Switching from EM to surgery

[whatsthepoint]

EM PGY-1 here. I switched to EM late in 4th year of medical school after dual applying for a surgical subspecialty. Ever since I have missed the operating room dearly. I never gave gen surg a chance as I had minimal exposure to it until now rotating on Trauma Surgery and ACS. I had a mentor in medical school who tried to get me to do general surgery for 3 years straight and now I see the light.

Am I better off pursuing a preliminary surgery year in the SOAP next month, or apply in the match as an EM PGY-2? I have my PD's support and he is aware.

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[Pir8DeacDoc]

Does your current hospital have general surgery residency? Staying on board at your current place would be the least life disruptive and probably easier to slot into without losing years here or there. Prelim spot is a bit of a gamble. Though it can obviously work out

 

[flightdoc09]

New EM attending here. I switched to EM last minute my 4th year as well. Was a tough decision, as I loved doing stuff in the OR. Even as an intern on gen surg, or a 3rd year on trauma, I would go to the OR and get to assist. Some attendings even let me do quite a bit. I still do miss the OR, and I think if I was younger when I was a med student, gen surg would have been a no-brainer.

But 2 things kept me from pursuing it. One was during one of my audition rotations, I was paired with a preceptor attending that was always saying I did everything wrong, never did anything right, and just made me feel like crap for the first 3.5 weeks. Despite all the residents I worked with saying good things about me. Then my last few days there he changed his tune and on my exit interview actually said I did a lot of things well. But because of that I was miserable the whole month, waking up extra early, going to sleep extra late, I lost weight, etc. Then, I also did a 12 hour thoracic surgery case during my Sub-I in 4th year that about wrecked me physically. I was probably dumb and let myself get dehydrated so I wouldn't have to keep scrubbing out. Both of those got me contemplating about what it would be like doing a 5 year residency going through that. And being older, I thought about what it may be like trying to get married, start a family, while doing that as well.

One of my upper level residents felt similar about doing surgery. She almost switched, but ended up staying and doing a trauma critical care fellowship (as opposed to medical crit care). So a possible different option.

Overall, I'm happy in EM. I think burn out is likely higher, and the state of our medical system doesn't help (as you're aware). But I do still miss the OR. I'm not trying to discourage you. Just giving you some other perspective. And to warn you about getting into a toxic program. If that place I did a Sub-I at was better, or I got paired with a less grumpy/mean preceptor, I would have probably ended up going into surgery.

 

[Dr.LeoSpaceman]

In either case, decent chance you'll be applying in the match for categorical positions next year. Taking the prelim spot gives you another option in that you could take an open PGY2 GS spot, though you shouldn't count on that. The prelim spot also gives you some "street cred" regarding how serious you are about surgery. The downside is that you'll give up a safe backup plan of just continuing in your EM residency if you don't match. If you don't match after a prelim year, it can get dicey.

Where you have an option for a prelim year also is a big part. I would not go to a place that uses a large cohort of prelims as warm bodies. You'd want to try and find a place that has a small group of prelims with a strong track record of placing them in categorical spots.

Ultimately it's a tough decision. If you see any way that you could be happy in EM long-term (including with a fellowship, etc.), I'd probably just apply to categorical positions next year to avoid burning potential bridges.

 

[whatsthepoint]

In either case, decent chance you'll be applying in the match for categorical positions next year. Taking the prelim spot gives you another option in that you could take an open PGY2 GS spot, though you shouldn't count on that. The prelim spot also gives you some "street cred" regarding how serious you are about surgery. The downside is that you'll give up a safe backup plan of just continuing in your EM residency if you don't match. If you don't match after a prelim year, it can get dicey.

Where you have an option for a prelim year also is a big part. I would not go to a place that uses a large cohort of prelims as warm bodies. You'd want to try and find a place that has a small group of prelims with a strong track record of placing them in categorical spots.

Ultimately it's a tough decision. If you see any way that you could be happy in EM long-term (including with a fellowship, etc.), I'd probably just apply to categorical positions next year to avoid burning potential bridges.

This is such a tough decision. I am struggling a lot with it.

Wouldn't applying from my categorical spot potentially burn bridges too though?

 

[Dr.LeoSpaceman]

This is such a tough decision. I am struggling a lot with it.

Wouldn't applying from my categorical spot potentially burn bridges too though?

It shouldn't be, but you would need to have that direct and unambiguous conversation with your current PD. If your PD is expecting you are leaving the program regardless of the outcome of the match next year, that obviously complicates things.

