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Re-applying to Residency Advice - EM to IM

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NonLinearPath

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I'm a recent MD grad from an east coast med school who matched into an academic West Coast emergency medicine program. This application cycle was particularly hard for me because I hadn't been able to visit programs and cities. I unfortunately ended up prioritizing reputation and program length over location. On top of that I'd been split between EM vs IM. Because of COVID and scheduling, I completed my IM sub-I in January 2021. I really enjoyed my IM sub-I and could envision a career in heme/onc (I have a research background in onc).

After the match, I realized that proximity to family is my number one value. I understand I haven't yet experienced residency, but I can't imagine three years in a city a 5+ hour flight from my closest family with a 3 hour time change. It's been a pretty dark couple of weeks. We are into orientation month, and I can already tell that the vibe of my program and cohort is more family centric. The majority of my co-residents are from the area. Many also have kids, and we haven't had social events understandably so with COVID restrictions and their family obligations. I already feel isolated without my family and friends on the East coast, and I haven't even started shifts yet.

I have given myself to mid/late-August to decide a course of action. The following are some of the options I am considering, and I'd love any feedback from folks who have heard of or gone through similar experiences. I've read most previous threads and articles from SDN and reddit, but I'd appreciate advice specific to my situation.
  • I end up loving my first 3 months, and stick to completing the residency. Even thought the EM job market looks abysmal, I'm hoping to land any job in Chicago or NYC.
  • Re-entering the match: applying to Mid West & East Coast internal medicine programs
    • this option seems like a lot of work because I'll need to get my med school to give me an ERAS token, submit a MSPE, and get a medicine chair letter together (I did well on medicine rotations). I'll also need to get a letter from a medicine doctor during my ICU rotation at my current residency. Fortunately one of my medical school mentors who wrote a letter for my EM app is an IM hospitalist, and I plan on reaching out to him to see what he thinks/if he'll write me another letter. I'm also very close with my med school advising dean, and I think he'll back me no matter what I decide. Mid/late-august is my decision deadline because ERAS needs to be in by September 29th this year.
    • I understand that ultimately I'll need to have a PD letter supporting my decision. There is conflicting advice out there about telling your PD. I'd probably tell my PD in September. However, September is early, and my PD won't know me very well. I'd prefer to be upfront about my thought process with my PD. I'm not sure how realistic it would be to tell my PD what I'm thinking and frame it like "With the limitations of a majority virtual MS4, I'm not certain EM is the right fit for me. I'm interested in IM and passionate about oncology. Could I apply to IM this cycle and delay the decision until rank list is due? That way I have until March 2022 to make a decision." - obviously I'd word it better than that. The number of interviews I'd get could also affect my decision, since I don't want to be left without any residency spot. I have a family connection to a community IM program in my preferred geographic area. I'm not concerned about prestige, so I'd be happy to land there if they'd take me.
    • I plan on taking and passing Step 3 in November. I hit the median on Step 1 and 2, so I don't have good or bad board scores. I'm going buckle down and make sure I pass step 3. I figure that may be a concern for some IM PDs.
    • Am I damaged goods re-applying in the match? Is this option even viable? I just don't want to complete intern year and then have to re-enter the match as a EM PGY-2. At that point I'd just complete my residency.
  • Transfer: Waiting until November/December and then emailing EM and IM PDs in my geographic areas of interest for PGY-2 positions. I'll avoid emailing PDs at the same institutions.
    • The retention rate for EM is pretty high, so I don't think this is a viable option. I'll email 4 year EM programs in my area of interest first. From advice I read online, I'll email only one program at a time and wait for their response. Then I'll continue down my prioritized list of programs. I'm going to talk to my EM med school mentor in August once I make a decision to see what he/she thinks.
    • The IM drop out rate seems higher and there are more spots. I'd love to be able to slide into a PGY-2 position which counts some of my EM intern experience towards IM requirements. I don't mind taking 3.5-4 years to finish IM. It would be 4 years anyway if I reapplied via the match. I'll start with this list after I've exhausted EM transfer options.
    • I know the odds of either are low, but it’s not impossible. I know someone who switched geographic areas in the same specialty. Again, should I be upfront with my PD or only talk to my PD once I know there is an open position somewhere. I'm hoping to not completely light the bridge on fire, and my PD seems like an understanding and supportive individual. Alternatively I can bring it up to my class specific APD first - the APD mentioned thinking about leaving medicine during residency when we were on an intro call.
    • In both the re-apply and transfer scenarios, I’m uncertain how CMS funding will work since I’ll have used one year of funding.
  • Complete my intern year and leave for industry: I have a business background from before medical school. If I’m truly not happy by the end of my 1st year of residency, I’m confident I can get a job in consulting, equity research, or the life sciences industry. It puts the kibosh on any future as a clinician, but at least I’d be happy. I also enjoy the macro healthcare work. By completing intern year I'll honor my contract and be a licensed physician (non-boarded) able to prescribe meds.
I apologize for the lengthy post, but again, I'd appreciate any input. I understand that I'm early in my decision tree and that my thinking may change. I'm sure after a couple months of trying to keep my feet underneath me as an intern, I'll have a different perspective.
 

