by Elizabeth Losada, MD
SDN Staff Writer
During her 4th year of medical school J.T. struggled to decide between applying for residency in Ob-Gyn and Family Medicine. She ultimately chose Ob-Gyn because she liked the surgical aspects of the field. J.T. started her intern year and found that she did not enjoy the OR as much as she had thought she would. She also missed the broad spectrum of patients and problems that she had seen in Family Medicine. As the months passed J.T. became convinced she should have picked Family Medicine for residency. She voiced her concerns to her program director and was pleasantly surprised by her program director’s supportive response. It was too late for J.T. to re-enter the match, but by calling programs in the area after the match she was able to find a position in Family Medicine for the following year.
S.M. matched to a preliminary year in Internal Medicine and an advanced position in Anesthesiology. Surprisingly, he found himself enjoying intern year much more than he had expected. At the end of intern year he moved on to Anesthesiology. Several months later S.M. realized he had been happier with the day-to-day work in Internal Medicine than in Anesthesiology. After speaking with the program directors from his preliminary Internal Medicine program and his Anesthesiology program, he arranged to finish the year in Anesthesiology and then return to the Internal Medicine program as a PGY-2.
While it is commonly assumed that specialty choice for residency is an immutable decision, the true stories of the residents above demonstrate that it is possible to change directions after starting residency. Anecdotally it is said that as many as ten percent of all residents switch specialties each year.
Studies looking at resident attrition rates have yielded some data on specialty switching among residents. Attrition rates account for all residents who leave residency programs, not just those who change specialties. This includes residents who leave medicine completely and those who switch to another program within the same specialty. A study of Ob-Gyn resident attrition by McAlister et al. in 2008 (1) noted 2004-2005 ACGME reported annual resident attrition rates of 5.8% in Surgery, 5.1% in Ob-Gyn, 4.7% in Family Medicine, and 2.1% in Internal Medicine. Of 1055 categorical Ob-Gyn residents who entered programs in 2001, 21% (228 residents) had left their original program after four years and were categorized in the attrition group. Within the attrition group 33% (75 residents) switched specialties and 39% (29 residents) moved to primary care residencies.
Longo et al. (2) examined resident attrition from a general surgery residency program over a 20-year period and found a 30% attrition rate. Of the 30 residents who did not complete their training at the program, 63% (19 residents) switched to other specialties, including plastic surgery and medicine most commonly. The most common reasons cited for leaving the program included “lifestyle” and “passion for another specialty.”
One conclusion that can be drawn from the above studies and from the numerous posts on the Student Doctor Network forums regarding switching specialties is that residents who are unhappy in their programs and are contemplating making a move to another field are not alone. Commonly, the decision to change fields is fraught with feelings of isolation and self-doubt. “I felt like there was something wrong with me,” said M.J., a resident who is in the process of switching fields. “All of my fellow interns seemed happy. I mean we all had our bad days, but I was really the odd man out in being so unhappy overall. I felt so frustrated. I had worked so hard to get here. Why couldn’t I be happy like everyone else was? There was really no one who understood what I was going through.”
Attendings who work in medical education often caution new interns and residents who are unhappy in their programs initially to avoid making hasty decision to switch fields. The stress of adjusting to being an intern or a new resident, often in a new hospital system, can be overwhelming. With time to adjust to new responsibilities the specialty may turn out to be the correct fit. But for some interns and residents, time only makes it clear that a change is needed. “It took me awhile to realize to I did not just have the intern blues,” said M.J. “But I am glad I gave it some time to realize that the field was just a bad fit for me. The timeline will likely be different for different people, but I think that anyone who is questioning reaches a point where it becomes pretty clear what to do.”
Because leaving for another field will impact on the resident’s current program, residents who are thinking of switching often struggle with when to tell others in the program about their plans. Posts about switching specialties on SDN express fears about speaking to the program director, in particular. Having the program director’s support, however, is important for obtaining a position in a new specialty. Many residency programs require a letter from the program director for applicants who have current/past residency training. Additionally, residents will need time off to attend interviews. Thus, it is unlikely that a resident can successfully switch fields without talking to his current program director.
“I think it is important for residents thinking of switching fields to find someone to talk with that they trust,” said M.J. “I first went to a faculty member in my program and advisors from my medical school. Once I had made up my mind that I needed to switch, I went to my program director and was very honest about what had been going on. It went better than I expected and it was like a weight was lifted.” In the best of circumstances the program director will be supportive of the resident’s struggle, provide advice about making to decision to switch, and assistance in finding a new position. Posters on SDN emphasize that the interaction with the program director is likely to go most smoothly if the resident gives the program sufficient time to find a replacement resident before leaving. This will also spare the departing resident’s colleagues from having to absorb extra work.
How one goes about finding a new residency position varies, depending on the type of switch being made. For some residents, especially those who decide to switch early on or who are switching to a field that is drastically different from their current specialty, the easiest way to switch may be to re-enter the match. Going through the match again provides the most options for finding a new first-year position. For residents who have completed training that may count towards the requirements for another field, looking for a position outside the match may make the most sense. Simply calling area programs to ask about openings has been successful for some residents. Additionally, several websites (see below) offer notification of off-cycle positions and application services.
Regardless of what method a resident uses to look for a new position, standard information like a current CV, letters of recommendation, and a personal statement addressing the reasons for switching specialties will be needed. “I was advised to get a letter from my program director and a supportive faculty member in my current program,” said M.J. “I also got some of my letter writers from medical school to update the letters they had written for me originally. I ended up with four strong letters that painted a good picture of what I done in medical school and my current program.”
SDN posts also emphasize the importance of making a convincing case for why one is switching and how the new specialty is going to be a better fit. Program directors want to be sure that the resident is not simply going to leave the new program soon after starting.
Deciding to leave a residency program to switch specialties is never an easy decision. Residents who switch specialties may fear not finding a new position, facing negative reactions from their current residency programs, and could end up extending the length of their overall training. But for those who have decided to switch fields, the benefits clearly outweigh the risks.
“I could not see myself having a future in my current specialty anymore,” said M.J. “At the end of the day you have to think about the next several decades of your life, and not the next few years. Yes, switching has been a difficult process, but it would have been much worse to stay where I am at, and end up doing a specialty I hated for the next 35 years. I would tell anyone who feels they are in the wrong field to really explore that feeling and to take the risk and make a change if you know that is what you need to do.”
Websites for Off-Cycle Residency Positions:
SDN Positions Forum (http://forums.studentdoctor.net/forumdisplay.php?f=290): SDN members can post available and wanted internship, residency, and fellowship positions.
Resident Swap (www.residentswap.org): Database of currently open residency positions posted directly or advertised on other sites. Also offers application service with options for residents to swap their current position with other users and for couples to search for positions together. $79.99/month, discounts available for 3-month subscription.
FindAResident (www.findaresident.com): AAMC program that supplements ERAS by allowing applicants to post their information and apply to ACGME-accredited off-cycle positions posted by residency programs. $75.00 for applicants, $30.00 for current active ERAS users.
1. McAlister, RP, Andriole, DA, Brotherton, SE, and Jeffe, DB. (2008). Attrition in residents entering US obstetrics and gynecology residencies: analysis of National GME Census data. Am J Obstet Gynecol 199(5): 574.e1-574.e6.
2. Longo, WE, Seashore, J, Duffy, A, and Udelsman, R. (2009). Attrition of categorical general surgery residents: results of a 20-year audit. Am J Surg 197(6): 774-778.