Hoping to switch specialty during internship year

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[QofQuimica]

My questions are, I haven’t told the surgery PD that I’m currently doing IM, and in the surgical specialty I’m applying for, doing an IM internship is very much looked down upon even though having IM experience would help patient management. If I quit, and reapply, would other PDs find out where and which specialty I worked at? Does my current IM PD have to write a statement in order for me to reapply and switch program?

Yes and yes. There's nothing they won't know about you, so just put any idea of conveniently forgetting to mention your prior training history out of your mind. People can and do change programs, and it sounds like you have a good lead. BUT, what you don't want to do is resign your current position without a new position lined up. Unless there is a currently open intern slot in the surgery program, I suggest that you apply this fall to start the surgery program as an intern next July, and plan on finishing your IM intern year. That will be the best way to burn the fewest bridges with your current program and ultimately get what you want. Plus, presumably you need a way to support yourself for the next year, and being an IM intern is infinitely better than being unemployed for a year, especially with your loans coming due this January.

 

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[colbgw02]

Let's just get this out there: are we talking about ophthalmology? I know they'll accept a TY internship, so maybe they would accept an IM one as well? Otherwise, you're going to have to repeat your internship for a surgical subspecialty anyway, so all of this worry is meaningless. Besides, if you're really worried about it, just do a surgical internship. No one is going to think less of you as a candidate because you did both an IM and surgical internship.

 

[QofQuimica]

I do not have student loans so money is not a major issue, and I can take on another medically related job to support myself in the mean time if necessary or even do research.

It's good you don't have a lot of loans hanging over your head; that puts you in a better position than most new grads. But unless you're a nontrad with prior medical work experience in some other capacity (ex. as a nurse, etc.), you are not qualified to do any job in medicine with just an MD degree + one week of internship. Doing research is not as good as having a clinical job in terms of preparing for a clinical career. As with anything, you get good at what you practice. If you practice doing research, those are the skills you will develop. If you want to be a researcher and never practice, that might be fine. But you want to be a clinician. In that case, the best thing to do is to spend this year doing a clinical internship of some kind.

The issue is interview season lasts about 2 to 3 months, and there is no way that my current PD would give me 2 to 3 months of vacation so that I can reapply, which means I would have to resign before interview season starts, am I correct?

No, what it means is that you will use your days off to interview. You may need to swap with colleagues and work other days for them later in the year, use vacation days, etc.

Also, I am seriously concerned that my IM training history may hurt my chances. I understand that programs get their information from ERAS and can I just simply not fill out that I did an IM internship if I quit after 1 or 2 months?

I'm not a surgeon, so I can't say for sure how doing an IM intern year will affect your app for a surgical residency. But I find it very hard to believe that any surgery program would consider an IM intern year as a major negative that will make you a worse surgeon. As you pointed out yourself, you will be learning patient management skills in IM, and certainly any months you spend doing critical care (ICU) will be relevant to surgery. In addition, many surgical patients have medical problems also, so even floor and clinic months are at least somewhat useful. I really can't think of any downside to doing an IM intern year before a surgery residency except that you have to spend an extra year, and it will affect your funding. But in terms of your training, the extra knowledge could only help you. Why do you think it will be viewed as such a big negative?

Again, you CANNOT omit the information about your prior training from your application. Residency is a monopoly. ACGME/ERAS already know you're doing an IM program. Your future PD will also know.

 

[rokshana]

Let's just get this out there: are we talking about ophthalmology? I know they'll accept a TY internship, so maybe they would accept an IM one as well? Otherwise, you're going to have to repeat your internship for a surgical subspecialty anyway, so all of this worry is meaningless. Besides, if you're really worried about it, just do a surgical internship. No one is going to think less of you as a candidate because you did both an IM and surgical internship.

optho allows for an IM internship to count for the intern year…in fact i think its unusual for them to do a prelim surgery year...

 

[ThoracicGuy]

Thanks QofQuimica

I do not have student loans so money is not a major issue, and I can take on another medically related job to support myself in the mean time if necessary or even do research.

The issue is interview season lasts about 2 to 3 months, and there is no way that my current PD would give me 2 to 3 months of vacation so that I can reapply, which means I would have to resign before interview season starts, am I correct?

Also, I am seriously concerned that my IM training history may hurt my chances. I understand that programs get their information from ERAS and can I just simply not fill out that I did an IM internship if I quit after 1 or 2 months?

Quitting instead of completing your intern year would be a much bigger red flag than having an intern year of IM. If you quit, you will have to explain that every time you get a medical license or apply for hospital privileges. Don't do that to yourself.

