IM to neuro, again!

[polynexusmorph]

Hi everyone,

Sorry if this is repetitive but this is the only place I'm safely getting suggestions from.

I've posted here before about my issue but I'll summarize. I'm in an IM program with a very difficult PD that's not much involved with the program. I wanted to switch to neuro after a few months of internship but I was scared to do so because of them. I can add more details if relevant.

I still want to switch neuro as I can't see myself doing IM. Now I have my mid-year evaluation which was excellent, as well as my MiniCEX & ITE. I signed a letter of intent too. So I believe it's difficult for my PD to give me bad recommendations as I'll directly complain to the Chair/DIO/ACGME for retaliation with evidence. We're also unionized

I'm an older US-IMG. My Step 2 score was high. I have excellent neuro LORs from the institution I rotated at prior to residency. Minimal research on my CV.

How can I transfer with the least risk possible?
-Strike the conversation now and hope a neuro spot opens until July? My PD will try to replace me immediately (which is understandable)
-Wait until a spot opens then discuss with my PD
-Apply for an R position in September while working as a PGY2 in IM
-Apply for an R position in September while pursuing a research year
-Wait until signing the PGY2 contract (late April) to collect more evidence of my efficiency as a resident, then speak with the PD

My goals in order are:
1-Work as a physician in the US
2-Work as a neurologist in the US
3-Graduate in time in neurology

Thank you in advance! I'm open to any suggestions except finishing IM then applying to neuro. I don't have the stamina for that

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[ThoracicGuy]

Hi everyone,

Sorry if this is repetitive but this is the only place I'm safely getting suggestions from.

I've posted here before about my issue but I'll summarize. I'm in an IM program with a very difficult PD that's not much involved with the program. I wanted to switch to neuro after a few months of internship but I was scared to do so because of them. I can add more details if relevant.

I still want to switch neuro as I can't see myself doing IM. Now I have my mid-year evaluation which was excellent, as well as my MiniCEX & ITE. I signed a letter of intent too. So I believe it's difficult for my PD to give me bad recommendations as I'll directly complain to the Chair/DIO/ACGME for retaliation with evidence. We're also unionized

I'm an older US-IMG. My Step 2 score was high. I have excellent neuro LORs from the institution I rotated at prior to residency. Minimal research on my CV.

How can I transfer with the least risk possible?
-Strike the conversation now and hope a neuro spot opens until July? My PD will try to replace me immediately (which is understandable)
-Wait until a spot opens then discuss with my PD
-Apply for an R position in September while working as a PGY2 in IM
-Apply for an R position in September while pursuing a research year
-Wait until signing the PGY2 contract (late April) to collect more evidence of my efficiency as a resident, then speak with the PD

My goals in order are:
1-Work as a physician in the US
2-Work as a neurologist in the US
3-Graduate in time in neurology

Thank you in advance! I'm open to any suggestions except finishing IM then applying to neuro. I don't have the stamina for that

As you get out of med school and into training, any LOR from med school are going to hold less and less value. Have you had any rotations with any Neurology faculty during your IM months yet? Do you have a Neuro program at your location? Talking with them about your goals and options would be useful.

Your risks with switching is that you could end up without a program. Having been a US-IMG, you are going to be at a bit of disadvantage. Yes, having the evals in will be helpful, but if they want to be vindictive, that can be swept under the rug or twisted. It depends on how your PD would take it and want to move with it.

Do you have any faculty at your program that you would trust to honestly talk with you about this in confidence?

 

[polynexusmorph]

Sure, I guess, if you don't want to be a real doctor . . .

So anything other than IM is not a real doctor?

 

[polynexusmorph]

As you get out of med school and into training, any LOR from med school are going to hold less and less value. Have you had any rotations with any Neurology faculty during your IM months yet? Do you have a Neuro program at your location? Talking with them about your goals and options would be useful.

Your risks with switching is that you could end up without a program. Having been a US-IMG, you are going to be at a bit of disadvantage. Yes, having the evals in will be helpful, but if they want to be vindictive, that can be swept under the rug or twisted. It depends on how your PD would take it and want to move with it.

Do you have any faculty at your program that you would trust to honestly talk with you about this in confidence?

