Switching out

[SecondThoughts]

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So I'm currently a soon-to-graduate 4th year, and I've matched into pathology at an upper-tier program with a lot of name recognition. Within the last few months, I've discovered emergency medicine and realized I would rather do it than path. I know that since I've matched, I'm committed to at least one year of residency with them. I also realize that since path has no internship year, I would have to apply through the match and hit the interview trail again.

That being said, my question is when should I let my program know that I don't intend to finish my residency with them? Immediately so that I can try to schedule vacation days for interview season, or give them a month or two to get to know me before I drop the bomb? For what it's worth, it's a fairly large program which takes 8-10 residents every year and have been operating at slightly less than full capacity (my class will bring them to full quota, and my leaving will bring them down to one less resident, which they've been at for at least a year). Any advice would be appreciated.

 

[Ombret]

If your decision is firm, you need to talk with your future program director (on the phone) immediately. Your program may already be working on next year's schedule. A month or two into next year will be way too late for them to give you the flexibility you need for interviews and your program-mates will not be happy at having to shuffle around their schedules to accommodate you.

If your decision is not firm... you might want to think twice. Maybe you are just having buyer's remorse. Every specialty choice involves giving something up. Even though you are not going to be totally backing out on your path program, you are not going to look all that rosy on the EM application trail and the program you wind up at for EM may not be quite as "upper-tier" as the one where you matched for pathology. If EM is what you want, then you should do it. But I'm just sayin'.

 

[MirkoCrocop]

So I'm currently a soon-to-graduate 4th year, and I've matched into pathology at an upper-tier program with a lot of name recognition. Within the last few months, I've discovered emergency medicine and realized I would rather do it than path. I know that since I've matched, I'm committed to at least one year of residency with them. I also realize that since path has no internship year, I would have to apply through the match and hit the interview trail again.

That being said, my question is when should I let my program know that I don't intend to finish my residency with them? Immediately so that I can try to schedule vacation days for interview season, or give them a month or two to get to know me before I drop the bomb? For what it's worth, it's a fairly large program which takes 8-10 residents every year and have been operating at slightly less than full capacity (my class will bring them to full quota, and my leaving will bring them down to one less resident, which they've been at for at least a year). Any advice would be appreciated.

Do NOT let them know of your intentions.

Put EM books all over your desk and stuff your white coat with ACLS protocols/EM laminated reference cards.

Carry an endotracheal tube and laryngoscope with you at ALL times (including CP conferences)

They'll get the idea.

 

[ilovepath]

It's an interesting duo of specialities to be interested in. I know of another path res to switch to er, though it was much later. I have a hard time grasping the appeal of 2 very different niches. I really get the path to rads or visa verca or path's switching in and out of surg. Em and more of the clinical switches are harder for me to get perspective on.

So I'm currently a soon-to-graduate 4th year, and I've matched into pathology at an upper-tier program with a lot of name recognition. Within the last few months, I've discovered emergency medicine and realized I would rather do it than path. I know that since I've matched, I'm committed to at least one year of residency with them. I also realize that since path has no internship year, I would have to apply through the match and hit the interview trail again.

That being said, my question is when should I let my program know that I don't intend to finish my residency with them? Immediately so that I can try to schedule vacation days for interview season, or give them a month or two to get to know me before I drop the bomb? For what it's worth, it's a fairly large program which takes 8-10 residents every year and have been operating at slightly less than full capacity (my class will bring them to full quota, and my leaving will bring them down to one less resident, which they've been at for at least a year). Any advice would be appreciated.

 

[2121115]

Tell them now. And tell them that you are going to do EM and ask out of your contract. They may let you out of doing the year with them. They don't want someone there who doesn't want to be there, trust me. It brings down morale. You are going to be working ass hard during first in a messy gross environment (the gross room) and staying late. If you don't want to be a pathologist this is going to get you real down. Negativity is infectious.

