What happens to TRI? (Traditional Rotating Internship)

[heychloe]

I have a lot of questions about the TRI, pre and post merger.
I did a quick search and could not find all the answers so I hope you guys will be generous enough to answer some of the questions.

Pre-merger
I noticed a lot of students from my school scrambling into TRI after failing their initial match. Many were going for more competitive specialty (EM, Surgery) but not all.

1. So what happens after the TRI? I'm sure this depends on the strength of the individual candidates, but do they really have a chance of matching their intended PGY1 position? or PGY2 position?
2. How does this chance differ by specialty? EM? IM? FM? Surgery?

3. What is the consequence if they fail to match again after a TRI? OMM clinic for life?

4. Why would anyone choose to do TRI to begin with, other than going into radiology where you need internship training first? Even then, is TRI treated equivalently to Transitional internship?
When is TRI a good idea?


Class of 2019
Let's say someone from a class of 2019 scrambles into TRI, and they face the post-merger ACGME in 2020.
5. Do they even have an option of applying to an ACGME PGY2? Or only PGY1 positions? Can they realistically match? What's the deal with the 'funding issue?'


Class of 2020
6. Is there going to be a TRI post-merger? What happens to ~10% of students who would have scrambled into TRI premerger? Would they not match at all?



TLDR: Should we avoid TRI at all cost? Is there any circumstance where TRI is a good option?

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[NuttyEngDude]

TRI is synonymous to Transitional Year so most likely they will become those in ACGME. Avoiding it at ALL costs? Maybe at most costs, you want to match and another year of uncertainty is certainly stressful. If you think you can build a better application then it's better to get paid and have additional clinical experience and research than nothing. Some are able to get the specialty they desire, others will lower their expectations on specialty or location. Whether they can apply to PGY1 or PGY2 positions is up to the program (and program director). If they fail to match they can still sign onto undesirable programs that were still unable to fill their spots. But these are dwindling due to the sheer volume of new, upcoming graduates and IMGs.

IMO, TRI is only a good idea if you already have your specialty matched and need to get your first intern year done.

 

[Cath Up]

I have a lot of questions about the TRI, pre and post merger.
I did a quick search and could not find all the answers so I hope you guys will be generous enough to answer some of the questions.

Pre-merger
I noticed a lot of students from my school scrambling into TRI after failing their initial match. Many were going for more competitive specialty (EM, Surgery) but not all.

1. So what happens after the TRI? I'm sure this depends on the strength of the individual candidates, but do they really have a chance of matching their intended PGY1 position? or PGY2 position?
2. How does this chance differ by specialty? EM? IM? FM? Surgery?

3. What is the consequence if they fail to match again after a TRI? OMM clinic for life?

4. Why would anyone choose to do TRI to begin with, other than going into radiology where you need internship training first? Even then, is TRI treated equivalently to Transitional internship?
When is TRI a good idea?


Class of 2019
Let's say someone from a class of 2019 scrambles into TRI, and they face the post-merger ACGME in 2020.
5. Do they even have an option of applying to an ACGME PGY2? Or only PGY1 positions? Can they realistically match? What's the deal with the 'funding issue?'


Class of 2020
6. Is there going to be a TRI post-merger? What happens to ~10% of students who would have scrambled into TRI premerger? Would they not match at all?



TLDR: Should we avoid TRI at all cost? Is there any circumstance where TRI is a good option?

I have looked at your school's historic residency placement many times. The TRI placements this year is pretty consistent with previous years. I don't think that makes it any more acceptable, but the data was there.

And thank you for asking this question- I would like to know more about it as well.

 

[Geraltofrivia]

Also curious about this. Absolutely petrified of not matching again. ugh.

 

[W19]

If you do a TRI, you can still get a medical license in almost all 50 states... You can open a cash practice and also see medicaid patients...

IMO it's better to find a less competitive specialty that is somewhat closer to your preferred specialty than doing a stand alone preliminary year... Someone at my school wasted 3 yrs of his life and end up matching FM this year. He would have been done with FM residency next month if he was realistic...

 

[starri]

As a counterpoint, if you are truly passionate about something and are able to A) know you're going to have to work your butt off to impress a PD, and B) accept the risk that you may end up marking time for a year and end up back in the same place, taking the shot can work out.

I'm not giving the idea a Recommend, but I'm also not giving it an Avoid.

Or, in the words of the great philosopher James Tiberius Kirk once said, I don't believe in the no-win scenario.

 

[CajunMedic]

I can answer number 1 and kinda number 2 and 4 : it depends on the TRI and the student.

A little backstory for those who may have not seen my other posts: didn't match AOA EM with decent COMLEX, great SLOE's, experience, and research. Withdrew from ACGME match based on the 2016 Charting Outcomes data (only had a 46% chance=only 2 ranks) and the fact that my preferred TRI was not holding spots for those unmatched in the ACGME.

