Primary care, categorical rankings

[washableglue]

I applied to many primary care and some categorical tracks with plans to practice outpatient medicine, possibly "specialize" in geriatrics. I just completed some more consult electives and realize that I may want to subspecialize after all in fields like nephrology or gi. I'm still 50-75% sure that primary care may be the future for me but am not sure if the track is best choice at this point in time. My questions are:

1) Should I withdraw my app from the PC tracks at the sites I applied and how do I do that without withdrawing my whole application? / When I add the categorical tracks for some sites where I only applied PC, will it be considered a new application that is being submitted late?

2) Does interviewing for the primary care program affect my ranking on the categorical list of the same institution? (i.e. will the categorical program rank me lower if they know the primary care program ranks me to match?). There are some programs where I definitely would be happy in the PC track, but would prefer categorical given my new interests.

3) Is it bad form to rank a categorical program over a PC program at the same institution? I ask because I always personally felt that people who are applying into PC should be dedicated to primary care and not just using it as a backup for that institution.

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[Solara]

I applied to many primary care and some categorical tracks with plans to practice outpatient medicine, possibly "specialize" in geriatrics. I just completed some more consult electives and realize that I may want to subspecialize after all in fields like nephrology or gi. I'm still 50-75% sure that primary care may be the future for me but am not sure if the track is best choice at this point in time. My questions are:

1) Should I withdraw my app from the PC tracks at the sites I applied and how do I do that without withdrawing my whole application? / When I add the categorical tracks for some sites where I only applied PC, will it be considered a new application that is being submitted late?

2) Does interviewing for the primary care program affect my ranking on the categorical list of the same institution? (i.e. will the categorical program rank me lower if they know the primary care program ranks me to match?). There are some programs where I definitely would be happy in the PC track, but would prefer categorical given my new interests.

3) Is it bad form to rank a categorical program over a PC program at the same institution? I ask because I always personally felt that people who are applying into PC should be dedicated to primary care and not just using it as a backup for that institution.

Some of these questions would probably be best answered by a PC program director, and I don't know how many people here are so familiar with these specific questions. I probably wouldn't withdraw your application. If you apply to categorical to places you only applied PC, then yes it will be a new application since Categorical have separate NRMP IDs.

I honestly don't know about how categorical will rank you if they know you're applying to PC. That would be a question best answered by a PD or PC program director. If you're brave enough, you can email a program director (or even call) and ask him/herself. Perhaps you can find a program that you did not apply to and call the PD there, incase you're worried about that phone call affecting your chances. They'll probably be uber busy since it's interview season, but you can pick their brain for a little bit and see how that process usually works.

I wouldn't say it's bad form to rank Categorical>PC. Programs won't know what you ranked them until final results have been released and you're locked into a residency. At that point you're going to be there for 3 years and I doubt there's going to be any ill sentiment.

Good luck!

 

[the argus]

It all depends on the individual institution. Some places have PC programs that are completely separate from the categorical program with different program directors. Some have PC tracks within the overall categorical program but still with individual program directors. And some are just PC tracks within the categorical program with just a single program director.

Whether you can apply to both at a single institution is completely institution dependent. I know for sure that some of the places that have completely separate programs often interview the same applicant for both programs, and it doesn't affect their final rankings. Some tracks within programs also specifically say you can apply to both (i.e. NYU, http://www.med.nyu.edu/medicine/edu...u-primary-care-residency-program/primary-care, UPenn, http://www.uphs.upenn.edu/internal-medicine-residency/our_program/FAQ_PC.html).

The only way to answer your questions is to look at the program websites, and if the answers are not there, email the program. I assume the answers will differ among individual institutions.

 

[ShuperNewbie]

I'm just wondering out loud here, because I don't know where this came from, but I wonder where this idea came about that one cannot sub-specialize coming out of a primary care program? Granted the track is designed to place people into careers in General IM, but every year there are plenty of people who sub-specialize coming from PC tracks. I feel like this is one of those things that started out logically, and then got blown out of proportion, much like how in the pre-med forums people propogate this myth of "don't apply twice because it'll hurt you for your second application" (not true for the vast, vast, vast majority of the time... anyone who has reviewed 1000+ applications for anything will know that's it's quite difficult to... well... memorize all of them). You will have no trouble matching into nephrology coming out of a well known GIM program. The idea that nephrology fellowship directors will look at an applicant and think "oh this person is from UCSF/MGH/UPenn/Yale/NYU but they're coming from the primary care track... I'm going to toss them into this "other" pile I reserve for less qualified applicants" is so absurd that it's frankly laughable. GI may be a little tougher but, at least from my viewpoint, the PC track at my institution has never NOT had someone match into GI that intended to do GI.

