PGY1 GS-Prelim vs IM-Prelim vs TY?

[emdee_inside]

For students applying to DR (advanced, starting PGY-2), what are the pros and cons of completing a PGY-1 in general surgery vs internal medicine vs transitional year? And how would students prepare for each (eg LORs, 4th year rotations, etc)? And what is the relative proportion of programs to apply to for each of these scenarios? For example, in a 50:10:10:10 ratio, that would mean for every 50 DR programs, one should apply to 10 GS-P, 10 IM-P, and 10 TY programs. Curious to hear everyone's thoughts and grazie!

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[SeisK]

If you’re thinking of doing IR at one point, GS > / = Prelim >> TY, not just because you might look better to independent IR residencies (how true this actually ends up being in practice is unclear), but because with the increasing clinical nature of IR, you really want to be as comfortable as possible managing ward patients and ICU patients. The demographic of an IR patient is most commonly the surgical one, but I think any program that has you managing inpatients on the regular to a rigorous extent should prepare you for it. Look at it this way: some IR programs have even gone so far to be the primaries on patients and have wings dedicated to them only. If your patient (since your primary) has a K+ of 2.8 and is starting to feel achy, do you want to have to call medicine every time? What about someone whose blood glucose overnight was 350? Or do you want to demonstrate that you are a clinical specialist, you are capable of taking care of your patients, and you’ll be able to handle it yourself? The more time you spend doing this in the setting most paralleling that of the IR hospitalist, the better. In this case, GS ~= Prelim >> TY, unless the TY is one of those fake ones.

If you know for a fact you don’t want to do IR, or you’re pretty sure you don’t, then TY > Prelim >> GS. Go for as chill a life as possible—there is some contention, but I think the prevailing opinion among most radiologists is that their intern year helped them some, but not that much, and it’s better to not make yourself miserable during it. Bluntly, then, go for the TY that has as little call and night responsibility as possible. There aren’t many left (I’d say 3/4 - 4/5 of TYs aren’t chill anymore, they’re just prelims in disguise), but there are a few chill ones I know, and one or two that are so chill that I’ve heard residents coming out of them actually felt worse for having gone through them.

I think one letter in the “specialty” you’re wanting to do the prelim year in is great, but this isn’t a necessity. They see you’re applying for their prelim year, they know you aren’t going to be an internist / surgeon. That being said, I DID NOT have a letter from IM, and I felt like I got fewer prelim year interview invites than my peers that did. I applied to 47 intern years (way overkill, I know) but only got back like 20 interviews, half of which were TYs, and I only applied to 15 TYs. The lack of a letter may hurt.

The goal number of interviews to shoot for, I’ve heard, is 8-10. Short of that and you start to itch closer to partially matching, and no one wants to SOAP for prelim spots. But if it comes down to this, there’s always surgery prelim programs you can SOAP into because they never fill for malignancy reasons. Worst case scenario is you don’t match prelim, and you fail to SOAP, in which case you have to give up your advanced spot. But again, I think I’ve only ever heard of one case of this, and I believe this was a guy who adamantly refused a surgery prelim year even when the air got very thin.

 

[irwarrior]

Agree with surgery preliminary year if planning on going into VIR. It also prepares you for some aspects of diagnostic radiology as it is anatomy based (unlike IM which is more physiology/pharmacology based). You also learn what the operations are and what the expected post op complications are. You also learn much of the staging of cancers for thoracic, liver, pancreas, biliary, gastric, colon, rectal, sarcomas etc. For IR it preps you by making you learn the day to day existence of a modern day IR doc. It also enhances your technical skills and often times you get a few months of vascular surgery which improves your Endovascular skillset. The ICU experience you get to deal with bleeding (mass transfusion), dissections, PE, cold legs and thrombolysis and the occasional sepsis. You may miss out on ARDS patients as that will usually be covered in the MICU .

 

[emdee_inside]

Ahh @SeisK so helpful thank you! So to summarize, my plan of attack would be something like:
1. If DR all the way, then get 2 LORs (DR rotation, DR peds) + 1 LOR (research preferably DR) + 1 LOR (Medicine service eg GenMed, MICU, GI consults, etc) for the IM-P or TY.
2. If [DR + ESIR] or [IR categorical], then get 1 LOR (DR) + 1 LOR (IR) + 1 LOR (research preferably IR) + 1 LOR (Surgery service eg GenSurg, SICU, Surg Onc, acute care surg, etc) for the GS-P.

