Going Unmatched vs Backing Up with Family Medicine

[CaRMsSucks]

I applied to CaRMs this year for both a competitive specialty and family and got fewer interviews than I had hoped for in the competitive specialty but got all of my FM interviews. I am hoping for the best but I realize that I have a choice to make about whether or not I would prefer to go unmatched and try again next year or take family and hope that I will grow to like it or have the opportunity to transfer out/do a re-entry training program/find a +1 that I enjoy. 

I changed my mind about my path during early clerkship and believe that the competitive specialty is the best fit for me. However, getting enough experience in my competitive specialty was difficult, especially during a pandemic with no opportunities to do visiting electives. I did some elective time + research in the specialty, but looking at residents who were previously accepted, they have many more publications +/- master’s and PhD’s, compared to where I am at right now. I think this was a major weakness of my application. As far as I know, I don’t have any red flags that would keep me from matching. I think that my references were strong (some of them told me specifically that the letters would be strong) and I used all of my letters at places where I got interviews, so I don’t think that there were any issues there. 

Going into clerkship, I thought that I would want to do FM but realized during my family rotations that I didn’t enjoy the actual job, regardless of being in an academic or community FM clinic. I hated not getting to focus on any one discipline, having to juggle several non-specific, unrelated issues and always feeling rushed. I felt that I wasn't able to provide high quality, in-depth care with the constraints of a bread and butter FM practice. My preceptors didn’t seem to be passionate about their careers, many admitted that it wasn't their first choice discipline and just had the ‘9-4 and then leave’ mentality. The most mentally drained that I had felt during clerkship was after my FM rotations.

I’ve been seeing plenty of negative FM posts on PM101 from people who backed up and wished they had gone unmatched for a year. It seems like they felt similarly to how I do now about FM when they backed up and now they regret their choice. I have also met plenty of unhappy FM residents at my home FM program and one of them flat-out told me that he doesn’t find the work to be fulfilling or challenging in FM residency and he would switch programs if he could.

I’m trying to decide if I should rank some of the FM programs that I applied to as a back-up or if I should only rank the programs in the specialty, with the intent of taking a year off and re-applying to CaRMs next year if I don’t match to one of the programs where I interviewed. I am not planning to apply to the second round of CaRMs this year because of some of the restrictions on being able to transfer programs in PGY-1 for people who matched in round 2 (unless a spot in my specialty of interest is available in round 2, which is unlikely). I also know that transferring is extremely difficult and if I match to FM, I would need to be committed to sticking with it in the long-term.

In my year off, I would pursue research opportunities in the field (open to doing an MSc or research fellowship in Canada or the US) as well as more electives in an extension of clerkship. I truly did not feel ready to apply to CaRMs this year and if my current interviews don't work out, a year off to build my career wouldn’t be the worst thing for me. I'm also planning to write the USMLE's and apply to both CaRMs and ERAS next year for the competitive specialty. I would also explore other options in less competitive specialties that may be a better fit for me than FM. 

Anyone have any advice on my options and/or other things to do in a year off? Or success stories from those who went unmatched previously but ended up where they wanted to be? Thanks in advance for your input! I’m really trying to be proactive about my decision since I’ve seen so many people get burned by the ‘just hope for the best’ mentality and they ended up going unmatched without a plan or are in a back-up specialty and aren’t happy. Plus a lot of deadlines for applying to research internships/Master's are coming up quick and I want to be prepared to hit the ground running and be productive next year if I get bad news on match day. Also wondering how FM programs view re-applicants who they interviewed in the previous year but did not match there? 

