Looking to change residency positions, kinda an atypical situation

[Lamping]

I think I posted this in the wrong forum initially, sorry!

I'm currently part way through my PGY-1 year as a categorical general surgery resident in a great program in the US. I've completed a preliminary year at another US school in general surgery while I was figuring out what I wanted to do with myself. However, over the past six-eight months I've come to realize that I don't like the operating room and am mcuh better outside of it than I am in it. It never 'clicked' for me like I had thought it would. I'm completely fine with the hours, acuity, and workload, but I just don't treasure the OR. After re-examining my aspirations and interests, I am pretty sure that a position in Internal Medicine is where I should be. I know that this sounds like a radical shift, but it's absolutely not a case of the grass being greener. I've really thought this out.

Here's my issue. I'm currently being offered an interview at my home program with their internal medicine department, but this is a really recent development for me and I'm pretty sure that I have missed the chance to match into any other program in ERAS for this application season. My home program is only interviewing me this late in the season as a special case and the phone calls I've made to other program offices have indicated that their IM residency interviews are all filled. So in a way, all my eggs are in one basket. The alternative would be to apply during the next ERAS season, and here's my issue: What do I do in the meantime?

I've got my step 3 scheduled for December and I'm pretty sure I will pass it. My step 1 and 2 scores are great and my LORs from both medical school and my residency experience are very good. I've been doing great so far this year and have gotten great feedback from all my colleagues and a wonderful letter of support from my current program director. My program director is extremely supportive and has been doing everything possible to help me out (I'm so fortunate that way). I feel like I will be in a good position for the match next year, if it comes to that. I graduated from a good US medical school in the top quartile somewhere, though no AOA. I have some bench research experience, a couple pubs, lots of volunteering and leadership/work experience while in medical school.

Do I have any career options? If I need to look for a job in the meantime while I apply during next year's ERAS, I'll have finished 2 years in a residency and have completed my step 3.

Thank you so much for your help. I'm feeling a little lost here and, well, really nervous.

---

Members don't see this ad.

 

[NotAProgDirector]

You have several options:

1. You could get a license and work. A US grad can get a license in all states with 2 years of GME and all of the steps completed. You might be able to work in an ED, or maybe assisting in an OR. Jobs like this aren't easy to find because you're a square peg in a world of round holes (i.e. no one is advertising for partially trained residents), but if you're willing to look around and "work the system" you might find something.
2. Research. Won't pay well, but you could get a position somewhere.
3. Hunt for an off cycle PGY-1. Perhaps you could start in September or October.

Don't forget to consider setting up an ERAS application and applying to a single program so you can participate in SOAP.

 

[b-real]

You have several options:

1. You could get a license and work. A US grad can get a license in all states with 2 years of GME and all of the steps completed. You might be able to work in an ED, or maybe assisting in an OR. Jobs like this aren't easy to find because you're a square peg in a world of round holes (i.e. no one is advertising for partially trained residents), but if you're willing to look around and "work the system" you might find something.
2. Research. Won't pay well, but you could get a position somewhere.
3. Hunt for an off cycle PGY-1. Perhaps you could start in September or October.

Don't forget to consider setting up an ERAS application and applying to a single program so you can participate in SOAP.

Man everyone loves to rag on EM; contrary to popular opinion, you can't just work in an ED. You may be able to get some small hospital in the sticks to take you on, but only because there's nobody else. I would highly advise against this, though. You're not residency-trained in EM. It's a different way of doing things. You'll also be called on to do many things you wouldn't in an urban setting. If something goes wrong and your inexperience betrays you, your license and career is on the line.

 

[TexasPhysician]

Man everyone loves to rag on EM; contrary to popular opinion, you can't just work in an ED. You may be able to get some small hospital in the sticks to take you on, but only because there's nobody else.

I think you underestimate the shortage of EM trained folks. I've been at academic centers that can't find enough em docs. They have FM boarded docs making $350k+ because no EM options. This is a fairly decent sized city. Based on that, I'd bet there are plenty of more rural ED's looking.

 

[rokshana]

I think you underestimate the shortage of EM trained folks. I've been at academic centers that can't find enough em docs. They have FM boarded docs making $350k+ because no EM options. This is a fairly decent sized city. Based on that, I'd bet there are plenty of more rural ED's looking.

I agree….i get recruiters calling and emailing me with EM spots all the time…sure not in big cities, but aPD never said that those spots would be the ones to fill a year. His problem will be the fact that he has only done 2 years of residency, not that he isn't EM trained, so yes, if you are FM or IM trained, you still can just work in an ED if you want...