 

[Solara]

This is just my opinion but you should not apply into a PC track if you plan on specializing. PC programs are looking for people who will stay in primary care. Importantly, they also receive grants that are conditional on how many of their graduates stay in primary care. If you go onto specialize, that hurts your institution if they receive things like Hursa grants which give the programs more money if their graduates actually stay in primary care. Now sometimes people do a PC residency and then specialize in ID so that they can provide primary care with a focus in HIV, or specialize in geriatrics and focus on primary care under the realm of geriatrics. That is fine and then the PC program is still eligible for that grant money.

Again this is just my opinion but I think it's blatantly dishonest if you say that you're going to stay in PC when you have full intent on specializing, especially when these programs are specifically looking for folks who will stay in PC for the aforementioned reasons

 

[washableglue]

I'm just wondering out loud here, because I don't know where this came from, but I wonder where this idea came about that one cannot sub-specialize coming out of a primary care program? Granted the track is designed to place people into careers in General IM, but every year there are plenty of people who sub-specialize coming from PC tracks. I feel like this is one of those things that started out logically, and then got blown out of proportion, much like how in the pre-med forums people propogate this myth of "don't apply twice because it'll hurt you for your second application" (not true for the vast, vast, vast majority of the time... anyone who has reviewed 1000+ applications for anything will know that's it's quite difficult to... well... memorize all of them). You will have no trouble matching into nephrology coming out of a well known GIM program. The idea that nephrology fellowship directors will look at an applicant and think "oh this person is from UCSF/MGH/UPenn/Yale/NYU but they're coming from the primary care track... I'm going to toss them into this "other" pile I reserve for less qualified applicants" is so absurd that it's frankly laughable. GI may be a little tougher but, at least from my viewpoint, the PC track at my institution has never NOT had someone match into GI that intended to do GI.

This is just my opinion but you should not apply into a PC track if you plan on specializing. PC programs are looking for people who will stay in primary care. Importantly, they also receive grants that are conditional on how many of their graduates stay in primary care. If you go onto specialize, that hurts your institution if they receive things like Hursa grants which give the programs more money if their graduates actually stay in primary care. Now sometimes people do a PC residency and then specialize in ID so that they can provide primary care with a focus in HIV, or specialize in geriatrics and focus on primary care under the realm of geriatrics. That is fine and then the PC program is still eligible for that grant money.

Again this is just my opinion but I think it's blatantly dishonest if you say that you're going to stay in PC when you have full intent on specializing, especially when these programs are specifically looking for folks who will stay in PC for the aforementioned reasons

Thanks for the responses everyone! I understand that anyone can still sub specialize from the primary care track-- I believe the statistic at many places is about 30% still do. However, I agree with Solara's sentiment that PC programs were created with the mission to generate primary care physicians, and subspecializing into fields like cards/GI defeats that mission. With the current primary care shortage and as someone who has advocated for primary care funding and programming throughout medical school, I feel very invested in retention in these programs. That said, people sometimes end up connecting with a specialty that they did not have any idea they would like! I feel like that's the nature of medical school where we have only limited immersion in the specialty services until we do 4th year electives. For me those fields were GI and nephrology... so my predicament is that I just don't know where I will be several years from now. I can certainly see myself as a primary care doc, applying for a geri fellowship, or applying into a non-primary care fellowship.

Is there anyone on here who sub-specialized out of a primary care track? I would love to hear your personal experience (I realize that it will also be very institution dependent).

 

[Solara]

Yea, it's understandable if someone is on the fence. Maybe they intend on PC and then find that they really want to specialize. That happens a lot.

I'm applying into PC programs so that influences my opinion here. I'm fine if more competitive people genuinely interested into primary care get into programs I'm also applying into. But it does not make me happy when some of these same more competitive people who are fully intending to specialize click the PC checkbox on ERAS simply to make it as their backup. There are much fewer interview spots for PC programs and so it makes it more challenging.

 

[the argus]

I think you guys are being a little dramatic here. Primary care programs are still IM programs. There are no special ACGME requirements for primary care vs categorical IM programs, they are all just under IM.

This idea that by planning to specialize you're stealing a spot from someone that is interested in primary care is pretty silly. In general, primary care programs just mandate more outpatient time and spend more time with geriatrics, which someone in a categorical program could easily do just by switching their electives around. Lots of people go into primary care from traditional categorical IM programs, and they make just as good PCPs as people coming from primary care IM programs.

You should go to an IM program where you feel comfortable, regardless whether it's a primary care program or not. People specialize after primary care residencies, and people do primary care after categorical residencies, thats just reality.

 

[Solara]

I think you guys are being a little dramatic here. Primary care programs are still IM programs. There are no special ACGME requirements for primary care vs categorical IM programs, they are all just under IM.

This idea that by planning to specialize you're stealing a spot from someone that is interested in primary care is pretty silly. In general, primary care programs just mandate more outpatient time and spend more time with geriatrics, which someone in a categorical program could easily do just by switching their electives around. Lots of people go into primary care from traditional categorical IM programs, and they make just as good PCPs as people coming from primary care IM programs.

