To switch or not to switch

[La Fiera]

Crap!!
I thought I had everything figured out for what I was going to do in medicine but it just seems that I am either getting cold feet, or I really wasn't that happy to begin with my first choice anyway. If you have any advice please let me know especially since it is so late in 4th year and I have no other LOR to go into different fields, and haven't started on a new Personal statement.

I was convinced that I would go into Family Practice, so much that I accepted a full 2 year scholarship from the NHCS to do primary care. The catch is, if you should go back on your comittment to the NHCS, you have to repay them 3 times the amount that they loaned you- which would end up being $300,000 + in my case. This may seem like a lot, but in actuality, its not as bad as it sounds because I would have ended up paying this much interest had I taken out loans from the government and private companies.

I wanted to go into FP because of the continuity, the generality of the conditions and patients (young, old, sick, etc) seen, the fact that FP's affect more people than any other health care specialty (I'm talking numbers). Also, I really like working with my hands, and the procedures that FP's can do in the clinic (eg excision of moles etc.) or in the OR- eg. c-section really attracted me. Most of all, I like the fact that FP's can work in small rural ER's because there is no one else to do it! I love the ED! Furthermore, it seems as you can do so many different things with FP, that are not available in other fields.

Here's the problem that I started thinking about the last few weeks. I thought about whether or not I would be happy in FP and I couldn't say that I would with certainty- I imagined coming into the office and dreading seeing pts with Diabetes and HTN everyday where all I would be doing was adjusting meds. Or evaluating a pt's social situation and trying to see how I could work with it- (I want to be a doctor, not a social worker). And in a recent clerkship I did in FP all I seemed to see was chronic pain and just the things I am dreading. So my question to you is this- should I stick with FP in hopes of eventually find a job in a smaller ER, or maybe as a hospitalist because this is what I have already applied to and had a few inerviews in (not to mention that I have a scholarship in)?

The other options:
ER:
Something that I have always really enjoyed, but ruled out earlier b/c of 1. the lack of continuity, and not knowing if you really did the right thing with the patient (unless you follow them through the hospital course) 2. knowing the 1st few steps of how to take care of a med or surg pt but then not knowing how to continue care. 3. the scholarship I got to do primary care

Surgery:
I love working with my hands and I am good at it. But I do not want to be slave for the next 5+ years and then some. I like my life, I like going out and persuing other interests. Furthermore, I don't like laparascopic surgery- somehow the fun got lost in it. I really like Trauma surgery- but again thats a good 6 -7 year residency, which I might not even be guarenteed to get! Furthermore, 8 hrs in surgery would probably destroy my little ADHD mind.

Medicine:
Surprisingly, I really liked the ICU. Its general, and the physiology behind the diseases that you see in the ICU is absolutely fascinating to me. I know I couldn't specialize in one organ- I would get bored for sure. The problem with Hospitalists is that it seems as all they do all day is scutwork- call everyone else involved and get paged and then write ridiculously long notes.

OB/Gyne:
The problem with this is that you don't get to see any male patients, and not too many kids. Not too mention that you are a slave during residency just like the surgeons, and your malpractice is ridiculous.

So. There it is. I am also afraid that I left considering changing fields a little too long. I really screwed myself with ER and Surgery, as they are competetive and have sent out most of their invites to interview. I'd also have to get more letters from who knows? On top of that My Step 1 score was at the national average, and my Step 2 a little lower than that, so I don't know how favorably they'll look upon that (I didn't put so much effort in as I was just aiming to pass- FP is the least competetive field of all and I hate tests)
Then again, I don't know if I should change, as I think I went into FP for the right reasons, and it will let me do international medine (such as Doc's without borders), and wilderness medicine. But doing ER and surgery especially, are also great for international medicine. Er is probably even better for wilderness med considering they have fellowships in it.
Anyway. If you have any suggestions please let me know!
Thanks alot everyone!

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[pazzer2]

If you are thinking about switching now, then do it.

Don't match into a residency and get second thoughts later. It is MUCH harder to switch after you start your residency.

 

[Mike59]

Is don't know much about these alternate PGY1 years but would a "transitional year" be a legitimate option? In theory wouldn't this give you more time to figure things out? I think half the problem for all of us is being forced to decide about a career so early in the game.

 

[sparky5]

I completely hear all your thoughts and have the same reservations about FP and the other fields you mentioned. I'd love to hear how you resolve this. Goood luck.
hopefully you can find something that suits you.

 

[gungho]

did fp 19 years, now in 2nd yr path residency for many of the concerns you voiced. also had nhsc obligation. considered er residency early in fp residency, but couldn't get in. have done a fair amount of er work over the years (and continue to moonlight). VERY happy i switched. any questions, PM me.