 

[b-real]

I agree….i get recruiters calling and emailing me with EM spots all the time…sure not in big cities, but aPD never said that those spots would be the ones to fill a year. His problem will be the fact that he has only done 2 years of residency, not that he isn't EM trained, so yes, if you are FM or IM trained, you still can just work in an ED if you want...

That's great that you get recruiting emails from rural EDs, and yes - if you or the OP choose - you can absolutely work in the ED. My point, however, is that it's not a good idea. If you're not specifically trained in EM, that will be a problem. The places you are likely to work in will offer very little in the way of backup. How many central lines, intubations, chest tubes, transvenous pacers have you placed in residency? Crikes performed? Someone who has a medical license with just a preliminary year under their belt (i.e. the OP) cannot possibly be expected to perform those tasks and more confidently and competently.

 

[rokshana]

That's great that you get recruiting emails from rural EDs, and yes - if you or the OP choose - you can absolutely work in the ED. My point, however, is that it's not a good idea. If you're not specifically trained in EM, that will be a problem. The places you are likely to work in will offer very little in the way of backup. How many central lines, intubations, chest tubes, transvenous pacers have you placed in residency? Crikes performed? Someone who has a medical license with just a preliminary year under their belt (i.e. the OP) cannot possibly be expected to perform those tasks and more confidently and competently.

trust me if i never step foot in an ED again is too soon….its the 7th circle to me, but that being said, some of the best "ER" I docs have have had the pleasure to work with have been IM and FM trained….the EM guys just seem to want to get some sort of dispo on them and "get them the hell out of my ER" (direct quote from an EM guy)….and I would image a GS resident that has 2 years under their belt has probably done more of those procedures than the equivalent 2nd year EM resident, so….

to the OP you could be a house physician for the dept of surgery…i've seen those positions, especially in the NE…basically act as a surgical resident at places that don't have residents.

 

[Arcan57]

trust me if i never step foot in an ED again is too soon….its the 7th circle to me, but that being said, some of the best "ER" I docs have have had the pleasure to work with have been IM and FM trained….the EM guys just seem to want to get some sort of dispo on them and "get them the hell out of my ER" (direct quote from an EM guy)….and I would image a GS resident that has 2 years under their belt has probably done more of those procedures than the equivalent 2nd year EM resident, so….

to the OP you could be a house physician for the dept of surgery…i've seen those positions, especially in the NE…basically act as a surgical resident at places that don't have residents.

There are some great IM/FM/GSurg trained EPs who have been in the pit for 15-20 yrs. Exceptions don't make rules and there is a noticeable dropoff in ability in EM for younger docs trained in other specialties. Especially as they go farther from their field of training (ie OB emergencies, appropriately triaging trauma, anything involving sick kids) misses become more frequent.

I would also argue that using the ED as a clinical decision unit to spare in-patient docs from having to perform work-ups is very attractive if you're an in-patient doc but it's not in the best interests of the patients (especially the ones waiting in the lobby who can't get back to a room because somebody decided that they wouldn't admit until the HIDA scan/CCTA/tagged bleeding scan came back). While I definitely appreciate it doesn't matter to the consultants we are on the phone with, most of our work doesn't involve consultation and getting patients out of the ED is a necessity so that we can see the leaking AAA, AMI, cirrhotic GI bleed, anticoagulated SDH, or ruptured ectopic that's sitting out in the waiting room. But I'm sure you already knew that.

 

[rokshana]

There are some great IM/FM/GSurg trained EPs who have been in the pit for 15-20 yrs. Exceptions don't make rules and there is a noticeable dropoff in ability in EM for younger docs trained in other specialties. Especially as they go farther from their field of training (ie OB emergencies, appropriately triaging trauma, anything involving sick kids) misses become more frequent.

I would also argue that using the ED as a clinical decision unit to spare in-patient docs from having to perform work-ups is very attractive if you're an in-patient doc but it's not in the best interests of the patients (especially the ones waiting in the lobby who can't get back to a room because somebody decided that they wouldn't admit until the HIDA scan/CCTA/tagged bleeding scan came back). While I definitely appreciate it doesn't matter to the consultants we are on the phone with, most of our work doesn't involve consultation and getting patients out of the ED is a necessity so that we can see the leaking AAA, AMI, cirrhotic GI bleed, anticoagulated SDH, or ruptured ectopic that's sitting out in the waiting room. But I'm sure you already knew that.

yes,that may be true enough, but i would have appreciated (when i was a hospitalist) that the actively stroking or STEMI patient not be sent to my floor from the ED just for me to turn around and arrange to airlift them to the tertiary hospital for the emergent t-Pa or cath…probably would have been faster out of the ED…just saying'…

my work day was much brighter when i knew those old school guys were on service the same time I was…knew the pts that they wanted admitted truly needed to be admitted...