I go occasionally to help with neuro so they know pretty well and I have a rotation coming. We don't have a neuro program at our hospital. I already talked with the Chief of neuro and they said they'll be happy to write a letter and make calls after my PD approves

I'm not sure about the faculty/attendings, and the issue is that it has to go through the PD which no one can affect

May I ask what my chances are to match an R position if I apply in September without being enrolled in a program? I can live a year without a salary.
Is it better to wait until signing the PGY2 contract before bringing it up to the PD? Or is it better to apply while working as a PGY2 in IM? I believe funding will be an issue

Thank you for your response

 

[ThoracicGuy]

I go occasionally to help with neuro so they know pretty well and I have a rotation coming. We don't have a neuro program at our hospital. I already talked with the Chief of neuro and they said they'll be happy to write a letter and make calls after my PD approves

I'm not sure about the faculty/attendings, and the issue is that it has to go through the PD which no one can affect

May I ask what my chances are to match an R position if I apply in September without being enrolled in a program? I can live a year without a salary.
Is it better to wait until signing the PGY2 contract before bringing it up to the PD? Or is it better to apply while working as a PGY2 in IM? I believe funding will be an issue

Thank you for your response

You don't want to go without being in training if you can avoid it. No guarantee that you'd match and the farther you go without being in medicine, the harder it will be for you.

 

[polynexusmorph]

No. I also count surgical specialties, anes, psych, peds, OB, and rads.

Everyone else, Not real (or hardly real) doctors.

Here's your litmus test: Ask yourself, in a 3rd World country, what kind of doctors are people really desperate for? In the starved, law-less regions of Africa, no one is looking for a neurologist to hand-wave at a stroke he can't fix, nor an advanced-dementia case that modern medicine has no real cure for. (Here is a first world country, we have such luxuries and the money to waste)

Well, that's such a weird statement to make but anyways:

-we're in a first world country
-stroke outcomes improve with timely tPA & thrombectomy
-Google "adacanumab" for dementia
-New drugs are under investigation for ALS
-People with MS, epilepsy, myasthenia gravis can lead almost normal lives now
-A patient would probably be happy to have a neurologist/neurointensivist if they have status epilepticus or a non-surgical ICH, or need an LP for meningitis
-I come from a 3rd world country. My grandmother died of ischemic stroke complications that wasn't tPA because no neurologist was on call, and my dad has been suffering from Parkinson's disease 2/2 lack of individualized therapy & movement disorder specialists, as well as limited treatment options there

So yeah

 

[mistafab]

I go occasionally to help with neuro so they know pretty well and I have a rotation coming. We don't have a neuro program at our hospital. I already talked with the Chief of neuro and they said they'll be happy to write a letter and make calls after my PD approves

I'm not sure about the faculty/attendings, and the issue is that it has to go through the PD which no one can affect

May I ask what my chances are to match an R position if I apply in September without being enrolled in a program? I can live a year without a salary.
Is it better to wait until signing the PGY2 contract before bringing it up to the PD? Or is it better to apply while working as a PGY2 in IM? I believe funding will be an issue

Thank you for your response

I strongly recommend you do not give up your job when you apply. If you don’t match, apply again the next cycle and keep working. In the end, you can always try for a second residency after you complete your training.

But if you have no job, you may have no shot. It’s a big risk for a program to recruit an MD who hasn’t been working and didn’t complete training. You don’t want to be stuck in a situation like that.

You’re doing a great job on paper, and if you complete your training eventually (only 3 years) it’s impossible for someone to say you’re not qualified. And at that point, even a brain dead PD would write a good letter for you since they are the ones who let you loose on the world.

 

[CrispyWonTon]

I would 100% advise you to initiate any discussion for transfer only after having some sort of surity about a position actually being available and you being a good fit for said position. Dealing in what-ifs won't do you any benefit at this stage. What is a letter of intent in regards to IM residency? We never had anything of the sort.

 

[michaelrack]

Well, that's such a weird statement to make but anyways:

-we're in a first world country

-Google "adacanumab" for dementia


So yeah

Googled it, adacanumab is being discontinued.... it's too expensive for even a first world country.


So yeah

 

[xenotype]

The path ahead is quite risky for you unless you can secure a spot (eg outside the match or within the match) for sure. Especially if PD is not supportive, you need a sure bet. If you can find a spot that you 100% have secured then you could proceed with your plan cautiously. This will be a hard thing to get, but outside the match spots do come up here and there. Just hoping a spot becomes available and discarding your IM R2 position is a very bad idea. I would highly, highly recommend for you to position yourself for a neurocritical care fellowship instead and just suffer through the rest of IM training if you don't get a sure spot. Neurology PGY2 is almost always worse than any IM training at most programs anyways, and is about the worst non-surgical specialty residency year you can do. Neurocritical care meshes well with IM training and would give you much of the hospital neurology that you want, including acute stroke and opens up telemed opportunities as well. There are some other fellowships that would be options as well within the neurology realm that would not require a neurology residency like headache, brain injury, possibly even MS etc- these aren't competitive and would be an easy 1yr addon to NCC to build out more basic neurology skills without going through a neurology residency at a relaxing pace in call demands/clinic.

