Spitting distance to IM, now loving EM rotation, options?

[JHACO WACKO]

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Well crap, medical school has flown by, I wasn't ready to make a decision on specialty and ended up applying to IM.

Last month I was on a rural FM rotation that I loved more than any other rotation to date, because in addition to working in a clinic that saw a lot of minor acute issues we also saw patients in the small ER in town. It was immensely satisfying to me and I figured that with my IM apps already out there, I could potentially do IM-->rural practice and do similar work down the road.

Now I am on my required 4th year EM rotation...bottom line is that I am loving every aspect of it--the variety of complaints, the simple procedures, rapid assessment, the interactions with EMS/other physicians, and the camaraderie of the ED. So much so that I am freaking out that I've already committed to IM.

So I need a game plan, and would love some feedback on this if you all would indulge me:

Option 1: Find some way to delay graduation, withdraw from the match, do another couple of EM rotations next summer for LORs, and reapply to EM next cycle.

Option 2: Proceed to match in categorical IM, do another EM rotation this spring to get a SLOR, tell IM PD I want to do EM and try to reapply during intern year.

Option 3: Match and complete IM residency, try to do a second residency in EM.

Unaswered questions I have are:

1) Will I be able to use 4th year SLORs if I am applying as an intern?

2) Since none of the IM programs I am applying to have an EM program at the same institution (doh!), will a letter from my intern EM rotation be of any value?

3) Funding issue aside, would completion of an IM program be valued by PDs if I were to try and go the second residency route?

Thanks for reading my long post and offering any input!

 

[Zanegray]

Let me start by saying I am not sure what the right answer is here. I am an EM intern. But as I was reading this it struck me that there are still some 2-4 EM programs out there I think, meaning, they require a TY somewhere - maybe your IM intern year would qualify for this.

Tough situation - good luck.

 

[gman33]

Do you have an EM program at your school?
If so, I'd try to talk to the PD.
Ask him/her how candidates in your situation would be evaluated.

I have no real experience in this matter, but I would think that your best shot is as a first time applicant. I really wouldn't go down the whole doing another residency first road.

I guess it's too late to try to switch up and start applying EM this year.

I just don't think it's a good idea to match into something knowing you are going to bail. It may raise flags for matching into a future EM program. I know plenty of people switch, but I don't think it's ideal.

 

[thethom]

More likely to be functional in an ED with FM training (what will you do with peds patients that come in without any training with kids during residency, or gynecologic issues for that matter).

Though its late in the application part of the interview season, you could probably try to call up some local FM programs and see if they'd consider your application.

 

[Groove]

Difficult, but not impossible situation by any means. I empathize with you.

Let's start by developing a winning strategy. You need to first of all assess yourself honestly as a potential EM candidate. Do you have a solid application with good grades, evals, and above average board scores? EM remains a moderately competitive specialty and the worst thing that could happen would be for you to invest the additional time and energy into applying, only to fail in the match. First and foremost, make sure that your chances of succeeding are up to par on paper. Correlate your numbers with the latest copy of "Charting Outcomes for the Match" from the NRMP website.

Second, you need to feel very committed to this route because it's going to take some work. I know it's difficult to get a good and accurate impression of work as an ED physician during 1 or 2 short rotations, but I think that most of us that pursued EM fell in love with the ED for a variety of reasons. If there's one place in the hospital that people develop a love or hate relationship, it's definitely the ED. I know few people that hover on the fence in their feelings about the work that goes on down there. I often tell students that if you're on the fence about EM, and about working in the ED, it probably isn't the right place for you. On top of that, research all the negatives about working in the ED. Imagine all the psych pts and drug seekers, the condescending consults, the specialists that will always consider you a glorified triage nurse, the litigation, the high stress environment that you will be required to work in during nights, weekends and holidays to some extent for the rest of your career. There are plenty of positives to EM, otherwise some of us wouldn't be so gung ho about pursuing the specialty, but the negatives are very real and worth some serious consideration. You need to be committed and stick with it. I'm not a fan of jumping programs/residencies. It's a tricky game to play and one that can backfire in a very lethal way. Not worth it IMO, so if you finally match into EM, be prepared to stick it out.

