealing.

 

[Groove]

Back in med school, I liked EM, but didn't think I could deal with the weekend/night shifts for a career. The attendings had significant burnout and vented to me on every shift, which made things less attractive. I figured it'd probably be better for me to avoid EM.

Fast forward to now. I'm in FM and happy in my program. As part of our curriculum, we do a month of EM every year. I never thought I'd say this, but I've been loving it, sometimes more so than FM. I'm given a lot more autonomy than I did as a medical student so I have a much better understanding of the expectations in EM. Love the wide breadth like FM but I appreciate the higher acuity, opportunities for more procedures, and all the craziness going on. I still like the continuity and lifestyle of FM, but part of me thinks I would've been a better fit for a combined FM/EM program. Probably wouldn't have been competitive enough, but that's another issue.

I'm not sure where to go from here. I don't mind practicing FM, but I also have the EM itch and would love the capability to work in the ED. From what I gather, EM fellowships don't allow me to practice in any ED. And the EDs that do hire primary care physicians don't necessarily require an EM fellowship. I don't mind working rural EDs, but I know my FM training won't fully prepare me for everything that walks in. I've thought about doing a second residency, but I've heard that there may be funding issues. The EM attendings at my community hospital are happy to write glowing LORs, but I'm assuming that those won't suffice as the SLOE is the standard. What's the best way to get my foot in the door?

Nothing replaces an EM residency. That being said if I was in your position, I would finish out FM and go do a year of EM fellowship. I just don’t know that I would have the stomach for another residency in your position. Sure, some jobs will be off limits but you’ll always be able to find a good gig for the remainder of your career.

If the lack of being ABEM is going to drive you crazy, then sure...go for it but your chances of successfully practicing EM are greatest in the first scenario.

I’ve got a very experienced colleague that is FM and tried for years to get into an EM residency and was ultimately unsuccessful. It’s an uphill fight. EM has always been competitive and lack of GME funding as well as having to train out any bad habits you may have picked up in residency will be a deterrent.

 

[s109442]

Hi I’m an FP doing rural ER. I spent my third year of residency doing spit ICU/ER rotations, I was lucky we were the only residency in the hospital so I got comfortable with invasive procedures quickly. I spent a lot of unofficial time working with The ER/ICU and with cardiologists that year. Weekend classes are fine. I would say in a typical month where I work 8 - 24 hour shifts there are 2-4 intubations, 1-5 traumas mostly car accidents and farmer type trauma, you have to be able to do peripheral ultrasound line’s and CVL’s as the population is obese, and they smoke, there veins are torturous and calcified. If you cannot get access or intubate people die. Don’t just go give this a try. Trust me it’s loney out in a rural ER.

 

[BigGAC1]

I’ve got a very experienced colleague that is FM and tried for years to get into an EM residency and was ultimately unsuccessful. It’s an uphill fight. EM has always been competitive and lack of GME funding as well as having to train out any bad habits you may have picked up in residency will be a deterrent.

IM resident here. I worked my ass off applying EM and didn't get it. Then I reapplied as a PGY1 - still didn't get it (in fact I somehow got less interviews than I did as an MS4). I love EM and honestly still see myself being happiest in EM, and would 100% be willing to stick it out through a 2nd residency if it meant I could practice EM as a career (and I'd actually love to be EM/IM boarded). But you're not the first I've heard it from that reapplying is a real uphill battle as someone already boarded in a different specialty. I just don't get it - you'd think that the added experience would make an individual a far more desirable candidate, but it just doesn't seem like this is the way its viewed.

At this point I'm just sick of beating my head against the application process wall.

 

[BoardingDoc]

I just don't get it - you'd think that the added experience would make an individual a far more desirable candidate, but it just doesn't seem like this is the way its viewed.

The issue in a lot of these cases is teachability. You have certainly learned to do or see things a certain way in IM. Some of those things will be directly transferrable to EM, however, some of them will be antithetical to the practice of EM. As such, an EM program will need to "unteach" you many of those old habits before teaching you the new way of doing it. This is considerably harder than simply hiring a blank slate of a new resident.

 

[Groove]

IM resident here. I worked my ass off applying EM and didn't get it. Then I reapplied as a PGY1 - still didn't get it (in fact I somehow got less interviews than I did as an MS4). I love EM and honestly still see myself being happiest in EM, and would 100% be willing to stick it out through a 2nd residency if it meant I could practice EM as a career (and I'd actually love to be EM/IM boarded). But you're not the first I've heard it from that reapplying is a real uphill battle as someone already boarded in a different specialty. I just don't get it - you'd think that the added experience would make an individual a far more desirable candidate, but it just doesn't seem like this is the way its viewed.

At this point I'm just sick of beating my head against the application process wall.

Just do Pulm/CC. It’s an attainable path for you since you are already doing IM and there are many similarities. If I hadn't gotten into EM, I could easily have seen myself doing ICU with probably similar degrees of career satisfaction.

