Matching Again? Any Help Appreciated

[redemptionMD]

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Hello everyone,

I've been a fan of SDN for many years and have lurked in Cyber-space gaining insight from everyone's residency posts...Now, I figure the time has come to reach out formally for help.

My brief biographical sketch: I've taken a lot of lumps in Medicine because, I finally belatedly realized, I gravitate towards a nurturing learning environment, which oftentimes isn't practical, I realize. I've stuck with it over the years because I similarly really do care about reaching people and helping them, and after some detours, realized a few years back that Primary Care is the place to do it...

Now, educationally, I'm an AMG, graduated and got my MD from a relatively middle-echelon state school (nothing either too fancy or highbrow), 2007. I got straight in after a BS/MD program, so transition to clinical years was pretty tough...MS-III was marked by potholes, and I had to repeat two clerkships and even take a medical leave of absence...but graduate I did, and straightaway matched to my first choice of Psychiatry programs. To help me, I thought, figure out via the proxy of patients, why we tick the way we do.

While the first couple of months were smooth, I soon became aware that I was just. no. good. with acutely disturbed patients. The psychiatric ER rotation month ended any aspirations I had had to become a psychiatrist, because I just couldn't handle that pathology (although, to whatever degree I was exposed to it, I grooved on the outpatient therapy end of the spectrum). To my not-surprise, I started to stumble, and long story short, by February of the PGY-1 year I was told by PD that I wasn't getting to PGY-2, although he kept my contract going and me plugged in so that, at least on paper, I'd have a full PGY-1 year (I worked as his research assistant for 4 months on a project he had going, until the end of the year). He could have just let me go, with only 8 months on the books. We parted on relatively good terms, with him actually extending an offer to me to re-interview should the stars align again.

PD provided a lot of professional and emotional support in the interim, and after a lot of soul-searching, I realized I'd get a lot of that continuity satisfaction, without some of that Psychiatry nebulousness, in primary care. So, long story short, I took and passed USMLE Step 3 within the 7 year window, although I did have to take it twice, and with a underwhelming score the second time around (time out from clinical medicine while a Psychiatry resident). I reached out here, there, and beyond, and long story short, after multiple primary care observerships and externships, and 2 subsequent Match cycles, I again Matched back into my first choice of Family Medicine programs.

In 2011, I started and successfully completed my PGY-1 and technically all of my PGY-II in FM. However, I wasn't promoted to PGY-III, for a number of reasons, including difficulty assuming a leadership role (overnight senior, Code Blues, etc), difficulty maintaining focus due to certain knowledge base and psychological issues (difficulty coping with intense/stressful situations), and a generally underwhelming performance as a 2 (although the feedback that I've gotten is that interpersonally, I engender the warm-and-fuzzies, so to speak). After remediation, I tendered my resignation as a face-saving gesture to avoid contract non-renewal, and left the program in 8/13.

Once burned, twice shy; twice burned? ...I've spent every day since then examining my soul under the light of the harshest questions one could ask myself, and the answer has still been: Yes, I want to be in Medicine. I can't explain why, but I have this burning desire to heal people. It actually guts me when I see people deteriorate (a real reason why Codes were never my "thing", psychiatric or otherwise). So, I'm willing to do whatever it takes to "make it".

In the time since August, I've re-located to be closer to family; gotten licensed; hooked back up with my kindly old local FM mentor for 4 months, who basically taught me how to be a good doctor from scratch through service as his "junior colleague" as it were; gotten into the teaching fold (teaching/SPing for FMGs prepping for the USMLE Step 2 CS--critical thinking, differentials, thought process, physical examination skills, etc); re-certed ACLS and trying to gain mastery and instructor status; have been working locally in a GP capacity in a multispecialty office for going on 4 months, doing general adult primary care; and have intercurrently been shadowing Rounds in the local MICU (with an option on turning that into an "audition rotation" so to speak, in the near future) because I want to get comfortable with the acutely ill. I spend as much leftover time as I have (I would estimate 85%) reading, keeping up-to-date. I also have a sympathetic ear in the form of letters and potential letters from the attendings or attending colleagues I've crossed paths with, post-2013.

My question is: do I have ANY chance, no matter HOW remote, of re-Matching somewhere and completing a primary care residency? ...I am aware of all, if not most of the practicalities involved (I can save that for a later post). Or is it a lost cause? My choices at this point would still be Family Medicine; or, depending upon transferability of experience, general Internal Medicine.

I also want to mention that the backdrop of all of these failures was a severe, and initially un-diagnosed, chronic illness that hit worst during FM PGY-1. But leaving that aside...

Humble thanks for any honest critiques, here.

 

[Law2Doc]

So you had to repeat some clinical rotations, had a failure on step three, two residency washouts (including a resignation after already not being promoted) and a self proclaimed psychological issue with difficulty coping with intense/stressful situations. that's a lot of red flags. Honestly it kind of sounds like places were already willing to give you your second and third chances, so you might be pushing it looking for a fourth.

If your psych PDs offer to reinterview you still stands you should take it. You might want to start looking at those threads on SDN asking what you can do with a license but no residency, because frankly based on your history stemming all the way back to clinical rotations, the wards maybe aren't the right place for you.

 

[QofQuimica]

I don't think any of us can answer your question. You need to reach out to some family med PDs and see what they say. But I have to agree with L2D that maybe clinical medicine isn't your bag....would you consider something nonclinical like preventative med?

 

[NotAProgDirector]

I think it's going to be a serious challenge. You've had problems at all levels -- medical school and both of the residencies you've started. Your best chance would be a spot back in FM or psych. I believe FM requires that the last 2 years be at the same program, so you'd be starting back as a PGY-2 again. I think your chances in IM are minimal. Here's the biggest issue in my view: you failed out of two prior residencies because of difficulty with knowledge and anxiety / difficulty in stressful situations. What's different now that changes that?

If you're working as a physician, you might be best off trying to solidify that. Perhaps you can build a career working with someone else without completing a residency.

 

[Shikima]

Have you considered PM&R? I don't know much about it but it's possible that might be a bag to look into? Also, consider going to talk therapy for those "stuck points" you've got going on.

 

[Law2Doc]

Have you considered PM&R? I don't know much about it but it's possible that might be a bag to look into? Also, consider going to talk therapy for those "stuck points" you've got going on.

