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Extremely rare. You really can't do much with an MD without residency so if people are struggling in residency they usually will switch to family to get out ASAP in 2 years then at least they have the certification to assist in whatever their next step is, and the CCFP allows you a pretty broad scope depending on where you practice. Otherwise if you're really burning out or struggling most places will let you take a LOA and come back to finish.

Reasons for dropping/transfer out vary but its the stuff you can basically guess, not enjoying the subject matter/lifestyle/patient population/etc of their matched specialty as much as they thought they would. The grass is always greener. Conflicts with staff/residents/colleagues. Changes in life circumstances, having children or divorces for example change priorities.

Now if you're asking what's the relative transfer rate of the more intense specialties vs "lifestyle" specialties, those numbers are not published. Anecdotally, it's obviously higher. People tend to move out of surgery and into anesthesia for instance, from what I've seen.

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11 minutes ago, bearded frog said:

Extremely rare. You really can't do much with an MD without residency so if people are struggling in residency they usually will switch to family to get out ASAP in 2 years then at least they have the certification to assist in whatever their next step is, and the CCFP allows you a pretty broad scope depending on where you practice. Otherwise if you're really burning out or struggling most places will let you take a LOA and come back to finish.

Reasons for dropping/transfer out vary but its the stuff you can basically guess, not enjoying the subject matter/lifestyle/patient population/etc of their matched specialty as much as they thought they would. The grass is always greener. Conflicts with staff/residents/colleagues. Changes in life circumstances, having children or divorces for example change priorities.

Now if you're asking what's the relative transfer rate of the more intense specialties vs "lifestyle" specialties, those numbers are not published. Anecdotally, it's obviously higher. People tend to move out of surgery and into anesthesia for instance, from what I've seen.

Yep, very rare but it does happen. I also agree that there are probably more transfers into lifestyle specialties than vice versa. I know residents in my year that left for FM from the specialties for a variety of reasons. I only knew one case in my year of someone transferring from FM to a surgical specialty. The numbers aren't published as far as I know but they're pretty low and I wouldn't bank on transfers as a reliable way out either.

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15 hours ago, cotecc said:

Do programs kick residents out or intentionally hire more residents to eventually weed some out? 

Residents being kicked out is vary rare and extremely difficult for programs. Unless there is an obvious professionalism/legal violation, then there is years of remediation/probation prior to being asked to leave, and there have been court cases requiring residents to be let back in.  Depending on the reason most places will try to transfer them out instead of kicking them out, as it looks bad for the program. If you are struggling with procedural skills they will encourage you to transfer to a medical field, if you are having trouble with patient interactions they will suggest pathology,  etc.

Residency spots are extremely limited and in general the more the better for a program as they do a lot of service coverage, and having a resident kicked out looks extremely bad for the program, its a small world in Canada, with only ~15 general surgery programs for instance, the perception that you kick out residents or are toxic is going to get around very quickly.

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US programs do not take on more residents than they need with the goal of weeding them out either. Probably, the chance of residences getting kicked out of programs is the same in the US as Canada, but with hundreds more programs in the US, it happens more frequently overall, with the caveat that in the US there are non-academic residencies that are much less supported so while still rare there are a few "toxic" residencies that are not very supportive of residents, and you'll occasionally hear horror stories on studentdoctor, that you of course have to take with a grain of salt since you're only getting one side of the story.

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Transfers to other programs are somewhat common in surgery. In the tougher programs attrition rate averages about one transfer every other cohort year (i.e. 0.5/year). Anecdotally I have heard the more "lifestyle balanced" surgical subspecialties (urology, ENT) have a lower dropout rate than the more "work oriented" ones. Common reasons for switching out include realizing they don't like the OR as much as they thought they did, or the fact that residency overwhelmingly consumed their lives, or because their priorities shifted in life, or all of the above. If you are a poorly performing resident it is rare the program will proactively try to kick you out, as they want your warm body for the call pool (otherwise this would demoralize the remaining residents by increasing call load).