Ok, if everything is otherwise in order, you need to work on getting those SLOR's from EM faculty. Normally, I would suggest getting them at different institutions but in your case, I would get them from anybody who could give you a very positive evaluation. If it's all within the same ED, then so be it. If you can get them in time, I would suggest contacting some of the new EM programs (are there any this year?) who probably have a lower number application pool. Also, contact PDs at some of the lower competitive programs. I would not be too picky if I were you considering your situation. Plus, with RRC guidelines, I feel there is a very good chance to get solid training wherever you go. If you can start sooner rather than later, I'd go that route rather than waste an extra year.

I do not agree with pursuing a categorical IM residency. I think matching into a categorical position with the full knowledge that you will be dropping out after 1 year is dishonest and potentially jeopardizes your relationship with the PD, who has to write a satisfactory letter on your behalf when you leave the program, I might add. Imagine some of the worst case scenarios. You could let some of your fellow interns know about your EM ambitions and word will quickly get around the program to the IM staff and eventually your PD. You could be quickly black balled and given bad evaluations during some of your rotations. These evals will be read by the EM programs that you are applying to. If you think low ball stuff like this doesn't go on in some programs, think again. I would suggest applying to prelim/transitional medicine positions, or even scrambling into one. That should be very easy and will give no commitment to additional training past your first year. Try to pick a place that is geographically near some of the EM programs that you are interested in because, unless you are rich, I'm sure money and time will be tight during your intern year and interviews will be difficult find time to go on. If you can do a prelim/transitional year at an EM program that you have a good chance of matching into, that's the best option yet.

Finally, stand back and try to look at the big picture. Ask yourself why you picked IM in the first place? Are there specialties that interested you? The nice thing about IM is that there is almost something available for almost anyone. Medicine is a big sandbox and there are plenty of toys to suit just about any kid. You have many more post residency options than you do if you finish an EM residency. That is starting to change, but it's going to be a slow process as the specialty continues to mature and evolve. I will say this, the mere fact that you applied for IM in the first place would make me ask you to search yourself. What do I mean by that? Well, I can't speak for all the other EM residents, but an IM residency never even crossed my mind. I mean, I was mildly interested in the idea of hospitalist medicine, but the idea of rounding incessantly and mentally masturbating over rare syndromes, vent settings and developing shotgun reflexes for ordering HIT antibody tests for anybody with a 10 point drop in platelets was never my idea of fun. Honestly, there were some IM specialties that interested me but the thought of 3 years of IM as a sort of twisted fraternity hazing process was just too painful. I don't think I'm a minority in that sentiment among other EM residents.

Anyway, think it over and keep us updated. Sorry for the long windedness. It's the guinness.

 

[gman33]

Groove's post above is right on the money in so many ways.
Great advice!

I'm trying my best to get early exposure to all the fields I have any interest in.
It kind of sucks if your interests lie in fields which get little exposure during third year.

 

[JHACO WACKO]

Groove:

Thank you for the time you put into that reply, it is very helpful!

 

[anonymousEM]

You need your advisor(preferably the PD from your school's EM program) to make calls for you if you want to have a chance at getting any EM invites for interviews this year. Most have already made their invitations but would still consider a colleague's favor especially if they have a hole in the schedule. Once you get the interviews, you are on the same ground as else. Impress appropriately and hope for the best in the match.

Are you able to do another EM elective before the match lists go in? It's not too late to make a good impression at a program either--it's always easier to consider a known quantity.

 

[peppy]

I do not agree with pursuing a categorical IM residency. I think matching into a categorical position with the full knowledge that you will be dropping out after 1 year is dishonest and potentially jeopardizes your relationship with the PD, who has to write a satisfactory letter on your behalf when you leave the program, I might add. Imagine some of the worst case scenarios.

I think this is great advice. You have nothing to lose by pursuing a prelim medicine year since you could then get into a PGY-2 IM spot if you end up deciding that IM is truly for you after all.

Interviewing as an intern is not as easy as it is for med students, but it is far easier and more practical as a prelim/transitional year than it is as a categorical resident since the prelim/TY programs fully expect you to want to take time off during interview season.