 

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[ram006]

My contract says I’m not allowed to accept a different residency position during my internship year. And also, contract renewal for PGY2 is in Jan and match is in March. So I would have to quit at some point. Wouldn’t it be better for my program is I were to quit sooner so they can find a replacement rather than waiting until March.

That sounds very atypical, you wouldn't be the first resident to switch specialties after intern year so I'm not sure how that is even possible but, in the case that it is, you should tell your PD you want to switch. Part of making that moves requires the courage to be upfront with people about your career goals.

Your post suggests you have no interest in remaining in IM past a couple of months from now so I'm not really sure why you're concerned with renewing your contract.

Quitting makes you a quitter. Finishing your intern year and switching makes you someone who had a change of heart. I'm not sure why you think you need 3 months of vacation to interview, but residents interview for fellowships every year...

As a surgery resident I try to limit how much I buy in to the "hardcore surgeon" mentality and have even gotten in to some pretty heated arguments about it, but I would be pretty vocal about not taking someone who bailed on their program like you're describing. You signed a contract, that's supposed to mean something. None of us are unique snowflakes, they can find someone by the end of the year to replace you but leaving now or mid year puts them in a much more difficult situation. You also have to be prepared for trying to switch and failing. If you quit and fail to match, which is a high probablility based on a lot of things, you're going to be in a terrible situation.

It would also help if you told us what surgical specialty you're applying for so people who have made the same move can chime in.

 

[ram006]

optho allows for an IM internship to count for the intern year…in fact i think its unusual for them to do a prelim surgery year...

Are we calling Ophtho a surgical specialty these days? I kid, I kid...

 

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[ThoracicGuy]

I want to reapply for ortho. Another concern of mine is I may potentially run out of funding. I called NRMP and was told I am only allocated a certain amount of years of federal funding for the specialty I matched first. So for IM my program gets 3 years of funding, after internship year I have 2 years remaining. Even if I switched to Ortho afterwards, I would retain the 2 years and that means I'm 3 years short. I'm concerned the vast majority of programs including the one I want to get back to won't be able to accommodate this. Has anyone had success switching from a shorter to a longer specialty?

I have heard people having dual specialties like neuro + neurosurg, how did they make that possible?

Thanks.

Have you seen the stats for reapplicants for ortho? The success rate is extremely low. Funding isn't so much an issue as much as being a reapplicant. I'm not so sure that you should burn what you have for something that you have a low chance of getting. Yes, this PD that you rotated at is giving positive feedback, but unless you have a contract in front of you, nothing is a given. Have you considered what you will do if you leave your program after this year and apply for the match and then don't match? Will you go back to IM? Would you look for a prelim general surgery spot? You won't have many good options and your chances for the match a third time around will likely go even worse.

Think very hard about this decision before you proceed.

 

[ram006]

I want to reapply for ortho. Another concern of mine is I may potentially run out of funding. I called NRMP and was told I am only allocated a certain amount of years of federal funding for the specialty I matched first. So for IM my program gets 3 years of funding, after internship year I have 2 years remaining. Even if I switched to Ortho afterwards, I would retain the 2 years and that means I'm 3 years short. I'm concerned the vast majority of programs including the one I want to get back to won't be able to accommodate this. Has anyone had success switching from a shorter to a longer specialty?

I have heard people having dual specialties like neuro + neurosurg, how did they make that possible?

Thanks.

I feel your pain brother(or sister, whichever I can't tell). I tried to switch into Ortho after choosing geography over specialty as well. I took a different approach, though, in that I applied and matched categorical surgery( bc I knew I would rather operate than not) and I wanted to be guaranteed a chance to finish a residency on time. I was only interested in switching at the same institute(because of geography) and they didn't bite. I met with both their PD and chair to arrange a rotation with them. Both said they would interview me but, really, that essentially means nothing.

Here's the tough love part. You have to be honest with yourself about why you didn't match. If you haven't improved that area, you need to. For example, a bad step 1 score is not fixed by research.

You're funding will certainly be an issue. It came up multiple times with me and I'm not sure that if you quit you necessarily get it back so this year may already be gone. I was also told that you are allocated an initial amount of GME funding based on the specialty you match in to. Unfortunately, no one is the dean's office ever counsels students about because all they care about are their match statistics. Not that I'm bitter or anything.

The bottom line is this: Ortho is competetive. They have to like you so much that not only do they want you to match there, but they're willing to pay 3 years of your salary out of pocket (or through the hospital or whatever).