 

[sophiejane]

You pretty much answered your own question: you should do rural FP. The scenario you mentioned of managing HTN and DM and social issues day in and day out is part of FM, but it doesn't have to be all of it. Especially in a small town.

My current plan is to do an FP residency then a 1-year ER fellowship so I can feel competent covering the ER in a smaller regional hospital, but still have an office-based practice. I want to do colonoscopies and minor procedures as well.

All of this is possible (and profitable) in the right rural community--I know a number of docs in my area with practices that include all of the things you mentioned and more, and they are doing quite well for themselves. Most importantly, they are happy.

 

[lowbudget]

Do Pulm Crit Care, Cards, or GI. You can finish out your primary care obligation by practicing in IM first, then go for fellowship. Personally, bronchs, chest tubes, caths, and scopes would bore me if I had to do it every day, but that's why I'm doing FP and not specialty medicine. I think it'll suit your thirst for critical patients.

Realize however that DM, HTN and chronic pain is EVERYWHERE. There is no escape and everyone must deal with it somehow. Please also realize that every specialty has it's bread and butter patients (for FP, it's DM and HTN; for ER, it's CP r/o MI and abscess I&D) so there's really no way to get around pt's that are boring/tedious.

 

[skypilot]

My suggestion is to do Medicine instead of FP. Fulfill your primary care obligation in a few years, then consider doing a fellowship later. Medicine in some incarnations looks exactly like FP. In other incarnations it looks very different.

 

[La Fiera]

Thanx for all your replies-
you have given me a lot to think about!

Where can you do fellowships in ER? I thought they canned the programs in Tennessee, those where the only ones I know about!

I am leaning away from IM, as it seems not to fit as well as EM, or the more hands on fields. I do like working with really sick pts though. I also really appreciate the Physiology that goes on in the Unit- but I think I would be overwhelmed with much of the futility of the ICU, and how little affect I would have on the general population.

Lucky enough for me, I managed to get 2 LOR's for EM in the last day, and now i just need a 3rd. At least this will buy me time to figure out what to do.

The point that every field has its bread and butter stuff is a good one, I guess the grass is always greener on the other side!

Thanks!

 

[CambieMD]

My suggestion is to do Medicine instead of FP. Fulfill your primary care obligation in a few years, then consider doing a fellowship later. Medicine in some incarnations looks exactly like FP. In other incarnations it looks very different.

I would suggest that you complete an IM residency. IM gives you the option to specialize if you so desire. IM would give you more options down the road. The truth of the matter is that scholarship programs that dictate your specialty are often not the great bargins that the first appear to be.

CambieMD

p.s.
I can tell you a lot about being in a field that you do not want to be in.

 

[sophiejane]

http://www.aafp.org/fellowships/other.html

If they have canned all three TN programs, then Oklahoma seems to be your only option for an EM fellowship, but I haven't done any research on the TN program so I don't know about that.

There are also programs for FM/EM...I know of some osteopathic ones but not sure about allo.

Could you do a traditional rotating internship somewhere and start EM after that? Or do you have to be accepted to an EM program first?

I've heard that IM is not always a good choice if you want to practice rural medicine. I think for me the deciding factor between IM and FM was that I realized I really liked seeing kids and teenagers as well as adults. I found IM pretty depressing and not as rewarding as I thought it would be. People don't often get well--they might make some progress, but you aren't going to make that big of a difference in anyone's life if they come to you already pretty sick, which seems to be common in IM patient populations.

If you like variety, I would think IM would not be the way to go, especially an office-based practice. My time so far spent with specialists has been interesting, but the lack of variety is the downside for me. Kind of like visiting Disneyland. Fun for a day, but I wouldn't want to live there...

By the way, in a rural hospital, if your patient is in the ICU, you take care of them there, too. Granted the very serious cases will get shipped out, but you'd stabilize them first.

It's all about what you are and are not willing to give up. There are no perfect jobs.

 

[La Fiera]

So, just to let anyone who was interested know what happened to me-
I matched in ER at my number 3- Lincoln Hospital in NYC, a great ER program and am super stoked. I had a whole bunch of people come up to me the day and night of match to tell me how worried they were about me, how brave I was for making the switch last minute, and my situation. So I wanted to pass this on, and give future med students in the same situation hope- cause I really didn't think that I had a chance! I ended up getting 14 interview invites (I applied to 23), went to 9, ranked 9, and matched at number 3.

 

[secretwave101]

If you're trying to avoid bread-and-butter medicine, you're in trouble. The trick is to find what you like doing over and over and over. Or, stated another way, what could you do over and over and not go crazy doing it?