A research year is a big risk. You could potentially make it work but the longer you have a gap from clinical practice the bigger an issue it is. If PD also gives a bad reference your entire career is in major danger.

As for the other comments-
- aducanumab and lecanumab are indeed worthless unless you are the 1 drug company shill on our section of the forums that gets paid to post their opinions. Affordability isn't even the main issue. The benefit is not even detectable to patients/families in exchange for serious side effects and frequent MRIs to monitor those. I don't care to see dementia consults because there is very little to offer 99% of the time. It is not an interesting part of neurology.
- TPA and thrombectomy are awesome when you get a big win and a patient with severe deficits walks out of the hospital completely fixed which happens once a month or so, and terrible when you have a tragic outcome which happens about once every 6 months or so in a busy inpatient practice. Treating stroke is not like surgery or cardiology where many of your patients do great and you get constant satisfaction fixing problems. It feels more like a desperate roll of the dice that occasionally works out dramatically awesome and usually does very little, with a rare sad outcome. I don't have to do straight up social work and scut like all the IM hospitalists though, and that is the best part of my specialty.
- Every other specialty thinks neurologists are worthless till they or a close family member get a neurologic problem. Or they get sued because they didn't consult us on a problem that was treatable and missed an intervention window out of ignorance and a patient has a bad outcome. That always tends to encourage liberal neurology consults going forward including the nice bread and butter issues that pay my bills. I don't really care if other specialties think I am useless- most of neurology is handholding for other specialties who have no clue how to do a neuro exam or approach any problem that has neurologic symptoms, and then there are non-neurologists that think they don't need us that decide something like TPA candidacy/miss a treatable LVO on their own and completely screw it up in a legally indefensible manner. There are plenty of cases in neurology where we have nothing to offer besides hail mary steroids, but if you don't follow a reasonable checklist to get there or fix the treatable problems that do exist you will get your ass sued off because the disability from a neurologic bad outcome is quite often horrendous and at or above your malpractice policy limit.

TLDR- get a for sure spot in or outside the match offered from somewhere or sign your IM R2 contract. buckle down, and prep for a neurocritical care fellowship, then do essentially what you want to do anyways. IM is very portable and you absolutely need to finish some sort of training to be employable as an attending physician.

 

[comp1]

I've never heard of anyone saying neurologists were worthless....

 

[polynexusmorph]

The path ahead is quite risky for you unless you can secure a spot (eg outside the match or within the match) for sure. Especially if PD is not supportive, you need a sure bet. If you can find a spot that you 100% have secured then you could proceed with your plan cautiously. This will be a hard thing to get, but outside the match spots do come up here and there. Just hoping a spot becomes available and discarding your IM R2 position is a very bad idea. I would highly, highly recommend for you to position yourself for a neurocritical care fellowship instead and just suffer through the rest of IM training if you don't get a sure spot. Neurology PGY2 is almost always worse than any IM training at most programs anyways, and is about the worst non-surgical specialty residency year you can do. Neurocritical care meshes well with IM training and would give you much of the hospital neurology that you want, including acute stroke and opens up telemed opportunities as well. There are some other fellowships that would be options as well within the neurology realm that would not require a neurology residency like headache, brain injury, possibly even MS etc- these aren't competitive and would be an easy 1yr addon to NCC to build out more basic neurology skills without going through a neurology residency at a relaxing pace in call demands/clinic.

A research year is a big risk. You could potentially make it work but the longer you have a gap from clinical practice the bigger an issue it is. If PD also gives a bad reference your entire career is in major danger.