 

[whatsthepoint]

It shouldn't be, but you would need to have that direct and unambiguous conversation with your current PD. If your PD is expecting you are leaving the program regardless of the outcome of the match next year, that obviously complicates things.

Update: Somehow I made it through this intern year, and I am finishing my last month in the ED as an intern. My program is aware of my desire to switch but is giving me the option to stay if I want to finish out the 3-year program. However, if I decide I want to switch, then I have to leave after this intern year ends. I know the logical answer is to stay. But I truly feel miserable here and feel like I don't belong. I miss the operating room so much.
I'm a USMD with 24x step 2. Can I leave my program after June 30, and take the next academic year off to apply to surgery? Or will this be career suicide?

 

[Dr.LeoSpaceman]

Update: Somehow I made it through this intern year, and I am finishing my last month in the ED as an intern. My program is aware of my desire to switch but is giving me the option to stay if I want to finish out the 3-year program. However, if I decide I want to switch, then I have to leave after this intern year ends. I know the logical answer is to stay. But I truly feel miserable here and feel like I don't belong. I miss the operating room so much.
I'm a USMD with 24x step 2. Can I leave my program after June 30, and take the next academic year off to apply to surgery? Or will this be career suicide?

Can you leave and try to match into surgery? Of course you can. But I think it would be an enormous gamble. You'd have to 100% be willing to accept an outcome that means you don't end up in clinical medicine at all. Or that you knock around in a few prelim years and still end up in something that isn't surgery. Whether those outcomes are still better than slogging through to finish EM is something only you can answer.

Is your current PD willing to write you a strong letter? Where are your other letters coming from? Those are key questions. But in my mind it's a bit of a red flag (whether real or perceived) that you aren't going to be in a program while applying.

 

[Smurfette]

Update: Somehow I made it through this intern year, and I am finishing my last month in the ED as an intern. My program is aware of my desire to switch but is giving me the option to stay if I want to finish out the 3-year program. However, if I decide I want to switch, then I have to leave after this intern year ends. I know the logical answer is to stay. But I truly feel miserable here and feel like I don't belong. I miss the operating room so much.
I'm a USMD with 24x step 2. Can I leave my program after June 30, and take the next academic year off to apply to surgery? Or will this be career suicide?

IMO You're better off staying in your current program and applying next year for a surgery spot. That way you maintain an income, keep active clinically and if you don't match into a surgery spot, you can reassess whether you want to try for something else or finish and become board certified to give you some long-term options.

 

[Apollyon]

This dude started 3 threads in the Gen Res forum about this same thing. Nothing has changed except as above.

 

[whatsthepoint]

This dude started 3 threads in the Gen Res forum about this same thing. Nothing has changed except as above.

God forbid. I was told to come to my old thread. Get the **** over it. What value does your comment add to this conversation? Nothing.

 

[ThoracicGuy]

God forbid. I was told to come to my old thread. Get the **** over it. What value does your comment add to this conversation? Nothing.

 

[Apollyon]

God forbid. I was told to come to my old thread. Get the **** over it. What value does your comment add to this conversation? Nothing.

Dude, this is why people don't help.

 

[eyeeye_captain]

Grand scheme you’re almost certainly going to be better off sticking with EM. Get out, tailor your gig to something tolerable, and keep it moving.

As above, I worry significantly about your letters. If the PD is already telling you to get out the door if you’re going to apply, which then gives them a scheduling headache for 2 years instead of 1, I don’t suspect that one will be rosy. Miserable residents often have performance issues, which may come up if you happen to fit the bill. I don’t think you applied surgery originally, so who will remember you from third year rotations to help you out?

General surgery has gotten more competitive with what looks like a 74.5% match rate in 2025 (1114/1496) for MD seniors for categorical. That would be bumping up against the subspecialties for difficulty, and graduates fare worse than seniors. Do you think your app has what it takes?

There are programs out there that are prelim mills and would be happy to put a warm body to work without any real path forward. If you’re hurting now, that potential option hurts worse. If you can slog through a prelim maybe you can find a PGY-2 opening since more people leave surgery than jump in, but programs like that aren’t going to give you many interview days.

Training gaps aren’t super common outside of research years, so that would probably raise an eyebrow or two.

I feel for you. The last year or so hasn’t worked out anything like you expected or wanted. If you’re willing to take the very real risk of chasing yourself out of clinical medicine, then I hope you beat what look like really tough odds with switching.