PM&R requires a prelim year first -- i don't know if anything the OP has done so far counts much toward that and frankly a prelim IM or surgery year isn't going to play to OPs strengths.

 

[Shikima]

PM&R requires a prelim year first -- i don't know if anything the OP has done so far counts much toward that and frankly a prelim IM or surgery year isn't going to play to OPs strengths.

Thanks for that update. I agree that it would be difficult, however, the latter suggestion would be helpful in overcoming the weak areas lending himself to success.

 

[mercaptovizadeh]

I hate to be blunt, but based on your story I just don't feel that clinical medicine is your thing. You can give it another go, but I would advise you to first figure out how to deal with the issues that seem to have caused you so much trouble the first two times. These seem to be knowledge deficiencies and dealing with stressful/acute situations. Formulate a plan to deal with these things (and the issue with stressful/acute situations may in fact have something to do with the knowledge deficiencies) and only then try to go back into clinical medicine.

 

[Raryn]

Thanks for that update. I agree that it would be difficult, however, the latter suggestion would be helpful in overcoming the weak areas lending himself to success.

The FM year(s) would probably count towards a prelim year. At least on paper. If he got credit for the time.

 

[redemptionMD]

Hello all,

Thank you for the multitude of opinions.

I cannot deny that I'm not the most convincing candidate on paper. I have, however, meditated on the feedback given to me in each instance, and while I don't expect the world to hand me another chance on a silver platter, I'm willing to work my hardest to rectify any deficiencies I have.

When I left my Family Medicine program, my faculty advisor, although he agreed with the concerns other faculty had, also exhorted me to "keep working at it...my God, you were 'getting there'; we just ran out of time." I have taken that to mean I have potential.

While it's an ongoing process, I have worked steadily to remedy my weak points. Concrete steps I have taken are to: solidify my skill set in stressful/urgent/emergent situations, by becoming more proficient at managing critically ill and dying patients. I've re-certified ACLS and plan to use those skills during my time in the Critical Care world, during which time I'm planning on following as many MICU patients as possible (should I be able to convert my observership into an actual elective experience). I have drilled my ACLS competencies over and over, and they are fairly automatic at this point. I even have the chance to become certified as an instructor. One potential way I can maintain these abilities is to volunteer my time with the community ambulance corps, which would be made up of other volunteers like myself.

I've been teaching and tutoring junior medical students in diagnosis, critical thinking skills, and developing differential and plans. This forces me to deploy my own skills, in those areas. I learn most from what I don't know. I am finding that as I learn more, old blocks are disappearing and I'm coming up with new skill sets to acquire. Such is the process of growth.

I've probed my mentors' minds for insights into their thought process when they're working up patients. I have come up with not just that, but stories of their own defeats and struggles while training. I want to keep going.

Finally, I've functioned in an independent capacity at my clinic for close to a quarter now. While I generally see routine, outpatient disease processes in my patients, there are always the unpredictable cases that require me to be on "my toes." In four months, I have sent about 10 patients to the ER (for varied things like MI presenting with atypical symptoms, mild pancreatitis, COPD/asthma exacerbations, opiate overdoses, anaphylactic reactions, alcohol withdrawal with GI bleed, etc). I generally expect stable, routine cases when I come into work, but of course, constantly reviewing differentials in my head. I would argue that it takes some clinical insight to be constantly prepared to expect the worst.

I would also note that transitioning from not-great med student/resident to fully functioning generalist physician was no easy task. I am actually proud of the progress I've made over the last 10 months. I thank God for the chances I have been given. But, I would definitely be remiss, if I took myself for granted and didn't push myself further, as you all seem to be suggesting (I appreciate that).

I grab every chance I get to stop and read more about clinical cases. I am considering going to the September AAFP Board Review course in Chicago for Family Medicine.

On a personal level, I've been placed on medication and am working through "mental blocks" with a reputed therapist, as Shikima suggests. I've worked on "being more fully present" via Eastern techniques like meditation. I exercise not daily, but regularly, to improve my health and my spirits.

I actually look forward to the challenging scenarios I encounter almost daily, because it enables me to push past my pre-existing skill set and boundaries, and increase my level of personal responsibility. I consider this God's way of teaching me how to succeed through deep adversity.

Please, do continue to tell me how I can develop the attitudes/skills that would allow me to be successful clinically. I do not pretend to have it all figured out. And I also do not lack for insight. If this is God's way of telling me through SDN that I should not practice clinically, I accept that as my destiny. However, at the moment, I believe I can still change my destiny.

Humble thank-you's all around.

 

[redemptionMD]

"While the patient's prognosis may be grim, I do not believe it is terminal, at this time."

 

[NotAProgDirector]

The longer you wait, the harder it will be.

There really isn't anything more that you can do -- you've gotten personal help, you're on medication, you are clinically active with a full license and are doing well.

Your best chance moving forward is another FP position. Options include:

1. Your old program. Sounds like you left on good terms. If they have a PGY 2/3 drop out, maybe they will take you back?
2. A new program. As mentioned above, I believe this requires restarting your PGY-2 although I may be incorrect about that.
3. Continue to build your career as is.

You may need to be very flexible regarding where you train. Best of luck!

 

[redemptionMD]

Thank you, aProgDirector. I value your insights.

As I mentioned in my first posting, I am fairly comprehensively aware of the practicalities involved. Family Medicine is my "go-to" because I enjoy it (still), and because it's now a"known quantity." I am aware that it does require me to repeat my PGY-2 year. I do wonder, if I might not be an asset to the program in that respect, having acquired my "sea legs" in the real world, and subsequently repeating a PGY-level I have actually already done (albeit not getting credit for successful completion). Feel free to "reality check" me if I'm wrong. However, I would also be willing to entertain Internal Medicine, and I was wondering if you could clarify your assessment of THAT as "minimal" (am I missing something fairly obvious?)

I am aware of funding implications.

As to some of the other helpful comments put on the table: Yes, I am aware of, and also enthusiastic about Public Health/General Preventative Medicine. My understanding is that it can be undertaken as either a residency (after a PGY-1) or a fellowship. My desire would be to tackle a clinical residency first. (Prior to my successful Family Medicine Match in 2011, I had completed the first semester of an MPH program--yet rotation-wise, have not had any PH/GPM experiences, although I do have a contact in the field whom I am considering reaching out to).

I am aware that the longer I wait, the harder it will be. I had similar thinking prior to my 2011 Match...this is why I am reaching out, now.

