Preliminary Medicine vs Transitional Year Internships

I’ve noticed a trend when I talk to applicants on the trail: a significant number of faculty advisors are giving some questionable advice, such as recommending that their students applying to advanced specialties (e.g. derm, ophtho, rads) only apply to preliminary medicine programs because transitional year (TY) programs are too competitive. That, combined with a lot of mystery about internship programs and the fact that most TYs are not at recognizable university-based hospitals, means that applicants are at a disadvantage when it comes to making an informed decision about where to fulfill their internship requirement. I talk with applicants at dinners and lunches who already regret treating their internships like an afterthought and wish they had put more time into researching their options. I’ll address some myths below:

The harder I work the better [blank] I’ll be

There are those that believe that the difficulty (hours worked, suffering, etc) of an internship directly correlates with the quality of clinical training and thus will seek out spots at predominately categorical university-based programs (or even do a preliminary surgery year). I would personally argue that this is not necessarily the case and is certainly not required for long-term proficiency in the non-IM field of your future, such as radiology (additional thoughts here). You lose the skills you do not use, so your temporarily increased proficiency in managing vent settings will be irrelevant to you in your predominantly outpatient ophthalmology practice. My feeling is that for the true advanced specialties, finding the most pleasant or most locationally-convenient internship should be your goal if you have a choice. Those entering pseudoadvanced specialties (mostly categorical with a full off-service intern year = neurology, most anesthesia and rehab), typically will complete their internships in the same location they complete the bulk of their training and are only rarely found in TY programs.

Given the endemic rates of resident and physician burnout, hunting for hurt is probably not the most thoughtful long-term career planning decision. Additionally, many of the same hospitals that are proud of their “teaching” are the same ones that lack adequate ancillary services (like social work) that allow you to focus on actually learning clinical medicine. Lastly, putting in central lines in the ICU isn’t a long-term skill you’d use in dermatology.1At my institution, neurologists do not place their own Quinton catheters for plasmapheresis, even after a brutal multi-ICU rotation internship. Presumably, it is their attendings that are not comfortable supervising. So all those central lines they dropped in the unit were for nothing; most of these residents will never do one ever again.

Preliminary Medicine programs are easier to get into

Yes and no. Getting into a preliminary medicine program is easier than getting into a transitional year program. However, getting into a specific prelim program isn’t necessarily a straightforward proposition. You have to keep in mind that TYs are typically at non-academic centers and are filled exclusively with people just like you: temporary manpower. So outside of regional bias, any applicant has a fair shot. TY spots aren’t generally earmarked for people who match within the institution for their advanced program or local medical students etc.

The preliminary years at the same hospital as many of the academic advanced programs you’re likely applying to are a different beast. In many cases, the majority of these spots are reserved for residents within the same institution. So out of 8 preliminary medicine spots, say 4 might be marked every year for neurology residents. Looking at the total number of spots can be misleading; in some cases, every single preliminary spot is vouched for (but ERAS doesn’t tell you that). Other programs may fill all of their preliminary spots with their own local medical students before they leave to complete residency elsewhere, with none left over for you. You’d be surprised how often the different departments at many large institutions have zero relationship or communication.

As a personal example: When I applied several years ago, I received a radiology interview at a large academic center on the East Coast. I couples matched, so I emailed the program director to tell him my circumstances and ask about completing my internship within his institution so my wife and I would be together. He essentially said, “Sure no problem, we’ve done that before.” Long story short, the medicine program had made a decision two years prior to fill all of their spots with their local medical students and were not interviewing any external candidates. Luckily I asked before wasting my time and money interviewing at a program that I wouldn’t have ranked highly (my wife, unfortunately, had already interviewed before we uncovered the rest of the story). Of course, that medicine program was still happy to waste my application money and time. The NRMP rule means that every spot has to be “available” in the match; that doesn’t mean it’s really available to you.

Getting an advanced spot at an institution doesn’t mean you’ll also get a prelim. UTHSCSA’s radiology residency offers a well-known pseudo-categorical program, with an optional but guaranteed prelim at their medicine department. This is a very nice gesture, but it is rare. If you apply to only a handful of prelims without knowing the likelihood of actually landing a spot at any of them, it’s possible to end up dry. If you really know you can stay at your medical school for internship though, which is relatively common, then you can feel more comfortable being bold.

So if staying in a particular location at a particular preliminary year is a big deal for you (couples match, for example), then you need to take your internship just as seriously as your real job. If you don’t really care, then rest assured there is a spot somewhere for you even if you blow it off entirely (at least in a preliminary surgery).

A TY is useless, like the fourth year of medical school

I occasionally hear that a rotating internship is useless because you don’t spend enough time in any field to reach proficiency. Because TYs are generally thought of as “cush” (sadly/generally not true anymore), word on the street is that it’s an extra fourth year of medical school where no one expects anything from you. In reality, most TYs are essentially preliminary medicine programs with a couple of elective months tacked on, so that’s largely untrue. I can assure you that basic wardwork is well within the purview of any ACGME-accredited intern year. All interns are doctors for their patients, write orders, and do their share of scut. This is universal. You’ll also remember that you learn fast on your feet: if you think back on third year, you’ll remember the panic and cluelessness of your first day on a new rotation and then getting pretty comfortable in a few weeks (just in time to move on). An extra month of work on the wards or a few extra patients is unlikely to make a long-term impact on your medical knowledge or career in an entirely different field.

Other programs do offer true surgery rotations. You can imagine that for residents going into radiology, for example, a tour throughout clinical medicine that includes surgical pathology and management is perhaps the best foundation for training in a field that interprets images for patients with the full breadth of clinical problems, both medical and surgical, acute and chronic. The two months of surgery during my TY were the hardest months of the year but also the most clinically formative and rewarding.2While two were great, I wouldn’t have wanted twelve. Variety is good. Exhaustion is bad.

If I like medicine I should do a medicine year

Many medical students who are interested in surgery end up ultimately pursuing other fields, so just as you don’t have to hate surgery to choose internal medicine or hate patients to choose radiology, you’re not picking a TY because you hate clinical medicine or work in general. It’s still work. As above, most TYs are largely general medicine intern years with a couple of electives.3Mine was particularly broad and included 3 medicine wards, 2 surgery, 2 ER, 1 medicine outpatient, 2 peds, 2 electives. I’ve never met someone who said there wasn’t enough medicine in their intern year.

Having a hard internship will ruin your life

From the points above, it may sound as though I’m arguing that doing a hard-core preliminary medicine year will ruin you forever. If you read internet forums, depressed post-match fourth years will be implying that it does as well. I will admit that nearly every person I personally know who did a true academic-style preliminary year is jealous of their peers who chose/matched differently and regretted not applying differently. But after a few months into the rest of their careers, however, the bruises and scars fade and it doesn’t really matter. So if you need to do a tough prelim year because of location factors, the couples match, a spouse’s job, or anything else, don’t sweat it. It’s only a year in what’s already been and will continue to be a long journey.