Any advice on which IM service or GS service would be best or does it really not matter?

 

[irwarrior]

For GS vascular surgery is high yield as it is similar from an endovascular standpoint.

 

[SeisK]

Ahh @SeisK so helpful thank you! So to summarize, my plan of attack would be something like:
1. If DR all the way, then get 2 LORs (DR rotation, DR peds) + 1 LOR (research preferably DR) + 1 LOR (Medicine service eg GenMed, MICU, GI consults, etc) for the IM-P or TY.
2. If [DR + ESIR] or [IR categorical], then get 1 LOR (DR) + 1 LOR (IR) + 1 LOR (research preferably IR) + 1 LOR (Surgery service eg GenSurg, SICU, Surg Onc, acute care surg, etc) for the GS-P.

Any advice on which IM service or GS service would be best or does it really not matter?

1. I think that’s too many clinical DR letters. Clinical DR letters really aren’t meaningful unless you had a very unusual rotation where they treated you like a resident—letting you read images and generating prelim reports. You’d be better served getting more clinical letters here, but they can be from various specialties—ortho, obgyn, family, peds, im, gs, etc. Maybe even psych, idk. I definitely would not have more than 1 “clinical” DR letter, and honestly I think 0 clinical DR letters might even be better because it’s a better way to demonstrate how good of a doc you are.
2. This I’m less sure of. I didn’t apply categorical IR, but I was under the impression you apply to it like a surgical subspecialty, in which case you want all 4 of your letters being IR related (3 clinical 1 research). You can upload as many letters as you want into ERAS, but each program can only get a max of 4, in which case for your prelim programs you’ll want to remove one of the IR letters (probably the research one) and replace it with the GS letter, or the prelim medicine letter, or whatever.

 

[bobjonesbob]

As far as how many prelims to apply to, it really depends on your competitiveness. The chillest TYs are essentially as competitive as any residency out there (steps >250, AOA, etc.) because they attract the best applicants from multiple specialties. So if you're a lower tier rads applicant you'll have trouble getting many TY interviews. Also helps to know what the deal is at your home program. At my school any decent rads applicant can get a surgery prelim spot if you meet with the PD so that allows people to have a solid backup option.

 

[Bin Rushd]

Do you guys think any changes to the curriculum of TYs will happen for this upcoming year due to COVID-19? Some of them have up to 19 weeks of electives -- with the decreased volume of elective operations and sub-specialty practices, is it possible TYs may force their residents into strictly the wards (or just where most help is needed).....

 

[AndM17]

I’d say 3/4 - 4/5 of TYs aren’t chill anymore, they’re just prelims in disguise

I completely agree with this. While I loved my experience as a TY it was definitely not "chill"; it was inpatient-based with plenty of ICU and night float experiences. My impression is that TY's have become basically prelim medicine years with the ability to do non-medical electives. Please correct me if you know more about this, but my understanding is that the ACGME revamped its TY requirements to make them more rigorous. It's not "fifth year medical school" anymore.

@Bin Rushd policies about redeploying residents due to Covid are generally made at the hospital/program level based on staffing needs not at a national level. Since TY's are general residents, I would imagine they could be redeployed anywhere in an "intern" role.

 

[SeisK]

I completely agree with this. While I loved my experience as a TY it was definitely not "chill"; it was inpatient-based with plenty of ICU and night float experiences. My impression is that TY's have become basically prelim medicine years with the ability to do non-medical electives. Please correct me if you know more about this, but my understanding is that the ACGME revamped its TY requirements to make them more rigorous. It's not "fifth year medical school" anymore.

@Bin Rushd policies about redeploying residents due to Covid are generally made at the hospital/program level based on staffing needs not at a national level. Since TY's are general residents, I would imagine they could be redeployed anywhere in an "intern" role.

My understanding was that some programs are still super chill beyond being healthy, and because these have maintained their accreditation it isn’t an ACGME issue. I was under the impression that teaching hospitals feel the squeeze of declining reimbursements more, and therefore they found they could make their TYs as defacto prelims for free labor while still meeting the TY requisites.

 

[recycledpaper]

TY all the way. There's a few prelims that are cush too. Do your research well and enjoy MS5.