I considered PMNR, but have no strong inclination towards it, transferability aside.

It's interesting, the idea about "building my career as is." My current assignment as a GP has me working in an office seeing a high volume of complex patients--hence greatly augmenting my learning curve--but financially, our Department is not doing well and may close (through no personal reflection on my abilities). I am valued and respected in the Center, and just yesterday, the Boss asked my what my long-term goals are and re-iterated that he is hoping for a long, prosperous collaboration together. Moreover, our Department is a close-knit one, and I have some supervisory responsibilities to one adult NP. The third member of our group is a Board-certified Internist, whom I have taken into my confidence, and is genuinely supportive of me and has given me quite positive feedback (the worst he's ever said is that I've made some "rookie mistakes" that come from being young in the profession, and a function of limited independent experience--not incompetence, and my patients have done well).

Yet I can't help but feel that I need to learn more. Hence, training.

What would be the best way of acquiring knowledge and filling in the potholes?

Lastly, I feel compelled to point out that health issues seriously impacted my ability to perform at a high level. I did not receive a diagnosis until my PGY-1 year in 2011. I am wondering if it should be mentioned at all. I do know that the ABFM has a clause stating that inter-program transfers beyond the PGY-1 level are possible with proper documentation of catastrophic but temporary illness. My treating specialist has agreed to provide such support and documentation--but only, of course, if that is even relevant. I do not wish to "pass the buck" of responsibility onto this when I was simply subpar.

I am accepting responsibility for my poor performance.

Thank you all, again.

 

[Shikima]

There is self critical, and then there is being self critical. Improving "rookie mistakes"? Be active in the clinical environment... see more cases. If I were a betting man, the approach with mindfulness training with your therapist may be the wrong direction and looking at self-doubt and negative esteem with the second guessing that persistently arises as a common theme would be more helpful.

 

[redemptionMD]

Thank you, Shikima. I am working on all of those issues.

 

[BlondeDocteur]

I think you've done a lot of soul-searching and sound mature and reasonable about your situation. It seems like high-pressure, high-acuity situations just aren't for you, fundamentally and psychologically, and for the most part every single specialty will have those.

I think the absolute best option for you would be Occupational Medicine. You've already completed two internships and a PGY-2 so you've met the baseline requirements. If there are ever emergencies in Occ Med they must be rare as hen's teeth. You can actually have a comfortable lifestyle, stay connected to patients, and avoid all of the stress which has caused you to fail.

 

[redemptionMD]

Thank you, BlondeDocteur. I am a fan of Scrubs. 🙂

Can you comment in more detail about Occupational Medicine? ...When I left my second program, I had a multitude of conversations with attendings and faculty who were still supportive of my continued forays. One wise OB/GYN had mentioned Public Health/General Preventative Medicine, which might cater to my strengths, and which she had herself done. After meditating upon that for many months, I decided that that would be a great parallel track, especially given the nature of my pre-existing medical situation. I can easily see the "segue" into that field (hence, my thought about approaching a contact in the field for experience). I even have a well-thought out, PH/GPM Personal Statement already written out (and had done so way back in December) for that purpose. Naturally, I also have a "re-entry" Personal Statement already written out for Family Medicine.

Is Occupational Medicine a facet of that same coin? I am under the impression that it is. And, I appreciate those who have pointed me to that arena.

But...and this is a big but...I can't help but feel that I should try to attain a clinical Board certification. To do that means finishing what I've already started. I actually do enjoy clinical work. Even though it may not be one of my strengths, is there not logic in trying to correct those weaknesses? I am trying so hard... 🙁 ...In fact, I just got back from one of my weekend tutoring sessions. I have a tendency to doubt my own progress, but I look back at where I was one year ago, fresh having left residency, and I feel proud of what I've accomplished essentially on my own in 11 months. I have had to nurture my own dream on my own for a long time, and didn't have anyone cheering me on during residency.

Again, my understanding is that PH/GPM can be done at the fellowship level. *After* a clinical residency. While I think I'm a lot more savvy as a result of my post-2013 clinical experiences, and *definitely* much motivated, I suppose I'm thinking of PH/GPM currently as a bit of a "fallback option." Also, I fear that jobs in that field may be hard to come by.

I suppose what I am saying is that, although I had never considered it until the topic had been broached, and I can see 1) how it might suit me, and 2) how I might become a great leader in that field, it still seems like "second favorite." Another question is, if Boarded in PH/GPM, can I still see patients under the conventional insurance-driven paradigm?

I am going to look into PH/GPM/Occ Med further, and see if I can approach any real-life practitioners. I appreciate that advice. I do.

I will keep everyone posted. Thanks all, for the genuine attempts to help me.

 

[BlondeDocteur]

Occ Med is a boarded specialty that can only be entered after the successful completion of an internship (though they often like 2 years of training, which you have). It's similar to GPM except the focus-- surprise!-- is on occupational health. They can do anything from assessing radiation safety for nuclear workers to giving executive physicals.

If you go that route, you could potentially have something resembling a primary care continuity clinic.

Here's a randomly selected program to get you going:

http://deohs.washington.edu/oem

 

[QofQuimica]

I'd argue that getting boarded in something is better than getting boarded in nothing. So why not apply for both FM and PM? No law saying you can only apply in one specialty, and you'll have the benefit of being able to explore both options simultaneously, hopefully resulting in a successful match.

 

[redemptionMD]

Hello all,

So, over the past few weeks I've completed the preliminary steps in doing my ERAS application (I have to squeeze things in because I am wearing several hats simultaneously). Demographics, educational history, USMLE transcripts all ready to go. Personal statements uploaded. Working on the LOR piece.

Does anyone know if I can apply to a Family Medicine PGY-2 through ERAS? The program websites I've perused all indicate their process is outside the match. Is this generally true or am I missing something in ERAS?

Thank you all again and God bless.

 

[BlondeDocteur]

ERAS is for PGY-1 only, except in the case of Advanced residencies which require a separate internship (radiology, some anesthesia, some neurology, radiation oncology, dermatology, ophtho). You can only find PGY-2s in FM outside of the match, and you apply like for any other normal job.

 

[redemptionMD]

Ah...but don't Public Health/General Preventative Medicine and Occupational Medicine start at the PGY-2 level? Don't I use ERAS for them?

Thanks.

 

[BlondeDocteur]

Yes-- they are considered Advanced residencies.

