You quietly inquire about possible open positions in your field (ie, ask friends, look at postings in your residency office/GME, on websites, etc.). When you have decided to go ahead and apply for another position - either through the match or individuallly with each program, then you have to let your PD know. He/she will have to provide a letter of good standing for you and you may have to get more LORs as well.
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