They will probably cut you loose. If you tell them and they don't cut you loose, you will be the bitch for everything next year. Not a good position to be in. Frat-style hazing and "short end of the stick" call/rotations/scut/etc. Especially if you are at one of the high profile northeastern programs.

Just try to back out and let them reschedule the year with people who want to be there. Better for everyone. Get a job as an EMT or see if you can scramble to a transitional year or do research. Anything is better than being a bitch intern grossing until 11pm with no pay off of being a pathologist down the line.

 

[Sir James Bond]

Are you prepared for the onslaught of Shift Work Sleep Disorder?

 

[SecondThoughts]

Tell them now. And tell them that you are going to do EM and ask out of your contract. They may let you out of doing the year with them. They don't want someone there who doesn't want to be there, trust me. It brings down morale. You are going to be working ass hard during first in a messy gross environment (the gross room) and staying late. If you don't want to be a pathologist this is going to get you real down. Negativity is infectious.

They will probably cut you loose. If you tell them and they don't cut you loose, you will be the bitch for everything next year. Not a good position to be in. Frat-style hazing and "short end of the stick" call/rotations/scut/etc. Especially if you are at one of the high profile northeastern programs.

Just try to back out and let them reschedule the year with people who want to be there. Better for everyone. Get a job as an EMT or see if you can scramble to a transitional year or do research. Anything is better than being a bitch intern grossing until 11pm with no pay off of being a pathologist down the line.

I considered the possibility of talking to my program and being let go from my contract, but apparently when one matches through NRMP, the NRMP has ultimate say as to whether or not a contract for the first year of training can be cancelled. One has to go through the process of applying to the NRMP for a waiver, and each request of such is reviewed by the NRMP on a case-by-case basis, and they declare yes or no. In my case, I would have to demonstrate to the NRMP that maintaining my contract would cause "serious and extreme hardship" on my part, and then they ultimately have the say as to whether or not the contract will be cancelled. Any other route of first year contract cancellation results in a match violation for both the resident and the program, and temporary (?) banishment from the NRMP match in the future. When it comes to subsequent contract renewals however, it's all between the program and the resident.

As far as I can tell, I'm stuck with pathology for a year. Which from a subject matter standpoint, isn't such a bad deal. I still really enjoy pathology (based on what I've experienced in three 4th year rotations) and find it fascinating as hell, and up until I discovered emergency medicine, I couldn't imagine doing anything else. I enjoy both fields almost equally, but upon considering other aspects of both fields, EM just seems to come out on top.

 

[Ombret]

Well, I don't suppose having a future EM resident on frozens will sap any more energy than having some future dermatologist as your medicine intern. Godspeed.

 

[Autopsy Sweet]

I considered the possibility of talking to my program and being let go from my contract, but apparently when one matches through NRMP, the NRMP has ultimate say as to whether or not a contract for the first year of training can be cancelled. One has to go through the process of applying to the NRMP for a waiver, and each request of such is reviewed by the NRMP on a case-by-case basis, and they declare yes or no. In my case, I would have to demonstrate to the NRMP that maintaining my contract would cause "serious and extreme hardship" on my part, and then they ultimately have the say as to whether or not the contract will be cancelled. Any other route of first year contract cancellation results in a match violation for both the resident and the program, and temporary (?) banishment from the NRMP match in the future. When it comes to subsequent contract renewals however, it's all between the program and the resident.

As far as I can tell, I'm stuck with pathology for a year. Which from a subject matter standpoint, isn't such a bad deal. I still really enjoy pathology (based on what I've experienced in three 4th year rotations) and find it fascinating as hell, and up until I discovered emergency medicine, I couldn't imagine doing anything else. I enjoy both fields almost equally, but upon considering other aspects of both fields, EM just seems to come out on top.