 

[redemptionMD]

Hello kind people of SDN,

I wanted to reach out again for further advice. I've definitely regained enough confidence to give residency applications another shot. That said, I've approached one-off clinical PGY-2 positions in Family Medicine in the usual fashion for a person in this situation.

I have full understanding of how tough this has been. That said, I've gotten some feedback from programs with vacancies that have rejected me in terms of why I was not selected. The idea seems to be that, as someone who had completed but not received credit for his PGY-2 in Family Medicine, I'd need to repeat both that year and advance to PGY-3 as per the rules of ABFM. (This is the only way I'd qualify to sit for the Board exam). However, having only one year left of funding, I'm told that I would need to seek a program that doesn't require "federal funding" (i.e., CMS).

I've been aware of the practical issue regarding funding (DME + IME) from Day #1, so hearing so was no shocker to me. My question is: realistic as I am about the small chance of finding such a program, how would I go about finding out which programs don't require funding from federal sources? My understanding is that there have to be such programs there, even if they aren't in the vast majority. I know of individuals who've made the jump even though the funding wasn't readily apparent. Is there a way to narrow my search parameters to programs that A) have a PGY-2 vacancy; and B) aren't as dependent upon Medicare funding? Would I be able to market myself to those programs?

Finally, BlondeDocteur's advice has been well-taken. Considering the practical issues preventing me from completing a clinical residency, of late the idea of doing an Occupational Medicine residency have begun to resonate with me. I've researched the topic, and have a fair to moderate understanding of what the specialty's all about "on paper" and am approaching certain people starting next week to discuss their experiences of it. My understanding of the field is that it's an area that I may succeed in with reasonable competence, which caters to my existing strengths and clinical training, perhaps avoids the pitfalls and weaknesses that I've had thus far, and provides the opportunity to work in sectors of the economy that were not as apparent as in clinical medicine. I believe I'd be a marketable candidate in this field, and it's my understanding that the Season just opened up this week...

Further thoughts appreciated.

 

[ThoracicGuy]

Hello kind people of SDN,

<snip>

I've been aware of the practical issue regarding funding (DME + IME) from Day #1, so hearing so was no shocker to me. My question is: realistic as I am about the small chance of finding such a program, how would I go about finding out which programs don't require funding from federal sources? My understanding is that there have to be such programs there, even if they aren't in the vast majority. I know of individuals who've made the jump even though the funding wasn't readily apparent. Is there a way to narrow my search parameters to programs that A) have a PGY-2 vacancy; and B) aren't as dependent upon Medicare funding? Would I be able to market myself to those programs?

<snip>

Just as a clarification, going over your limit doesn't mean they get zero money, just a decreased amount. For most programs this won't be an issue. This could be a way a program lets you down easy.

 

[PMR_doc]

Sorry to hijack the thread, but given the discussion of switching and what not, I wanted to ask a follow up question. I am hoping to switch residency programs, not fields, due to location issues. My school is telling me that they don't send stuff to programs directly and that I have to apply through ERAS which is not what I want/can do as these programs are not going through ERAS. How else can I do this?
I have contacted a few programs that seem to have open spots but have not heard back. Should I assume they are not interested or that they are reviewing apps or what? I applied recently.

Can I request my dean's letter/med school transcript and send it directly? Can I otherwise make up an app through ERAS and the program can download stuff even though they are not going through ERAS?

Any help/advice would be helpful.

Also regarding the OP's thread - I agree 100% with BlondeDoctour, I think occupational med is the way to go. Decent schedule, few to none emergencies, and the residency itself is probably the most relaxed possible residency ever.

The longer you wait, the harder it will be.

There really isn't anything more that you can do -- you've gotten personal help, you're on medication, you are clinically active with a full license and are doing well.

Your best chance moving forward is another FP position. Options include:

1. Your old program. Sounds like you left on good terms. If they have a PGY 2/3 drop out, maybe they will take you back?
2. A new program. As mentioned above, I believe this requires restarting your PGY-2 although I may be incorrect about that.
3. Continue to build your career as is.

You may need to be very flexible regarding where you train. Best of luck![/QUOTE

 

[dozitgetchahi]

How bout pathology?

Totally different work environment and none of the 'acute care stress' that seemed to cause you problems (not that there isn't stress - there certainly is - just of a different sort that may be more manageable for you). It's also not especially competitive and no prelim year is required.

 

[gutonc]

I've been aware of the practical issue regarding funding (DME + IME) from Day #1, so hearing so was no shocker to me. My question is: realistic as I am about the small chance of finding such a program, how would I go about finding out which programs don't require funding from federal sources? My understanding is that there have to be such programs there, even if they aren't in the vast majority. I know of individuals who've made the jump even though the funding wasn't readily apparent. Is there a way to narrow my search parameters to programs that A) have a PGY-2 vacancy; and B) aren't as dependent upon Medicare funding? Would I be able to market myself to those programs?

"It's not you, it's me."

Heard that before? If not, you've lived a really blessed life in the relationship department. But now you have heard it, apparently from several different "people".

They are correct that you'd have to complete 2 full years (at least) at a new program, that's an AAFP requirement. But the "funding discrepancy" is on the order of $20-30K for your final year. Do some programs really not have that money? Of course. But most of them are just trying to give you an ego sparing reason for their "no".

The answer to your actual question is "no", there isn't really a way to find those programs. Outside of Peds programs, I'm not familiar with any that don't, in some way or another, rely on CMS funding for their residents.

 

[redemptionMD]

Hello,

Thanks for the replies thus far.

Thus, 3 things:

1) "It's not you, it's me." OK then. Then speaking as objectively and unemotionally as possible:

I've been wearing my "big-boy" pants for quite a while now. Successfully. The fact of the matter is, I get more solicitations from recruiters based upon the strength of my post-residency credentials (most of whom can do nothing because of the block) than I do interest from residency programs (because of their own prerogatives).

If I were arguing I'm unenviably perfect and I didn't need to check my ego at the door, then there would be no reason for me to consider further clinical training. However, with my life experience now, I can confidently declare that I obviously have the skill and ability to function well enough on my own, and I'm no longer as beholden to self-doubt.

Taking all of this into account, I find it reasonable to continue trying for that clinical spot.

However, I'm not getting any younger.

Hence:

2) Pathology. Transitional year aside, that's still 3 years of additional training. Aren't we coming up against the same funding issue? That's that $20-$30K discrepancy x 2 instead of x 1, which just makes it a harder sell (plus, I'm not all that sold on it myself).

