FormerEyeGuy

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My career is spiralling into the abyss. Every time I move forward another unforeseen obstacle derails me. I really need some good advice on how to fix this mess. I keep taking two steps forward and one back. I seem to be getting bad advice at every turn.

Here's the story so far...I'm a US citizen, have a BA in Chemistry but went to a Caribbean med school that does not support its students. Students are responsible for setting up all their third and fourth year clinicals by themselves since the school does not have a contract with any US hospitals. The first hospital I did clinicals in CLOSED three weeks after I got there. I ended up doing clinicals in a horrible hospital that charges FMG's $300/week but really doesn't train anyone. My USMLE scores on Step 1 and 2 are average at best. I entered ERAS a few years ago in the hopes of getting a Pathology residency. I did not match and did not find a position through the Scramble.

I was told to reapply to ERAS the next year and pretty much give up on a career in Pathology. I was advised to just take "any residency" and then try to transfer into Pathology after I pass Step 3. I applied to Pathology and Family Practice programs and matched in Family Practice in March 2007.

As part of the Family program, I rotated through Pathology and was told that if I really wanted a career in Pathology, I should do another one month rotation in Pathology in a "lower tier" program that might accept me. I've done three years of Neuro research and have worked in Path related fields before going back to med school, so I come across a lot better in person than my USMLE scores would lead people to believe.

I was dismissed from the Family Practice program after four months because I was too slow in seeing patients. I was miserable there anyway and was happy to leave. A month later, I got a one month "observership" with a nearby Path program. I loved the place and they said they "would love to have me." They told me they would offer me one of their residency positions that they were going to hold outside of the Match, so I did not enter the 2008 Match this March.

Last week, they told me that their Medical Education Dept. declined their request to give me a contract because of some rule that I had never heard of before.

Apparently, by starting my residency career in Family Practice (a three year program), the federal government will only reimburse my residency training for three years, so the Path program that accepted me would not be reimbursed completely for my four years of training...and since the hospital is going through financial difficulties laying people off, they decided they couldn't accept giving a contract to someone without getting full reimbursement for the whole four years that I would be there.

So if I had never taken the residency in Family Practice that I really didn't want in the first place, I'd be a happy first year Path resident now. Instead, tomorrow I have to start scrabling to see what unfilled positions in Pathology might be left...which I'm sure will be none since the Scramble started two months ago. So I'm looking at another year off and the 2009 Match to get back into Pathology.

The advice I'm getting now is to find other low tier programs that will allow me to do a one month "observership" in the hopes of getting a position through next year's Match. I'm also being told to give up on Path because it is too competitive for my USMLE scores and go back to another Family program. I don't want to do Family Practice.

I'm currently studying for Step 3 and working outside of medicine to pay my bills. I'm hoping to get a few more LoR's from the Path program that wanted me but couldn't take me...but I really don't know where to turn to next.

Anyone got any advice?

Anyone know of a low tier program that would take a look at me doing an "observership"?
 

Matte Kudesai

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the federal government will only reimburse my residency training for three years, so the Path program that accepted me would not be reimbursed completely for my four years of training...and since the hospital is going through financial difficulties laying people off, they decided they couldn't accept giving a contract to someone without getting full reimbursement for the whole four years that I would be there.
This part does not make sense. From my understanding reimbursement is for a position in a residency program. Regardless of the individuals background if a residency program is approved for a spot it will be reimbursed. This should hold true regardless of an individuals situation.

If this is an approved established position, the hospital can give it to anyone that has the credentials. Lots of people change fields. I have never of this being an issue before. Did they offer you a contract? Who offered you this outside of the match position?

Unfortunately it is becoming increasingly evident that someone's word is practically worthless. If you really want to do pathology.. Try and complete your application.. All steps etc. Work hard for a strong path letter if possible and definitely go through the match casting a wide net. If anyone offers you anything outside of the match make sure it is official.
 

Path or bust

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This part does not make sense. From my understanding reimbursement is for a position in a residency program. Regardless of the individuals background if a residency program is approved for a spot it will be reimbursed. This should hold true regardless of an individuals situation.

If this is an approved established position, the hospital can give it to anyone that has the credentials. Lots of people change fields. I have never of this being an issue before. Did they offer you a contract? Who offered you this outside of the match position?