[CaRMS2021]

I really resonated with your post. I interviewed at just over half of the programs in my competitive specialty and nearly all FM programs I backed up with. What ultimately made the difference for me was that I did not know anyone in that specialty who got in on their second try + my application ticked all the boxes - I had research, letters, CV etc, of course it would've been nice to have more Pubs, Conferences, whatnot but I couldn't see a way to improve my app in less than a year to apply again that would make a significant difference. Therefore, I backed up and ranked every Family program and site possible to ensure I would not have to deal with the limbo of 2nd round. Thankfully, things worked out so I cant speak to being in Family. Best of luck

[lovemedicinesomuch]

Last year,  I applied to dermatology + plastics + FM . I got 3 interviews in derm, 2 interviews in plastics and FM interview at every program I applied to ( despite my minimal interest in FM). I ended up in my back up specialty FM ( but top choice program in FM). I am quite unhappy with FM, as I feel for me it is not intellectually stimulating, and you are often times tasked with mostly administrative duties that are vaguely related to medicine. A lot of my day I spend doing prescription refill,  or filling insurance forms, or doing preventative work. I don't particularly enjoy any of these tasks, as I don't find it academically challenging in any way.   I applied to transfer, and I am in the process of transferring to another specialty that I find more satisfying than FM ( but not derm or plastics). If I go back in time, I think I would still choose FM over going unmatched, as getting into very competitive specialties may involve a bit of luck...

I am also doing my USMLEs during my FM residency for the possibility of doing another residency in the US ( in FM residency, you will have so much free time to study for USMLEs). FM is also a residency that you can use to earn money until you have a better opportunity. I also went to a 3 year school, so I graduated quite young and I didn't mind spending 2 years in FM to build my knowledge and skills further until I have better opportunities in life.

A lot of FM residents are not happy with FM, because FM was not their top choice. However, the ones who chose FM as their top choice are mostly happy with it. It seems that in current CaRMS climate, a lot of people are 'forced' into FM with how competitive most other specialties are becoming.  I don't necessarily regret backing up with FM.   FM is excellent for life work balance,  and I really enjoyed having a lot of time to spnd with my friends and family. I was mostly using FM as a stepping stone for something , until I find a better residency and FM allowed me to do that. 

I wish you all the best, and I genuinely hope you get what you want, as it is truly a sad situation to end up doing FM when you truly don't like it that much.  

[indefatigable]

There's so many individual factors that it's hard to make a definitive statement with respect to future chances.  Like others have said, to some extent it depends on the discipline - some adcoms are more open to re-applicants than others.  It also depends on the application - if research was lacking compared to other applicants then a year off might make sense.  Properly assessing what can be added in a year off is important too - if clerkship extension is feasible then this might make your application more competitive given that you mentioned you were a late-comer to the discipline or give you a new "parallel plan".  

Many people mention writing the US MLEs also during an additional year, but I'm not sure how feasible this really is on top of all other activities - those are really a step up compared to MCCQE in terms of time commitment even Step 2 for a competitive score. Very few non-visa CMGs actually match to ERAS.  

Transferring is at best a crapshoot - but, I don't think matching in round 2 or round 1 really makes a difference.  Some schools/provinces have more generous transfer policies than others.  

There's really no guarantees and I think it comes down to whether the opportunity to try again would be worth it for you regardless of how it works out.  Maybe that might give you more peace of mind or maybe you may think it's more important it to start residency sooner.  For whatever it's worth, I know of people that have transferred out of cardiac and general surg and even derm (as well as unmatched & transfers into derm/plastics).

[shikimate]

It's a hard choice, but if you want to be "practical", then backing up with FM is probably the way to go. Then maybe you'll find some kind of +1 that fits your goals.

The problem I see with a gap year is that CaRMS isn't going to drastically change in terms of competitiveness for the very top specialties. So it doesn't get any easier next year compared to this year. Who knows, maybe that gap year could even work against you theoretically. 

I also agree with others that the government's plan is clearly pushing more grads into FM to fill the gaps in primary care. This is an open secret. So therefore I don't see CaRMS getting any less competitive in the coming years for non-FM specialties, save for the esoterics like nuclear medicine, medical microbiology, pediatric neurology etc. 

[jb24]

It really depends on the competitive specialty, but most AFAIK are not very accommodating of re-applicants, so I think that would be a huge gamble. Sadly the way the system is set up, is that CaRMS is a one shot go for most specialties.

Transfers in, or re-entry positions with return of service requirements do open time to time.