This is partially correct, and partially incorrect. You are required, by the match agreement that you signed when you submitted applications through the NRMP, to SHOW UP on the first day....nothing more. You ARE NOT required to finish the year (this brings up other issues, though, if you don't). Just to be clear, though, you are not required to finish anything more than the first day of your matched residency program. Here is what the NRMP website says "The listing of an applicant by a program on its certified rank order list or of a program by an applicant on the applicant's certified rank order list establishes a binding commitment to offer or to accept an appointment if a match results and <b>to begin training</b> on the date specified in the appointment contract." You can look it up for yourself, but it doesn't elaborate any more on this. (see reference here: http://www.nrmp.org/res_match/policies/map_main.html#match_commit)

You are correct in that you would have to demonstrate hardship, and they are serious when they say "serious and extreme hardship." I was in a similar situation and the NRMP rep I spoke to actually took it personally when I asked for info about requesting a release of the contract. MOREOVER, even though my program was willing to let me out of the agreement because they knew I didn't want to be there, the NRMP told us that we would both be violating the rules even though it was mutually acceptable.

You could show up for a week, a month, whatever you want and then quit and this allows you to fulfill your obligation through the NRMP, but this leaves the program in a bind if they aren't expecting it. This can look bad, though, during interviews. I think quitting also means that you would have to go into repayment on med school loans (if you have them), so it wasn't an option for me.

You mentioned that if you broke your contract that you wouldn't be allowed to go through the NRMP match for a designated time but my question is "why would you?" You are not required to go through the match ever again, since it's only REQUIRED for 4th year med students. For your remaining programs you can absolutely go outside the match, and save yourself some time and money. I did this, applied to the one path program I wanted, interviewed and had my offer letter in October and saved myself the trouble of having to repeat the match process. On the other hand, some programs will not consider people outside of the match, so you have to know how it works in EM and how the programs lean on this topic. By the way, the program does not get in trouble if you decide not to show up because they were willing to fulfill their side of the agreement.

My advice to you is to complete the year of path but let them know after the first few months that it's not really what you were expecting and it doesn't fit. This way, you don't cause problems for your program, and program directors in the future will see you as an honorable person who follows through with his/her commitments, even when it's hard. Future programs would respect this (the alternative is that they could see you as a quitter). You could see if your EM residency would give you credit for a few months done during that year (long shot but worth asking, I got 2 months credit out of the first year I did). Who knows? You may rekindle your love of path and decide not to switch after all.

Best of luck.

 

[ilovepath]

Why would you be forced into repayment of your med school loans?
I'm assuming you have a sallie mae residency forbearance right? We cant get deferments anymore I don't think, you'd go into economic hardship forbearance if you left.

This is partially correct, and partially incorrect. You are required, by the match agreement that you signed when you submitted applications through the NRMP, to SHOW UP on the first day....nothing more. You ARE NOT required to finish the year (this brings up other issues, though, if you don't). Just to be clear, though, you are not required to finish anything more than the first day of your matched residency program. Here is what the NRMP website says "The listing of an applicant by a program on its certified rank order list or of a program by an applicant on the applicant's certified rank order list establishes a binding commitment to offer or to accept an appointment if a match results and <b>to begin training</b> on the date specified in the appointment contract." You can look it up for yourself, but it doesn't elaborate any more on this. (see reference here: http://www.nrmp.org/res_match/policies/map_main.html#match_commit)

You are correct in that you would have to demonstrate hardship, and they are serious when they say "serious and extreme hardship." I was in a similar situation and the NRMP rep I spoke to actually took it personally when I asked for info about requesting a release of the contract. MOREOVER, even though my program was willing to let me out of the agreement because they knew I didn't want to be there, the NRMP told us that we would both be violating the rules even though it was mutually acceptable.

You could show up for a week, a month, whatever you want and then quit and this allows you to fulfill your obligation through the NRMP, but this leaves the program in a bind if they aren't expecting it. This can look bad, though, during interviews. I think quitting also means that you would have to go into repayment on med school loans (if you have them), so it wasn't an option for me.