3) Prev Med/Occ Med. From what I've read it's subsidized by NIOSH, not Medicare. To what degree? Does my last year of funding still come into play, and if so, what's the relative breakdown? True, I'm going to talk to people about this, but if anyone knows offhand, please let me know.

I'm pleased that much of my medical knowledge would be transferable, even though the Occ Med POV is different, and I would get a clean slate.

Thanks.

 

[PMR_doc]

People worry too much about funding. As other people have pointed out, funding is really a non-issue if a program takes you in. Sure SOME programs may not want to deal with someone who may run out of funding but many programs don't care. And if they take you in, you still get a large % of the funding - you MAY not get all of it, but most people do and I know a number of people hwo have switched, etc and have had their programs support them fully. So I don't think that's the main issue with you. Worry about getting into a program first. I think occ med is prob the best- you have done a year, so you would need 2 more which are rather relaxed in this field and it's a rather un competitive field, does not go through ERAS and you may even be able to apply for spots now. Given that it's not competitive they may be more tolerant of previous issues youve had.

 

[redemptionMD]

I also like the idea of the MPH I'd be getting along the way in Occ Med/Prev Med, which is something I'd explored earlier.

 

[gutonc]

People worry too much about funding. As other people have pointed out, funding is really a non-issue if a program takes you in. Sure SOME programs may not want to deal with someone who may run out of funding but many programs don't care. And if they take you in, you still get a large % of the funding - you MAY not get all of it, but most people do and I know a number of people hwo have switched, etc and have had their programs support them fully. So I don't think that's the main issue with you. Worry about getting into a program first. I think occ med is prob the best- you have done a year, so you would need 2 more which are rather relaxed in this field and it's a rather un competitive field, does not go through ERAS and you may even be able to apply for spots now. Given that it's not competitive they may be more tolerant of previous issues youve had.

Just to clarify, if an ACGME program takes you, full CMS funding or not, they have to pay you the same they pay everyone else in your PGY cohort. So they're the ones taking it in the shorts, not you.

 

[redemptionMD]

I like everyone's ideas. As an aside--this is really neither here not there but just yesterday I stumbled across the idea of MROs--medical review officers--which is something out of OEM, but not even materially different from what I've done in my OP practice of primary care, which goes to show the similarities.

(Hell, from what I've read, in theory I could become an MRO now if I wanted, being a licensed MD and all).

 

[PMR_doc]

Technically yes but you i think it makes sense to try and get a residency

I like everyone's ideas. As an aside--this is really neither here not there but just yesterday I stumbled across the idea of MROs--medical review officers--which is something out of OEM, but not even materially different from what I've done in my OP practice of primary care, which goes to show the similarities.

(Hell, from what I've read, in theory I could become an MRO now if I wanted, being a licensed MD and all).

 

[redemptionMD]

Anyone know realistic and accurate salary figures for single-Boarded OEM? Sure, the Internet says one thing, but it's not internally consistent.

Has anyone ever had any practical experience of Molecular Genetics?

 

[redemptionMD]

Technically yes but you i think it makes sense to try and get a residency

Of course, PMR_doc, of course!

 

[redemptionMD]

Every physician I've ever known, from early in intern year onwards, gets a **** ton of solicitations from recruiters.

This says nothing about the strength of anyones' credentials. They go fishing after anyone with an MD after their name.

Fair enough, SouthernSurgeon; as I said, no ego here. But I also know I can do a good job..

 

[Dral]

Every physician I've ever known, from early in intern year onwards, gets a **** ton of solicitations from recruiters.

This says nothing about the strength of anyones' credentials. They go fishing after anyone with an MD after their name.

Yep, I used to get tons of stuff during my intern year for medicine jobs...even though I was going on to Derm residency...they really have no idea who they are sending that stuff to other than the person being a physician. It used to make me laugh actually.

 

[NotAProgDirector]

Sorry to hijack the thread, but given the discussion of switching and what not, I wanted to ask a follow up question. I am hoping to switch residency programs, not fields, due to location issues. My school is telling me that they don't send stuff to programs directly and that I have to apply through ERAS which is not what I want/can do as these programs are not going through ERAS. How else can I do this?
I have contacted a few programs that seem to have open spots but have not heard back. Should I assume they are not interested or that they are reviewing apps or what? I applied recently.

Can I request my dean's letter/med school transcript and send it directly? Can I otherwise make up an app through ERAS and the program can download stuff even though they are not going through ERAS?

You have several options:

1. You can talk to someone higher up the "food chain" at your medical school. If you're applying for positions outside of ERAS, you obviously can't use ERAS to apply for them. If you're applying to a small number of programs, they may be willing to send them out for you. If your plan is to send an application to every program out there, they probably won't.

2. You can ask them to send you a copy. It will be labeled "unofficial" (or something similar) but many programs won't care. Ultimately, if a program decides to offer you a spot, they may want an official copy -- then they can contact your school to get it.

3. You could ask your current program to forward the MSPE that was part of your ERAS application. Note that this is technically against the ERAS rules -- they tell us specifically not to do this. But it happens.

 

[redemptionMD]

Hello again,

Thanks for the new information.

Again, if anyone has clear data on the compensation of an Occ Med MD, that would be helpful to know.

In a general sense; this discussion has me a little bit confused regarding the funding issue. I thought I was well-informed about DME and IME, but let's go back to the basics.

If I were any other fresh MD grad, how does funding work for residency vs. for fellowship?

My understanding is that you get an allocation for residency depending upon what you pick right out of med school; and that for those who successfully finish (in other words, the majority of you out there), any subsequent fellowship is re-imbursed at the 50% DME level.

I realize, with full clarity, that I'm not in a prime position to be counting my chickens, but that said, should I be successful in finishing a primary residency (whether that's a clinical one or the oft-touted Prev Med/Occ Med), I would love to keep open the option of a fellowship.

For clarification purposes: if I were to hypothetically complete a FM residency, I had considered a Sports Med fellowship afterwards. To whatever degree that that's not off the table, if you'll humor me, would any fellowship money (funding) be available for me...or should I just exit with the primary Board certification? I could also foresee doing Occ Med as a FELLOWSHIP under that logic.