That's a pretty big leap of faith to make considering there is no shortage of well qualified junior AOA, 260 type geeks out there competing for that same spot you want. You have to live with the decision, but this is the real world and not everyone gets what they want my man. You could go for it and end up in resident purgatory. You have to be ok with that choice.

 

[Raryn]

First of all, you never "run out" of funding. When you use up your initial funding, future years are still funded at approximately 2/3 of the regular amount, depending on some regional changes. If you're in a medicare funded spot then, your program is required to make up the difference. You still get paid the regular amount.

Even that though is a non-issue for most medical centers, especially large academic ones. Most spots are medicare funded, it's true, but at least some spots at almost any program are self-funded or funded through the state or something else. What they do is just shuffle the money around and when you "run out", they just say you're in a spot that isn't funded by medicare, and the full medicare funding is going to a spot that someone else is in. It's all a paperwork thing that the GME office knows how to handle.

 

[ram006]

First of all, you never "run out" of funding. When you use up your initial funding, future years are still funded at approximately 2/3 of the regular amount, depending on some regional changes. If you're in a medicare funded spot then, your program is required to make up the difference. You still get paid the regular amount.

Even that though is a non-issue for most medical centers, especially large academic ones. Most spots are medicare funded, it's true, but at least some spots at almost any program are self-funded or funded through the state or something else. What they do is just shuffle the money around and when you "run out", they just say you're in a spot that isn't funded by medicare, and the full medicare funding is going to a spot that someone else is in. It's all a paperwork thing that the GME office knows how to handle.

I agree that often times programs will find salary lines from different sources (the hospital, private practice groups that "rent a resident", etc). That's sort of besides the point.

The key issue is whether or not they have to. Ortho programs are relatively small and for the most part don't need to deal with the headaches of finding funding when they have a bunch of well qualified applicants. So like I said, they have to want you bad enough to be willing to deal with funding issues (either partial or full). As a side note, I can assure you, theoretically, funding can definitely run out. There are actual proposed budget cuts that include no longer using medicare to pay residents.

The 2/3 thing sounds like an actual stat. Mind posting your source? I have to admit, I have wondered how exactly independent PRS residents are paid if they did another residency before starting. But basically what you're saying is contradictory to what an ortho PD and chair told me. Given that our department also has these issues I don't think they're making it up.

The issue is an interest of mine and I've tried to become more politically active within local and state medical societies. Not much success though. No one really seems to care about resident salaries once they graduate from residency.

There was a nice publication by the ACS about how medicare funds support GME but I don't remember that. I do however remember indirect GME funds being paid directly to the hospital despite having no oversight in place to ensure they were going towards resident education... that's a whole 'nother chestnut.

 

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[Raryn]

I agree that often times programs will find salary lines from different sources (the hospital, private practice groups that "rent a resident", etc). That's sort of besides the point.

The key issue is whether or not they have to. Ortho programs are relatively small and for the most part don't need to deal with the headaches of finding funding when they have a bunch of well qualified applicants. So like I said, they have to want you bad enough to be willing to deal with funding issues (either partial or full). As a side note, I can assure you, theoretically, funding can definitely run out. There are actual proposed budget cuts that include no longer using medicare to pay residents.

The 2/3 thing sounds like an actual stat. Mind posting your source? I have to admit, I have wondered how exactly independent PRS residents are paid if they did another residency before starting. But basically what you're saying is contradictory to what an ortho PD and chair told me. Given that our department also has these issues I don't think they're making it up.

The issue is an interest of mine and I've tried to become more politically active within local and state medical societies. Not much success though. No one really seems to care about resident salaries once they graduate from residency.

There was a nice publication by the ACS about how medicare funds support GME but I don't remember that. I do however remember indirect GME funds being paid directly to the hospital despite having no oversight in place to ensure they were going towards resident education... that's a whole 'nother chestnut.

The medicare slots caps are more of a per-institution than a per-program thing, so the size of the program doesn't particularly matter.

Regarding what happens when the funding "runs out":
This is fairly complicated, but medicare funding is in two pots. Direct and Indirect Medical Education. When you "run out" of funding but are still training in a medicare funding spot, your funding from DME is reduced by 50%... but you still get the FULL amount of IME. The total proportion that is removed from the DME+IME pot really varies from region to region, but generally speaking, we're talking about no more than 20-35% total reduction. You're not exactly funded at a rate of zero. I'd send a link but I don't have a decent one handy. Google around or you can wait for someone like @aProgDirector (who has posted on this many, many times) to respond.