It's a tough decision. Your school will push you to back up with FM. I don't like to take risks, so probably would back up if I were you, but each person has their own risk tolerance.

Matching to competitive specialties is likely just as hard, or harder in the US.

[1029384756md]

Going to the US will be tough, easier if you're American. If you're not sure about going unmatched, apply and match to an unpopular 5yr specialty. Once you have funding, it's easier to transfer into your desired specialty in PGY1.

[bearded frog]

It's really individual. I just applied peds because I couldn't imagine being happy doing FM or anything else. Also, it wasn't a derm/plastics/ent level of competitiveness so I figured I would have a reasonable shot on a reapplication (and I went to a 3 year school so thought applying after 4 wouldn't be too bad). I ended up having a reasonable number of interviews too, which means I had a reasonable shot. I think depending on how many interviews for the compeditive specialty you got would tell you something, as there's a difference between an excellent candidate who just missed a spot and a long shot. I definitely would have backed up with something the second time around though, just to get something. Applying US without connections for a compeditive US specialty too is an uphill battle. You realistically don't have a year though as you're done in may and references are due in January, and it's hard to move the needle in that time. It's all about personal risk tolerance.

[RepresentativeSalad]

On 3/10/2022 at 8:37 PM, lovemedicinesomuch said:

Last year,  I applied to dermatology + plastics + FM . I got 3 interviews in derm, 2 interviews in plastics and FM interview at every program I applied to ( despite my minimal interest in FM). I ended up in my back up specialty FM ( but top choice program in FM). I am quite unhappy with FM, as I feel for me it is not intellectually stimulating, and you are often times tasked with mostly administrative duties that are vaguely related to medicine. A lot of my day I spend doing prescription refill,  or filling insurance forms, or doing preventative work. I don't particularly enjoy any of these tasks, as I don't find it academically challenging in any way.   I applied to transfer, and I am in the process of transferring to another specialty that I find more satisfying than FM ( but not derm or plastics). If I go back in time, I think I would still choose FM over going unmatched, as getting into very competitive specialties may involve a bit of luck...

I am also doing my USMLEs during my FM residency for the possibility of doing another residency in the US ( in FM residency, you will have so much free time to study for USMLEs). FM is also a residency that you can use to earn money until you have a better opportunity. I also went to a 3 year school, so I graduated quite young and I didn't mind spending 2 years in FM to build my knowledge and skills further until I have better opportunities in life.

A lot of FM residents are not happy with FM, because FM was not their top choice. However, the ones who chose FM as their top choice are mostly happy with it. It seems that in current CaRMS climate, a lot of people are 'forced' into FM with how competitive most other specialties are becoming.  I don't necessarily regret backing up with FM.   FM is excellent for life work balance,  and I really enjoyed having a lot of time to spnd with my friends and family. I was mostly using FM as a stepping stone for something , until I find a better residency and FM allowed me to do that. 

I wish you all the best, and I genuinely hope you get what you want, as it is truly a sad situation to end up doing FM when you truly don't like it that much.  

To everyone who backed up with FM and is unhappy/not interested: 

Please, PLEASE stop with the undermining tone and narrative around FM as a career choice. 
 

YOU chose to back up with a specialty you don’t enjoy, and you understood that by ranking, you might match there. I’m sure if I chose to rank specialties I don’t enjoy, I wouldn’t find them intellectually stimulating either, I get it.
 

Maybe you don’t realize it, but these messages with an air of poo-pooing FM are doing a disservice to those students/residents/physicians with a genuine passion for FM, and to the communities that are backboned by FM.  Family medicine is an exceptionally challenging career and much broader in scope than “filling prescriptions and completing insurance forms”.  There are loads of opportunity for intellectual stimulation.  It’s not just some stepping stone between medical school and another career - ranking FM with no interest or intent to practice means having potentially taken a seat from someone who wants to be a family doctor and to meet massive unmet needs in our society.  

