I was having a discussion with some colleagues regarding this topic. we came up with LAC/USC, highland, or cook county. anyone else have thoughts on this. we considered volume, amt of scut, paucity of backup, overall hrs, etc

Highland malignant? It's one of my top choices. When I rotated there it seemed very mellow. Busy, poor support staff, but it seemed like the residents didn't work more than they do elsewhere. The fourth year residents work 40 hours/week! I've heard maricopa, denver, and cook county are malignant - this is pure heresay though.

OK, HOW ABOUT ADDING THE CHARITY PROGRAM TO THE LIST. I HEAR ATTENDINGS ARE ESSENTIALLY ABSENT FROM THE DEPT MOST OF THE TIME(WE HAVE A CHARITY GRAD HERE)

I always thought a "malignant" program was one where lower level residents and medical students only spoke to attendings when they were spoken too and when attendings did speak to them it was only to let them know how stupid they were or how badly they had "screwed up". The institutionalized practice of persistent, malicious pimping also makes a program malignant in my book. But that is just my humble perception.

I was thinking more along the lines of most hrs worked, least supervision, most call...

Come on, fellas, there are some "famously malignant" programs out there. Sadly, most of them are in New York. Take Lincoln, for example. Its residents' burnout and bitterness have achieved world renown.

I'd rather not badmouth too many of the other NY programs, but most of them are also known for being malignant. Malignant, meaning: extraordinarily high patient volume, poor anicillary staff (Resident conversation commonly overheard: "Lemme just wheel you to x-ray, Miss Jones"; "Oh, Mr. Johnson, you've been sitting here for three hours without getting your Lasix? Let's see if we can get this IV started on you,"), little to no teaching during shifts, residents used as slave labor to keep the hospital out of the red.

I won't name the other programs in NY famous for being malignant, but rest assured, there are many.

Don't get me wrong: I love NY and it's a great place to train in terms of the pathology and volume. However, you can learn just as much and see as much pathology under more enjoyable conditions.




My dos pesos,

hornet871 ;)

New York programs are truly the classic malignant places...I was warned to stay out of New York City and New Jersey. A newly malignant place has to be Denver, now that they've added the required surgical PGY1. If I wanted to be a surgeon.....

Originally posted by Desperado
A newly malignant place has to be Denver, now that they've added the required surgical PGY1. If I wanted to be a surgeon.....

What exactly makes this a malignant program? I think you're being a bit short sighted if the 5 months of surgery & surgery subspecialties scares you off. The perspective, knowledge, and perhaps technical skills you might acquire will make you a better doctor overall and are 100% relevant to many of the ER patients you'll see over a career. The comments of their program director on their website really seemed thoughful & they clearly set that year up with long-term education goals in mind

Desperado, just a point about the Denver internship year...from their website, the rotations are an almost even division between medical and surgical subspecialties, like a transition year (Gen Surg, Neuro Surg, Plastics, Ped Surg, Uro, Ortho) plus Anesthesia, Ward Medicine (2 months), EM, MICU, and CCU. Yeah, it's a lot of surgery, but not a true prelim surg year. Anyways, back to the post, can anyone comment about Johns Hopkins? What is the true story behind this "malignant, residents-never-happy" residency?

It may be that the program director really believes all those surgery rotations are truly beneficial for an EP. Or, perhaps he is just painting the fact that the hospital is short on slave labor on its surgical rotations in the best possible light. You can interpret it as you will....(I will admit I have not rotated, nor interviewed there.) The comments on the Denver website are very helpful for anyone going into EM, and I also recommend they be read by all.

At any rate, yes, it isn't quite as bad as a true surgical internship, but you can compare as you like.

Denver EM: Anesthesia, CCU, EM, MICU, Medicinex2, Surgeryx6 (Ortho, neuro, general, uro, plastics, peds)

University of Michigan (PGY1-4 also) EM: EMx3, Medicine, Surgery (Trauma), Peds, Peds EM, Anesthesia, CCU, MICU, OB/GYN, Neuro

Typical Transitional year: Medicinex4, MICU, Surgeryx3, EM, Ambulatory, Electivesx2

Typical Surgery year: Surgeryx9(Generalx4, Vascularx2, Uro, Ortho, Neuro,) Anesthesia, SICU, Research

You decide for yourself which one the Denver PGY1 looks most like. But anyone can see it is quite different from the PGY1 offered at most 4 year EM programs, as illustrated here by the U of Michigan. To soften my previous statement, other than this unique choice of PGY1 rotations, I haven't heard anything else that would suggest to me that Denver is malignant.

I see your point re. the difference with Michigan, but look a little closer. If you have a pgy 2-4 program, why put someone in the ER for 3 months during their intern year? You've got 3 years training of that + a whole career of that waiting for you. It's the same thing I try to teach my students not going into surgery
..... "You've got 3 months (3rd + 4th year med school rotations) to learn everything you will know about surgery for the rest of your life. You won't have to learn how to do an operation, but you do need to learn what we do, how we think, & when you need to call one.......".