Rural FP probably offers the widest variety of any specialty anywhere. Urban IM in an outpaitent setting offers some of the LEAST variety - talk about adjusting HTN and diabetes meds!

The main thing IM has going for it is the opportunity to specialize. The IM specialties really are quite different from general outpatient medicine. However, even there, you'll be doing the same same same all the time.

I don't think many people like the idea of specializing. Most of us have this innate desire to be able to take care of pretty much anything our patients need, so to be good at doing it. These days, things just don't work like that. We all gotta deal.

 

[sophiejane]

So, just to let anyone who was interested know what happened to me-
I matched in ER at my number 3- Lincoln Hospital in NYC, a great ER program and am super stoked. I had a whole bunch of people come up to me the day and night of match to tell me how worried they were about me, how brave I was for making the switch last minute, and my situation. So I wanted to pass this on, and give future med students in the same situation hope- cause I really didn't think that I had a chance! I ended up getting 14 interview invites (I applied to 23), went to 9, ranked 9, and matched at number 3.

Posting your joy at getting out of FM on the FM board might not win you too many warm fuzzies here. But I'm glad you found your niche, at least for now...

 

[sophiejane]

Most of us have this innate desire to be able to take care of pretty much anything our patients need, so to be good at doing it. These days, things just don't work like that. We all gotta deal.

What do you mean by that? Most FPs are able to take care of the majority of their patients' needs on a daily basis, at least if they are even moderately competent docs...

 

[8744]

Posting your joy at getting out of FM on the FM board might not win you too many warm fuzzies here. But I'm glad you found your niche, at least for now...

Hey, I matched to EM from FP too. I am no fan of FP but if you go to a small, unopposed community program you can get some pretty good training. I understand that some of the top FP program teach their residents how to do C-sections, lap-chole's, appendectomies, and other basic operations.

I have friends in little FP programs in Louisiana who get great training. Now whether they will do these things once they get into practice is another question.

After my year at Duke, I can definitely say the following:

1. If your bag is community medicine you should think about Duke next year as they are absolutely committed to it and the new program director is working hard to fix some of the problems he inherited. If you are not into it then don't bother because they don't want you either. The PD assured us that he would rather not fill than take people who were at odds with the program's new direction.

2. Your training in FP will suffer at a big academic center because it is so easy to punt. On the other hand you will get pretty good training on your off-service months.

3. Mid-level providors are the wave of the future in FP more so than any other specialty. Not that residency trained FPs are going to disappear but you'd better plan on incorporating them into your practice if you want to make money.

 

[deleted87716]

Not that residency trained FPs are going to disappear but you'd better plan on incorporating them into your practice if you want to make money.

Midlevels have their place, but certainly not in every practice.

 

[sophiejane]

Mid-level providors are the wave of the future in FP more so than any other specialty. Not that residency trained FPs are going to disappear but you'd better plan on incorporating them into your practice if you want to make money.

Can we puh-leeease put this lame argument to rest, PandaBear. Please. Folks here don't agree with you, and you are not going to change any minds here. If we did agree with you, we'd probably be on the EM board, like you probably should be...

You no more know what the "wave of the future" is than anyone else. So just get thee to the EM board and start hanging with your new brothers.

 

[8744]

Can we puh-leeease put this lame argument to rest, PandaBear. Please. Folks here don't agree with you, and you are not going to change any minds here. If we did agree with you, we'd probably be on the EM board, like you probably should be...

You no more know what the "wave of the future" is than anyone else. So just get thee to the EM board and start hanging with your new brothers.

Meow.

 

[FamilyMD]

Can we puh-leeease put this lame argument to rest, PandaBear. Please. Folks here don't agree with you, and you are not going to change any minds here. If we did agree with you, we'd probably be on the EM board, like you probably should be...

You no more know what the "wave of the future" is than anyone else. So just get thee to the EM board and start hanging with your new brothers.

Agreed! Funny how some people try to convince themselves they did the right thing by bashing what they left behind. Sounds like second thoughts to me....

 

[8744]

Agreed! Funny how some people try to convince themselves they did the right thing by bashing what they left behind. Sounds like second thoughts to me....

Hmmm. Let's see....change my mind and go back to Family Medicine...let me see...let me see...ooh...this is hard.....

Um, no.

And I'm not bashing it. I'm helping some of you who have doubts make a decision.

 

[deleted87716]

Sounds like second thoughts to me....

Panda Bear has stated that the only reason he scrambled into the FM spot at Duke was because he failed to match into Emergency Medicine last year. His comments about family medicine should be viewed in this context.