Family medicine occasionally has people switching out, usually because FM was their backup.

As for "ROAD" (an arbitrary made acronym... these specialties don't share much in common with each other), I haven't heard of any resident who has switched out.

 

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48 minutes ago, 1D7 said:

Transfers to other programs are somewhat common in surgery. In the tougher programs attrition rate averages about one transfer every other cohort year (i.e. 0.5/year). Anecdotally I have heard the more "lifestyle balanced" surgical subspecialties (urology, ENT) have a lower dropout rate than the more "work oriented" ones. Common reasons for switching out include realizing they don't like the OR as much as they thought they did, or the fact that residency overwhelmingly consumed their lives, or because their priorities shifted in life, or all of the above. If you are a poorly performing resident it is rare the program will proactively try to kick you out, as they want your warm body for the call pool (otherwise this would demoralize the remaining residents by increasing call load).

Family medicine occasionally has people switching out, usually because FM was their backup.

As for "ROAD" (an arbitrary made acronym... these specialties don't share much in common with each other), I haven't heard of any resident who has switched out.

 

A lot of this depends on where you were trained and the luck of the people that were there. In my program in radiology we had 5 people leave in the 4 years of the program I was paying attention to - 3 to family med, 1 to nuc med, and 1 to derm (and that is just those that actually left - obviously others thought about it). That rate was higher that the surgery programs. That program accepts 6 people (sometimes 7) a year. I know other places where similar things have happened as well. 

I bring this up because regardless of the program residency is a hard long progress, call is often brutal, and somethings on "ROAD" are not at all as rosy as they may appear at times. 

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9 minutes ago, MrsAaronSamuels said:

Sorry all for the basic question. What is ROAD and what does it refer to? 

Radiology, ophthalmology, anesthesia, dermatology. Someone made this acronym to say that these specialties are the "road to happiness", despite these specialties doing very different things, having different lifestyle/call, different pay, different degree of patient interaction.

24 minutes ago, rmorelan said:

A lot of this depends on where you were trained and the luck of the people that were there. In my program in radiology we had 5 people leave in the 4 years of the program I was paying attention to - 3 to family med, 1 to nuc med, and 1 to derm (and that is just those that actually left - obviously others thought about it). That rate was higher that the surgery programs. That program accepts 6 people (sometimes 7) a year. I know other places where similar things have happened as well. 

I bring this up because regardless of the program residency is a hard long progress, call is often brutal, and somethings on "ROAD" are not at all as rosy as they may appear at times. 

Must have been rough losing that many. Agreed that residency is tough all around.

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11 minutes ago, 1D7 said:

Radiology, ophthalmology, anesthesia, dermatology. Someone made this acronym to say that these specialties are the "road to happiness", despite these specialties doing very different things, having different lifestyle/call, different pay, different degree of patient interaction.

Must have been rough losing that many. Agreed that residency is tough all around.

It sounds like the lost residents were spread out over multiple classes, and nuc med is technically radiology + 2yr fellowship, so that one isn't exactly a loss. That said, I'm interested to know how somebody managed to transfer into derm, especially from rads (two specialties which, while visual-based, have very different scopes)!

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8 minutes ago, insomnias said:

It sounds like the lost residents were spread out over multiple classes, and nuc med is technically radiology + 2yr fellowship, so that one isn't exactly a loss. That said, I'm interested to know how somebody managed to transfer into derm, especially from rads (two specialties which, while visual-based, have very different scopes)!

Transfers are often into unrelated specialties. Basically every surgical resident transferring into FM/IM are doing something completely different with little overlap.

Having 5 losses is very painful. In many programs that's the loss of 1 or more than 1 full cohort worth of residents who would otherwise be sharing call... in other words 20% increase in call. Nuclear medicine is an independent 5 year program in some places, regardless they don't share in radiology call.