GoSpursGo

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Your last paragraph is really the bottom line. Keep track of all your other considerations, but as you say your perspective may change. Don’t jump to decisions with incomplete information.
 
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RoyalRailer

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I understand that ultimately I'll need to have a PD letter supporting my decision.
Do we really need a LoR from our current PD to be uploaded on eras?

I plan on applying to a different speciality this September also, and have received conflicting information on this.

An advisor at my medical school stated I don’t need a LoR from my current PD, but I have read on here and Reddit that I will need a LoR. Of course I plan on telling my PD my plans, but is a letter really necessary??
 

NotAProgDirector

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It depends by what you mean by "really need".

There are no "rules", so you can do whatever you want. There's no official requirement.

But, any new program is going to want to know how you've done in your prior program. There's a huge difference between doing-fine-but-want-to-switch and failing-out-due-to-major-professionalism-problems. The best way to address this is to have a letter from your PD stating such. A letter like this also gives any new PD the legal right to contact your old PD to have a conversation and get the whole story.

I think your yield will be much higher with a PD letter. Even if you're having problems.
 
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RoyalRailer

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It depends by what you mean by "really need".

There are no "rules", so you can do whatever you want. There's no official requirement.

But, any new program is going to want to know how you've done in your prior program. There's a huge difference between doing-fine-but-want-to-switch and failing-out-due-to-major-professionalism-problems. The best way to address this is to have a letter from your PD stating such. A letter like this also gives any new PD the legal right to contact your old PD to have a conversation and get the whole story.

I think your yield will be much higher with a PD letter. Even if you're having problems.
Thank you for that. Helps greatly!
 

Redpancreas

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I'm a recent MD grad from an east coast med school who matched into an academic West Coast emergency medicine program. This application cycle was particularly hard for me because I hadn't been able to visit programs and cities. I unfortunately ended up prioritizing reputation and program length over location. On top of that I'd been split between EM vs IM. Because of COVID and scheduling, I completed my IM sub-I in January 2021. I really enjoyed my IM sub-I and could envision a career in heme/onc (I have a research background in onc).

After the match, I realized that proximity to family is my number one value. I understand I haven't yet experienced residency, but I can't imagine three years in a city a 5+ hour flight from my closest family with a 3 hour time change. It's been a pretty dark couple of weeks. We are into orientation month, and I can already tell that the vibe of my program and cohort is more family centric. The majority of my co-residents are from the area. Many also have kids, and we haven't had social events understandably so with COVID restrictions and their family obligations. I already feel isolated without my family and friends on the East coast, and I haven't even started shifts yet.

