Doing it the Hard Way
So I didn’t match last year and scrambled into a categorical position in Family Medicine. A categorical position as opposed to a preliminary position guarantees you a position for the total duration of the training for your specialty. It should be obvious that it is much more difficult to switch specialties out of a categorical position than out of a preliminary position. When you are in a preliminary position it is understood that you are either going to your primary specialty after your year is up or that you will be re-applying for the match. Your program director will not be shocked if you ask for time off to interview and you don’t have to explain yourself or apologize to anybody.
Not that you have to apologize or explain if you switch from a categorical position. You only sign a contract at any program for a year at a time so you are perfectly within your contractual rights to leave at the end of the year. However, since accepting such a position is a de facto acknowledgment that you intend to complete training your Program Director will naturally be surprised and not a little put out. From his point of view he will now have a hole in his roster which he may or may not be able to fill especially if it is a non-competitive specialty. Remember for all of the happy happy talk you may hear during orientation you are a low-paid and therefore extremely economical part of the health care team and your warm educated body is needed to by various hospital services to provide cheap medical labor. His program has service requirements which he must meet and you are kind of leaving him in a lurch.
Still, most big academic centers won’t grind to a halt if you leave. You can’t let your natural distaste for letting people down keep you from securing your own future. This sounds incredibly selfish but there it is. I just want you to see it from the program director’s point of view and add this to the reasons to let him know early when you decide to switch. Not only will this give him a longer lead time to re-work schedules but if you actually submit a letter of resignation he can start looking for someone to fill your empty second year spot.
I thought I was going to settle for Family Medicine and for the first couple of months of intern year I stuck to it even though I was becoming rapidly demoralized. I just didn’t like it that much. And if you must know I’m not crazy about Duke. Maybe once I get clear of the place and get some sea room I’ll tell you why. I decided to start filling out my ERAS application even though I hadn’t made a decision yet. In early September I asked my wife’s permission to switch specialties. I laid out my case and as certain things about the program and Family Medicine made her uneasy it was not a hard sell. Still, we had just moved three kids and five dogs along with all of our possessions across the country so she was not thrilled about potentially doing it twice in less than a year. Additionally, even though I was later of accused of never really intending to stay (using the Duke name as an “in” to other programs) we had bought a house and stood to take a bath on it when we moved.
My plan was to see if I got any interviews before telling my program. If I didn’t get any I would keep my mouth shut and suck it up as there is no point in needlessly rocking the boat. Unfortunately you do need a program directors letter so you have to tell your program eventually. By the middle of October, early in the process and before November 1st after which you can expect the bulk of your invitations to interview, I had already received four invitations which seemed to me an auspicious start. I told my program that week and then fought for the next three months to get time off to interview.
The interview season runs from roughly November to the first week in February. Unfortunately I had inpatient rotations during all those months. Inpatient rotations (or ward months) usually have call, rounding, and a lot of grunt work which needs to be done by the interns. Since your program has service requirements, basically an agreement with the hosting service to provide labor in exchange for training you, if you are absent someone from program has to cover for you. If you are sick they usually pull one of the interns off of an outpatient rotation where the presence of one intern is not so critical. I did two weeks of outpatient ENT, for example, and since all I really did was follow the attending around he was perfectly ambivalent to my presence.
One of the reason to tell your program early is to allow them time to switch the schedule around to give you at least one easy month, preferably January, in which to schedule your interviews. I was promised time off to interview, I dutifully scheduled most of my interviews as late as I could to give my program the lead time to switch the schedules, and then as January rolled around found that nothing had been done. Your program doesn’t have to do jack for you, you understand, as switching specialties is a personal problem. On the other hand you have got to interview or you will not match, simple as that.
This kind of left me in a quandary. As my abbreviated interview season rolled into view nothing had been done and no arrangements had been made. The assumption was that I wasn’t serious or that I would arrange my own time off with my fellow interns on the service switching call days here and there. This is possible but Iâ€™m not ready to stake my future on the generosity of people who are themselves overworked and whose schedules are so tight that they can’t possibly take a call day for you without seriously violating the duty hour rules. I think an attempt was made to shame me into not interviewing by threatening to make my colleagues who were on easy rotations suffer by doing my call.
This hit pretty hard because as a former Marine Infantryman if there’s one thing I never do is let somebody carry my pack. Everybody has their moral code and not burdening others is a big part of mine. Still, I had to interview so I was forced to go up the chain of command and ask for help above my program. This was not received very well.
Finally, I plainly told my program that if I didn’t interview, I wouldn’t match and if I didn’t match, there was no way I would stay in family medicine so under those circumstances I might as well just quit and go back to my original career. (Structural Engineering, as I have mentioned.) This is kind of a risky thing to do. I have been out of the engineering business now for almost five years, have an inactive Professional Engineering License, no contacts, and am five years out of practice. Getting back into business would take between six months to a year and in case you don’t know it interns are not paid that well and most of us live pretty much from hand to mouth. Besides, I left the engineering business to be a doctor. I wasn’t too keen on that option. So I was pretty leery about suggesting that I might quit. They might have said, “OK, there’s the door. Have a nice life,” at which point I could have either held my head high, shaken hands all around and said, “It’s been nice” or eaten a big helping of cold crow and groveled for my job back.
You have to understand that I really, really want to do Emergency Medicine. Ever since the end of third year I couldn’t picture myself doing anything else so it seemed worth the risk.
You do have some leverage, however, particularly at a small program with a lot of service requirements. My resignation, while not catastrophic to the program, would require the reshuffling of schedules to fill service requirements. Some services rely on the interns and there are very few spares floating around. This kind of hole in a roster has a pretty big ripple effect in the schedule for a few months. When I implied that I might quit, my program had to ask itself what it was worth to keep me. Fortunately it was worth a little schedule switching. My program director who is actually a decent guy working hard to solve (and succeeding at it) some of the structural problems he inherited squared the whole situation away.
The moral here is this: If you plan on leaving, tell your program early. They cannot fire you for wanting to switch specialties as your contract is for a year and binding on both parties. Also, think about when you will interview and if you don’t have a rotation during which you can miss a few days make sure to ask for and get a schedule change. I was not as aggressive at this as I should have been and I don’t think my program realized how serious I was about switching. I wasn’t just throwing out a couple of applications hoping for a few local interviews (I was skunked in North Carolina, if you must know, except for Duke which was a courtesy interview). I eventually went on six trips to cover nine Emergency Medicine interviews. I managed to get in one in November, under the wire as the planets aligned just right on that occasion, two at the end of December as one of my upper levels was kind enough to cover two days of night float, and the rest I did in January during a rotation where I was an â€œextra intern. I went on the last interview in early February when I finally got on an outpatient rotation and it was here that I eventually matched.
You just never know. I would also say that even though you are switching, you need to stay motivated for the specialty you are in and give good service for your pay. Don’t drop the ball and don’t get a short-timers attitude. I think every one who knows me will admit that I have been very gung ho and have shirked none of my responsibilities. I don’t hate Family Medicine. It is a perfectly decent specialty with it’s own complexities and focus. It’s just, as I found, not for me.
All’s well that ends well. This last six months has been quite an adventure full of red-eye flights and long road trips made in total darkness there and back. I confess that until I matched Durham has always made me uneasy. I came here, in my mind, a failure and I believed that maybe I had finally hit the wall.
Not today my friends.