Unfortunately it is becoming increasingly evident that someone's word is practically worthless. If you really want to do pathology.. Try and complete your application.. All steps etc. Work hard for a strong path letter if possible and definitely go through the match casting a wide net. If anyone offers you anything outside of the match make sure it is official.
Believe it or not, this is a medicare GME rule when changing fields. They will only fund the years your previous residency amounted to. So if he was in familypractice they will only fund 3 out of his 4 years in path. Makes no sense to me.
 

paleman

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This part does not make sense. From my understanding reimbursement is for a position in a residency program. Regardless of the individuals background if a residency program is approved for a spot it will be reimbursed. This should hold true regardless of an individuals situation.
not true medicare pays for only 1 residency per individual. you can change residency after 1 or 2 years depending on your situation - if they are telling you they will not fund your path residency you could have a very hard time finding one anywhere.
 

Matte Kudesai

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not true medicare pays for only 1 residency per individual. you can change residency after 1 or 2 years depending on your situation - if they are telling you they will not fund your path residency you could have a very hard time finding one anywhere.
People switch residencies all the time. How are they getting funded if this is true?
 

Cloaca

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Believe it or not, this is a medicare GME rule when changing fields. They will only fund the years your previous residency amounted to. So if he was in familypractice they will only fund 3 out of his 4 years in path. Makes no sense to me.
I believe this is true - I was told about it as a medical student. That the government only pays for you to do one residency, and that is the number of years you get funded for, whether you stay in that program or not. So a person going from a 3 year to a 4 or 5 year program has to be funded by the hospital/department entirely. People do change all the time but perhaps larger hospitals can afford to "absorb" the difference? I'm not sure how that works.
 

DrGregoryHouse

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My student affairs office was crystal clear on this. I'll try to explain...


When you match the government allocates a certain amount of money based on the number of years of your program. Examples:
  • FP = 3 yrs of funding
  • Surgery = 5 yrs of funding
  • Pathology = 4 yrs of funding
Switching (or more accurately starting over) does not affect your number of yrs of funding. Examples:
  • Start in FP, you have 3 years of funding. You've already used 1. So you have 2 left. Pathology is 4. You are 2 short.
  • If you had started in surgery, you have 5 years of funding, you would have used 1. You would have had 4 left. You are safe for full 4 years of Pathology funding.
There is another rule. Categorical versus Preliminary programs. If you do a preliminary year, it does not count to your funding. So a 1 year preliminary internship in internal medicine and you can try for a rematch with new funding. But a 3 categorical year internal medicine program you cannot get more funding (Though I'm not exactly sure if there is an exception for Path because it does not require an internship, but I don't think it would make a difference). Example:
  • One preliminary year program in IM, rematch into path = safe for full funding in any program
  • Three categorical year program in IM, rematch into path, switch after one year = you do not get more funding than you were originally allotted

I hope this was helpful, it's late and I'm burnt out from studying. You should be really pissed off at your med school for not telling you about the funding situation and encouraging you to do a preliminary year.

PS: Do you think the family practice people just fired you because you were planning on leaving their program anyway?
 

Path or bust

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not true medicare pays for only 1 residency per individual. you can change residency after 1 or 2 years depending on your situation - if they are telling you they will not fund your path residency you could have a very hard time finding one anywhere.

I think what the OP is saying is that his program is in a position where they cannot absorb the cost of having to independently fund (which many institutions do) years that are not covered by medicare funding.

Here is a direct link from the AAMC Medicare GME funding book:

http://www.aamc.org/advocacy/library/gme/dgmebroc.pdf

What is considered an initial residency period, and
when does it begin?
The initial residency period is the minimum number of years
in which a resident is eligible for specialty certification. It is
based on the minimum accredited length listed for each spe-
cialty in the Graduate Medical Education Directory (sometimes
called the Green Book), published by the American Medical
Association (AMA). The initial residency period is determined
at the time the resident first enters a training program and
does not change, even if the resident later changes special-
ties. For this reason, it is very important that you understand
that the residency program in which you begin training de-
termines the number of years in which Medicare will make
full direct graduate medical education payment to the hospi-
tal for your training
. The Medicare program has published a
list of specialties and initial residency periods, which may-be
found in the Appendix. Except for geriatrics and preventive
medicine, all subspecialty training is beyond the initial resi-
dency period, and each FTE is counted as a 0.5 FTE.
If you started your residency training before July 1, 1995,
your initial residency period is counted differently. It is the
minimum number of years required to be eligible for board
certification plus one year. Regardless of when your training
begins the initial residency period may not exceed 5 years


Does training time for which Medicare does not pay
count against my initial residency period limitation?
Yes. It does not matter whether or not Medicare makes any
payment towards your training. All training time that counts
towards certification in a specialty is counted against your
initial residency period for purposes of determining Medicare’s
DGME payment. So even if you completed a residency pro-
gram that Medicare did not support, any training which you
may wish to do later will be considered
 
OP
F

FormerEyeGuy

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Hey Dr. House

Thanks for your input. I never heard of this rule before it bit me. One of the problems coming from a Caribbean med school is the lack of support and information/advice/guidance you get regarding your career decisions. Sadly, this one has proved costly. I'm not pissed at the school. I'm more pissed at myself.