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2 hours ago, insomnias said:

It sounds like the lost residents were spread out over multiple classes, and nuc med is technically radiology + 2yr fellowship, so that one isn't exactly a loss. That said, I'm interested to know how somebody managed to transfer into derm, especially from rads (two specialties which, while visual-based, have very different scopes)!

ha - don't tell a 5 year nuc resident it is technically radiology :) That would be like telling a vascular surgeon they are just general surgery with a dab of extra training - great way to start an argument. Plus it was a loss to the program specifically - that person leaving as yet another blow to us for sure (none of these people leaving was a end loss to the medical profession as a whole since they are of course all doctors in new fields).

How to transfer to derm? Well they is simply a lot of common things anyone is looking for in a residency and when you are a competitive program/field you probably have those things (smart, hardworking, easy to get a long with and have actual communication skills......) Only thing left is an interest in the field, and people can have interest in more than one field. The criteria that Ottawa looks for also specifically (how they weigh the various factors) also probably made it easier than it otherwise would have been.

 

 

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5 hours ago, bearded frog said:

US programs do not take on more residents than they need with the goal of weeding them out either. Probably, the chance of residences getting kicked out of programs is the same in the US as Canada, but with hundreds more programs in the US, it happens more frequently overall, with the caveat that in the US there are non-academic residencies that are much less supported so while still rare there are a few "toxic" residencies that are not very supportive of residents, and you'll occasionally hear horror stories on studentdoctor, that you of course have to take with a grain of salt since you're only getting one side of the story.

it doesn't serve a program to have people leaving - it damages your program's reputation so on a very clear practical level it is not a logical thing to do (and of course you shouldn't do it for reasons of professionalism and fairness - but even if you weren't respecting that I find the hard limits just pushes it over the edge). 

 

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5 hours ago, rmorelan said:

A lot of this depends on where you were trained and the luck of the people that were there. In my program in radiology we had 5 people leave in the 4 years of the program I was paying attention to - 3 to family med, 1 to nuc med, and 1 to derm (and that is just those that actually left - obviously others thought about it). That rate was higher that the surgery programs. That program accepts 6 people (sometimes 7) a year. I know other places where similar things have happened as well. 

I bring this up because regardless of the program residency is a hard long progress, call is often brutal, and somethings on "ROAD" are not at all as rosy as they may appear at times. 

Woah, that is a ton of people leaving. Obviously your co-residents at the time left for various reasons, but it does seem surprising as I thought Ottawa radiology was a top 3 program. And as you said, people leaving would damage a program's rep

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1 hour ago, 1D7 said:

Radiology, ophthalmology, anesthesia, dermatology. Someone made this acronym to say that these specialties are the "road to happiness", despite these specialties doing very different things, having different lifestyle/call, different pay, different degree of patient interaction.

Must have been rough losing that many. Agreed that residency is tough all around.

snowball effect - call is a zero sum game, even doing more call so if you lose someone everyone does more and that increases the risk of other breaking down. 

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5 hours ago, garlic said:

Woah, that is a ton of people leaving. Obviously your co-residents at the time left for various reasons, but it does seem surprising as I thought Ottawa radiology was a top 3 program. And as you said, people leaving would damage a program's rep

part of being a top tier program often means high volume of work, and an "aggressive" call schedule. Sweat now, or bleed later approach to things. It is similar to say a surgery problem where a better program has you doing more cases. The more you do the better you get, but it does involve doing the cases ha. 

In many fields that isn't much of a surprise - but if you think radiology is on the the "ROAD" to happiness I would point out that over time that road has developed a lot of bumps and more than a few pot holes as well. 

People leaving does I think force you to examine a program - I mean if you found out there was a non-zero chance a program was tough enough that people equally motivated to you would leave it then it would give you pause. You have to ask why - sometimes it is just bad luck, and sometimes people find out it just isn't what they want to do. At Ottawa - which for the record is a fantastic educational program for radiology - had a combination of people deciding to leaving for various reasons, with an associated snowball effect on call shifts per remaining resident over a background of a intense program. Of course if you get through all that you are very well prepared, and that is where is part Ottawa's reputation comes from. 