There are a few factors to consider:

1. Will they get you ready for residency and the match again, or are you cheap labor?
- I chose the TRI I did for a couple of reasons: it's connected to my #1 EM program, the TRI PD was the PD of the EM program when I auditioned (got promoted between audition and rank list time-new PD made the list) and wrote me a killer SLOE. Traditionally, they either move someone over to the EM program as an off-cycle spot opens up, or they will take them in the match. I'll be treated as an EM resident and expected to function as one-even taking the EM inservice exam.

2. Am I competitive in my chosen field?
- Realistically, how do you look on paper? Do you have the stats for what you're interested in? There was no inclination that I wasn't a competitive EM candidate from my school, aways, evals, etc.

3. If you were competitive, where did you go wrong?
- DO with no USMLE? Didn't apply broadly enough? Targeted the wrong programs? No interview skills? I only applied to 13 as a DO, while comparable MD students apply to 30-40

4. What did your interviewers think?
- I reached out to everywhere I interviewed a couple of months after the match. I got one "should have stayed in ACGME, we had you ranked to match, I'll look for your app this cycle". Different PD told me "there was a question about your teachability since you spent so long in EMS. It's probably an unfair judgement, but we matched very high on the list this year"

5. Is there anything I can do to improve my app?
- Time for USMLE? Looking at something where you might be able to get research? Crush Step 3?

For me, it was a tough decision, roll the ACGME dice and match, get stuck doing something I don't want to do at a program of a questionable quality, or take the sure thing that will give me the best shot at getting into my #1 choice or matching EM. I did, however, decide to take the USMLE Step 1. I finished rotations early and had time to finish 1 qBank and working my way through UWorld. Once I start my TRI, I'll meet with the PD and see if it still fits in my game plan and how I'm stacking up to stay there.

tl;dr: depends on the candidate and TRI, fairly multi-factorial

 

[heychloe]

Thank you for sharing your experience. I hope everything goes as planned next year. Keep us posted!

 

[hallowmann]

...1. So what happens after the TRI? I'm sure this depends on the strength of the individual candidates, but do they really have a chance of matching their intended PGY1 position? or PGY2 position?...

They reapply during their TRI for PGY1 and PGY2 positions (most will realistically be going PGY1, but some may get lucky with an R2 program). Your chances of matching a residency with a gap year after med school plummet. TRI is still GME time, which means its residency training that came be applied for licensure, credit in categorical programs, and you preserve your clinical skills/knowledge, making programs more willing to look at you.

2. How does this chance differ by specialty? EM? IM? FM? Surgery?

?? They differ based on the competitiveness of each field. Matching IM/FM is much easier out of a TRI than matching EM or Surgery.

3. What is the consequence if they fail to match again after a TRI? OMM clinic for life?

Failing to match again means they will have to scramble into something else and hopefully make it somewhere. You can't practice OMM without a medical license.

That said, you can practice medicine (and technically surgery) with a medical license, and you can attain a medical license in >30 states with 1 yr of GME (like a TRI) and a full series of a licensing exam (COMLEX 1-3). Your jobs will be limited due to limited insurance accepting you as a biller, but you could for example hang a shingle and open up a GP practice, do physicals for the military, work in prisons, and depending on the need in the area, work in the VA.

4. Why would anyone choose to do TRI to begin with, other than going into radiology where you need internship training first? Even then, is TRI treated equivalently to Transitional internship?
When is TRI a good idea?

TRI is equivalent to a TY. People choose it because of the reasons I described above (they could get licensed and in turn work as a doctor with it, it improves their chances for reapplying to categorical programs if they don't match, etc.).

Its rare that people are "choosing" a TRI in the sense that they apply and match to it only, unless they are already applying to an advanced position residency (like radiology), plan to apply to AOA Derm (you have to apply as an intern to AOA Derm residencies), want to only do 1 yr of GME for whatever reason, etc.

In most cases the people scrambling into TRIs went unmatched and are hoping to reapply to the match for categorical spots in the residency of their choice. Doing a TRI is the best option an unmatched applicant has with the exception of scrambling into a categorical residency.

Class of 2019
Let's say someone from a class of 2019 scrambles into TRI, and they face the post-merger ACGME in 2020.
5. Do they even have an option of applying to an ACGME PGY2? Or only PGY1 positions? Can they realistically match? What's the deal with the 'funding issue?'

Yes, they do potentially have that option (provided the program either becomes ACGME accredited or had pre-accreditation at the time of training), but this will be highly program dependent on how much credit they afford for the completed TRI, and in general their best bet will be applying to categorical programs.

Don't worry about funding, its a concern, but generally a minor one. Basically programs will only be given 2/3 of the money they would get if they were getting someone who matched directly into a TRI (it varies, but something like $100k/resident/yr as opposed to $150k). Its rarely an issue for programs though, and if you're in that situation, you can't do anything about it, so don't worry about it.

Class of 2020
6. Is there going to be a TRI post-merger? What happens to ~10% of students who would have scrambled into TRI premerger? Would they not match at all?

TRIs are transitioning to TYs. They will still be around. They'll have to SOAP into TYs or other categorical programs.

TLDR: Should we avoid TRI at all cost? Is there any circumstance where TRI is a good option?