 

[Americanbum]

TY year especially if you have one with DR program attached. You can do IR for 2 months just to prep also.

Also going through bunch of different rotations helps a lot in the long term than just doing straight internal medicine or surgery.

 

[BroDoc22]

If you’re thinking of doing IR at one point, GS > / = Prelim >> TY, not just because you might look better to independent IR residencies (how true this actually ends up being in practice is unclear), but because with the increasing clinical nature of IR, you really want to be as comfortable as possible managing ward patients and ICU patients. The demographic of an IR patient is most commonly the surgical one, but I think any program that has you managing inpatients on the regular to a rigorous extent should prepare you for it. Look at it this way: some IR programs have even gone so far to be the primaries on patients and have wings dedicated to them only. If your patient (since your primary) has a K+ of 2.8 and is starting to feel achy, do you want to have to call medicine every time? What about someone whose blood glucose overnight was 350? Or do you want to demonstrate that you are a clinical specialist, you are capable of taking care of your patients, and you’ll be able to handle it yourself? The more time you spend doing this in the setting most paralleling that of the IR hospitalist, the better. In this case, GS ~= Prelim >> TY, unless the TY is one of those fake ones.

If you know for a fact you don’t want to do IR, or you’re pretty sure you don’t, then TY > Prelim >> GS. Go for as chill a life as possible—there is some contention, but I think the prevailing opinion among most radiologists is that their intern year helped them some, but not that much, and it’s better to not make yourself miserable during it. Bluntly, then, go for the TY that has as little call and night responsibility as possible. There aren’t many left (I’d say 3/4 - 4/5 of TYs aren’t chill anymore, they’re just prelims in disguise), but there are a few chill ones I know, and one or two that are so chill that I’ve heard residents coming out of them actually felt worse for having gone through them.

I think one letter in the “specialty” you’re wanting to do the prelim year in is great, but this isn’t a necessity. They see you’re applying for their prelim year, they know you aren’t going to be an internist / surgeon. That being said, I DID NOT have a letter from IM, and I felt like I got fewer prelim year interview invites than my peers that did. I applied to 47 intern years (way overkill, I know) but only got back like 20 interviews, half of which were TYs, and I only applied to 15 TYs. The lack of a letter may hurt.

The goal number of interviews to shoot for, I’ve heard, is 8-10. Short of that and you start to itch closer to partially matching, and no one wants to SOAP for prelim spots. But if it comes down to this, there’s always surgery prelim programs you can SOAP into because they never fill for malignancy reasons. Worst case scenario is you don’t match prelim, and you fail to SOAP, in which case you have to give up your advanced spot. But again, I think I’ve only ever heard of one case of this, and I believe this was a guy who adamantly refused a surgery prelim year even when the air got very thin.

I disagree with this sentiment that doing a TY will make you less prepared to handle floor pt's compared to a GS or IM prelim. My TY has required 6 intense months on medicine with 3 months outpatient and 3 months elective and I would feel more than able to handle basic floor issues without any issues. My TY also let me do a month of IR and Surgery while giving me three chill months a 4 weeks of vacation. You dont have to kill yourself in internship to prepare for the rigors of IR to be prepared.

 

[SeisK]

I disagree with this sentiment that doing a TY will make you less prepared to handle floor pt's compared to a GS or IM prelim. My TY has required 6 intense months on medicine with 3 months outpatient and 3 months elective and I would feel more than able to handle basic floor issues without any issues. My TY also let me do a month of IR and Surgery while giving me three chill months a 4 weeks of vacation. You dont have to kill yourself in internship to prepare for the rigors of IR to be prepared.

I feel like I addressed this when I said “some TYs are prelims in disguise.”

 

[irwarrior]

Though there are some Transitional years that are as rigorous as prelim surgery and IM , many are not. For DR fellowships, it is probably not much of an issue, but in IR (where there are pretty high time demands) the surgical preliminary year is favored by many IR program directors. So, if all things are equal in an application cycle for independent spots they are looking for any distinguishing features to weed out the applicants and this may have some role in the decision tree (although other things including letters, involvement in SIR and research are weighed heavily).

If you are trying to stay at the same program that you do DR/ESIR it will likely not be an issue as they have at least 3 years to directly observe your work ethic as well as clinical and technical abilities.