When you’re forced to eat a turd sandwich, pick the smaller one. In this case I think that’s staying in EM.

 

[Crayola227]

IMO You're better off staying in your current program and applying next year for a surgery spot. That way you maintain an income, keep active clinically and if you don't match into a surgery spot, you can reassess whether you want to try for something else or finish and become board certified to give you some long-term options.

This

 

[Crayola227]

God forbid. I was told to come to my old thread. Get the **** over it. What value does your comment add to this conversation? Nothing.

I understand you're emotional and also that comment may have made you feel picked on. But seriously, try not to directly tell someone to **** off here.

 

[Crayola227]

Grand scheme you’re almost certainly going to be better off sticking with EM. Get out, tailor your gig to something tolerable, and keep it moving.

As above, I worry significantly about your letters. If the PD is already telling you to get out the door if you’re going to apply, which then gives them a scheduling headache for 2 years instead of 1, I don’t suspect that one will be rosy. Miserable residents often have performance issues, which may come up if you happen to fit the bill. I don’t think you applied surgery originally, so who will remember you from third year rotations to help you out?

General surgery has gotten more competitive with what looks like a 74.5% match rate in 2025 (1114/1496) for MD seniors for categorical. That would be bumping up against the subspecialties for difficulty, and graduates fare worse than seniors. Do you think your app has what it takes?

There are programs out there that are prelim mills and would be happy to put a warm body to work without any real path forward. If you’re hurting now, that potential option hurts worse. If you can slog through a prelim maybe you can find a PGY-2 opening since more people leave surgery than jump in, but programs like that aren’t going to give you many interview days.

Training gaps aren’t super common outside of research years, so that would probably raise an eyebrow or two.

I feel for you. The last year or so hasn’t worked out anything like you expected or wanted. If you’re willing to take the very real risk of chasing yourself out of clinical medicine, then I hope you beat what look like really tough odds with switching.

When you’re forced to eat a turd sandwich, pick the smaller one. In this case I think that’s staying in EM.

Also this.

I think I caught somewhere the OP took the step 2 USMLE 24 times? That can't possibly be right.

 

[Dr.LeoSpaceman]

IMO You're better off staying in your current program and applying next year for a surgery spot. That way you maintain an income, keep active clinically and if you don't match into a surgery spot, you can reassess whether you want to try for something else or finish and become board certified to give you some long-term options.

The problem is that (apparently) this isn't an option. If I read it correctly, the PD is telling the OP they have to choose to stay in the program for year 2 (and not apply to GS) or leave after PGY1 and apply while in a gap year.

Obviously the PD of the EM can't technically stop OP from staying and then applying to GS, but they can functionally make it near impossible to be successful if they restrict time for interviews or won't provide a (strong letter). The fact that this is the PD's position means either one or both of two things: the PD is kind of a jerk and/or there are existing red flags for OP that make the PD less-than-sympathetic to the situation. Neither one of these are positives as it relates to chances of matching into GS.

EDIT: Though I suppose the other issue may be that if EM is like surgery, the PD won't be able to fill an empty PGY3 spot if it's the final year. In which case, they don't want to risk OP sticking around, matching into surgery, then being stuck short a PGY3.

 

[Crayola227]

It's not only about not chasing yourself out of clinical medicine, it's that a lack of board certification is just an awful thing long term. Having an unrestricted license is like, OK but still bad (if you have the opportunity to take step 3 and get it with your program's blessing, do it  ASAP). Get it on lockdown before any relations with the program can sour and become a barrier.

Not having a license = unspeakable badness for job prospects.

Having a license and no board cert = yeah, there's jobs but again, you've restricted your options so much, it's going to be worse for you than toughing out 2 years and being in a much better place.

The right answer is always going to be finishing a residency no matter the cost. The right thing to do is whatever makes that the surest bet. I don't know much about how things get viewed, but my guess is that sticking it out with finishing a residency in something you don't want is going to help you more in making a switch, although you won't have funding left. You'll probably get more support from your PD. You show surgery stick-to-it-iveness, because a worry is always will the unhappy resident not sticking it out, switch and not repeat the pattern of being unhappy and uninterested.

You're better off making it such that you have a board cert before you go off chasing the unknown. It doesn't seem to me like your odds of matching surg are worse if you go forward with EM. That someone is turning down 6 figures for more training after completing training.... but if you don't succeed matching you'll be glad you did the training.