As for the other comments-
- aducanumab and lecanumab are indeed worthless unless you are the 1 drug company shill on our section of the forums that gets paid to post their opinions. Affordability isn't even the main issue. The benefit is not even detectable to patients/families in exchange for serious side effects and frequent MRIs to monitor those. I don't care to see dementia consults because there is very little to offer 99% of the time. It is not an interesting part of neurology.
- TPA and thrombectomy are awesome when you get a big win and a patient with severe deficits walks out of the hospital completely fixed which happens once a month or so, and terrible when you have a tragic outcome which happens about once every 6 months or so in a busy inpatient practice. Treating stroke is not like surgery or cardiology where many of your patients do great and you get constant satisfaction fixing problems. It feels more like a desperate roll of the dice that occasionally works out dramatically awesome and usually does very little, with a rare sad outcome. I don't have to do straight up social work and scut like all the IM hospitalists though, and that is the best part of my specialty.
- Every other specialty thinks neurologists are worthless till they or a close family member get a neurologic problem. Or they get sued because they didn't consult us on a problem that was treatable and missed an intervention window out of ignorance and a patient has a bad outcome. That always tends to encourage liberal neurology consults going forward including the nice bread and butter issues that pay my bills. I don't really care if other specialties think I am useless- most of neurology is handholding for other specialties who have no clue how to do a neuro exam or approach any problem that has neurologic symptoms, and then there are non-neurologists that think they don't need us that decide something like TPA candidacy/miss a treatable LVO on their own and completely screw it up in a legally indefensible manner. There are plenty of cases in neurology where we have nothing to offer besides hail mary steroids, but if you don't follow a reasonable checklist to get there or fix the treatable problems that do exist you will get your ass sued off because the disability from a neurologic bad outcome is quite often horrendous and at or above your malpractice policy limit.

TLDR- get a for sure spot in or outside the match offered from somewhere or sign your IM R2 contract. buckle down, and prep for a neurocritical care fellowship, then do essentially what you want to do anyways. IM is very portable and you absolutely need to finish some sort of training to be employable as an attending physician.

Thank you for your extensive & detailed response! I totally get what you're saying but I'm suffering internally as an internist. Any rotation outside IM is much more tolerable for me (ED, ICU...etc)

I would like to add two events that happened during the last few weeks.
I received the official 6-monthly evaluation (which I believe gets sent to ACGME) and I scored above average, and the offer letter for PGY2. Those will make it very difficult for my PD to deny me a letter of good standing. I don't need them to write an LOR as I can obtain LORs from attendings, and probably the chair & APD as long as I confirm that I'm leaving and I'm not under the authority of our PD.

Would you suggest that I apply for an R position in neurology while working as a PGY2 in IM? Although this seems stupid as I'm one year away from graduating, I would rather prolong my training by a year to finish a neurology residency.

Another alternative is applying now for the pre-residency year that the university of New Mexico offers. If I match there, I'm still getting paid and working at a reputable institution as a resident (non accredited year, though) but if I don't get the position and don't secure a spot, my whole career is jeopardized and my only option is to cross fingers and apply to a PGY2 neuro position this September.

The problem is that no program would consider me without a letter of good standing (or at least an LOR from an attending at my institution) because they need to know that I'm not a psychopath and I'm an "okay" resident, and second some programs will consider it unethical/unprofessional to apply behind my current program's back

Again thanks for taking the time to write your reply.

 

[polynexusmorph]

I would 100% advise you to initiate any discussion for transfer only after having some sort of surity about a position actually being available and you being a good fit for said position. Dealing in what-ifs won't do you any benefit at this stage. What is a letter of intent in regards to IM residency? We never had anything of the sort.

How would a program risk offering me a position without someone testifying to my "adequacy" as a resident? It's a huge gamble/red flag to take someone without a reference from their current institution.

The letter of intent is a one page saying we intend to offer you a pgy2 position with this amount of salary. It's not a contract.

 

[ThoracicGuy]

Thank you for your extensive & detailed response! I totally get what you're saying but I'm suffering internally as an internist. Any rotation outside IM is much more tolerable for me (ED, ICU...etc)

I would like to add two events that happened during the last few weeks.
I received the official 6-monthly evaluation (which I believe gets sent to ACGME) and I scored above average, and the offer letter for PGY2. Those will make it very difficult for my PD to deny me a letter of good standing. I don't need them to write an LOR as I can obtain LORs from attendings, and probably the chair & APD as long as I confirm that I'm leaving and I'm not under the authority of our PD.

Would you suggest that I apply for an R position in neurology while working as a PGY2 in IM? Although this seems stupid as I'm one year away from graduating, I would rather prolong my training by a year to finish a neurology residency.

Another alternative is applying now for the pre-residency year that the university of New Mexico offers. If I match there, I'm still getting paid and working at a reputable institution as a resident (non accredited year, though) but if I don't get the position and don't secure a spot, my whole career is jeopardized and my only option is to cross fingers and apply to a PGY2 neuro position this September.

The problem is that no program would consider me without a letter of good standing (or at least an LOR from an attending at my institution) because they need to know that I'm not a psychopath and I'm an "okay" resident, and second some programs will consider it unethical/unprofessional to apply behind my current program's back

Again thanks for taking the time to write your reply.