 

 

[indefatigable]

7 hours ago, RepresentativeSalad said:

To everyone who backed up with FM and is unhappy/not interested: 

Please, PLEASE stop with the undermining tone and narrative around FM as a career choice. 

YOU chose to back up with a specialty you don’t enjoy, and you understood that by ranking, you might match there. I’m sure if I chose to rank specialties I don’t enjoy, I wouldn’t find them intellectually stimulating either, I get it.

Maybe you don’t realize it, but these messages with an air of poo-pooing FM are doing a disservice to those students/residents/physicians with a genuine passion for FM, and to the communities that are backboned by FM.  Family medicine is an exceptionally challenging career and much broader in scope than “filling prescriptions and completing insurance forms”.  There are loads of opportunity for intellectual stimulation.  It’s not just some stepping stone between medical school and another career - ranking FM with no interest or intent to practice means having potentially taken a seat from someone who wants to be a family doctor and to meet massive unmet needs in our society.  
 

But what better way for potential applicants to see that they may not be happy with FM and thus shouldn't apply?  especially since the title of the thread is "Going unmatched vs backing up with FM".  

I really think that diversity of opinion is a good thing and can help applicants make the most informed decision possible.  Why not expand on why you think FM is such a fulfilling and stimulating career - even on another thread?  I mean, I get it if the thread just becomes an echo chamber that's one thing.  But, well articulated opinions could show another side of FM that you are passionate about.  

It's provinces/med schools/programs that set quotas for what kind of doctors are going to be produced at the end.  Since medicine is almost always a full career commitment when med school debt etc gets factored in, ultimately this means that the supply of FPs is increased relative to its demand amongst medical students (as compared to other specialties).  So there will be a significant number of FM residents that didn't want FM as a top choice.  

So maybe this thread could not only help dissuade unconvinced FM applicants but could also help even premeds understand some of the realities of the residency matching process and make sure they would be comfortable on the other side before they've made that big commitment towards medicine.   

 I personal think too much optimism or cynicism each has its disadvantages.  

[Supernintendo Chalmers]

Am I the only one who didn't want FM originally, ended up in it, and now I am happy?? 

Maybe I got lucky with who I worked with as a resident and where I locumed, but I am generally pleased with my job. I find one of the big things with FM has been figuring out what in the job I am happy with and what I am unhappy with and changing my practice accordingly. Like most people, I really dislike paperwork and insurance fights, so I try to offset it by charging the insurance companies adequately for my time. I don't like arguing with patients over naturopath bloodwork, so I tell people right off the bat those aren't conversations I will engage in. I find the variety is enough to keep me on my toes between easy and complex visits, but I did carve out one or two areas where I get to "be an expert" including MSK medicine and gender-affirming care. I find some of the most important things to keep me happy are to be clear with what I need from staff/patients/colleagues, set clear boundaries (eg. my patients know they aren't coming into an appointment with 10 items generally, and if they do they know they will be asked to book multiple appointments), maximize the parts of FM that I like, and minimize (or get aggressively compensated for) the parts that I don't. It's not perfect, but no job is!

[Dice]

Quote

Maybe I got lucky with who I worked with as a resident and where I locumed, but I am generally pleased with my job. I find one of the big things with FM has been figuring out what in the job I am happy with and what I am unhappy with and changing my practice accordingly. Like most people, I really dislike paperwork and insurance fights, so I try to offset it by charging the insurance companies adequately for my time. I don't like arguing with patients over naturopath bloodwork, so I tell people right off the bat those aren't conversations I will engage in. I find the variety is enough to keep me on my toes between easy and complex visits, but I did carve out one or two areas where I get to "be an expert" including MSK medicine and gender-affirming care. I find some of the most important things to keep me happy are to be clear with what I need from staff/patients/colleagues, set clear boundaries (eg. my patients know they aren't coming into an appointment with 10 items generally, and if they do they know they will be asked to book multiple appointments), maximize the parts of FM that I like, and minimize (or get aggressively compensated for) the parts that I don't. It's not perfect, but no job is!

This is so smart. I <3 FM, but I wanna be just like you!