Ultimately a job is a job, there's a reason one must be paid to do it. I would see it as just something you have to do now to set yourself up later, like O chem was for med school. Don't let 2 years of EM ruin the rest of your life and career.

I know suck it up is never what a suffering resident wants to hear, especially when you can imagine saving yourself a lot of painful work. The trade off is not worth it if it goes south though imho.

 

[RockClimberMed]

Also this.

I think I caught somewhere the OP took the step 2 USMLE 24 times? That can't possibly be right.

If youre referring to the 24x Step 2 in OPs comment...It means they scored anywhere from 240-249..not sure why ppl feel the need to obfuscate the exact number when asking for advice, but who knows.

 

[Crayola227]

If youre referring to the 24x Step 2 in OPs comment...It means they scored anywhere from 240-249..not sure why ppl feel the need to obfuscate the exact number when asking for advice, but who knows.

Could just as easily use a number a couple points off without having a practical effect on advice given, if they don't want the exact real score out there.

 

[Crayola227]

24 times, really? lmao,

We see people who indicate they took the USMLE as follows: "I'm an IMG, 2x Step 2" to indicate how many attempts they have taken the step to get a pass. They usually don't bother to mention a score at that point because they understand the number of times they retook (aka failed) a step is more relevant to their chances than any score they may have received subsequently. We've see some truly shocking number of attempts on this board. Usually FMGs not US, which made what I thought you wrote make even less sense. We also get trolls that make posts that seem real enough and make sense except they'll slip on one ridiculous element to see who notices and takes bait.

I assumed you had made a typo. I see people say "240s" or "low 240s" more commonly, not really 23x or some such. But I haven't been to allo in a while maybe WAMC threads have changed.

Obviously the PD of the EM can't technically stop OP from staying and then applying to GS, but they can functionally make it near impossible to be successful if they restrict time for interviews or won't provide a (strong letter). The fact that this is the PD's position means either one or both of two things: the PD is kind of a jerk and/or there are existing red flags for OP that make the PD less-than-sympathetic to the situation. Neither one of these are positives as it relates to chances of matching into GSGS.

The PD can also sink your boat entirely even if you do interview, not just through a letter but a simple phone call from one PD to another, which isn't uncommon in a situation like this.

The PD holds enormous power on every single thing that transpires here moving forward. Really the odds are good that whatever results the PD wants is what they get.

 

[operaman]

Agree with the others - stick it out. You’re only losing one year on your surgery career and you’re keeping options open. Just apply during your pgy3 year and if you match, start gen Surg after you graduate EM.

Your PD shouldn’t mind since you’ll complete won’t be leaving him in the lurch. If you don’t match, then take an EM attending job and make good money while you apply again or figure out a next move.

Bailing now is a lot of risk for a maximum payout of one extra year as a surgeon.

 

[mmchick]

Agree with the others - stick it out. You’re only losing one year on your surgery career and you’re keeping options open. Just apply during your pgy3 year and if you match, start gen Surg after you graduate EM.

Your PD shouldn’t mind since you’ll complete won’t be leaving him in the lurch. If you don’t match, then take an EM attending job and make good money while you apply again or figure out a next move.

Bailing now is a lot of risk for a maximum payout of one extra year as a surgeon.

I’m also in a very similar boat… strongly considering general surgery switch from EM. Reading through all of this it does make most sense / least risk to finish out EM residency and apply during PGY3. How should one go about securing appropriate letters if someone were to do this seriously? One of my thoughts is just being an absolute stellar resident during our trauma surgery months, getting to know the attendings and other residents really well, expressing some vague interest etc. Perhaps garnering some support from their side as well as my PD/program of course. What to make of the funding mess if someone applies as an almost-attending…?

 

[ThoracicGuy]

I’m also in a very similar boat… strongly considering general surgery switch from EM. Reading through all of this it does make most sense / least risk to finish out EM residency and apply during PGY3. How should one go about securing appropriate letters if someone were to do this seriously? One of my thoughts is just being an absolute stellar resident during our trauma surgery months, getting to know the attendings and other residents really well, expressing some vague interest etc. Perhaps garnering some support from their side as well as my PD/program of course. What to make of the funding mess if someone applies as an almost-attending…?

I would express more than vague interest on your trauma and critical care rotations (if you do them with surgery). Let them know explicitly that you are thinking about applying for general surgery after you finish in ER. They will be your letter writers for LOR.