I think again a lot of this boils down to awareness and that only comes with people being clear - radiology residency is no walk in the park, and even with our evolving improvements to the call schedule there are a relatively few number of residents and a lot of shifts to cover, and those shifts are very busy and go all night long (it is a running joke at many places that PARO requires radiology resident to have a call room by contract requirements. What is the point? No one is ever going to use it). Furthermore as staff it is also very busy, and has a lot of call in many places. You just have to know what you are getting into. 

 

 

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20 hours ago, rmorelan said:

ha - don't tell a 5 year nuc resident it is technically radiology :) That would be like telling a vascular surgeon they are just general surgery with a dab of extra training - great way to start an argument. Plus it was a loss to the program specifically - that person leaving as yet another blow to us for sure (none of these people leaving was a end loss to the medical profession as a whole since they are of course all doctors in new fields).

How to transfer to derm? Well they is simply a lot of common things anyone is looking for in a residency and when you are a competitive program/field you probably have those things (smart, hardworking, easy to get a long with and have actual communication skills......) Only thing left is an interest in the field, and people can have interest in more than one field. The criteria that Ottawa looks for also specifically (how they weigh the various factors) also probably made it easier than it otherwise would have been.

 

 

 

22 hours ago, 1D7 said:

Transfers are often into unrelated specialties. Basically every surgical resident transferring into FM/IM are doing something completely different with little overlap.

Having 5 losses is very painful. In many programs that's the loss of 1 or more than 1 full cohort worth of residents who would otherwise be sharing call... in other words 20% increase in call. Nuclear medicine is an independent 5 year program in some places, regardless they don't share in radiology call.

Yeah, my bad, I didn't realize nuc med has 5 year programs -- at my university it's 5 + 2

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29 minutes ago, insomnias said:

 

Yeah, my bad, I didn't realize nuc med has 5 year programs -- at my university it's 5 + 2

they honestly probably won't for much longer - it is the death of an entire specialty in medicine in a sense. The +2 is a relatively new addition to the landscape. The main reason the 5 year program still exists in Canada is that Quebec won't let you bill under two specialities, and considers them separate (rads and nucs) to prevent cross billing. Without that the last bastion of nucs in Canada would likely crumble too. Sooner or later rads in Quebec will convince people that rads should be able to read it as well just like the rest of the country/US. When I left Ottawa they started hiring rads with the 2 year fellowship to work in the nucs dept for the first time. 

Not that the work will go away - but more and more of it does not make as much sense unless it is also under rads. At classic example now is PET studies but also so much imaging is related that you really need to be able to work with it all. Plus their bread and butter study - Bone mineral density studies no longer even uses a radioisotope so it isn't even really their area. It is just an x ray. Rads has been aggressively reclaiming those more lucrative studies in many places.  

Again the work itself is critical and the nuc med staff are highly skilled. It is just they have a really hard time fitting in to a modern system, particularly at relatively smaller community practises (why higher someone who does nucs, when you can higher someone that does nucs and rad and thus be on your ~10 staff to actually help out with modern day call requirements, and all the other work plus do "something" while the nuc studies are being done - there is a lot of dead time in nucs). 

 

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I've heard of rare instances where residents take prolonged LOA for personal/health reasons, don't know what happened afterwards. I do know resident who was fired after convicted of crime and license was stripped. The US is bit different in that residents get less representation and switching residency is easier, that's why you see people jump from one place to another or switch entire fields after doing maybe 1-2 years in one field.

But otherwise it's very hard to fire a resident based on academics here, they just have to keep giving them probations and remediations etc. If they fire base on poor academics then I am pretty sure the provincial resident association would have the lawyers sue them. Unfortunately this means once a while you'll meet a "dead weight" resident who is struggling, burnt out, but have nowhere else to go.

I do wish they bring back general internship or even a preliminary year, which I think would be a much better buffer for new grads who aren't sure what they really want to do yet. 