 

[ram006]

The medicare slots caps are more of a per-institution than a per-program thing, so the size of the program doesn't particularly matter.

Regarding what happens when the funding "runs out":
This is fairly complicated, but medicare funding is in two pots. Direct and Indirect Medical Education. When you "run out" of funding but are still training in a medicare funding spot, your funding from DME is reduced by 50%... but you still get the FULL amount of IME. The total proportion that is removed from the DME+IME pot really varies from region to region, but generally speaking, we're talking about no more than 20-35% total reduction. You're not exactly funded at a rate of zero. I'd send a link but I don't have a decent one handy. Google around or you can wait for someone like @aProgDirector (who has posted on this many, many times) to respond.

nice. thanks.

 

[ram006]

Found another thread. WS to the rescue.

http://forums.studentdoctor.net/thr...lties-funding-question.1055729/#post-14912644

 

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[mercaptovizadeh]

Why is your IM internship "very much looked down upon"? Doesn't really make sense, especially seeing as how badly orthos suck at managing medical problems perioperatively and dump their patients for specious reasons (who often have wound infections and other surgical issues going on) onto IM. One would think an IM intern year would help prevent you from consulting/dumping every diabetic and hypertensive patient post-surgery.

I think you should just finish your IM residency and then reapply to ortho if you still find you absolutely must switch. I don't think it'll be very easy to apply and interview for ortho without doing serious damage in your PD's eyes and likely ruining any chance of finishing up IM if you fail to match into ortho. I'd also look at other ways you can touch on "ortho things" from an IM perspective. Have you considered a procedural IM fellowship such as interventional cards or GI? Or what about the medical angle on bone/joint/connective tissue disease in rheumatology?

 

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[ThoracicGuy]

Not all PDs are as sensible as you are.

I miss the interactions and the feeling of being in the OR. I really don't want to settle half heartedly for something in between, like being a GI or interventional card doc when I wanted to be a surgeon. Anyways, I hope things work out, otherwise I guess Europe is where I'm at.

Are you an EU citizen? If not, its unlikely you'll be able to get into a european training program. As for ortho, your chances are poor. General surgery might be an option to consider.

 

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[mercaptovizadeh]

I think you need to make an honest appraisal of the situation. A few points.

1.) Did you apply to ortho as well as IM and failed to match into ortho, or did you just apply to IM? If you failed to match ortho the first time around, I don't think your chances are any better this time around, only worse.

2.) Are your pre-residency qualifications adequate to have a realistic chance at matching ortho as a reapplicant? Your step 1, step 2, clinical rotation grades and LORs.

3.) Are you independently wealthy? You mentioned you have no loans. Could you finance part of your residency training, so that there wouldn't be any financial barrier to an ortho program taking you?

4.) You said you like the OR and want to operate. If this matters so much to you, I think you should at least consider a few options other than ortho. General surgery is a lot closer to IM, and probably wouldn't be quite as hostile (as you're telling us) to an IM intern year. Also, general surgery will be less competitive to match. Ophtho and anesthesia would allow an IM intern year and you could be doing stuff in the OR with those, albeit not surgery with anesthesia and only a very narrow kind of surgery in ophtho.

5.) I think you should complete your IM residency. If you try to switch and fail - which is very likely at this point, given how competitive ortho is and how much (according to you) they look down on IM - you are not likely to have a great time completing that IM residency. Your PD is not going to be the most supportive at that point, should you choose to go on to do an IM fellowship or even reapply to a surgical specialty after residency. There have been people who complete IM and then go on to do ortho or gen surg or what have you. Here's an example:

http://www.linkedin.com/pub/surya-mundluru/70/b64/b32

Granted, this guy did medical school and med-peds residency at Penn/CHOP, so I'm sure that helped, but these people do exist.

 

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[Winged Scapula]

3.) Are you independently wealthy? You mentioned you have no loans. Could you finance part of your residency training, so that there wouldn't be any financial barrier to an ortho program taking you?

Financing your own residency or working without pay is an ACGME violation.

 

[mercaptovizadeh]

5) I really don’t like IM and I’m not in ortho for the money, so there is really no point finishing IM then apply for ortho afterwards. If I can’t get an ortho spot here, I’ll probably just go to Europe.

It seems you have this figured out. Good luck!

 

[michaelrack]

Financing your own residency or working without pay is an ACGME violation.

There was an episode of ER about this, in which Dr. Carter donated his paycheck