 

[Smurfette]

I’m also in a very similar boat… strongly considering general surgery switch from EM. Reading through all of this it does make most sense / least risk to finish out EM residency and apply during PGY3. How should one go about securing appropriate letters if someone were to do this seriously? One of my thoughts is just being an absolute stellar resident during our trauma surgery months, getting to know the attendings and other residents really well, expressing some vague interest etc. Perhaps garnering some support from their side as well as my PD/program of course. What to make of the funding mess if someone applies as an almost-attending…?

Honestly, you need to note the questions you are asked by the surgery team when you consult them and use it to become a resident that the surgery residents think speaks their language by knowing what they want to know. Note scars on bellies and get a surgical history before you are calling them about an SBO. Look at recent op notes when post op patients show up in the ER with complications so you know what was done. Do a good exam on patients so they know when you are calling about a tender belly, it is legit a tender belly. Look at the imaging you order and not just the reports. If they are down in the ER trying to reduce a hernia, watch them and learn. It sounds simple, but you'd be surprised how often I am told completely wrong or simply made up information and find nothing is as advertised when I show up in the ER.

 

[mmchick]

Honestly, you need to note the questions you are asked by the surgery team when you consult them and use it to become a resident that the surgery residents think speaks their language by knowing what they want to know. Note scars on bellies and get a surgical history before you are calling them about an SBO. Look at recent op notes when post op patients show up in the ER with complications so you know what was done. Do a good exam on patients so they know when you are calling about a tender belly, it is legit a tender belly. Look at the imaging you order and not just the reports. If they are down in the ER trying to reduce a hernia, watch them and learn. It sounds simple, but you'd be surprised how often I am told completely wrong or simply made up information and find nothing is as advertised when I show up in the ER.

... this is a little irrelevant to my question and just a bitter take towards EPs, thanks for sharing. Yes we all know sub specialists love to **** on EM about everything we don’t know and forget to acknowledge what we do/what we catch/what we don’t consult for being generalists. It’s not the EP’s job to know what actual abdomens are indeed surgical acute abdomens. If someone’s having new postoperative pain,10 times out of 10 we’re obligated to call you considering they just had a surgery and are now having pain… even if their exam isn’t that exciting. It’s the world we live in. We’re often damned if we do damned if we don’t. I’ve gotten yelled at for not calling and calling surgeons down, for both exciting and not exciting patients. You can’t win.

The things you pointed out are things I love to try and do when feasible. Unfortunately the reality of the ED is half the time patients don’t even know what surgeries they’ve had, much less give me a reliable HPI.. I try to look at all my CT scans but when you’re throwing spaghetti at the wall and have 14 simultaneous patients, you don’t always get 10 minutes to scroll through someone’s CTAP to look for anything that might “pop out” with all of our *formal radiology training* outside of what the radiologist calls. Can’t say I’ve met many EPs that will make a call on something a radiologist didn’t formally read or correct something… considering we’re completely not credentialed to do so.

 

[DocSurgeon]

... this is a little irrelevant to my question and just a bitter take towards EPs, thanks for sharing. Yes we all know sub specialists love to **** on EM about everything we don’t know and forget to acknowledge what we do/what we catch/what we don’t consult for being generalists. It’s not the EP’s job to know what actual abdomens are indeed surgical acute abdomens. If someone’s having new postoperative pain,10 times out of 10 we’re obligated to call you considering they just had a surgery and are now having pain… even if their exam isn’t that exciting. It’s the world we live in. We’re often damned if we do damned if we don’t. I’ve gotten yelled at for not calling and calling surgeons down, for both exciting and not exciting patients. You can’t win.

The things you pointed out are things I love to try and do when feasible. Unfortunately the reality of the ED is half the time patients don’t even know what surgeries they’ve had, much less give me a reliable HPI.. I try to look at all my CT scans but when you’re throwing spaghetti at the wall and have 14 simultaneous patients, you don’t always get 10 minutes to scroll through someone’s CTAP to look for anything that might “pop out” with all of our *formal radiology training* outside of what the radiologist calls. Can’t say I’ve met many EPs that will make a call on something a radiologist didn’t formally read or correct something… considering we’re completely not credentialed to do so.

I would hard disagree on a couple things here. As an EP you should know surgical from nonsurgical abdomen. You’re on the front lines and absolutely need to be able to differentiate “sick vs non sick.”