I have given myself to mid/late-August to decide a course of action. The following are some of the options I am considering, and I'd love any feedback from folks who have heard of or gone through similar experiences. I've read most previous threads and articles from SDN and reddit, but I'd appreciate advice specific to my situation.
  • I end up loving my first 3 months, and stick to completing the residency. Even thought the EM job market looks abysmal, I'm hoping to land any job in Chicago or NYC.
  • Re-entering the match: applying to Mid West & East Coast internal medicine programs
    • this option seems like a lot of work because I'll need to get my med school to give me an ERAS token, submit a MSPE, and get a medicine chair letter together (I did well on medicine rotations). I'll also need to get a letter from a medicine doctor during my ICU rotation at my current residency. Fortunately one of my medical school mentors who wrote a letter for my EM app is an IM hospitalist, and I plan on reaching out to him to see what he thinks/if he'll write me another letter. I'm also very close with my med school advising dean, and I think he'll back me no matter what I decide. Mid/late-august is my decision deadline because ERAS needs to be in by September 29th this year.
    • I understand that ultimately I'll need to have a PD letter supporting my decision. There is conflicting advice out there about telling your PD. I'd probably tell my PD in September. However, September is early, and my PD won't know me very well. I'd prefer to be upfront about my thought process with my PD. I'm not sure how realistic it would be to tell my PD what I'm thinking and frame it like "With the limitations of a majority virtual MS4, I'm not certain EM is the right fit for me. I'm interested in IM and passionate about oncology. Could I apply to IM this cycle and delay the decision until rank list is due? That way I have until March 2022 to make a decision." - obviously I'd word it better than that. The number of interviews I'd get could also affect my decision, since I don't want to be left without any residency spot. I have a family connection to a community IM program in my preferred geographic area. I'm not concerned about prestige, so I'd be happy to land there if they'd take me.
    • I plan on taking and passing Step 3 in November. I hit the median on Step 1 and 2, so I don't have good or bad board scores. I'm going buckle down and make sure I pass step 3. I figure that may be a concern for some IM PDs.
    • Am I damaged goods re-applying in the match? Is this option even viable? I just don't want to complete intern year and then have to re-enter the match as a EM PGY-2. At that point I'd just complete my residency.
  • Transfer: Waiting until November/December and then emailing EM and IM PDs in my geographic areas of interest for PGY-2 positions. I'll avoid emailing PDs at the same institutions.
    • The retention rate for EM is pretty high, so I don't think this is a viable option. I'll email 4 year EM programs in my area of interest first. From advice I read online, I'll email only one program at a time and wait for their response. Then I'll continue down my prioritized list of programs. I'm going to talk to my EM med school mentor in August once I make a decision to see what he/she thinks.
    • The IM drop out rate seems higher and there are more spots. I'd love to be able to slide into a PGY-2 position which counts some of my EM intern experience towards IM requirements. I don't mind taking 3.5-4 years to finish IM. It would be 4 years anyway if I reapplied via the match. I'll start with this list after I've exhausted EM transfer options.
    • I know the odds of either are low, but it’s not impossible. I know someone who switched geographic areas in the same specialty. Again, should I be upfront with my PD or only talk to my PD once I know there is an open position somewhere. I'm hoping to not completely light the bridge on fire, and my PD seems like an understanding and supportive individual. Alternatively I can bring it up to my class specific APD first - the APD mentioned thinking about leaving medicine during residency when we were on an intro call.
    • In both the re-apply and transfer scenarios, I’m uncertain how CMS funding will work since I’ll have used one year of funding.
  • Complete my intern year and leave for industry: I have a business background from before medical school. If I’m truly not happy by the end of my 1st year of residency, I’m confident I can get a job in consulting, equity research, or the life sciences industry. It puts the kibosh on any future as a clinician, but at least I’d be happy. I also enjoy the macro healthcare work. By completing intern year I'll honor my contract and be a licensed physician (non-boarded) able to prescribe meds.
I apologize for the lengthy post, but again, I'd appreciate any input. I understand that I'm early in my decision tree and that my thinking may change. I'm sure after a couple months of trying to keep my feet underneath me as an intern, I'll have a different perspective.

A couple points.

The best thing to do is try to find happiness wherever you're at...because whatever alternative route is uncertain. This is the correct answer everyone here will say and I agree with it. That said, here are my thoughts if that doesn't work out.

It sounds like you would happier in IM than EM. You've already listed quite a few stumbling blocks so it's clear you've thought this through and read a few threads on here already. If you want to do this, I think you need to reapply to the match even if you're looking for transfers down the road instead of banking on a transfer to come through because it's much easier to find positions there and the "match train" only comes around once a year whereas people are accepting transfers year round even though some times are hotter than others. You can always keep the transfer as an option. I would not advise you to walk away from your current residency in case your match situation doesn't work out and the longer time you spend out of training, the worse it is. Don't worry about using up funding. It's a minor issue relative to leaving a program which I'll detail soon.