[8rue]

4 hours ago, Supernintendo Chalmers said:

I really dislike paperwork and insurance fights, so I try to offset it by charging the insurance companies adequately for my time

Can you elaborate a bit more on what this means/how you do this? Just curious as I know next to nothing about billing/dealing with insurance companies :/

4 hours ago, Supernintendo Chalmers said:

I don't like arguing with patients over naturopath bloodwork, so I tell people right off the bat those aren't conversations I will engage in.

How often does this happen in your practice? And when it does happen, what is your advice as to approaching things this way without harming the patient-provider relationship? Do you feel like you still manage to sway your patients away from engaging with such questionable practices or rather is it that you feel it isn't your job to do so? Definitely something I struggle with in FM and am curious to hear more of your thoughts.

Cool to see that you've adapted your practice around these oft-mentioned downsides of FM to find enjoyment in your career

[indefatigable]

7 hours ago, Supernintendo Chalmers said:

Am I the only one who didn't want FM originally, ended up in it, and now I am happy?? 

Maybe I got lucky with who I worked with as a resident and where I locumed, but I am generally pleased with my job. I find one of the big things with FM has been figuring out what in the job I am happy with and what I am unhappy with and changing my practice accordingly. Like most people, I really dislike paperwork and insurance fights, so I try to offset it by charging the insurance companies adequately for my time. I don't like arguing with patients over naturopath bloodwork, so I tell people right off the bat those aren't conversations I will engage in. I find the variety is enough to keep me on my toes between easy and complex visits, but I did carve out one or two areas where I get to "be an expert" including MSK medicine and gender-affirming care. I find some of the most important things to keep me happy are to be clear with what I need from staff/patients/colleagues, set clear boundaries (eg. my patients know they aren't coming into an appointment with 10 items generally, and if they do they know they will be asked to book multiple appointments), maximize the parts of FM that I like, and minimize (or get aggressively compensated for) the parts that I don't. It's not perfect, but no job is!

Good post.  Setting boundaries is important.   

I saw an article today about a relatively young FP quitting practice early partly due to burnout cause by difficulties with lack of boundaries.

https://www.cbc.ca/news/canada/montreal/first-person-family-medicine-quebec-health-reforms-technology-workload-1.6417193

[Supernintendo Chalmers]

3 hours ago, 8rue said:

Can you elaborate a bit more on what this means/how you do this? Just curious as I know next to nothing about billing/dealing with insurance companies :/

I am still within my first five years, so this may change. Typically, I bill with my province's third party guidelines for uninsured services and disregard any small print of "X Corporation will pay $50 and make the patient pay the rest". A massive corporation can pay the full price for my work, where they know if they try to offload the cost to the patient, you won't charge as much. I get payment before doing any of the paperwork/setting up the chart. If they have extra questions they can discuss with me in writing so there is a record. These are just some basic strategies that has helped me. Obviously, everyone is different!

How often does this happen in your practice? And when it does happen, what is your advice as to approaching things this way without harming the patient-provider relationship? Do you feel like you still manage to sway your patients away from engaging with such questionable practices or rather is it that you feel it isn't your job to do so? Definitely something I struggle with in FM and am curious to hear more of your thoughts.

This rarely happens in my practice because I explicitly tell my patients I won't do it in my intake, although I am happy to discuss the concerns their naturopath mentions and if warranted investigate on my own. I had a few people who chose not to join my practice after hearing that, but there are no shortages of patients who need a doctor. The very small number of people who still ask me if I would order their naturopath's bloodwork get an exploration of their concerns, a clear indication if I want to order something it is an exception to my typical rule, and then an overview of the tests I would like/not like. I also take the approach that my patients are responsible for their health and I don't try to police what healthcare providers they see - that takes too much energy and I need to reserve what I have to treat my patients to the best of my ability while also not burning out! I leave a line open that I am very happy to talk to my patients about alternative healthcare and if something really questionable comes up I will express my concerns, but in the end I just focus on my scope and relationship with my patients, provide my opinions/advice/boundaries, and they can choose. 