No. With the exception of scrambling into a categorical program, TRIs are the best option for medical students that don't match, and in some cases they may be preferable to scrambling into a random categorical program, as they may have more options for attaining a residency in the specialty and region they want in the next match as opposed to the available spots in the scramble.

Remember, you can licensed as a DO in >30 states with a licensing exam series and 1 yr of GME.

If you do a TRI, you can still get a medical license in almost all 50 states... You can open a cash practice and also see medicaid patients...

IMO it's better to find a less competitive specialty that is somewhat closer to your preferred specialty than doing a stand alone preliminary year... Someone at my school wasted 3 yrs of his life and end up matching FM this year. He would have been done with FM residency next month if he was realistic...

Actually, its something in 30s, not almost all 50 (I want to say its like 33 for MDs and 36 for DOs, but its been a while since I've checked all the state requirements). Many states require 2-3 yrs of GME for licensure. Also, for IMGs most (all?) states require at least 2 yrs of GME for licensure.

 

[W19]

Actually, its something in 30s, not almost all 50 (I want to say its like 33 for MDs and 36 for DOs, but its been a while since I've checked all the state requirements). Many states require 3 yrs of GME for licensure. Also, for IMGs most (all?) states require at least 2 yrs of GME for licensure.

Almost all states require 1-2 yr post grad training for AMG. There are a couple outliers.... You are correct regarding licensing requirement for DO.

FSMB | State-Specific Requirements For Initial Medical Licensure

 

[Shinken]

Our TRI program transitioned into an ACGME-accredited TY program. Essentially the same rotations, but now our TY program is very competitive, and we get applications from top candidates. In the ACGME world, a TY year is required for those going into anesthesiology, PM&R, dermatology, and radiology, to name a few. Therefore, all DO and MD applicants that have great stats and are either hoping to match into those, or have already matched, need a TY year.

Becoming ACGME accredited has been great for our applicant pool. We now have tons of excellent candidates to choose from. The downside of this transition is that those applicants with low to average stats are now finding it impossible to match into our program (not that they had an easy time before, but now it's essentially impossible for them).

When all TRI programs transition to ACGME, this will probably be the case. The TY year will not be a viable option to get an extra year of medical experience for those that didn't match due to less than stellar apps, because they'll be competing for TY spots with highly qualified applicants.

 

[Geraltofrivia]

Damn. I feel so lucky to have found a TRI based on the posts in this topic. Now I'm just hoping and praying to God that I match this next cycle. Thanks everybody.

 

[hallowmann]

Almost all states require 1-2 yr post grad training for AMG. There are a couple outliers.... You are correct regarding licensing requirement for DO.

FSMB | State-Specific Requirements For Initial Medical Licensure

Thanks. Its been a while since I've looked at it. I figured I would do this. These are the GME year requirements per states for licensure based on the FSMB link (most likely accurate, but not guaranteed, contact individual licensing boards for exact requirements).

Summary:
-35 states (+ DC & PR) allow licensure for DOs after 1 GME year, and 30 states (+ DC & PR) allow licensure for US MDs after 1 GME year.
-13 states require 2 GME years for DOs to attain licensure, and 17 states require 3 GME years for US MDs to attain licensure
-Two states (Nevada and South Dakota) require 3 GME years for DOs and three states (Nevada, South Dakota, and Maine) require 3 GME years for US MDs.
-Almost all states require 2-3 yrs GME for IMGs to attain licensure. Mississippi and Georgia are the only states that might allow an IMG to become licensed with only 1 year of GME depending on case-by-case basis.

1yr GME Required:
Alabama
Arizona
Arkansas
Cali
Colorado
Delaware
DC
Florida
Georgia
Hawaii
Idaho
Indiana
Iowa
Louisiana
DO-Maine
DO-Michigan
Minnesota
Mississippi
Missouri
Nebraska
DO-New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregan
DO-Pennsylvania
Tennessee
Texas
Vermont
Virginia
DO-Washington
West Virginia
PR


2yrs GME Required:
Alaska
Connecticut
Illinois
Kansas
Kentucky
Massachusetts
MD-Michigan
Montana
New Hampshire
New Jersey
MD-New Mexico
MD-Pennsylvania
Rhode Island
Utah
MD-Washington
Wisconsin
Wyoming


3yrs GME Required:
MD-Maine
Nevada
South Dakota

 

[2021Doctor]

Matching into a prelim IM position locks you into 3 years of GME funding, and prelim GS locks you into 5 years of GME funding. A TY doesn't lock you into anything, and you only get locked into funding once you start a terminal program.
https://members.aamc.org/eweb/upload/Medicare Payments for Graduate Medical Education 2013.pdf

This topic has been well covered on sdn by aProgDirector.

 

[starri]

When all TRI programs transition to ACGME, this will probably be the case. The TY year will not be a viable option to get an extra year of medical experience for those that didn't match due to less than stellar apps, because they'll be competing for TY spots with highly qualified applicants.

That will probably just shift the burden onto medicine and surgery prelims.

Although are we sure that TRI programs are becoming TY and not their own thing in the ACGME umbrella?