As far as imaging, you look at and read your own EKGs, right? Similarly, you need to look at every film you order. No one’s asking you to be better than a radiologist but you will catch things they miss. They’re humans too. But the more you look at the easier it gets and the faster you become.

All that being said, agree you guys get **** on too much for not knowing everything about everything and not/calling consultants. All that’s moot if you jump ship to the surgical side though. When/if you do, just try to remember that when you get your third call at 2 am and the person talking to you in the ED can’t tell you anything about the patient besides the lab and CT readout 🙂

I can’t emphasize the importance of sick vs not sick enough though. That’s important no matter where you land.

 

[mmchick]

I would hard disagree on a couple things here. As an EP you should know surgical from nonsurgical abdomen. You’re on the front lines and absolutely need to be able to differentiate “sick vs non sick.”

As far as imaging, you look at and read your own EKGs, right? Similarly, you need to look at every film you order. No one’s asking you to be better than a radiologist but you will catch things they miss. They’re humans too. But the more you look at the easier it gets and the faster you become.

All that being said, agree you guys get **** on too much for not knowing everything about everything and not/calling consultants. All that’s moot if you jump ship to the surgical side though. When/if you do, just try to remember that when you get your third call at 2 am and the person talking to you in the ED can’t tell you anything about the patient besides the lab and CT readout 🙂

I can’t emphasize the importance of sick vs not sick enough though. That’s important no matter where you land.

obviously EPs can tell sick from not sick.. that’s sort of like.. the whole gig. All EPs know a tender abdomen from a nontender abdomen.. yet your view is skewed as so far as “acute” abdomens, implying actual urgent surgical need, considering you have the experience of touching lots of abdomens and seeing lots of those open abdomens. You have the experience of actually seeing the proportion of these tender and nontender abdomens once you open them up. Our experience is limited to “yes this is a tender abdomen and therefore I’ll call someone else to come see it”. There is an important difference there.. sometimes our surgical colleagues fail to recognize this distinction.

Specialists also love to bring up these examples of EPs who haven’t “even seen” the patient and have no PE. I have met a lot of lazy EPs , I think we all mutually agree that having not met the patient or done a PE before consulting is completely unacceptable. That is not the standard of care. The extreme of us who are hands-off lazy do not represent the standard of care of EM.

Again this is sort of a derailment of what I was asking. But it is a pet peeve when someone clearly has a strong bias against EM for extreme or misunderstood reasons.. typical bandwagon of misery this field has to deal with.

 

[ThoracicGuy]

... this is a little irrelevant to my question and just a bitter take towards EPs, thanks for sharing. Yes we all know sub specialists love to **** on EM about everything we don’t know and forget to acknowledge what we do/what we catch/what we don’t consult for being generalists. It’s not the EP’s job to know what actual abdomens are indeed surgical acute abdomens. If someone’s having new postoperative pain,10 times out of 10 we’re obligated to call you considering they just had a surgery and are now having pain… even if their exam isn’t that exciting. It’s the world we live in. We’re often damned if we do damned if we don’t. I’ve gotten yelled at for not calling and calling surgeons down, for both exciting and not exciting patients. You can’t win.

The things you pointed out are things I love to try and do when feasible. Unfortunately the reality of the ED is half the time patients don’t even know what surgeries they’ve had, much less give me a reliable HPI.. I try to look at all my CT scans but when you’re throwing spaghetti at the wall and have 14 simultaneous patients, you don’t always get 10 minutes to scroll through someone’s CTAP to look for anything that might “pop out” with all of our *formal radiology training* outside of what the radiologist calls. Can’t say I’ve met many EPs that will make a call on something a radiologist didn’t formally read or correct something… considering we’re completely not credentialed to do so.

Her post was actually very relevant to your question. By doing as she wrote, you will go a long way in impressing the surgical residents and staff. That is who you are wanting to impress if you are wanting to go to a surgical residency. I would say that it is in the ER Physician's interests to understand when an abdomen is a surgical abdomen. What are you going to do if you end up working in a small ER somewhere and you don't have a surgeon in house. Are you going to call and have every one of them come in for some abdominal pain or will you be able to know which look to be surgical abdomens or not? You don't have to be right all the time, but if you can pick up that skill, that will help you go far.

No one is saying you have to be an expert in CT scans or anything else. They are saying to work on it, get the experience, and that will help you in the future.