You mentioned that if you broke your contract that you wouldn't be allowed to go through the NRMP match for a designated time but my question is "why would you?" You are not required to go through the match ever again, since it's only REQUIRED for 4th year med students. For your remaining programs you can absolutely go outside the match, and save yourself some time and money. I did this, applied to the one path program I wanted, interviewed and had my offer letter in October and saved myself the trouble of having to repeat the match process. On the other hand, some programs will not consider people outside of the match, so you have to know how it works in EM and how the programs lean on this topic. By the way, the program does not get in trouble if you decide not to show up because they were willing to fulfill their side of the agreement.

My advice to you is to complete the year of path but let them know after the first few months that it's not really what you were expecting and it doesn't fit. This way, you don't cause problems for your program, and program directors in the future will see you as an honorable person who follows through with his/her commitments, even when it's hard. Future programs would respect this (the alternative is that they could see you as a quitter). You could see if your EM residency would give you credit for a few months done during that year (long shot but worth asking, I got 2 months credit out of the first year I did). Who knows? You may rekindle your love of path and decide not to switch after all.

Best of luck.

 

[KCShaw]

Let them know when you know you know. It doesn't sound like you knew knew when you got into pathology in the first place. Emergency medicine generally isn't in hiding or unknown to be suddenly "discovered" post-match in 4th year of medicine; I would have serious concerns regarding the medical school that doesn't expose its students to emergency medicine at all until they're doing terminal electives/delayed mandatory rotations after the match. Meanwhile you'll have to prepare to explain the change of plans, particularly to EM program directors who need 24/7 department coverage rather than people they're just not sure will show up on the first day.

When you know know, then go and do it -- just not at the unecessary expense of others.

 

[Autopsy Sweet]

Why would you be forced into repayment of your med school loans?
I'm assuming you have a sallie mae residency forbearance right? We cant get deferments anymore I don't think, you'd go into economic hardship forbearance if you left.

I'm not 100% on this, but I remember being told that if you're not in an approved residency then loans automatically go into repayment because you don't qualify for deferment (back then) or forbearance. The rules are changed now, but I think that part of it remains.....that your ability to maintain forbearance is contingent upon you actually being in a training program. If you're not, then they want you to get a job (even if it's flipping burgers) and start paying them back. I could be totally wrong here so anyone else with more knowledge should chime in...... I also don't remember Sallie Mae having anything to do with it.....

 

[Ombret]

So SecondThoughts, are you still out there?--what did you decide to do? Just curious.

 

[dikoerastenie]

It's an interesting duo of specialities to be interested in. I know of another path res to switch to er, though it was much later. I have a hard time grasping the appeal of 2 very different niches. I really get the path to rads or visa verca or path's switching in and out of surg. Em and more of the clinical switches are harder for me to get perspective on.

I am considering these fields. I really like physiology and pathology. And I am a "poor conversationalist". I am kind of neutral with regards to working with a microscope. I don't think it is much better or much worse than using an ophthalmoscope to look for foreign bodies or diabetes. But my main draw to ER is that it would perhaps improve my conversation skills and make me a more positive person outside of work. Which I know is not the best reason to go into it. So my real reason is stability. I want to work my 12hrs and then do whatever in my geographical area of choice.

 

[KCShaw]

As a field I think EM is interesting -- it was one of the specialties I was at least somewhat "also" interested in during medical school. I liked the idea that anything could come through the door at any time, and feared I would get bored with most other specialties (in retrospect there are times I would love to be bored, though the term doesn't generally apply to medicine, it's more a matter of different things being "interesting"). The reality of it was somewhat less appealing. I also liked the idea of going in, doing my shift, then being "done" -- hand off your patients and go have a life. And if the average department regularly assigned static shifts it might even work out. Unfortunately the existence of rotating shifts (The Mother of All Evil) so in the course of 10 days or less you could work day, evening, and night shifts, and the reality that most departments seem to employ some version of it, for me obliterated the benefit of shift work in an infinite sort of way.

But, really...someone about to finish medical school has had their entire life to think about the decision of what specialty to enter, and at least 3+ years of intimate exposure to medicine culminating in this decision. Wrong decisions will be made and there are ways to change one's course through life, but flip flopping without even starting is just...difficult to describe, and I think difficult to completely understand.