Similarly: I'm still hoping someone can answer the question of how Occ Med residencies are funded. What I've come to understand is NIOSH, but how much? Analogously, I could really see myself doing a Clinical Informatics fellowship afterwards, as that really meshes with certain other outside interests I have.

To wit, if a person does Occ Med as a residency, does that draw from Medicare funds or is it all Federal grants? [Where does tuition for the MPH year factor in?] Would I theoretically still have that one year of funding left to use for a fellowship?

One step at a time, of course; and I'll be most grateful to get that primary Boards, of course; and yet this information would be really useful to know.

Or should I abandon the idea of a fellowship altogether? if not possible.

Thanks.

 

[NotAProgDirector]

If I were any other fresh MD grad, how does funding work for residency vs. for fellowship?

My understanding is that you get an allocation for residency depending upon what you pick right out of med school; and that for those who successfully finish (in other words, the majority of you out there), any subsequent fellowship is re-imbursed at the 50% DME level.

You would get 100% funding for the initial residency period (the minimum amount of time it takes to train into your field). After that, it's 50% of DME but 100% of IME.

Read this for more clarity: https://members.aamc.org/eweb/upload/Medicare Payments For Graduate Med Ed.pdf

I realize, with full clarity, that I'm not in a prime position to be counting my chickens, but that said, should I be successful in finishing a primary residency (whether that's a clinical one or the oft-touted Prev Med/Occ Med), I would love to keep open the option of a fellowship.

For clarification purposes: if I were to hypothetically complete a FM residency, I had considered a Sports Med fellowship afterwards. To whatever degree that that's not off the table, if you'll humor me, would any fellowship money (funding) be available for me...or should I just exit with the primary Board certification? I could also foresee doing Occ Med as a FELLOWSHIP under that logic.

You started in Psych. Because of that, you get 4 years of full funding, no matter what you do. You used one year in your Psych PGY-1, and 2 years in your FM residency. So, you have 1 year of full funding left. After that, everything is paid 50% DME / 100% IME. Since all fellowships are paid that way, this is not an issue. It might be an issue for any new primary residency program that takes you, since any year beyond your first will not get full reimbursement. Some programs may not care at all. But smaller commuinty programs without fellowships that are not above their cap may care quite a bit.

Similarly: I'm still hoping someone can answer the question of how Occ Med residencies are funded. What I've come to understand is NIOSH, but how much? Analogously, I could really see myself doing a Clinical Informatics fellowship afterwards, as that really meshes with certain other outside interests I have.

To wit, if a person does Occ Med as a residency, does that draw from Medicare funds or is it all Federal grants? [Where does tuition for the MPH year factor in?] Would I theoretically still have that one year of funding left to use for a fellowship?

Occ Med is completely a different beast. As you point out, it is not funded by Medicare so doesn't count for DME nor IME. Instead, programs fund it either by training grants from NIOSH, or simply out of their own budgets. In any case, your funding situation is meaningless to them. Clinical informatics is all internally funded -- there is no DME/IME so also a moot point. (Some informatics fellowships might have you work 25% to help pay your way)

 

[drkristy85]

You keep asserting that you are supposedly humble, wearing "big-boy" pants, understanding, and "have insight", doing all this "soul-searching", but reading your posts, it is easy to see right through your garbage into your true self. You are over-confident and full of yourself. You keep talking about how proud you are of yourself, and how successful you are. You are not successful. You have failed many times, and continue to do so.

It is hard to want to help someone who is so smug. It would be helpful to hear you explain exactly why you failed before. If you truly want to make it through this and get into a FM residency, then you need to really deflate your ego. Program directors can see through the bull****. You need to tell us exactly what happened. Leave out the excuses about your medical illness and psychological problems. Don't be vague. What actually happened? What did others say about what you did wrong? What did it look like to an outsider?

1. First, your clinical rotations. What were your attendings' comments? Irrespective of why you think you failed, what did they say (on paper evals) regarding the reason of failure? What did you do wrong? were you late? did you have poor attendance? did you fail to do the reading/were not prepared? were you rude to patients? rude to the attending/staff? blow off the rotation? have an attitude of not caring? Why did they choose to fail you?

2. the Psych PGY-1 year. You say you had trouble with the psychiatric ER rotation month because you couldn't handle the pathology. That is very vague. What do you mean by that? What specifically happened? What were your interactions with patients, staff, attendings like?

3. your FM residency. You said you had "difficulty assuming a leadership role (overnight senior, Code Blues, etc), difficulty maintaining focus due to certain knowledge base and psychological issues (difficulty coping with intense/stressful situations), and a generally underwhelming performance". Again, give us the specifics. What happened during the Code Blues? did you fail to act as a leader? What happened when you were an overnight SR? did you slip up on supervising the intern, or slip up on patient care? were you unable to juggle multiple responsibilities? What happened during the stressful situations-exactly?

4. What happened last year? did you apply for the match? it seemed like you had everything ready to go. What happened?


I would like to help you get into a residency. However, until you are 100% completely honest about your failures, it is hard to want to do so. Please be specific in your responses regarding your failures. No BS.

 

[redemptionMD]

<duplicate post; removed>

<full post below>

 

[redemptionMD]

drkristy85,

I was initially taken aback by your response, and thought about asking if I could respond to you privately rather than in a public forum. Being that this is therapeutic, in a way, however, after reflecting on that, I thought better of it, and I'm grateful for the challenge.

So many people have said (in the context of my approaching a barrier to FM vacancies in the form of the funding issue which aProgDirector has shed more light on--thank you), that the trite "it's not you, it's me" response I've gotten from programs is their way of allowing me to save face, so to speak. If that's true, I have to wonder why they'd have any interest in protecting my ego at all. I have to assume that there's something deficient about my application that I need to explore. So here's me being as candid as I can.

You want me to distance myself from any discussion of illness or psychological distress in my responses. I will do so.

"1. First, your clinical rotations. What were your attendings' comments? Irrespective of why you think you failed, what did they say (on paper evals) regarding the reason of failure? What did you do wrong? were you late? did you have poor attendance? did you fail to do the reading/were not prepared? were you rude to patients? rude to the attending/staff? blow off the rotation? have an attitude of not caring? Why did they choose to fail you?"

It's been a little while since I've looked at the performance evals (and I'm assuming you mean med school) and I don't have them in front of me to reference.