Like you say, give it a few months time before mentioning it to your PD. You don't want to give off the impression that you didn't even give EM a chance. It'll annoy the PD and make them ask why you chose EM in the first place. I would say wait until August 2021. Bring it up then (two months in). A major thing you need to realize is that A LOT of this is going to depend on the good will of your PD and they have full control of whether they're going to allow this to happen or not because you're going to need a letter from them. Don't be intimidated by that prospect though. At this point, while it's true they don't know you, who would after two months? Don't stress yourself out about trying to make a great impression to them. Just focus on being competent so you don't become a problem resident right from the get-go. That's all you can do and whether the PD opts to write the letter is in their hands, not yours. The letter doesn't have to be long. It just has to be there, certify you were in good standing for all XYZ months, and echo your whole thing about a change of heart etc. The PD doesn't personally have to attest to your work ethic or anything like that. Programs will look at it mainly to make sure there weren't issues and then will look at your other recent letters to gauge your aptitude for IM.

In terms of priorities once you start next week, I would prioritize any IM rotations you can get and try to get a letter from a hospitalist at your new academic center prior to match (October 2021 like you've said). That would bolster your IM application. I honestly would not worry about Step 3. I know it's an additional opportunity to bolster your application, but your Step 1/2 are both decent and Step 3 covers many intern year concepts. Transitioning to residency is tough enough and you shouldn't spend the introduction trying to do Step 3 prep.

Next, a major logistical issue you'll run into (which is why you may want to talk to your PD in August rather than September) is that the you and the program will struggle finding coverage for all the virtual interviews. They're all weekdays during workhours. Programs do have sick/personal days up to 15 days and then there's a 30 day ACGME leave time you can use across residencies but honestly doing either is going to be inevitably seen as poor form. That's because you're using all your offdays up front and then dipping without paying it back. Therefore, you need to try to get some of your vacation time switched to November/December (prime interview season). Now...this all becomes a mute point if you don't have an IM rotation set up before October and you have no vacation time from October - February. At that point, you're going to have to give the PD advanced notice so you can try to change your schedule. If not, try discussing with the chiefs as sometimes they handle scheduling stuff and try to switch with another resident on IM floors. At the beginning of that floor month, speak privately to that hospitalist about your interest.

The next bit is about getting into IM PD heads. I can probably say the #1 thing they're going to want to know (after confirming you're a normal US MD with average step scores and no red flags) is your commitment to the field. ERAS is filled with tons of weirdos applying to 600 programs who don't want any of them, but will say anything to buffer their insurance policies. Do everything you can to differentiate yourself from that and you will be rewarded. The good news is you do have recent and strong support from your medical school and hopefully will find someone at your EM program to help out too. Make sure you tell all your letter writers to emphasize your commitment to INTERNAL MEDICINE. If they ask you about your long term plans, mention the interest in oncology to further support your interest in IM. If they ask wth you didn't apply to IM initially, say you did (which you did) but you had competing priorities when ranking that are no longer priorities and your commitment is 100% with IM and that not ranking the IM programs first was a mistake. The best way to eliminate this doubt in PDs minds is have your current PD write in their letter your commitment to IM.

Now...a couple points about attempting to transfer. First, unless you're looking to go to an EM/IM program, only a few months will be eligible for transfer - up to 2 ED months (the amount IM does) and any IM ward months provided your place has an IM residency...and this is only if your accepting PD accepts those months). Speaking from experience, partial credit is often downgraded to no credit. Next, don't worry about how you will be funded. The way it works out is that CMS will still cover about 50-75% of your training costs even after you've used your limit. Some places will be turned off by this, many others won't be as they go over medicare cap to fund residents anyways. This is why you should apply broadly to IM.

Lastly a couple minor points are that all incoming interns I have talked to hate their class right now and thinks everyone is anti-social because of how little everyone is meeting and make similar assumptions that people are occupied with families, etc. The truth is social activities are probably still limited. Also in regards to EM, it's a contradiction to acknowledge EM's job market and say "all you want is a job in Chicago or NYC".
 
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Redpancreas

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Do we really need a LoR from our current PD to be uploaded on eras?

I plan on applying to a different speciality this September also, and have received conflicting information on this.