Two of those surgical rotations in the Denver schedule are likely not some of the more rigorous rotations, especially the GU rotation @ the VAMC, which having done it a few VA's, is mostly banker's hours with clinic-based low priority urologic problems (impotence, epidiimitis, testicle masses, hernias). The Plastics rotation is also likely not going to work you that hard, and focus on soft-tissue injury & techniques which you'll use. I like the OBGYN rotation that they have @ Michigan which would also seem very valuable to you, maybe they would consider adding that @ Denver at some point. That NES rotation is a great asset & will really serve you with the dozens+ closed head injuries you'll see. I learned so much from the one month I spent with them 5 years ago that helped me be a better doctor.

As to whether you're being pimped out for manpower issues(?).... I can think of no reason why an ED department would feel an obligation to help anyone else out in that respect. Rotations that residents complain bitterly about usually get dropped or reorganized. I'm sure of they (the current residents) felt like that, it would have been reexamined.

My (long-winded) point again is that you're only likely trading some lifestyle considerations on just a few months out of your training for what is very likely to end up making you a better doctor. Couple that with the July 2003 ACGME work hour rule restrictions, & some of those 100 hr+ weeks that will have been a memory. To boot, it sounds like you'd be eliminating a very fine program from consideration over it. Just something to think about. Best of luck!:)

Am I the only person who still believes that a malignant program (e.g., one that works you hard) is one that will most likely train you the best? Yes, there is a point of being overworked, but I think some people take this to the extreme.

I would rather have 3-4 years of being worked nearly to death and pushing me to the limits so I can graduate a top notch physician/surgeon than one that pampers me with 60 hour workweeks without call. Yes, those 60 hour workers (or 80 hours, whatever) will be able to read more, but there's only so much you can learn from a book. I have a feeling that with all the desires to have better family lives, more free time, etc., that the extra hours earned won't be spent reading or studying.

Maybe I'm just a glutten for punishment. Maybe it's because I'm not formally tied down in a relationship (marriage). Maybe it's because I don't have kids. My number one priority is my education, and all other things can take an aside for a few years until I complete it. I've devoted a lot of time to get to where I am, and I would like to finish as an excellent physician instead of a mediocre one. If that means making sacrifices to get there, then sobeit. However, even with 100 hours/week on a rotation as a third year, I'm still finding time to read and have a social life.

So what's my point? Some of us avoid the malignant programs, whereas some of us seek them out. I want to be pushed hard and to the limit so that I can learn as much as possible.

Originally posted by Geek Medic
I want to be pushed hard and to the limit so that I can learn as much as possible.

but I think the point is that 'malignant' does not necessarily relate to #hours (as they are supposedly now limited...) but to whether residents get to learn medicine, or whether they spend 90% of their time doing scut work, whether the attendings teach you, or ignore you, whether the program is set up as both a hospital and an educational experience, or just a health-billing people factory where both education and patient care have taken a back seat to cost cutting. I don't doubt anyone wants to end up as the best physician they can be. However, there are good ways and bad ways, easy ways and hard ways to do this. It will take work, but proper teaching, residency structure, mentoring, and reasonable support facilities all aid the learning experience. You will learn more spending 100 hours being a doctor with a knowledgeable and helpful attending within call than you will spending 100 hours doing scut with unapproachable or resentful faculty.

Agreed. There is more to malignancy than time. True, I did eliminate Denver from consideration early on, but not necessarily because of the PGY1 year. I eliminated it because of the PGY4 year. (I only applied to PGY1-3s.) There are plenty of great PGY1-3 programs out there, and if I decide I want another year of training, I'll do a fellowship. With regards to the point about why spend 3 months in the ED as a PGY1? It guess it depends on whether you believe emergency medicine is best learned in the ED, or on all the other services. Personally, I like working in the ED, that's why I've chosen EM. I'm not saying there isn't something of value for EPs to learn on other services, just that I personally believe 6 months of surgery as an intern is too much.

Responding to geek medic, I'd rather learn a ton for 12 hours a day, 6 days a week, than learn a little for 18 hours a day 7 days a week. There is more to learning than working hard. Starting IVs, chasing down radiology reports, and other scut has limited educational yield. I intend to work hard, but I'm looking for a good balance between time to read, time to be taught by attendings, and clinical time. More clinical time does not necessarily equal better education.

Congratulations on having a social life and being able to read while working 100 hours plus. That is actually very impressive, I know I don't do it very well. Let's see, if you add 7 hours a day for sleep and 2 hours a day to read that is a total of 163 hours a week (out of 168). How are those 5 hours of social life? Luckily you don't have to eat or shower. Or perhaps you have a unique ability to stay awake and read while averaging less than 7 hours sleep a day. I'm just giving you a hard time....but I submit either you don't really work 100 hours a week, you don't really read, you don't really sleep, or you don't really have much of a social life right now. (Or if you're like most of us, you read, sleep, eat, and socialize at work.) Nonetheless, if you really want a malignant residency, I suspect it won't be that hard to match into one.

Maybe I'm spoiled where I am because I rarely see residents doing scut. In fact, I have never seen a resident start an IV where I am (only central lines).

To Desperado, who said anything about getting 7 hours of sleep per night? I've only slept 4-5 hours per night since I was about 13 years old. Even in high school I remembered going to bed around 2 am and getting up at 6:30 to go to school. I guess it's a genetic thing since my father is the same way.