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45 minutes ago, shikimate said:

I've heard of rare instances where residents take prolonged LOA for personal/health reasons, don't know what happened afterwards. I do know resident who was fired after convicted of crime and license was stripped. The US is bit different in that residents get less representation and switching residency is easier, that's why you see people jump from one place to another or switch entire fields after doing maybe 1-2 years in one field.

But otherwise it's very hard to fire a resident based on academics here, they just have to keep giving them probations and remediations etc. If they fire base on poor academics then I am pretty sure the provincial resident association would have the lawyers sue them. Unfortunately this means once a while you'll meet a "dead weight" resident who is struggling, burnt out, but have nowhere else to go.

I do wish they bring back general internship or even a preliminary year, which I think would be a much better buffer for new grads who aren't sure what they really want to do yet. 

I am also a proponent of the general internship year that gives you the ability to do something. Right now the LMCC serves no purpose anymore other than a student tax. I think students right now are forced to choose a field too early and in many cases grow to resent their choice with no real opportunity to change. Furthermore, you have family medicine programs who want people who are truly interested in their field and refuse to be seen as a "back up" field. However, in a world where there is no ability to be a "general doctor" I would argue that some field has to offer the opportunity for a student who has fallen through the cracks to still be a doctor.

I'm unsure what kind of privileges these General MDs would have given the growing complexity of medicine. However, I would easily hire many R1s/R2s over the PAs and NPs I see at the centres I work at as a clinical associate. I'm sure if they apprenticed themselves to a FM for a number of years they would be safe enough to open their own practice. I suppose that destroys the purpose of FM programs though so I'm not sure if that dream really makes any sense or will ever be possible.

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2 hours ago, blah1234 said:

I am also a proponent of the general internship year that gives you the ability to do something. Right now the LMCC serves no purpose anymore other than a student tax. I think students right now are forced to choose a field too early and in many cases grow to resent their choice with no real opportunity to change. Furthermore, you have family medicine programs who want people who are truly interested in their field and refuse to be seen as a "back up" field. However, in a world where there is no ability to be a "general doctor" I would argue that some field has to offer the opportunity for a student who has fallen through the cracks to still be a doctor.

I'm unsure what kind of privileges these General MDs would have given the growing complexity of medicine. However, I would easily hire many R1s/R2s over the PAs and NPs I see at the centres I work at as a clinical associate. I'm sure if they apprenticed themselves to a FM for a number of years they would be safe enough to open their own practice. I suppose that destroys the purpose of FM programs though so I'm not sure if that dream really makes any sense or will ever be possible.

It is a bit silly to say the least - I would also personally love a general practice style license. 

Only thing I have ever seen it useful for it is does let me bypass the USMLE for many US states and various licensing bodies. 

Right now the fall through the cracks position is some kind of non-clinical research, corporate job or something like writing. I believe two people in my class in the end ended up there (although one case was simply self inflicted and fully deserved). 

As for what could a general practitioner do - that is an interesting question as I do believe family medicine truly is too complex and does need its own certification. Particular as a year of off service rotations like the US and most of us in Canada  hardly would prepare you for it at all. Still I would think you could focal on things PA or NPs would do as well, and there are things like surgical assisting perhaps? If you can do EM with doing some kind of community ER for an extended period time with your base FM then perhaps there is an argument you could advance to full FM if you similarly apprenticed under a FM for long enough and did the appropriate examinations etc. 

Medicine can have a tendency to be overly certified. I get the motivation but we also have to keep in mind that residency is a relatively short period of time in peoples' careers, and we can develop new skills (as we have to do in any case) as things go along. Some of those skills may not neatly fit in to a bucket we would call a fixed specialization - at some point every new aspect of medicine was not taught but rather developed by a practitioner, and every field of medicine started somewhere without a fancy title. Maybe I feel this way in part because I am a bit of a generalist myself with my hand in a lot of different areas of study both within medicine and outside of it. I am not a fan of absolutely boxing in people.   

 

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