An advisor at my medical school stated I don’t need a LoR from my current PD, but I have read on here and Reddit that I will need a LoR. Of course I plan on telling my PD my plans, but is a letter really necessary??

Yes, a PD LoR it's an unwritten requirement to verify your standing or to address any issues at your prior residency. Your yield will be much greater with a letter than without it. If you are confident that you are in a 1/100 case where you know your PD is going to throw you under the bus or whatever you can go without it but everyone will want to know what your program thought and you're going to be walking into a loaded interview (if you get any) and many places may reason that they won't even offer the interview without confirming your standing as a resident and in that case, it's much easier to keep postponing reviewing your app and to pick another one without that issue than it is to pick up a phone and call someone.
 
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RoyalRailer

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Yes, a PD LoR it's an unwritten requirement to verify your standing or to address any issues at your prior residency. Your yield will be much greater with a letter than without it. If you are confident that you are in a 1/100 case where you know your PD is going to throw you under the bus or whatever you can go without it but everyone will want to know what your program thought and you're going to be walking into a loaded interview (if you get any) and many places may reason that they won't even offer the interview without confirming your standing as a resident and in that case, it's much easier to keep postponing reviewing your app and to pick another one without that issue than it is to pick up a phone and call someone.
Makes complete sense. Thanks!
 

ankaa_baako

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I'm a recent MD grad from an east coast med school who matched into an academic West Coast emergency medicine program. This application cycle was particularly hard for me because I hadn't been able to visit programs and cities. I unfortunately ended up prioritizing reputation and program length over location. On top of that I'd been split between EM vs IM. Because of COVID and scheduling, I completed my IM sub-I in January 2021. I really enjoyed my IM sub-I and could envision a career in heme/onc (I have a research background in onc).

After the match, I realized that proximity to family is my number one value. I understand I haven't yet experienced residency, but I can't imagine three years in a city a 5+ hour flight from my closest family with a 3 hour time change. It's been a pretty dark couple of weeks. We are into orientation month, and I can already tell that the vibe of my program and cohort is more family centric. The majority of my co-residents are from the area. Many also have kids, and we haven't had social events understandably so with COVID restrictions and their family obligations. I already feel isolated without my family and friends on the East coast, and I haven't even started shifts yet.