 

[Smurfette]

... this is a little irrelevant to my question and just a bitter take towards EPs, thanks for sharing. Yes we all know sub specialists love to **** on EM about everything we don’t know and forget to acknowledge what we do/what we catch/what we don’t consult for being generalists. It’s not the EP’s job to know what actual abdomens are indeed surgical acute abdomens. If someone’s having new postoperative pain,10 times out of 10 we’re obligated to call you considering they just had a surgery and are now having pain… even if their exam isn’t that exciting. It’s the world we live in. We’re often damned if we do damned if we don’t. I’ve gotten yelled at for not calling and calling surgeons down, for both exciting and not exciting patients. You can’t win.

The things you pointed out are things I love to try and do when feasible. Unfortunately the reality of the ED is half the time patients don’t even know what surgeries they’ve had, much less give me a reliable HPI.. I try to look at all my CT scans but when you’re throwing spaghetti at the wall and have 14 simultaneous patients, you don’t always get 10 minutes to scroll through someone’s CTAP to look for anything that might “pop out” with all of our *formal radiology training* outside of what the radiologist calls. Can’t say I’ve met many EPs that will make a call on something a radiologist didn’t formally read or correct something… considering we’re completely not credentialed to do so.

Not a bitter take toward EPs. There are good and bad people in all specialties, but that was not the point. You asked, more or less, how to impress the surgeons because you've decided you want to be one. I gave you some pointers to impress surgeons as someone working in the ER but instead of thinking "I'll make a point of doing those things", you got defensive. You want to be the ER resident who the surgeons know is reliable and knows the info they will want. You need to stand out from your counterparts and leave an impression that makes them think you are (or could be) one of them. You need LORs from surgeons to apply for GS, so this impression is very important, especially since you will be at a disadvantage as a non-traditional applicant. One thing you DON'T want is the surgeons to hear you want to apply for GS and think among themselves "ugh, I hate it when that guy calls me, he'll make a terrible GS resident".

 

[LucidSplash]

Not a bitter take toward EPs. There are good and bad people in all specialties, but that was not the point. You asked, more or less, how to impress the surgeons because you've decided you want to be one. I gave you some pointers to impress surgeons as someone working in the ER but instead of thinking "I'll make a point of doing those things", you got defensive. You want to be the ER resident who the surgeons know is reliable and knows the info they will want. You need to stand out from your counterparts and leave an impression that makes them think you are (or could be) one of them. You need LORs from surgeons to apply for GS, so this impression is very important, especially since you will be at a disadvantage as a non-traditional applicant. One thing you DON'T want is the surgeons to hear you want to apply for GS and think among themselves "ugh, I hate it when that guy calls me, he'll make a terrible GS resident".

This.

I can think of several EM residents I worked with as a GS resident who would have had enthusiastic support from GS residents and faculty if they voiced interest in switching to GS, who were open to teaching points from us, who were reliable and who had me come running when they said it was urgent because I knew they knew their stuff.

And I can think of a few who would still set my teeth on edge if I saw their name on my phone today.

Just like I’m sure you can think of some GS residents and faculty who you are relieved when they pick up the phone and others you’d rather avoid.

You asked how and who to get letters from. Smurfette told you the best way to make yourself known to potential letter writers, in a positive frame. She told you how things ARE and gave you very helpful advice. No use getting defensive about it. She didn’t **** on EM docs. She told you what you already know to be true - some EM docs aren’t great at calling specialists. This is no different than the reality that some surgeons are dinguses. I am a surgeon and I know this to be true and I don’t get offended when someone says it. Saying it aloud shouldn’t make you defensive since you know it to be true.

 

[operaman]

Yes I too can still remember some ED resident names who were known to be idiots and call absolutely terrible consults without any concept of what to do beforehand. In ent world, it was almost like “patient has ears and nose, can you eval/tx?” If any of them had wanted to switch into our field I think we would have all laughed hysterically.

And then there were the good ones who clearly wanted to learn and tried really hard and we all really liked. They wouldn’t call terrible consults and the ones they called had a reasonable level of workup and treatment already such that it was time for a surgical team to take the next step, or other times they were able to see when something was going to go south fast and would call while we still had time to act.

If you want institutional support for your future application, gotta be beloved by your institution.

 

[mmchick]

Thanks for helpful nuggets of advice in between the otherwise bandwagon trickle of patronizing and condescending comments. Classic SDN.

 

[LucidSplash]

Thanks for helpful nuggets of advice in between the otherwise bandwagon trickle of patronizing and condescending comments. Classic SDN.