 

[BigGAC1]

The issue in a lot of these cases is teachability. You have certainly learned to do or see things a certain way in IM. Some of those things will be directly transferrable to EM, however, some of them will be antithetical to the practice of EM. As such, an EM program will need to "unteach" you many of those old habits before teaching you the new way of doing it. This is considerably harder than simply hiring a blank slate of a new resident.

Yeah I've heard that before, and I understand the argument - but its always seemed like kind of a cop-out to me. At this point in my career (including MS4 and IM residency) I've done a total of 9 months of EM in EDs across the country in different settings. I've had enough experience in EM to recognize the differences in the IM vs EM approach to patients, and I feel relatively proficient at compartmentalizing the two. All-in-all, what I'm saying is that I think I'm able to take the IM mentality and switch it on-and-off when I need to with relative ease - and I wish the added experience of an IM residency would be viewed as an asset rather than a liability to any potential program I might apply to in hopes of still doing EM in the future.

Just do Pulm/CC. It’s an attainable path for you since you are already doing IM and there are many similarities. If I hadn't gotten into EM, I could easily have seen myself doing ICU with probably similar degrees of career satisfaction.

Yeah that actually is the plan. It just doesn't seem like its possible to be accepted into an EM residency anymore if you're previously boarded in another specialty. And I do actually like the MICU. Critical Care and procedures are very much up my alley. Pulm is a cool field, and heavily procedural. I see myself being happy in Pulm/CC, I just still see EM as the field in which I would be happiEST (and I'm admittedly still bitter about not making it into EM after all the work that I put into it).

 

[enalli]

The issue in a lot of these cases is teachability. You have certainly learned to do or see things a certain way in IM. Some of those things will be directly transferrable to EM, however, some of them will be antithetical to the practice of EM. As such, an EM program will need to "unteach" you many of those old habits before teaching you the new way of doing it. This is considerably harder than simply hiring a blank slate of a new resident.

Is this actually rooted in reality? Have you seen a higher proportion of people completing a second residency be hindered more than they were helped by their prior training?

I get the point that the average internist/PCP would be a terrible fit for EM; but we're not talking about the average internist/PCP, we're talking about someone who is applying to EM--there is a lot of self-selection there already.

It seems to me that someone who already got through a residency program, is passionate about EM to the point of going through residency again, and has several years of direct patient care experience would be a huge asset to a residency program.

 

[BoardingDoc]

Is this actually rooted in reality? Have you seen a higher proportion of people completing a second residency be hindered more than they were helped by their prior training?

I get the point that the average internist/PCP would be a terrible fit for EM; but we're not talking about the average internist/PCP, we're talking about someone who is applying to EM--there is a lot of self-selection there already.

It seems to me that someone who already got through a residency program, is passionate about EM to the point of going through residency again, and has several years of direct patient care experience would be a huge asset to a residency program.

I'm not in academics, so I can't comment from the point of view of someone who is making these selections. That said, I have heard this said from several people in those roles on multiple occasions.

The only direct observation I can offer is that there was a surgical resident when I was an EM resident who had been an attending in her former country. She had significant problems accepting teaching points, believing that her original way of doing things was adequate. She ultimately did rather poorly in the program and had a well known reputation as the weakest of the surgical residents.

I'm not particularly for or against people completing a second residency, I'm was just offering what I've heard about why that can be difficult.

 

[CajunMedic]

This thread has been an interesting read. Since I'm finishing a transitional year, that's not an option this time. Worst case scenario of not matching, not SOAPing, not landing in one of the at least 2 programs slated for the April RRC meeting has me grabbing an FM or IM spot, then an EM fellowship (or pulm/CC if land IM). I honestly was planning on more rural/critical access hospitals anyway. If the worst comes to fruition, fighting for another residency may not be the battle for me.

I've only known 1 person who has done a second residency, was an anesthesiologist that got tired of gas and did an EM residency. There was a PGY-2 surgical resident on the trail last year who managed to land an EM intern spot as well.

 

[deleted109597]

I've known at least 5 people do two residencies. The oddest was EM=>Radiology.
Lots of FM=>EM. It's doable.
The "teachability" thing has more to do with the person than the previous residency. It's why we know plenty of old docs who stay on top of new advances, and old docs who haven't changed anything since residency finished.

 

[emergentmd]

I've known at least 5 people do two residencies. The oddest was EM=>Radiology.
Lots of FM=>EM. It's doable.
The "teachability" thing has more to do with the person than the previous residency. It's why we know plenty of old docs who stay on top of new advances, and old docs who haven't changed anything since residency finished.

I was very close to doing a rad residency after EM. Im glad I didn't. Another 4 yrs would be a killer.

 

[Groove]

I just still see EM as the field in which I would be happiEST (and I'm admittedly still bitter about not making it into EM after all the work that I put into it).

Trust me, you'll probably be happier. You'll be dealing with just as sick a pt population, if not more. More procedures. More critical care medicine. More codes. You'll be giving up lots of ob/gyn, peds, and some psych, big whoop. You'll be perceived much more as a true "specialist" in the hospital and command greater respect among your hospital peers. You'll have great variety...ICU, outpatient pulm clinic, hospital consults, etc..