I have given myself to mid/late-August to decide a course of action. The following are some of the options I am considering, and I'd love any feedback from folks who have heard of or gone through similar experiences. I've read most previous threads and articles from SDN and reddit, but I'd appreciate advice specific to my situation.
  • I end up loving my first 3 months, and stick to completing the residency. Even thought the EM job market looks abysmal, I'm hoping to land any job in Chicago or NYC.
  • Re-entering the match: applying to Mid West & East Coast internal medicine programs
    • this option seems like a lot of work because I'll need to get my med school to give me an ERAS token, submit a MSPE, and get a medicine chair letter together (I did well on medicine rotations). I'll also need to get a letter from a medicine doctor during my ICU rotation at my current residency. Fortunately one of my medical school mentors who wrote a letter for my EM app is an IM hospitalist, and I plan on reaching out to him to see what he thinks/if he'll write me another letter. I'm also very close with my med school advising dean, and I think he'll back me no matter what I decide. Mid/late-august is my decision deadline because ERAS needs to be in by September 29th this year.
    • I understand that ultimately I'll need to have a PD letter supporting my decision. There is conflicting advice out there about telling your PD. I'd probably tell my PD in September. However, September is early, and my PD won't know me very well. I'd prefer to be upfront about my thought process with my PD. I'm not sure how realistic it would be to tell my PD what I'm thinking and frame it like "With the limitations of a majority virtual MS4, I'm not certain EM is the right fit for me. I'm interested in IM and passionate about oncology. Could I apply to IM this cycle and delay the decision until rank list is due? That way I have until March 2022 to make a decision." - obviously I'd word it better than that. The number of interviews I'd get could also affect my decision, since I don't want to be left without any residency spot. I have a family connection to a community IM program in my preferred geographic area. I'm not concerned about prestige, so I'd be happy to land there if they'd take me.
    • I plan on taking and passing Step 3 in November. I hit the median on Step 1 and 2, so I don't have good or bad board scores. I'm going buckle down and make sure I pass step 3. I figure that may be a concern for some IM PDs.
    • Am I damaged goods re-applying in the match? Is this option even viable? I just don't want to complete intern year and then have to re-enter the match as a EM PGY-2. At that point I'd just complete my residency.
  • Transfer: Waiting until November/December and then emailing EM and IM PDs in my geographic areas of interest for PGY-2 positions. I'll avoid emailing PDs at the same institutions.
    • The retention rate for EM is pretty high, so I don't think this is a viable option. I'll email 4 year EM programs in my area of interest first. From advice I read online, I'll email only one program at a time and wait for their response. Then I'll continue down my prioritized list of programs. I'm going to talk to my EM med school mentor in August once I make a decision to see what he/she thinks.
    • The IM drop out rate seems higher and there are more spots. I'd love to be able to slide into a PGY-2 position which counts some of my EM intern experience towards IM requirements. I don't mind taking 3.5-4 years to finish IM. It would be 4 years anyway if I reapplied via the match. I'll start with this list after I've exhausted EM transfer options.
    • I know the odds of either are low, but it’s not impossible. I know someone who switched geographic areas in the same specialty. Again, should I be upfront with my PD or only talk to my PD once I know there is an open position somewhere. I'm hoping to not completely light the bridge on fire, and my PD seems like an understanding and supportive individual. Alternatively I can bring it up to my class specific APD first - the APD mentioned thinking about leaving medicine during residency when we were on an intro call.
    • In both the re-apply and transfer scenarios, I’m uncertain how CMS funding will work since I’ll have used one year of funding.
  • Complete my intern year and leave for industry: I have a business background from before medical school. If I’m truly not happy by the end of my 1st year of residency, I’m confident I can get a job in consulting, equity research, or the life sciences industry. It puts the kibosh on any future as a clinician, but at least I’d be happy. I also enjoy the macro healthcare work. By completing intern year I'll honor my contract and be a licensed physician (non-boarded) able to prescribe meds.
I apologize for the lengthy post, but again, I'd appreciate any input. I understand that I'm early in my decision tree and that my thinking may change. I'm sure after a couple months of trying to keep my feet underneath me as an intern, I'll have a different perspective.
Wow this!! I'm in similar position but in my case Gen Surg to IM. After my IM rotation the thought of IM came to my mind but covid made me think it was an anomaly. Now few weeks into Surgery residency and I don't see myself doing this. Its not the hours, its one of those things that hit me. Now I'm up every time thinking I messed up my life/career.

The rest is similar to the story above and in need of advice. Thank you.
 
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Iamnew2

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I'm a recent MD grad from an east coast med school who matched into an academic West Coast emergency medicine program. This application cycle was particularly hard for me because I hadn't been able to visit programs and cities. I unfortunately ended up prioritizing reputation and program length over location. On top of that I'd been split between EM vs IM. Because of COVID and scheduling, I completed my IM sub-I in January 2021. I really enjoyed my IM sub-I and could envision a career in heme/onc (I have a research background in onc).

After the match, I realized that proximity to family is my number one value. I understand I haven't yet experienced residency, but I can't imagine three years in a city a 5+ hour flight from my closest family with a 3 hour time change. It's been a pretty dark couple of weeks. We are into orientation month, and I can already tell that the vibe of my program and cohort is more family centric. The majority of my co-residents are from the area. Many also have kids, and we haven't had social events understandably so with COVID restrictions and their family obligations. I already feel isolated without my family and friends on the East coast, and I haven't even started shifts yet.