Your PD can still deny you a letter of good standing if he wants. They can always hurt you more.

The safest path is to finish IM, apply while you are there to be able to start into a Neuro program as soon as you are done. This way you still have a chance to become board certified in something.

 

[polynexusmorph]

Your PD can still deny you a letter of good standing if he wants. They can always hurt you more.

The safest path is to finish IM, apply while you are there to be able to start into a Neuro program as soon as you are done. This way you still have a chance to become board certified in something.

This would make a strong case for retaliation. Our PD cowers if lawyers/union/DIO get involved. It happened (for a different issue) with another resident who's finishing their residency as chief. The chair, which is a very reasonable person, can sign the letter of good standing if it comes down to this. That's why I'm more willing to risk it now, as the SOAP is approaching and I'm okay with repeating the intern year in a neuro program.

 

[polynexusmorph]

Your PD can still deny you a letter of good standing if he wants. They can always hurt you more.

The safest path is to finish IM, apply while you are there to be able to start into a Neuro program as soon as you are done. This way you still have a chance to become board certified in something.

Also applying this September for a pgy2 position in neuro would make an even stronger case of retaliation (how can a resident be promoted to PGY1 if they didn't finish PGY1 in good standing?)

 

[ThoracicGuy]

This would make a strong case for retaliation. Our PD cowers if lawyers/union/DIO get involved. It happened (for a different issue) with another resident who's finishing their residency as chief. The chair, which is a very reasonable person, can sign the letter of good standing if it comes down to this. That's why I'm more willing to risk it now, as the SOAP is approaching and I'm okay with repeating the intern year in a neuro program.

But they can always try to get the reviews or whatever in to get the outcome they want. They can still hurt you more. Moving to legal action will likely take time and that's time you don't always have when you are then stuck in limbo without a training program. Not saying this would happen, but there is a risk.

 

[Giovanotto]

Thank you for your extensive & detailed response! I totally get what you're saying but I'm suffering internally as an internist. Any rotation outside IM is much more tolerable for me (ED, ICU...etc)

I would like to add two events that happened during the last few weeks.
I received the official 6-monthly evaluation (which I believe gets sent to ACGME) and I scored above average, and the offer letter for PGY2. Those will make it very difficult for my PD to deny me a letter of good standing. I don't need them to write an LOR as I can obtain LORs from attendings, and probably the chair & APD as long as I confirm that I'm leaving and I'm not under the authority of our PD.

Would you suggest that I apply for an R position in neurology while working as a PGY2 in IM? Although this seems stupid as I'm one year away from graduating, I would rather prolong my training by a year to finish a neurology residency.

Another alternative is applying now for the pre-residency year that the university of New Mexico offers. If I match there, I'm still getting paid and working at a reputable institution as a resident (non accredited year, though) but if I don't get the position and don't secure a spot, my whole career is jeopardized and my only option is to cross fingers and apply to a PGY2 neuro position this September.

The problem is that no program would consider me without a letter of good standing (or at least an LOR from an attending at my institution) because they need to know that I'm not a psychopath and I'm an "okay" resident, and second some programs will consider it unethical/unprofessional to apply behind my current program's back

Again thanks for taking the time to write your reply.

FWIF, I have heard that the program at the university of new mexico is pretty brutal/malignant, though that was a few years ago, and I'd hope things have changed since then.

 

[xenotype]

Your PD can still deny you a letter of good standing if he wants. They can always hurt you more.

The safest path is to finish IM, apply while you are there to be able to start into a Neuro program as soon as you are done. This way you still have a chance to become board certified in something.

Agree 100%. Lawyers can work but it is a gamble and burns every bridge in the process. If your new program (presuming you even find a spot) finds out that you threatened litigation or involved a lawyer they will bow out, guaranteed. Pre-residency neuro spots can help secure a residency spot but you have to be well liked and make no enemies the year you are there- they are not a guarantee and in your position not knowing anyone in a position of power at the residency before hand are a major gamble. The question here is if you want to gamble your entire future career because the stakes are high, the risks are high, and this absolutely can blow up in your face and ruin your entire career. Keeping your head down, finishing IM, and doing neurocritical care or some of the other many neuro fellowships open to IM is a far less risky route. Personally I would never take the gamble you are about to do, I would rather 100% have a career waiting for me and figure out how to fit my interests in it later. That is generally not that hard to do especially if you are willing to lose a couple years of income for a fellowship in something.