 

[b-real]

yes,that may be true enough, but i would have appreciated (when i was a hospitalist) that the actively stroking or STEMI patient not be sent to my floor from the ED just for me to turn around and arrange to airlift them to the tertiary hospital for the emergent t-Pa or cath…probably would have been faster out of the ED…just saying'…

my work day was much brighter when i knew those old school guys were on service the same time I was…knew the pts that they wanted admitted truly needed to be admitted...

This sounds odd. For one, that a STEMI or an "actively stroking" pt would be dispo'd to the floor and two, that a hospitalist would accept those patients. There's an embellishment for the sake of framing an argument or more to the story.

 

[rokshana]

This sounds odd. For one, that a STEMI or an "actively stroking" pt would be dispo'd to the floor and two, that a hospitalist would accept those patients. There's an embellishment for the sake of framing an argument or more to the story.

no true story…the active stroke i refused in the ED, though the ED doc thought our hospital could handle it ( he didn't believe it was still evolving…i begged to differ) and the STEMI….well, he swore the EKG he did in the ED had no ST elevations (though it "conveniently" couldn't be found in the ED) so he put standing orders on her and sent her to the cards floor…imagine my surprise when the floor nurse calls me to say the pt who just arrived was having excruciating CP…and when we got an EKG, well…

sure, extreme examples, but true nonetheless…and probably not as uncommon as one may think with the push to get people out of the ED without an appropriate w/u…some things SHOULD be done in the ED and not necessarily on the floor...

 

[Arcan57]

no true story…the active stroke i refused in the ED, though the ED doc thought our hospital could handle it ( he didn't believe it was still evolving…i begged to differ) and the STEMI….well, he swore the EKG he did in the ED had no ST elevations (though it "conveniently" couldn't be found in the ED) so he put standing orders on her and sent her to the cards floor…imagine my surprise when the floor nurse calls me to say the pt who just arrived was having excruciating CP…and when we got an EKG, well…

sure, extreme examples, but true nonetheless…and probably not as uncommon as one may think with the push to get people out of the ED without an appropriate w/u…some things SHOULD be done in the ED and not necessarily on the floor...

So your two examples of being a wall for inappropriate admissions are a patient with an "evolving" CVA (were you concerned about edema causing severe ICP in a cerebellar stroke necessitating craniotomy, since that's basically the only scenario that's going to require specialized care outside of tPA) and a patient with CP that developed an STEMI. The second bugs me more than the first (a lot of places I've worked have a mish-mash of bizarre rules surrounding CVA care). Some patients with non-diagnostic EKGs and nl initial troponin are going to develop an AMI. Some of the AMIs will be STEMIs. If you're basing your "EM sux" stance on the fact that a patient with a seemingly benign presentation was admitted to a monitored setting because of concern for disease process that intervally developed then you're anecdote says more about you then the EPs with whom you were working.

 

[rokshana]

So your two examples of being a wall for inappropriate admissions are a patient with an "evolving" CVA (were you concerned about edema causing severe ICP in a cerebellar stroke necessitating craniotomy, since that's basically the only scenario that's going to require specialized care outside of tPA) and a patient with CP that developed an STEMI. The second bugs me more than the first (a lot of places I've worked have a mish-mash of bizarre rules surrounding CVA care). Some patients with non-diagnostic EKGs and nl initial troponin are going to develop an AMI. Some of the AMIs will be STEMIs. If you're basing your "EM sux" stance on the fact that a patient with a seemingly benign presentation was admitted to a monitored setting because of concern for disease process that intervally developed then you're anecdote says more about you then the EPs with whom you were working.

they are couple of examples but just the tip of the iceberg…EM and IM will always be on the opposite sides of this ...which is why I find more compatibility with those ED docs that are trained IM…we think alike…their philosophy tends to be "what can I do to keep this person from having to be admitted"…the EM trained doc is generally "where can this person go, quickly"….quickly may be in the hospital's best interest, but not necessarily the pt's….think that some ED docs have lost sight of that…(and troponins were up in the ED…trust it was a big brough ha ha that the STEMI was missed)…my point initially was not that EM sux, but that there are people trained in other disciplines that are just as capable (and sometimes even moreso) to work in an ED….its not so specialized, say like neurosurgery, that you MUST be EM trained to do it...

 

[Arcan57]

my point initially was not that EM sux, but that there are people trained in other disciplines that are just as capable (and sometimes even moreso) to work in an ED….its not so specialized, say like neurosurgery, that you MUST be EM trained to do it...

And I couldn't disagree more with that statement, for the reasons I posted previously.