You should go to an IM program where you feel comfortable, regardless whether it's a primary care program or not. People specialize after primary care residencies, and people do primary care after categorical residencies, thats just reality.

You make some valid points, and I both agree and disagree.

I think the main issue here is that these programs are specifically looking for people who will stay in primary care. Some of them receive grants that are conditional on how many graduates stay in primary care, hence the strong incentive to find people who will actually stay on. It's important to be genuine and honest when the program wants you to stay in primary care. It's one thing if you specialize because you later realize you don't like primary care. It's another thing if you fully intend on specializing and are dishonest with the program on selling your interest in primary care, which ends up hurting the program (i.e., b/c of the grants they would have received) as well as any other applicants who had a genuine interest in PC.

 

[generalmedicine123]

I'm involved in admissions for a primary care track. I can't speak for other institutions, but we do try to look for candidates who are committed to our primary care mission. It may help slightly to only apply primary care vs. also applying to our categorical program, but it isn't decisive, unless we really think that someone's just trying to use the primary care track as a back door to our categorical residency. We've definitely moved people down the list because we don't think they really want to do primary care. Whether an applicant has also applied to the primacy care track doesn't seem to have an impact on categorical rankings.

Post-match, the program leadership have been disappointed but supportive when primary care residents have opted to sub-specialize.

 

[washableglue]

This is only borderline related but can anyone comment on whether the size of the primary care cohort is reflective of how strong their primary care track is? Some places seem to have 10+ spots while others have only 4-5.

 

[Solara]

This is only borderline related but can anyone comment on whether the size of the primary care cohort is reflective of how strong their primary care track is? Some places seem to have 10+ spots while others have only 4-5.

I doubt it. Part of that also depends on how much funding the program has. It is essentially identical to categorical except that you spend more of your electives doing primary care. I.e., all the inpatient stuff you do is no different from the categorical residents, whether it be general medicine wards or a cards rotation. The outpatient clinic rotations are also no different. You're doing the same exact clinics as the categorical residents, except you spend a greater amount of time in clinics compared to wards. I'm sure each PC program might have some unique components in having didactic lectures or team based learning exercises here or there, but the bulk of the training comes from that increased outpatient time.

 

[washableglue]

I doubt it. Part of that also depends on how much funding the program has. It is essentially identical to categorical except that you spend more of your electives doing primary care. I.e., all the inpatient stuff you do is no different from the categorical residents, whether it be general medicine wards or a cards rotation. The outpatient clinic rotations are also no different. You're doing the same exact clinics as the categorical residents, except you spend a greater amount of time in clinics compared to wards. I'm sure each PC program might have some unique components in having didactic lectures or team based learning exercises here or there, but the bulk of the training comes from that increased outpatient time.

Hmm right. I was thinking more in terms of institutional culture around primary care--> less spots = less funding = weaker PC presence and support from rest of institution? As an example, when Columbia tried to eliminate their family medicine residency a few years ago, that sent a clear message that primary care was not something valued by the leadership... I want to avoid places like that whether I specialize or not! I feel like going into primary care is a uphill battle sometimes and don't want to make life any more difficult than needed with an unsupportive institution. Obviously, if a place has a PC track, they do care about PC... just wondering if more spots could indicate MORE love and support?

 

[LovelyBRass]

I just graduated from a PC residency and I have to say, it's so amazing for the training and for our morale to be around people who are excited about the mission of primary care and who actually go into it. It's interview season now so I'm not supposed to discourage people who are on the fence of PC v categorical (I'm a chief) but man... if you're all in, you wanna go some place that is all in as well. And if you're not... categorical programs still graduate plenty of PCPs I'm not saying that the folks in our PC track don't flirt with specialties and question their decisions - that happens with everyone and we are supportive - but nothing beats a PC track where people actually love primary care rather than click the box because they wanted more options.

With regards to your questions:
1) Should I withdraw my app from the PC tracks at the sites I applied and how do I do that without withdrawing my whole application? / When I add the categorical tracks for some sites where I only applied PC, will it be considered a new application that is being submitted late?

You don't have to withdraw, that decision is up to you. Withdrawing from PC would not affect your categorical application. It would not be considered a late application.

2) Does interviewing for the primary care program affect my ranking on the categorical list of the same institution? (i.e. will the categorical program rank me lower if they know the primary care program ranks me to match?). There are some programs where I definitely would be happy in the PC track, but would prefer categorical given my new interests.

Categorical rank is not affected by PC rank; if you would have matched either way, the match system defaults to the applicant's choice.

3) Is it bad form to rank a categorical program over a PC program at the same institution? I ask because I always personally felt that people who are applying into PC should be dedicated to primary care and not just using it as a backup for that institution.

There was one year where our program matched a ton of people into categorical that we had ranked for PC. That's definitely annoying. But it made us rethink how we choose folks to interview and how we evaluate interest. No one's mad at those residents or anything (none of them ended up choosing primary care anyway and a few of them will be chiefs!), but from our standpoint it was kind of a wake-up call.