Well, no worries about getting into surgery then. Enjoy EM.

 

[DocSurgeon]

obviously EPs can tell sick from not sick.. that’s sort of like.. the whole gig. All EPs know a tender abdomen from a nontender abdomen.. yet your view is skewed as so far as “acute” abdomens, implying actual urgent surgical need, considering you have the experience of touching lots of abdomens and seeing lots of those open abdomens. You have the experience of actually seeing the proportion of these tender and nontender abdomens once you open them up. Our experience is limited to “yes this is a tender abdomen and therefore I’ll call someone else to come see it”. There is an important difference there.. sometimes our surgical colleagues fail to recognize this distinction.

Specialists also love to bring up these examples of EPs who haven’t “even seen” the patient and have no PE. I have met a lot of lazy EPs , I think we all mutually agree that having not met the patient or done a PE before consulting is completely unacceptable. That is not the standard of care. The extreme of us who are hands-off lazy do not represent the standard of care of EM.

Again this is sort of a derailment of what I was asking. But it is a pet peeve when someone clearly has a strong bias against EM for extreme or misunderstood reasons.. typical bandwagon of misery this field has to deal with.

Sorry I'm kinda passionate about this. I have ED docs call me and straight up tell me "this is/not a surgical abdomen." I completely understand ya'll gotta be the Jack of All Trades but no one is asking you how to do the surgery, just if you think this patient needs it. It's a legitimate question well within your scope that you should be able to answer confidently. Lots of those guys that call the surgical bellies stop me in the hall after they see me to ask how the patient did or what ended up happening. Sometimes they tell me they just look their chart up later to see for themselves. I'm sure that's helped with their understanding of their exams. But whether you wanna be the resident that can only tell me "the patient's abdomen is (really) tender" or the one that can tell me the abdomen is rigid, locally/diffusely peritonitic, guarding but distractable, pain out of proportion, etc is entirely up to you. Like I said, I'm not even asking for that detail. I'll take yes/no surgical abdomen. But I do hear those descriptions from the really good ones so I know its taught somewhere.

But I'm getting way off the rails here... Way way off. I agree with what others have said. Make a good name for yourself in and out of surgery rotations, finish out residency, apply for surgery. As others have said, if you're still in the ER while applying for surgery, you need some friends in the field to vouch for you. Make friends however you think is best. Good luck.

 

[ACSurgeon]

Thanks for helpful nuggets of advice in between the otherwise bandwagon trickle of patronizing and condescending comments. Classic SDN.

The advice you got from the surgeons here was much more positive than the feedback you’ll get as a junior resident at a benign surgery program. They’re genuinely being helpful and maybe unintentionally offended you. You’re in for a real treat if you think this was condescending…

 

[ACSurgeon]

Update: Somehow I made it through this intern year, and I am finishing my last month in the ED as an intern. My program is aware of my desire to switch but is giving me the option to stay if I want to finish out the 3-year program. However, if I decide I want to switch, then I have to leave after this intern year ends. I know the logical answer is to stay. But I truly feel miserable here and feel like I don't belong. I miss the operating room so much.
I'm a USMD with 24x step 2. Can I leave my program after June 30, and take the next academic year off to apply to surgery? Or will this be career suicide?

- don’t ruin your career. Apply GS in your last year of EM and be board eligible

- regarding being miserable in EM: I understand that feeling like you have to do this for the rest of your career isn’t appealing, but if you’re doing it for security and know that you’re going to try really hard to switch to surgery, that should make these years more tolerable. If you’re interested in surgery, and have what it takes to succeed, you should be able to tough out two additional years of EM. Surgical training is long, and delayed gratification is part of the process. You’ll spend 2-3 years doing floor work and not feeling like a surgeon. I know EM residency is adding to that, but that’s the price to pay to be sure you can earn a physician salary no matter how this all shakes out. You shouldn’t be so miserable by the end of intern year. If you’re successful matching surgery after EM, the excitement of securing a path to your desired specialty should propel you forward. If you can’t match, then be glad you didn’t throw away your career for a dream.

- Once life all shakes out, this will seem a lot less significant. Your life outside of work will probably matter a lot more. Sure, I’d be sad if I couldn’t do surgery anymore, but I could see myself very satisfied in a number of specialties and for sure would prefer that over working urgent care or consulting gig etc.

Good luck! I hope it all works out for you