I Matched as a Prelim… Now What?

There’s no doubt about it, medical school is stressful. There’s constant deadlines, pressure to succeed, an endless amount of information being thrown at you in a finite amount of time. All of this stress culminates on match day, the day medical students find out if and where they will complete their post graduate training.

For me, match day was supposed to be December 13th 2017, so when I awoke to several messages about the match on December 8th, 2017 I was caught off guard.

The results had leaked!

I sprung out of bed and waited for what seemed like forever for the MODS website to load.  As I nervously clicked on the results tab, the words “Preliminary General Surgery Intern, PGY1 only” spring onto my screen.

My initial reaction was disbelief. It had to be a mistake! I had performed well on my rotations, I had strong letters of recommendation, and I believed my interviews had gone well. My disbelief quickly turned to embarrassment. I essentially hadn’t matched, I had no guarantee of a residency spot and I felt like I was put in a holding pattern. When I got an email from my dean congratulating me on matching into a General Surgery Residency I didn’t know what I was supposed to reply. When my classmates asked me where I matched I had to explain that I had received a preliminary year and that my future career plans were put on hold for an additional year, and when I saw “General Surgery” next to my name on my graduation brochure I felt like a fraud.

After medical school, the first year of training is called “internship”.  There are three potential outcomes for internship, categorical, transitional and preliminary. If you match into a categorical internship the intern year is incorporated into the residency program. This means after completing intern year one will continue on in that program as a 2nd year resident and will ultimate complete a residency in that specialty.  A transitional year is a year of generalized medical training in both surgical and medical specialties. Those interested in pursuing competitive and  highly specialized residencies like anesthesiology, radiation oncology, dermatology, etc. will often elect to do a transitional internship to better prepare and to make themselves a more competitive candidate. For many of these specialties they offer “PGY2” start residencies which means after completing a transitional intern year, you can match into a transitional program as a 2nd year resident. The final internship option is the preliminary year. A preliminary internship is a 1 year contract to train in either internal medicine or general surgery. After completing a preliminary internship one has to reapply for a residency program which typical means having to repeat intern year as a categorical. Preliminary years are like a placeholder, keeping you active in medicine as you reapply for residencies but they don’t count towards completing residency program.

After I finished having my pity party over the realization that I hadn’t matched into a categorical residency, I became determined to obtain a spot for the next match cycle. Now, one year later, I’m happy to report that I secured a categorical General Surgery residency position at my original #1 residency program! I decided to share my tips and tricks to make the most out of a preliminary internship year and how to maximize your potential to match.

Make Yourself a Better Candidate

Students who are in HPSP and match into a preliminary or transitional year are at a unique disadvantage. As the military match is in December, a full 3 months earlier than civilian counterparts, that means there is less time to improve your application profile. As I started working on my personal statement at the start of my intern year, I felt I had nothing new to add to what I had written the previous year.

I contacted all the program directors I had interviewed with and asked for feedback and advice as to how to improve my chances the next year. I was surprised that these physicians took time out of their busy schedules to email me or even call me to discuss my result and what I could do to stand out the following year. If you had a good rapport with an interviewer, use that connection and pick their brains.  They may be able to point out areas of improvement on your application or while interviewing. For me I got a lot of advice on how to do well during my intern year and what rotations were encouraged for the end of my 4th year.

It may be tempting to choose easy rotations to coast through the rest of 4th year, but I’d encourage you to choose rotations that challenge you. I opted to do a trauma surgery, ICU, and diagnostic radiology rotation specifically to gain exposure prior to starting intern year. I also opted to do a research rotation so I could talk about research interests in interviews (but keep in mind, only published research can earn you more points for your application profile).