As for the Family program...I was one of four first year residents in that program (with 6 first year spots) that either left or were dismissed in the first six months of joining the program. The program does not really train residents as much as they want them to work. I was never put on probation or anything like that, and I was never given anything written regarding my dismissal. I was happy to leave, as were the rest of the first years that left.
 
OP
F

FormerEyeGuy

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The Path program that planned to offer me a contract already had two Family Practice transfers in it...so I suspect this added to the unhappiness the Med Ed Dept had with the Path Dept...and their decision not to offer me a contract.

The Program Director and other attendings that I interviewed with, I believe acted in good faith regarding the position they said was mine. It was the decision of the hospital's Med Ed Dept later that vetoed my getting the contract.

Does anyone know where I should turn next? I really want to do Pathology.
 

Path or bust

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The Path program that planned to offer me a contract already had two Family Practice transfers in it...so I suspect this added to the unhappiness the Med Ed Dept had with the Path Dept...and their decision not to offer me a contract.

The Program Director and other attendings that I interviewed with, I believe acted in good faith regarding the position they said was mine. It was the decision of the hospital's Med Ed Dept later that vetoed my getting the contract.

Does anyone know where I should turn next? I really want to do Pathology.
Since you are a US citizen, have you considered the military? They would fund your 4 years independent of medicare. The funding issues you are in now would be obsolete. However, I don't know that they guarantee that you will get pathology. In general, they have been good in the past. I only mention this because you state that you really want path.

Another option is to contact individual programs and see if they can fund you. Some departments are just loaded and will have no problem taking you on, others not so much. The worst thing they can say is... no.
 
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FormerEyeGuy

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Since you are a US citizen, have you considered the military? They would fund your 4 years independent of medicare. The funding issues you are in now would be obsolete. However, I don't know that they guarantee that you will get pathology. In general, they have been good in the past. I only mention this because you state that you really want path.

I would love to join the military and get funding for residency but sadly, I am too old for the military. Thanks for trying though.
 

jux

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AP only or CP only? More likely AP of those two because it is less of a strain for the program...

edit: AP only is 3 years.
 

LADoc00

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holy crap...
my advice would be to take a deep breath and calm yourself.
The best backdoor avenue to path residency is basic sci research, assuming you like doing it.

I dont know what your financial sit is, could be very ugly.

Gluck
 

Ziehl-Neelsen

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Since you are a US citizen, have you considered the military? They would fund your 4 years independent of medicare. The funding issues you are in now would be obsolete. However, I don't know that they guarantee that you will get pathology. In general, they have been good in the past. I only mention this because you state that you really want path.

Another option is to contact individual programs and see if they can fund you. Some departments are just loaded and will have no problem taking you on, others not so much. The worst thing they can say is... no.
Just to clarify a few things...

The military's residencies are reserved for those individuals who accepted the Health Professions Scholarship (which is granted only to students attending accredited US medical schools) or graduated from the Uniformed Services University of Health Sciences. These individuals apply to match in their desired specialty with the majority finding spots within the military's GME program and a smaller group completing residency at civilian programs; the military obligation is then repaid after residency.

Although the military does grant many age waivers, I am sorry to have to tell the OP that he would not be able to procure a pathology residency through the US armed forces.
 

xanthines

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Really? What about that other thread on the Air Force residency thing?

-X

Edit: It's the Air Force Sponsorship Thread.

Just to clarify a few things...

The military's residencies are reserved for those individuals who accepted the Health Professions Scholarship (which is granted only to students attending accredited US medical schools) or graduated from the Uniformed Services University of Health Sciences. These individuals apply to match in their desired specialty with the majority finding spots within the military's GME program and a smaller group completing residency at civilian programs; the military obligation is then repaid after residency.

Although the military does grant many age waivers, I am sorry to have to tell the OP that he would not be able to procure a pathology residency through the US armed forces.
 

exPCM

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Additional GME funding infrormation:

Basically, Medicare generally does not fully reimburse a hospital for a resident who is doing a second residency after completing their first residency. A hospital usually only gets 50% of the reimbursement for a second residency. This means that many hospitals will not accept a resident for a second residency, especially when there is an almost endless supply of FMGs wanting to do a first residency for which the hospital will receive 100% reimbursement. The link below explains the situation in more detail.

http://www.ama-assn.org/ama/upload/mm/16/repga99.doc

I suggest you look at institutions which are doing well financially for which the funding issue may not be as critical. Good luck!