That said, I failed my Surgery clerkship by a narrow margin based upon my performance on the Shelf exam. None of the other "red flags" you mentioned apply: I was given average marks in terms of clinical fund of knowledge, interactions with superiors, and the other metrics. I was given a chance to take a makeup exam to remediate the grade, and neglected to change my study strategy (relied largely on the same written sources, didn't seek out extra help from faculty, or utilize any study groups, etc. for example). My score remained the same, and according to policy I had to repeat the clerkship itself to remedy the grade. I did so, after my leave of absence. and I put forth more effort. I spent many more hours in the library studying, I interacted more with faculty to answer clinical questions, and I ultimately boosted by score by roughly 10 points, so I passed).

After finding out I failed my Surgery clerkship, I was already in the 3-month core IM rotation. My feedback for this rotation was that I lacked knowledge base/clinical skills, specifically generating and exploring differential diagnoses in a level-appropriate way. I was also told that I demonstrated nervousness and awkwardness when interacting with patients and attendings. I was not, however, rude or indifferent either with staff or with patients. I failed this Shelf as well. I also had to repeat this clerkship. My performance the second time around, while not stellar (fail/pass/high pass/honors grading system), was in the passing range.

2. the Psych PGY-1 year. You say you had trouble with the psychiatric ER rotation month because you couldn't handle the pathology. That is very vague. What do you mean by that? What specifically happened? What were your interactions with patients, staff, attendings like?

During the Psych PGY-1 year, we interns spent two months each (12-hour shifts) in the hospital's psych ER. One month Day Float and one month Night Float, signing in and out to the corresponding intern (PGY-1). I believe I was scheduled for the Night Float rotation first. At this time, I often had to deal with multiple agitated patients. Many of them were psychotic. Several of them were naturally brought in by police. I had difficulty prioritizing and juggling these sick people. Our attending was basically off-site, and I didn't have a lot of confidence approaching him or her at night. This is where it becomes difficult to separate my clinical performance from my emotional strengths and weaknesses. I would often feel that the patients were pushing my buttons.

The prior (initial) four months, were my inpatient Psych intern months. I did not receive negative feedback from these months.

After performing poorly in the CPEP (psych ER), I was given "remedial" time in the inpatient unit. It was thought that, all things being relative, I needed a reprieve from CPEP and that the inpatient patients were more stable. I blundered with AM labs on a patient one day and my attending was upset. Soon after, I was told I would not be promoted, although I would be kept on to finish out the year in a non-clinical capacity. I did not get to do the 4 IM and 2 Neuro months.

Shortly before being let go, I was made to do a "mock interview" with a psychiatric inpatient (stablilized). Like a diagnostic interview (of me), I suppose. This was done in front of the residency PD, the Psychiatry director of the PGY-3 therapy continuity experience, and the psychologist who also administered that part of the PGY-3 curriculum. You might imagine this was a stressful experience, but it was a positive one. I received a high mark on this and a favorable impression (although it didn't factor into the ultimate decision). I was told after the 45 minutes or so were up that I performed in an unexpectedly high-level way. They specifically mentioned a PGY-2 level, for whatever reason. I was commended for my "psychological mindedness" all throughout PGY-1.

Based upon all of that and my PD extending the door to me to re-interview, I took this to mean that I have a skill level in performing therapy, which honestly is the reason I had developed an interest in Psychiaty to begin with.

Despite all of this, I was failed in the CPEP month, and therefore not promoted.

3. your FM residency. You said you had "difficulty assuming a leadership role (overnight senior, Code Blues, etc), difficulty maintaining focus due to certain knowledge base and psychological issues (difficulty coping with intense/stressful situations), and a generally underwhelming performance". Again, give us the specifics. What happened during the Code Blues? did you fail to act as a leader? What happened when you were an overnight SR? did you slip up on supervising the intern, or slip up on patient care? were you unable to juggle multiple responsibilities? What happened during the stressful situations-exactly?

During my FM residency I completed my PGY-1 and PGY-2 year, but have not gotten credit for the PGY-2 year. What happened is as follows. I took the ITE towards the end of the PGY-1 year along with everything else. My focus up until that point had been "getting through the grind", so to speak, the day-to-day. I could have taken it (the test) more seriously. I did not formally study for the test, beyond the kind of exposure that goes along with day-to-day intern rounding and hospital work. I ended up with a low score, and was promoted with some hesitation. During this time, the entirety of PGY-1, I did passing work in all of my rotations, including the Medicine months, which I was concerned about. During my PGY-2, I was given a typical rotation schedule. I again took the PGY-2 ITE, and I put forth more effort. I did demonstrate improvement compared to the previous year. but not by much and not a significant growth. Our program was structured such that the increase in responsibility from PGY-1 to PGY-2 in terms of incremental responsibility happens at mid-year (Decemberish to Januaryish). [It sounds more abrupt on paper than perhaps it should]. During this PGY-2 year up until the end of January, I was therefore on track. I again passed each rotation during the first half of PGY-2. When ITE scores came out, this coincided, roughly speaking, with the transitional part of PGY-2. At this point, I had been placed on 2-3 senior calls. I don't want to draw any un-neccessary parallels, but perhaps similarly to CPEP, emergency situations bring about panic. I can tell you that I was not as proactive during Codes as I ought to have been. Being "point person" as the senior was not a role I filled well. I am somewhat avoidant in terms of emergencies. I would show up, but I generally didn't "take charge." I did not even know the algorithms well.

I was not asked to serve as a senior on Medicine service at any time during PGY-2. I did, however, act as Senior on Pediatric service. This, again, happened shortly after the New Year. On our calls, generally one resident would handle the Medicine services, and another the Pediatrics/OB. A third would act as senior. After officially being placed on probation in around February, I continued to act as Pediatric Senior and do intern-level Medicine calls and Pedes/OB calls. So at points I would have the confusing position of being a Senior during the day and a Junior on calls. During one call night, the nursing staff in the nursery failed to notify me that two babies had been delivered. I had rounded and examined babies on other services that same night, without a problem, in the very same nursery. I am not passing the buck here, but there was an obvious breakdown in communication between residents and other staff here that would repeat itself with other situations, involving other residents as well, in the future. In essence, two babies were born overnight that went unexamined (myself, Pedes/OB "intern."). The next day I came in as Pediatric Senior, to round on said babies, and my attending and I discovered the oversight. Those two babies had not been examined in the first 24 hours of life. These babies ended up being perfectly healthy, but I realize that that's not the point. Shortly thereafter, he yanked me off the service and I was officially placed on probation at that point.