I have given myself to mid/late-August to decide a course of action. The following are some of the options I am considering, and I'd love any feedback from folks who have heard of or gone through similar experiences. I've read most previous threads and articles from SDN and reddit, but I'd appreciate advice specific to my situation.
  • I end up loving my first 3 months, and stick to completing the residency. Even thought the EM job market looks abysmal, I'm hoping to land any job in Chicago or NYC.
  • Re-entering the match: applying to Mid West & East Coast internal medicine programs
    • this option seems like a lot of work because I'll need to get my med school to give me an ERAS token, submit a MSPE, and get a medicine chair letter together (I did well on medicine rotations). I'll also need to get a letter from a medicine doctor during my ICU rotation at my current residency. Fortunately one of my medical school mentors who wrote a letter for my EM app is an IM hospitalist, and I plan on reaching out to him to see what he thinks/if he'll write me another letter. I'm also very close with my med school advising dean, and I think he'll back me no matter what I decide. Mid/late-august is my decision deadline because ERAS needs to be in by September 29th this year.
    • I understand that ultimately I'll need to have a PD letter supporting my decision. There is conflicting advice out there about telling your PD. I'd probably tell my PD in September. However, September is early, and my PD won't know me very well. I'd prefer to be upfront about my thought process with my PD. I'm not sure how realistic it would be to tell my PD what I'm thinking and frame it like "With the limitations of a majority virtual MS4, I'm not certain EM is the right fit for me. I'm interested in IM and passionate about oncology. Could I apply to IM this cycle and delay the decision until rank list is due? That way I have until March 2022 to make a decision." - obviously I'd word it better than that. The number of interviews I'd get could also affect my decision, since I don't want to be left without any residency spot. I have a family connection to a community IM program in my preferred geographic area. I'm not concerned about prestige, so I'd be happy to land there if they'd take me.
    • I plan on taking and passing Step 3 in November. I hit the median on Step 1 and 2, so I don't have good or bad board scores. I'm going buckle down and make sure I pass step 3. I figure that may be a concern for some IM PDs.
    • Am I damaged goods re-applying in the match? Is this option even viable? I just don't want to complete intern year and then have to re-enter the match as a EM PGY-2. At that point I'd just complete my residency.
  • Transfer: Waiting until November/December and then emailing EM and IM PDs in my geographic areas of interest for PGY-2 positions. I'll avoid emailing PDs at the same institutions.
    • The retention rate for EM is pretty high, so I don't think this is a viable option. I'll email 4 year EM programs in my area of interest first. From advice I read online, I'll email only one program at a time and wait for their response. Then I'll continue down my prioritized list of programs. I'm going to talk to my EM med school mentor in August once I make a decision to see what he/she thinks.
    • The IM drop out rate seems higher and there are more spots. I'd love to be able to slide into a PGY-2 position which counts some of my EM intern experience towards IM requirements. I don't mind taking 3.5-4 years to finish IM. It would be 4 years anyway if I reapplied via the match. I'll start with this list after I've exhausted EM transfer options.
    • I know the odds of either are low, but it’s not impossible. I know someone who switched geographic areas in the same specialty. Again, should I be upfront with my PD or only talk to my PD once I know there is an open position somewhere. I'm hoping to not completely light the bridge on fire, and my PD seems like an understanding and supportive individual. Alternatively I can bring it up to my class specific APD first - the APD mentioned thinking about leaving medicine during residency when we were on an intro call.
    • In both the re-apply and transfer scenarios, I’m uncertain how CMS funding will work since I’ll have used one year of funding.
  • Complete my intern year and leave for industry: I have a business background from before medical school. If I’m truly not happy by the end of my 1st year of residency, I’m confident I can get a job in consulting, equity research, or the life sciences industry. It puts the kibosh on any future as a clinician, but at least I’d be happy. I also enjoy the macro healthcare work. By completing intern year I'll honor my contract and be a licensed physician (non-boarded) able to prescribe meds.
I apologize for the lengthy post, but again, I'd appreciate any input. I understand that I'm early in my decision tree and that my thinking may change. I'm sure after a couple months of trying to keep my feet underneath me as an intern, I'll have a different perspective.

On the job front, even though the EM market may look abysmal right now, it happens with every specialty. I remember when I was in Rads, initially it was great then the job market went to crap, now it's back to much better now. I switched out for other reasons and glad I did but I wouldn't worry so much about the job market. Every specialty has ups and downs in this regard. I also remember in the past how EM was red hot and everyone wanted to go into EM and people talked about how they were making lots of money. I do agree that family is important, I personally feel that this is one of the most important decisions when applying and matching because residency is hard and family tends to be a good source of support. However make sure that a decision potentially leaving EM is not made in haste - with EM obviously there is a lot of down time so you at worst case scenario can visit more often or something. Don't leave EM just because you feel lonely. Also everyone thinks that getting a reasonable consulting job is so easy. It's not and it pays pennies compared to clinical medicine generally speaking. so. take your time before making any massive decision.
 
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