The weakest part of my application was my board scores which were on the low end of average for the typical surgical residency candidate.  Since I couldn’t go back and change my Level 1 score, I buckled down and got to work preparing for Level 3. Take Level 3 early on in your intern year. It will only become more difficult to study medicine basics the longer the year drags on. Also If you take it early enough your score may be back prior to when the board meets in November to choose applicants.  (Read about how to prepare for Level 3 here)

Lastly, keep in mind that you are now Active Duty! Be sure to prioritize military specific training (so. much. computer. training.) and the physical fitness test.  Do not think just because you are now a physician that you will be excused from any military requirements.

Improve your Application

Seek out letters of recommendation writers early! LOR are due mid-October so you’ll have to start seeking out letter writers fairly early on in your rotations in order to give the physician enough time to compile a letter before the deadline. While it is okay to use non Active Duty letter writers, keep in mind your LORs must be dated within 6 months of the deadline which means letters must be obtained between April of your 4th year through the first couple rotations of intern year. My personal opinion is that active duty letter writers are going to be weighed more favorably compared to civilian letter writers. Although civilian writers can have great name recognition within a certain hospital system or city, there is nothing more powerful than having a Colonel recommending you in front of a board of fellow military leaders.

Lastly pay attention to deadlines. Intern year is busy and the last thing on your mind might be filling out a form or having your final transcript sent to the Air Force Physicians Education Branch, but why risk your application not being considered due to a clerical error. Print out your to-do list, highlight the days, set reminders on your phone, do whatever it takes to make sure you are meeting all deadlines and your application is complete when you submit the paperwork.

Re-Apply Wisely

Even if you are hoping to match into a military residency or don’t plan on pursuing a civilian program, complete an application on ERAS. You need to have your name in the hat to be considered, even if you don’t plan on taking time off or spending money on traveling to interviews prior to the military match. If you don’t apply to a civilian program and you end up getting a civilian sponsored or civilian deferred position you may have to default to a flight surgery or GMO position because you aren’t eligible to participate in the civilian match.

In my opinion, unless you are an exceptionally strong candidate, rank Civilian Sponsored instead of Civilian Deferred. (See how they’re different here) Although civilian sponsored increases the time owed to the military in the long run, the benefits of matching into a program far outweigh the negatives. A Civilian Sponsored position is a fantastic bargaining chip because it essentially allows you to be a “bonus resident” for a residency program. Because the military will be paying your salary, several programs are willing to add an additional spot for civilian sponsored candidates. Keep in mind civilian sponsored does increase the number of years you will have to owe after residency, but it may be equivocal if the only other option is completing 2 years of flight medicine before being able to apply to residency if you don’t match.

Be A Good Intern

This should be a no-brainer but I think every program has horror story of preliminary interns gone rogue (taking unauthorized leave, turning off the call phone, etc.). I can understand that if you were hoping to be a pathologist/internist/radiologist and now you’re forced into a year as a general surgery intern working 80 hours in a career field you had no interest in being in that it is hard to be motivated to do well. However keep in mind the military is a relatively small group of people. If you are disinterested in your job, not a team player, or have a poor attitude on a rotation you don’t care for, programs will hear about it.  Additionally your program director is required to fill out an evaluation which is included in your residency application about your performance as a preliminary intern.

My final piece of advice: life isn’t always linear. The path between point A & B isn’t always a straight line or an easy journey. When I found out I had to delay my residency for an additional year I thought of all the negatives (owing another year of service, delaying attending pay by another year, having to go through the difficulties of intern year twice over). In hindsight I’m thankful I have an additional year of preparation. I recognize there are some of my basic science & patient care fundamentals that I needed to work on and now I have a built in additional year of experience under my belt. Additionally, I have another year of hands on education with amazing attendings. At the end of the day, I would do whatever it takes to be the general surgeon I’ve been dreaming of for the last decade. If it requires one extra year of being an intern, then so be it! Life has a way of working out for the better, so even if you match as a prelim, don’t match into the specialty of your choice, or have to serve as a flight doctor for a couple years it will be okay. Sounds cliche, but where there’s a will, there is always a way.



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