Strategies for Successfully Changing Specialty During Training

Despite performing well in the first 6 months of their intern year, a resident was unhappy and resigned without consulting with the program director (PD), faculty, Wellness Office, or Office of Graduate Medical Education (GME). Two days afterward they approached the PD of a desired new specialty to seek advice on transferring. There were no available postgraduate year (PGY) 1 positions into which to transfer, and because they had not completed their internship, they would be unable to start a PGY-2 position the following July. It was recommended that the resident request reinstatement by their former PD in order to complete their internship, but that PD declined. Subsequently they found a research position for the following 18 months while they went through the next Match cycle to obtain an internship or categorical position. Tragically, because they acted hastily (and had an unsympathetic former PD) they suffered a 2-year delay to their career.

Before taking any action, the trainee should engage in serious, extended reflection on their goals, skills, and interests. Questions to consider include:

Are there frustrations related to factors specific to this training program, institution, or personnel, rather than the specialty itself? In this case the program leadership (eg, Program Evaluation Committee), institutional leadership (eg, Program Review Committee), or the Accreditation Council for Graduate Medical Education (ACGME) Ombudsperson²  may be able to address some of the issues. Are the dissatisfactions related to the current phase of clinical training, rather than the specialty itself? If so, keep in mind that many specialties have disproportionately challenging rotations or onerous periods of training. Are mental health issues tainting the experience of this specialty? In one such case, a disillusioned trainee initially intending to quit medicine entirely was persuaded by their PD to take an extended leave of absence. They returned after 6 months having undergone psychotherapy for their depression, completed the program, and have been practicing successfully for many years.

An outstanding trainee in an intense specialty decided to switch to a less vigorous specialty as they did not enjoy the high-stakes nature of the original. This trainee made the switch with the support of their original program, graduated, and is a happy, successful practitioner in their new field.

This question can sometimes elucidate some of the reasons for discontent queried in the previous questions.

Mentors from medical school or the current program, Association of American Medical Colleges resources on specialty selection,³  current PD, designated institutional official, Office of GME, wellness staff, chief residents, friends, and family may offer key insights. Discussing misgivings with a PD may feel vulnerable and premature. However, PDs are experienced clinician-educators who are well-positioned to provide perspective on the challenges inherent in this stage of training or to recommend other mentors who may have experienced similar misgivings or who changed specialties themselves.

When preparing for a change of specialty, there are 2 main concerns: creation of a strong application for the new specialty, and strategies for a successful leave-taking.

Seek clinical opportunities in the specialty under consideration. Although medical school may have provided experience in this new specialty, perspectives have clearly changed. While PDs understand that initial specialty choice is made with limited information, those reviewing the application will want evidence of sincere interest and commitment to their specialty. They will be wondering, “Is this change a sincere reconsideration of career, or are they failing their original specialty, and will they also struggle in mine? Will this resident also be unhappy in my program and undermine morale among my residents?” Elective time, post-call days, weekends, and vacation time may be needed to explore the new specialty and confirm a genuine interest and fit. Additional resources to help search for open positions are listed in the Box.

The strongest position from which to apply to a new specialty is from within a current GME training program in which the trainee has excelled. Resignation before completion of PGY-1 means that the trainee will not have a medical license and therefore no moonlighting opportunities during transition to the new program.⁴  Remain in training! If health considerations make continuing in the program challenging, rather than resigning explore departmental leave options, moving to a part-time arrangement, or medical leave (a trainee is eligible to take leave under the Family and Medical Leave Act only if they have worked for the employer for 12 months⁵ ). In addition, PGY-1 will need to be completed or repeated (see the first resident example above).

Consider the timing of communicating the final decision to the current PD. Assuming the trainee gained their position through the National Resident Matching Program (NRMP), the NRMP Binding Commitment will be deemed to have been honored by the applicant so long as the applicant enters and remains in the training program through the first 45 calendar days after the start date of the relevant appointment contract.⁶  Also, GME trainees are usually employees on a yearly contract. There may be employer requirements for how much notice must be given. The current PD will appreciate transparency, and, whether or not the trainee uses the Match, the current PD will need to submit documentation to the new program.⁷  The current PD may also want to replace the trainee through the Match.

Investigate and negotiate with the current PD how much and what specific credit can be transferred from the old specialty to the new one. For example, will that emergency medicine rotation in family medicine count toward the emergency medicine rotation in internal medicine?

During all phases of this process, the trainee should continue to provide outstanding patient care, study hard, and demonstrate exemplary professionalism. When sharing the final decision, the goal is for the current PD to feel genuine sorrow at losing such a wonderful trainee and a desire to help make a successful new match.

Although the Match and Supplemental Offer and Acceptance Program are mainly designed to place residents into PGY-1 positions, the Match has subcategories, such as Reserved (ie, reserved for physicians with previous residency experience), and Advanced (ie, places residents into PGY-2 positions).⁸  These positions may present an avenue to transfer specialties through the Match. Know where those opportunities exist and be familiar with timelines for application and matching.⁹ 

The NRMP application should be created with the same care demonstrated by a fourth-year medical student, but with newly gained perspective. Applicants should honestly address the reasons for switching and the process undertaken—this will be a topic in any interview. Applicants should also highlight experience in, and commitment to, the new specialty, and underscore the knowledge and experience accrued from the previous specialty and the benefit that will offer to this new endeavor (eg, a general surgery resident transferring to anesthesiology has considerable applicable experience and knowledge). Request new letters of recommendation and/or request that authors update their previous letter; one letter must be from the current PD.⁷ 

At each stage of the process, recognize that the trainee signed a contract with their current program, and be considerate of the program’s needs. The trainee may need to use personal days, vacation days, or post-call days for interviews. In our experience, when a trainee engages in this process with sincerity and transparency, most PDs are more than willing to assist however they can, and these situations will resolve well for all concerned.

Considering alternate specialties is understandable, and changing specialties is effectively accomplished with some frequency. With a reflective approach, appropriate planning, and guidance, changing specialty can become part of the story of a very successful career.

The online supplementary data contains a visual abstract.