 

 

[Supernintendo Chalmers]

1 hour ago, indefatigable said:

Good post.  Setting boundaries is important.   

I saw an article today about a relatively young FP quitting practice early partly due to burnout cause by difficulties with lack of boundaries.

https://www.cbc.ca/news/canada/montreal/first-person-family-medicine-quebec-health-reforms-technology-workload-1.6417193

The first thing that happened when I locumed for the clinic I ended up in was my colleague pulling me aside and asking me to keep up with their boundaries and in handover reviewed people who may need stricter vs. less strict enforcement of these! I feel pretty lucky with the team I ended up in mentorship-wise and I also lucked out on the staff!

[lovemedicinesomuch]

On 4/13/2022 at 4:23 AM, RepresentativeSalad said:

To everyone who backed up with FM and is unhappy/not interested: 

Please, PLEASE stop with the undermining tone and narrative around FM as a career choice. 
 

YOU chose to back up with a specialty you don’t enjoy, and you understood that by ranking, you might match there. I’m sure if I chose to rank specialties I don’t enjoy, I wouldn’t find them intellectually stimulating either, I get it.
 

Maybe you don’t realize it, but these messages with an air of poo-pooing FM are doing a disservice to those students/residents/physicians with a genuine passion for FM, and to the communities that are backboned by FM.  Family medicine is an exceptionally challenging career and much broader in scope than “filling prescriptions and completing insurance forms”.  There are loads of opportunity for intellectual stimulation.  It’s not just some stepping stone between medical school and another career - ranking FM with no interest or intent to practice means having potentially taken a seat from someone who wants to be a family doctor and to meet massive unmet needs in our society.  

 

 

I understand what you are saying- and I was not undermining FM. I understand that FM can be a great choice for a lot of people, however, there is also a significant amount of residents in FM who should not be there. Several of these residents will take any transfer opportunities when they arise - and several of them will stay in FM because they could not transfer to their desired specialities. What do you suggest that people who don't get their first choice specialty do?  End up jobless after 100K worth of debt and at least 10 years worth of education? Or perhaps work in a speciality that it is not their first choice? There are so many people doing jobs they are not passionate about . I am sure you have also done jobs that you don't love and enjoy out of need. 

Over my medical school training, I was encouraged to 'back up' with FM from residents and school counsellors- and everyone knows that I did not have much interest at all in FM. All the FM schools across the country that I interviewed at had access to my resume and CV - I did not hide anything. FM also knows that they will be getting applicants that don't want to be there ( and they are okay with that given the number of unfilled spots in FM). It is an issue of supply and demand that is at play here (Not that FM is a poor career choice). 

On 4/13/2022 at 6:35 AM, indefatigable said:

But what better way for potential applicants to see that they may not be happy with FM and thus shouldn't apply?  especially since the title of the thread is "Going unmatched vs backing up with FM".  

I really think that diversity of opinion is a good thing and can help applicants make the most informed decision possible.  Why not expand on why you think FM is such a fulfilling and stimulating career - even on another thread?  I mean, I get it if the thread just becomes an echo chamber that's one thing.  But, well articulated opinions could show another side of FM that you are passionate about.  

It's provinces/med schools/programs that set quotas for what kind of doctors are going to be produced at the end.  Since medicine is almost always a full career commitment when med school debt etc gets factored in, ultimately this means that the supply of FPs is increased relative to its demand amongst medical students (as compared to other specialties).  So there will be a significant number of FM residents that didn't want FM as a top choice.  

So maybe this thread could not only help dissuade unconvinced FM applicants but could also help even premeds understand some of the realities of the residency matching process and make sure they would be comfortable on the other side before they've made that big commitment towards medicine.   

 I personal think too much optimism or cynicism each has its disadvantages.  

In an ideal world, It would be a dream that everyone gets their first or even second choice competitive speciality. I tried very hard for both plastics and derm and did not get it. I still wish I could do these specialties.As the above post, there will always be a significant number of FM residents that did not want to be there.