Up until this point, with the exception of the PGY-2 ITE, there was nothing on paper that was negative. Again, thus far I had passed every rotation. I took an FMLA leave for about 6 weeks and got my head screwed on straight. I spent that time studying.

Certain pre-conditions needed to be met to pass probation. I ran through mock clinical scenarios with supervising attendings. I had to take a makeup exam. I was given an experimental ICU rotation to do. I was able to produce a marginal performance on the makeup exam, and do satisfactorily on the scenarios although I was not as thorough and polished. I was told that I had failed that ICU rotation, though, based on insufficient progress. At the end of the day, it became obvious that I wasn't being promoted. I tendered a resignation letter.

4. What happened last year? did you apply for the match? it seemed like you had everything ready to go. What happened?

To be honest, as many efforts as I had made up from end of residency to last year, I felt that I hadn't vetted the outstanding issues well enough.

I've tried to be as clear and honest as I can in answering these questions. I've self-evaluated a lot, and I've tried to take as much responsibility as I can for the mistakes that I've made, when I've made them. I never intended to give the impression of being smug or arrogant.

Again, I'm aware this is a public forum and being this forthright isn't exactly something that is tremendously easy. But I appreciate further advice.

 

[redemptionMD]

aProgDirector, thank you for the clear information on funding and the handout, in your last post.

 

[NotAProgDirector]

Given all of these details, my opinion is that you're unlikely to find an IM or FM program willing to take you. My summary of your self-described story is that you had a marginal performance in medical school, a marginal performance in much of your PGY-1 work, and unsatisfactory PGY-2 work. Your main problems are medical knowledge, the ability to multitask, and the ability to manage unstable / urgent patients. Even with 100% of your time able to be dedicated to studying for Step 3, you still managed to fail once and barely pass the second time. Your work in an outpatient clinic is nice, but it doesn't really address your "panic under pressure" or lack of leadership skills in your PGY-2. Many of the statements that you are taking as positive reinforcement (i.e. that your Psych PD told you to consider reapplying) are likely platitudes to make you feel better about your lack of progress. That's the honest truth.

And your narrative / tone doesn't do you much benefit here. Above you asked what the salary of an Occ Med doc is. A simple answer is: "More than zero, which is what you might end up with.". How much an Occ Med doc makes is immaterial to you now. You are very close to having no career in medicine.

As others have suggested, I think your best option is trying to get an Occ Med, PM&R, or Preventive Med spot. Prev Med is often combined with IM or FM, so that may not be possible. And your biggest problem is that you have no idea what Occ Med is -- no experience, no letters, etc. And not much time to rectify that. The nice thing about Occ Med and PM&R is that they are pure outpatient specialties and have no emergencies to speak of. Hence, your prior problems become much less concerning.

 

[splik]

did you get your full medical license? if you are interested in psychotherapy am not sure why you dont just do further psychotherapy training and then practice as a psychotherapist. You seem to think this is your strength whereas things that constitute medical practice like dealing with high-acuity situations of putting out fires is not your strong suit.

also, not that this will help you find a program, but any programs that appeared after 1997 or added positions after 1997 do not get money from medicare for those residency positions

 

[NotAProgDirector]

any programs that appeared after 1997 or added positions after 1997 do not get money from medicare for those residency positions

It is more complicated than this. Brand new programs that start get new slots (although if a program closed in the past and is re-opening, that doesn't count), and increase the institutional cap. You are correct that programs that expand after 1997 do not get new funds for those expanded slots, but if an institution closes one program they can reallocate those slots to another program. Plus in many places the DME/IME dollars simply flow into the institution's main budget, so how many slots any one program is allowed to have isn't completely tied to an exact counting of funded slots.

 

[PMR_doc]

Ok, I have to correct a gross misconception here. Numerous people keep talking about PMR. PMR has gotten more and more competitive every year, and PMR fills to near capacity just about every year. So it's unrealistic to assume that and think that someone who has had a number of problems in med school and residency would just be accepted nilly willy at a PMR program. PMR PDs have no issues filling their programs with quality people who don't have any performance and/or clinical issues. So please let's stop suggesting that. In addition it is also a serious misconception to think that there are no emergencies in PMR and that it is an all outpt. specialty. Plenty of PMR docs work solely in an inpt. setting, and emergencies unfortunately do certainly come up, from the spinal cord pt. who needs to be transferred for autonomic dysreflexia, to the TBI pt. who destabilizes, not to mention that a successful intern year needs to be completed before this.

As an attending, sure you can find a job in a solely outpt. setting, but getting through residency is not that simple. The only residencies where it will be highly unlikely where you have true emergencies are derm - which will be impossible, and maybe Ophtho or Rad Onc which again you would not really have emergencies.

Realistically occupational medicine is really the only residency that is entirely outpatient where the OP could get into and there really are no significant issues with excessive clinical judgment, emergencies, competitiveness, etc.

Given all of these details, my opinion is that you're unlikely to find an IM or FM program willing to take you. My summary of your self-described story is that you had a marginal performance in medical school, a marginal performance in much of your PGY-1 work, and unsatisfactory PGY-2 work. Your main problems are medical knowledge, the ability to multitask, and the ability to manage unstable / urgent patients. Even with 100% of your time able to be dedicated to studying for Step 3, you still managed to fail once and barely pass the second time. Your work in an outpatient clinic is nice, but it doesn't really address your "panic under pressure" or lack of leadership skills in your PGY-2. Many of the statements that you are taking as positive reinforcement (i.e. that your Psych PD told you to consider reapplying) are likely platitudes to make you feel better about your lack of progress. That's the honest truth.

And your narrative / tone doesn't do you much benefit here. Above you asked what the salary of an Occ Med doc is. A simple answer is: "More than zero, which is what you might end up with.". How much an Occ Med doc makes is immaterial to you now. You are very close to having no career in medicine.

As others have suggested, I think your best option is trying to get an Occ Med, PM&R, or Preventive Med spot. Prev Med is often combined with IM or FM, so that may not be possible. And your biggest problem is that you have no idea what Occ Med is -- no experience, no letters, etc. And not much time to rectify that. The nice thing about Occ Med and PM&R is that they are pure outpatient specialties and have no emergencies to speak of. Hence, your prior problems become much less concerning.

 

[redemptionMD]

Wow. Thank you, all, for the sobering feedback and the "reality check."